21u-M/6.1 Monteggia lesion

Congruent and stable reduction of radiocapitellar joint dislocation requires correction of angulation and restoration of length of any ulnar fracture distal to the coronoid.

If this is not achieved, the radial head can remain dislocated and if reduced can redislocate or sublux.

This may lead to permanent loss of forearm function and operative treatment is recommended.

Overcorrection of the ulna may be necessary to stabilize the radial head. An osteotomy should be considered in the presence an incomplete fracture or established deformity.

Treatment of Monteggia lesions with more distal ulnar fractures is discussed in the forearm shaft section of Pediatric Surgery Reference.

Congruent and stable reduction of radiocapitellar joint dislocation requires correction of angulation and restoration of length of any ulnar fracture distal to the coronoid.

If this is not achieved, the radial head can remain dislocated and if reduced can redislocate or sublux.

This may lead to permanent loss of forearm function and operative treatment is recommended.

Overcorrection of the ulna may be necessary to stabilize the radial head. An osteotomy should be considered in the presence an incomplete fracture or established deformity.

Treatment of Monteggia lesions with more distal ulnar fractures is discussed in the forearm shaft section of Pediatric Surgery Reference.

Complications of radial head and neck fractures
Decision making and timing, Concept of fracture treatment2
Principles of nonoperative treatment, Pediatric polytrauma2

Skill level

Equipment

Main indications

Young child, fracture manipulation leading to stable ulnar fracture and reduced and stable radiocapitellar joint possible

A well-molded cast is recommended to ensure maintenance of satisfactory ulnar reduction with stable and congruent radiocapitellar joint reduction.

Early radiological follow-up is necessary to check radial head position. If there is any doubt about reduction, operative treatment of the ulna is recommended.

Reduction of bowing and greenstick injuries of the ulna, whilst simultaneously maintaining stable reduction of the radial head is difficult to achieve.

Contraindications

Radial head not perfectly reduced

Advantages

No requirement for implant removal

Disadvantages

Unstable radiocapitellar joint reduction
High risk of displacement requiring surgical treatment

Young child, fracture manipulation leading to stable ulnar fracture and reduced and stable radiocapitellar joint possible

A well-molded cast is recommended to ensure maintenance of satisfactory ulnar reduction with stable and congruent radiocapitellar joint reduction.

Early radiological follow-up is necessary to check radial head position. If there is any doubt about reduction, operative treatment of the ulna is recommended.

Reduction of bowing and greenstick injuries of the ulna, whilst simultaneously maintaining stable reduction of the radial head is difficult to achieve.

Contraindications

Radial head not perfectly reduced

Advantages

No requirement for implant removal

Disadvantages

Unstable radiocapitellar joint reduction
High risk of displacement requiring surgical treatment

Skill level

Equipment

Main indications

Any unstable or displaced fracture

If elastic nails are not available, the ESIN method can be performed with long stainless-steel K-wires.

If closed reduction is not possible, an open reduction may be necessary.

This treatment can be performed if image intensifier is not available with fracture reduction under direct vision.

Advantages

Cast-free rehabilitation
Minimally invasive treatment
Good alignment of fracture fragments
Predictably good functional outcome
Sufficient radial head stability

Disadvantages

Image intensifier recommended
Risk of nerve or tendon injury at entry point
Risk of infection
General anesthesia required
Second anesthetic required for implant removal

Any unstable or displaced fracture

If elastic nails are not available, the ESIN method can be performed with long stainless-steel K-wires.

If closed reduction is not possible, an open reduction may be necessary.

This treatment can be performed if image intensifier is not available with fracture reduction under direct vision.

Advantages

Cast-free rehabilitation
Minimally invasive treatment
Good alignment of fracture fragments
Predictably good functional outcome
Sufficient radial head stability

Disadvantages

Image intensifier recommended
Risk of nerve or tendon injury at entry point
Risk of infection
General anesthesia required
Second anesthetic required for implant removal

Skill level

Equipment

Main indications

Insufficient stability to hold radial head reduced, unstable injury in adolescents and young adults

Advantages

Cast-free rehabilitation
Anatomical reduction of joint (may require overcorrection of the ulna)
Absolute stability

Disadvantages

Risk of infection
Neurovascular injury
General anesthesia required
Second anesthetic required for implant removal
Scar(s)
Bulk of implant
Demanding technique
Image intensifier or arthrotomy necessary for radiocapitellar joint visualization

Insufficient stability to hold radial head reduced, unstable injury in adolescents and young adults

Advantages

Cast-free rehabilitation
Anatomical reduction of joint (may require overcorrection of the ulna)
Absolute stability

Disadvantages

Risk of infection
Neurovascular injury
General anesthesia required
Second anesthetic required for implant removal
Scar(s)
Bulk of implant
Demanding technique
Image intensifier or arthrotomy necessary for radiocapitellar joint visualization