Seminar on monteggia fracture AND TYPES.pptx

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1. Seminar on Monteggia Fracture Dislocation Presenter- Dr Sumit Kumar. Moderator-Dr Sangmesh (Senior Resident) Moderator-Dr Raju KP( Prof&HOD )

2. History Fracture of the upper third of the ulna with dislocation of the head of the radius was first described by Monteggia in 1814. Monteggia fracture-dislocations are rare but complex injury involving a fracture of the ulna associated with proximal radioulnar joint dissociation and radiocapitellar dislocation. comprise less 1% of total paediatric forearm fractures between 4-10 years of age.

3. EPIDEMIOLOGY Monteggia fractures constitute about 1 to 2 percent of forearm fractures. Of the monteggia fracture ,BADO Type 1 is most common, followed by type 3,type2 and type 4.

4. The annular (or orbicular) ligament is one of the prime stabilizers of the proximal radioulnar joint during forearm rotation. The annular ligament encircles the radial neck from its origin and insertion on the proximal ulna. Because of the shape of the radial head, the annular ligament tightens in supination. PATHOANATOMY AND APPLIED ANATOMY RELATING TO MONTEGGIA FRACTURE DISLOCATION

5. The annular ligament is confluent with the remainder of the lateral collateral ligamentous complex which provides stability to the radio capitellar and proximal radioulnar joints and resists varus stress. Displacement of the annular ligament occurs in a Monteggia lesion.

6. QUADRATE LIGAMENT The quadrate ligament is just distal to the annular ligament and connects the proximal radius and ulna .It has a dense anterior portion, thinner posterior portion, and even thinner central portion. The quadrate ligament also provides stability to the proximal radioulnar joint during forearm rotation. The anterior and posterior borders become taut at the extremes of supination and pronation, respectively.

7. The oblique cord, also known as the Weitbrecht ligament, extends at a 45-degree angle from the ulna proximally to the radius distally and is present in approximately 53% of forearms. The oblique cord originates just distal to the radial notch of the ulna and inserts just distal to the bicipital tuberosity of the radius. With supination, the oblique cord tightens and may provide a marginal increase in stability to the proximal radioulnar joint. The clinical relevance of this structure is uncertain.

8. Interosseous ligament The interosseous ligament is distal to the oblique ligament with its fibres running in the opposite direction. The central band is the stiffest stabilizing structure of the forearm.

9. BADO CLASSIFICATION

10. TYPE-1 Pulled elbow. Anterior dislocation of the radial head with ulnar metaphyseal or diaphyseal fractures and radial neck fractures. Anterior dislocation of the radial head with radial diaphyseal fractures more proximal to ulnar diaphyseal fractures. Anterior radial head dislocation with ulna trochlear dislocation and Anterior dislocation of the radial head with segmental ulna fracture.

11. TYPE 1 EQUIVALENT

12. Bado described type 2 equivalent to include posterior radial head dislocations associated with fractures of the proximal radial epiphysis or radial neck. Type 3 and type 4 equivalent Bado did not have equivalent lesions for the true type 3 and type 4 lesions.

13. TYPE 3 AND 4 EQIVALENT

14. LETTS CLASSIFIACTION

15. MECHANISM OF INJURY Direct trauma: Hyper pronation Hyperextension.

16. Direct blow theory: speed and boyd . The first theory proposed in English literature was the direct blow mechanism described by Speed and Boyd and endorsed by Smith.This theory was actually proposed by Monteggia , who noted that the fracture occurs when a direct blow on the posterior aspect of the forearm first produces a fracture through the ulna. Then, either by continued deformation or direct pressure, the radial head is forced anteriorly with respect to the capitellum, causing the radial head to dislocate.

17. In 1949, Evans demonstrated that hyperpronation of the forearm produced a fracture of the ulna with a subsequent dislocation of the radial head. He postulated that during a fall, the outstretched hand, initially in pronation, is forced into further pronation as the body twists above the planted hand and forearm. This hyperpronation forcibly rotates the radius over the middle of the ulna, resulting in either anterior dislocation of the radial head or fracture of the proximal third of the radius, along with fracture of the ulna. In actual patients reported on by Evans, the ulnar fractures demonstrated a pattern consistent with anterior tension and shear or longitudinal compression. Hyperpronation theory

18. The patient falls on an outstretched arm with forward momentum, forcing the elbow joint into hyperextension. Hyperextension theory: The radius is first dislocated anteriorly by the violent reflexive contracture of the biceps, forcing the radius away from the capitellum. Once the proximal radius dislocates, the weight of the body is transferred to the ulna. Because the radius is usually the main load bearing bone in the forearm, the ulna cannot handle the transmitted longitudinal force and, subsequently, fails in tension. This tension force produces an oblique fracture line or a greenstick fracture in the ulnar diaphysis or at the diaphyseal-metaphyseal junction. In addition to the momentum of the injury, the anterior angulation of the ulna results from the pull of the intact interosseous membrane on the distal fragment, causing it to follow the radius. The brachialis muscle causes the proximal ulnar fragment to flex. Hyperextension theory

19. Type 2 mechanism of injury-experimentally demonstrated by penrose occurs when the forarm is suddenly loaded in a longitudinal direction with the elbow in approximately 60 degree of flexion. Type 3-varus stress in combination with an outstenched hand planted against the fixed surface. Type 4-caused by hyperpronation .

20. Associated injuries for injuries for monteggia -fracture dislocations Fractures of wrist and the distal forearm,including distal radial and metaphyseal and diaphyseal injuries. Galeazzi fracture, radial head and neck. Fractures of the humeru s and lateral condyle.

21. Sings and symptoms of monteggia fracture dislocation Fusiform swelling about the elbow. Child has significant pain and limitation in flexion, extension, pronation and supination. Tenting of skin. May not be able to extend fingers at MCP joints due to posterior radial nerve palsy.

22. imaging

23. Type 1

24. Type 2

25. Differentiating feature between congenital and traumatic

26. Indications/Contraindications: Closed reduction and cast immobilization is recommended as an initial treatment strategy for all type I Monteggia fracture dislocations in which the ulna is plastically deformed or there is an incomplete fracture (greenstick or buckle) .Operative intervention is recommended if there is a failure to obtain and maintain ulnar fracture reduction or a failure to obtain and maintain a congruent reduction of the radiocapitellar joint. Inpatients with complete transverse or oblique fractures of the ulna, closed reduction alone risks loss of reduction in a cast and development of a chronic Monteggia lesion. In these fractures, operative intervention is recommended to facilitate maintenance of ulnar alignment an the radiocapitellar reduction. Treatment option for type 1 monteggia – fracture dislocation

27. Reduction of the Ulnar Fracture: The first step of the closed reduction is to re-establish the length of the ulna by longitudinal traction and manual correction of any angular deformity. The forearm is held in relaxed supination as longitudinal traction is applied with manual pressure directed over the apex of the deformity until the angulation is corrected clinically and radiographically. With plastic deformation fractures, this may necessitate significant force that usually requires general anesthesia . Within complete fractures, the correction of the ulnar deformity and radial head reduction can often be achieved with conscious sedation in the emergency room. Some papers have cited successful treatment of acute Monteggia lesions (defined as maintenance of the radiocapitellar reduction) with nonanatomic alignment of the ulnar fracture. However, anatomic reduction and healing of the ulna fracture is strongly advocated.

28. Reduction of the Radial Head : Once ulnar length and alignment have been reestablished , the radial head can be relocated. This is often accomplished by simply flexing the elbow to 90 degrees or more, thus producing Spontaneous reduction. Occasionally, posteriorly directed pressure over the anterior aspect of the radial head is necessary for reduction of the radial head. Flexion of the elbow to 110 to 120 degrees stabilizes the reduction. Once the radial head position is established, it should be scrutinized radiographically in numerous views to ensure a concentric reduction. With a type I lesion, the optimal radiographic

29. Type2 Non operative- the ulnar fracture is reduced by longitudinal traction in the line with the forearm while the elbow is held at 60 degree of flexion. The radial head may reduce spontaneously or may require gentle, anterior directed pressure applied to its posterior aspect.

30. Type 3 Non operative- the elbow is held in extension with longitudinal traction in valgus stress is placed on the ulna at the site of the fracture, producing clinical realignment. Radial head- may spontaneously reduce or need assistance with gentle pressure applied laterally. Ulnar length and alignment must be maintained to ensure a stable radial head.

31. Maintainance of reduction Reduction is maintained by a long –arm cast with the elbow in flexion. The degree of flexion varies depending on the direction of radial head dislocation. When the radius is in a straight lateral or anterolateral position ,flexion to 110 to 120 degree improves stability. If there is a posterolateral component to the dislocation, a position of only 70 to 80 degrees of flexion has been recommended. Forearm rotation usually is in supination, which tightens the interosseous membrane and further stabilizes the reduction.

32. Type 4 Nonoperative-closed reduction should be attempted initially, with the aim of transforming the type 4 lesion to type 1 lesion. Use of the image intensifier allows immediate confirmation of reduction, especially of the radial head. The elbow is immobilized in a long arm cast for 4 weeks in 110 to 120 degree of flexion with the forearm in neutral rotation. A short arm cast is used for an additional 4 weeks while early range of motion at the elbow and forearm is begun.

33. Operative treatment Indication- There are two indication for operative treatment of type 1 fracture dislocation. 1.failure of ulnar reduction. 2.failure of radial head reduction.

34. Failure of ulnar reduction If the ulnar fracture cannot be reduced or held in satisfactory alignment by closed treatment, operative intervention is indicated. The ulnar fracture can be reduced but not maintained because of the obliquity of the fracture,internal fixation combined with open or closed reduction may be necessary. Intramedullary fixation ,rather than fixation with a plate,is standard. Can be accomplished percutaneously ,using image intensification and flexible nail or K wire.

35. Failure of radial head reduction. more common in type 3 monteggia lesions. Results from the interposition of material, including torn fragments of the ruptured orbicular ligament and capsule or an entrapped orbicular ligament pulled over the radial head. Obstruction in reduction of the radial head by radial nerve entrapment between the radial head and ulna has been described.

36. Surgical approach 1.koachers approach: incison :begin skin incision over the lateral epicondyle and continue distally and obliquely directly over the lateral epicondyle to end at proximal ulna. Interneural plane- between anconaeus and ECU. Safer as it provides protection to the PIN.

37. complications Neglected monteggia fractures. Nerve injuriues . Periarticular ossifications. Compartment syndrome.

38. Old undetected fractures Recognition of a dislocated radial head at the time of injury can prevent the difficult problem of persistence radial head dislocation. The natural history of persistent dislocation is not benign and is associated with restricted motion, deformity, functional impairement , pain, degenerative arthritis, and late neuropathy.

39. An undetected ,isolated radial head dislocations with no apparent lesions of the ulna associated with remote trauma have been mistaken for congenital radial head dislocations. Kalamchi reported pain ,instability ,and restricted motion,especially loss of pronation and supination.He also noted that children have a valgus deformity and a prominence on the anterior aspect of the elbow.

40. Indication for treatment Normal concave radial head articular surface and Normal shape and contour of the ulna and radius .deformity of either correctable by osteotomy. At present, most authors advocate surgical reconstruction of a chronic monteggia when: The diagnosis is made earlier. There is preservation of the normal concave radial head and convex capitullem .

41. Surgical reconstruction Monteggia lesions have been variable in terms of: Annular ligament repair or reconstruction. Ulnar osteotomy alone or in combionation with ligament reconstruction

42. Annular ligament reconstruction Bell –Tawse used the central portion of the triceps tendon passed through a drill hole and around the radial neck to stabilize the reduction and immobilize the elbow in a longitudinal cast in extension. Bucknill and Lloyd –Roberts modified the Bell –Tawse procedure by using the lateral portion of the triceps tendon, with a transcapitellar pin for stability. The elbow was immobilized in flexion. Seel and Peterson described the use of two drill holes drilled in the proximal ulna.The holes are placed at the original attachments of the annular ligament and allow repair of the annular ligament.

43. Bell -Tawse

44. osteotomy Various method of osteotomies have been used to facilitate reduction of the radial head and prevent recurrent subluxation after annular ligament reconstruction. Kalamchi reported using a drill hole ulnar osteotomy to obtain reduction of the radial head in two patient. minimal periosteal stripping with this technique. Mehta used an osteotomy of the proximal ulna stabilized with bone graft. Exner reported that in patients with chronic dislocation of the radial head after missed type 1 monteggia lesions ,reduction was successfully obtained with ulnar cortiectomy and gradual lengthening using external fixator.

45. Nerve injuries 10 to 20 % incidence of radial nerve injuries ,making it the most common complication. Commonly associated with type 1 and 3 injuries. Posterior interosseous nerve commonly injured. Function usually returns to normal by 9 weeks.

46. Periarticular ossifiaction Around the radial head. Myositis ossificans.

47. Thank you

48. reference Rockwood and wilkins racctures in adults 8 th edition. Cambell’s operative orthopaedics 12 th edition Rockwood and green fractures in children 8 th edition.