The radial head will often reduce closed and remain stable once the ulna has been aligned.
Rotation of the forearm may be necessary to complete the reduction of the radial head.
After fixation of the ulna, use an image intensifier to carefully evaluate the position of the radial head relative to the capitellum.
This must be confirmed through a full range of flexion, extension, pronation and supination.
An arthrogram may be helpful, particularly in younger children with an unossified proximal radius.
Revision of ulnar reduction and fixation
At this stage the ulnar reduction can be revised if required, often to an overcorrected position, which usually results in a stable anatomic reduction of the radial head.
This can be achieved by overbending and reinserting the ulnar nail. An external fixator or a plate can produce further overcorrection if needed.
Ulnar osteotomy for plastic deformity
There is a strong tendency for the radial head to redislocate in a Monteggia lesion with plastic deformity of the ulna.
This is due to rebound of the ulna. Correction of the ulnar deformity with a precontoured elastic nail is recommended. If this is not successful, an osteotomy of the ulna should be considered.
Both of these maneuvers should be performed before considering open reduction of the radial head.
Complete reduction with the nail may not be possible in the following cases:
Bowing unresponsive to intraoperative correction
Narrow nail in a small medullary canal
In this situation, a small osteotome can be used to divide the bone through a small incision over the apex of the bowing.
If there is residual subluxation or instability in any position after optimization of the ulnar correction, there may be interposed tissue (usually annular ligament) in the radiocapitellar joint and an open reduction should be performed.
The annular ligament is the most common intraarticular block to reduction. In rare cases, the ligament can be gently repositioned around the radial head.
More often the ligament must be incised or excised to allow reduction of the radial head.
Reassessment of radial head position
Reassess the position and stability of the radial head by direct visual inspection and image intensification.
8. Final assessment
Check the completed osteosynthesis with image intensification. These images should be retained for documentation.
If an image intensifier is not available, an x-ray should be obtained before discharge.
Make sure that the plate is at the correct location, the screws are of appropriate length, the desired reduction has been achieved and the radial head remains in the appropriate position.
9. Aftercare following ESIN
Immediate postoperative care
Whilst the child remains in bed, the elbow and forearm should be elevated on pillows to reduce swelling and pain.
They should be encouraged to use the arm.
Cast immobilization is not necessary and hinders early recovery of joint movement.
For Monteggia lesions treated with ulnar nailing, the forearm may be immobilized in a cast in the position of maximum stability of the radiocapitellar joint for 2-4 weeks.
Ibuprofen and paracetamol should be administered regularly during the first 24-48 hours after surgery, with opiate analgesia for breakthrough pain.
Opiates should not be necessary after 48 hours and regular ibuprofen and paracetamol should be sufficient until 4-5 after injury or surgery.
The child should be examined if the level of pain is increasing or prolonged analgesia is needed.
The child should be examined regularly, to ensure finger range of motion is comfortable and adequate.
Neurological and vascular examination should also be performed.
Compartment syndrome should be considered in the presence of increasing pain, especially pain on passive stretching of muscles, decreasing range of active finger motion or deteriorating neurovascular signs, which is a late phenomenon.