Department of Orthopaedics

Chairperson& Moderator: Prof. & HOD: Dr. Kiran Kalaiah

Presenter : Dr. Yashavardhan .T.M

SEMINAR PRESENTATION ON: Injuries around elbow in pediatric age group.

Paediatric elbow fractures1. Anatomy

2. Ossification

3. Supracondylar Fractures

4. Lateral Condyle Fractures

5. Medial Epicondyle Avulsion

6. Proximal Radius Fractures

7. Radial head & neck fracture dislocation

8. Olecranon fracture

9. Nursemaid’s elbow

10. Elbow dislocation

11. Monteggia fracture dislocation.

Stability of the elbow - static and dynamic constraints 3 primary static constraints1) Ulno-humeral articulation,

2) the anterior bundle of the MCL

3) the lateral collateral ligament (LCL) complex

4 Secondary constraints1) Radio-capitellar articulation,

2) the common flexor tendons,

3) the common extensor tendons,

4) the capsule.

Dynamic stabilizers - Muscles that cross the elbow joint

Osteo-articular anatomyThe articular surfaces of the elbow joint

1. distal humerus,

2. the proximal ulna,

3. proximal radius The elbow -trochleogingylomoid jointhinged (ginglymoid) motion in flexion and extension

at the ulno-humeral and radio-capitellar articulationsradial (trochoid) motion in pronation and supination

at the proximal radio-ulnar joint

Osseous stability - enhanced in flexion1) coronoid process locks into the coronoid fossa of the distal humerus

2) radial head is contained in the radial fossa of the distal humerus

Osseous stability - enhanced in extension1) the tip of the olecranon rotates into the olecranon fossa.

2) The sublime tubercle is the attachment site for the anterior bundle of the MCL.

The MCL complex3 components:

1) the anterior bundle or anterior MCL

2) the posterior bundle

3) the transverse ligament

The origin of the MCL is at the antero-inferior surface of the medial epicondyle.

AMCLmost discrete structure inserts on the antero-medial aspect of the coronoid process, the sublime tubercle. Provide significant stability against valgus force• one of the primary static constraints of the elbow• The anterior bundle - divided into

1. anterior band

2. Posterior band

The transverse ligament

Runs between the coronoid and the tip of the olecranon

consists of horizontally oriented fibers that often cannot be separated from the capsule

The LCL complex

four components

1) radial collateral ligament,

2) the lateral ulnar collateral ligament,

3) the annular ligament,

4) the accessory collateral ligament

The LCL complex originates along the inferior surface of the lateral epicondyle.

Blood supply around elbow.

CARRYING ANGLE

It is the angle at which the humerus and forearm articulate, with the elbow in full extension, and the palms facing forward.

The carrying angle permits the arm to be swing without contacting the

hips.

Normal values.

Males=15

Female=20 deg

A line in the longitudinal axis of proximal end of radius passes to the centre of capitulum.

A line in the Anterior cortex of distal end of humerus passes to the centre of capitulum

Distruption from this indicates Fracture or Dislocation.

SUPRACONDYLAR FRACTURES OF THE DISTAL HUMERUS

1. Supracondylar fractures of the humerus are the most common type of elbow fracture in children and adolescents.

2. They account for 50% to 70% of all elbow fractures and are seen most frequently in children between the ages of 3 and 10 years.

3. The high incidence of residual deformity and the potential for neurovascular complications make supracondylar humeral fractures a serious injury.

4. When forced into hyperextension, the olecranon can act as a fulcrum through which an extension force can propagate a fracture across the medial and lateral columns.

5. Similarly, a force applied posteriorly with the elbow in flexion can create a fracture originating at the level of the olecranon fossa

Mechanism of Injury

Supracondylar humeral fractures may be the result of an extension or flexion force on the distal humerus. Usually they are the result of a fall on an outstretched hand, which causes hyperextension of the elbow.

These extension type supracondylar humeral fractures account for 95% to 98% of all supracondylar fractures. With hyperextension injuries the distal fragment will be displaced posteriorly.

Flexion-type supracondylar fractures are rare and occur in only 2% to 5% of cases. The mechanism of flexion supracondylar fractures is usually a direct blow on the posterior aspect of a flexed elbow that results in anterior displacement of the distal fragment.

ClassificationSupracondylar humeral fractures are usually initially classified as extension or flexion injuries and then according to the amount of radiographic displacement.

This three-part classification system was first described by Gartland in 1959.

There have been several modifications of this scheme. Wilkins subdivided type III injuries according to the coronal plane displacement of the distal fragment.

HISTORY – MECHANISM OF INJURY

Describes falling on an outstretched hand ( FOOSH injury) or other traumatic event

SYMPTOMS

• Severe pain • swelling, • inability to bend the arm • Loss or abnormal sensation and pulse • inability of normal distal arm functions • Children with nursemaid's elbow will not bend due to pain and hold arm slightly bent.

CLINICAL EXAMINATION

1) Pulse

2) Touch sensation of digits

3) Motor function -abduction and adduction

4) strength of the digits (ulnar nerve)

5) opposability of the thumb (median nerve).

• Posterior elbow dislocations -prominent olecranon and foreshortened forearm

• Anterior elbow dislocations elongated forearm, arm is held in extension

Radiographic Findings◦ The diagnosis of a supracondylar humeral fracture is confirmed radiographically.

Obtaining good-quality radiographs is complicated by the fact that the elbow is painful and difficult to move.

Imaging

obtain AP and lateral of humerus and elbow.

include entire length of humerus and forearm.

additional views obtain wrist radiographs if elbow injury present or distal tenderness oblique radiographs may assist in surgical planning, traction radiographs may assist in surgical planning

specifically evaluate if there is continuity of the trochlear fragment to medialepicondylar fragment, this can influence hardware choice

CT

often obtained for surgical planning.

helpful when shear fractures of the capitellum and trochlea are suspected.

3D CT scan.

MRI

◦ usually not indicated in acute injury.

Radiograph Anatomy/LandmarksFat pad sign.-Note the un- displaced fracture (Red Arrow).

-Note the posterior fat pad (Yellow Arrows).

Baumann’s angleBaumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the physis of the capitellum.

A normal angle is approximately 8-9°, and so when reducing paediatric supracondylar humerus fractures, a deviation of more than 5° from the contralateral side should not be accepted.

Ant.humeral lineAnterior Humeral Line

– Drawn along the anterior humeral cortex

– Should pass through the middle of the capitellum

– Variable in very young children

Humerocapitellar angleThe capitellum is angulated anteriorly about 30 degrees.

• The appearance of the distal humerus is similar to a hockey stick.

Radiocapitellar lineRadiocapitellar line should intersect the capitellum in all views.

• Make it a habit to evaluate this line on every paediatric elbow film

Treatment

the goal of treatment of supracondylar humeral fractures is to “avoid catastrophes” (vascular compromise, compartment syndrome) and “minimize embarrassments” (cubitus varus, iatrogenic nerve palsies).

Treatment of Nondisplaced Fractures

Treatment of nondisplaced fractures is straightforward and noncontroversial. It consists of long-arm cast immobilization for 3 weeks. often initially treat the patient in the emergency department with a posterior splint, with figure eight reinforcement. The position of the forearm in the long-arm cast has been the subject of a great deal of speculation.

For truly non-displaced fractures there is no theoretic advantage to pronation or supination. We generally immobilize non-displaced fractures with the forearm in neutral position.

The patient returns 5 to 10 days after injury for removal of the splint. Radiographs are repeated to ensure that no displacement has occurred, and the patient is placed in a long-arm cast for an additional 2 to 3 weeks, at which time immobilization is discontinued.

Treatment of Displaced Fractures

Several treatment options are available for the management of displaced fractures (types II and III). By definition, all these fractures require reduction. Usually, even for severe type III injuries, reduction can be accomplished in a closed fashion. Options exist in regard to the method of maintaining the reduction until the fracture has healed, including cast immobilization, traction, and percutaneous pin fixation.

If adequate closed reduction cannot be achieved, open reduction should be performed; this is almost universally followed by pin fixation.

Supracondylar HumerusFractures: ComplicationsImmediate:-

1. Vascular injury to brachial artery.

2. Nerve injury to radial nerve, median nerve (AIN) and ulnar nerve(in flexion type).

Early:-

1. Volkmann’s ischemia and

2. Compartment syndrome.

Late:-

1. Malunion-Cubitus varus

2. Myositis ossificans,

3. Volkmann’s ischemic contracture.

Transphyseal Fractures

Transphyseal fractures are most common in children younger than 2 years. They have been reported to result from abuse in up to 50% of children younger than 2 years.

In children of this age, the distal humerus is entirely cartilaginous or almost so, thus making interpretation of radiographs difficult and making diagnosis the most difficult aspect of this fracture.

Mechanism of InjuryThe mechanism of injury depends on the age of the patient.

In newborns and infants, there is usually a rotatory or shear force associated with birth trauma or child abuse.

In older children, the mechanism is usually a hyperextension force from a fall on an outstretched hand.

ClassificationDeLee and colleagues separated transphyseal fractures into three groups based on their radiographic appearance.

Their criteria included the presence or absence of the secondary ossification center of the radial head and the presence and size of the metaphyseal fragment (Thurston-Holland sign).

These radiographic parameters correspond to the age of the patient but add little to clinical management. These fractures may also be classified according to the Salter-Harris classification of physeal injuries.

In infants these injuries are usually Salter-Harris type I fractures. In older children they are usually type II injuries.

Toniolo and Wilkins proposed a simple classification based on the degree of displacement and comminution of the fracture fragments for pediatric T-condylar fractures.

Type I fractures are minimally displaced.

Type II fractures are displaced but do not have comminution of the metaphyseal fragments.

Type III fractures are displaced fractures with comminution of the metaphyseal fragments

Treatment of T-Condylar Distal Humerus FracturesIndications/Contraindications

ELBOW DISLOCATIONS Disruptions of the elbow joint represent a spectrum of injuries involving three separate articulations:

The radiocapitellar, the ulnohumeral, and the proximal radioulnar joints. Dislocations of the elbow joint in children are not common.

Of all elbow injuries in skeletally immature patients, Henrikson65 found that only about 3% of all were dislocations. The peak incidence of pediatricelbow dislocations typically occurs in the second decade of life, usually between 13 and 14 years of age when the physes begin to close.

Based on the National Electronic Injury Surveillance System database, the calculated incidence of elbow dislocations in adolescents aged 10 to 19 years old was 6.87 dislocations per 100,000 person years with an almost 2:1 ratio of injuries in males compared to females (incidence 8.91 vs. 4.72 per 100,000 person years).

POSTERIOR ELBOW DISLOCATIONSO’Driscoll et al. have proposed that most posterior elbow dislocations begin with disruption of the lateral ligaments and proceed along the anterior capsular structures to the medial ligaments.

Although this is likely the mechanism for the more rarely seen posteromedial elbow dislocation, for the more common posterior and postero lateral elbow dislocations, this notion has been challenged.

Associated Injuries with Posterior Elbow Dislocations

Fractures Associated with Posterior Elbow Dislocations:

A. medial epicondyle,

B. the coronoid process,

C. the radial head and the neck.

Soft Tissue Injuries Associated with Posterior Elbow Dislocations:

Signs and Symptoms of Posterior Elbow Dislocations

1. Crepitus is usually absent in children with a dislocation and the forearm appears shortened.

2. The prominence produced by the distal humeral articular surface is more distal and is palpable as a blunt articular surface.

3. The tip of the olecranon is displaced posteriorly and proximally so that its triangular relationship with the epicondyles is lost.

4. The skin may have a dimpled appearance over the olecranon fossa.

5. If the dislocation is postero-lateral, the radial head also may be prominent and easily palpable in the subcutaneous tissues.

Anteroposterior (AP) and lateral x-raysAnteroposterior (AP) and lateral x-rays usually are diagnostic of a posterior elbow dislocation.

There is a greater superimposition of the distal humerus on the proximal radius and ulna in the AP view.

The radial head may be proximally and laterally displaced, or it may be directly behind the mid-distal humerus, depending on whether the dislocation is postero-lateral, posterior, or posteromedial

Management.Nonoperative Treatment of Posterior Elbow Dislocations.

Operative Treatment of Posterior Elbow Dislocations

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TOPOSTERIOR ELBOW DISLOCATIONS

Recurrent Posterior DislocationsRecurrent posterior elbow dislocation is rare. In the combined series of dislocations, only 2 of 317 patients (0.6%) experienced recurrent dislocations.

Approximately 80% of recurrent dislocations are in males.

Three investigators have reported bilateral cases.

Pathology Contributing to Recurrent Posterior Dislocations

1) Osborne and Cotterill126 suggested that articular changes are secondary and that the primary defect is a failure of the posterolateralligamentous and capsular structures to become reattached after reduction.

2) With recurrent dislocations, the radial head impinges against the posterolateral margin of the capitellum, creating an osteochondraldefect.

Management Because nonsurgical management is so often unsuccessful, the treatment of recurrent posterior elbow dislocations is predominately surgical.

Various surgical procedures have been described to correct bone and soft tissue abnormalities

ANTERIOR ELBOW DISLOCATIONSMechanisms of Injury for Anterior Elbow Dislocations:

Anterior elbow dislocations usually are caused by a direct blow to the posterior aspect of the ɻexed elbow.

Hyperextension of the elbow also has been implicated in one study.

Associated Injuries with Anterior Elbow Dislocations

Associated fractures are common.

In children, the triceps insertion may be avulsed from the olecranon with a small piece of cortical bone. This fragment usually reduces to the olecranon after reduction.

Signs and Symptoms of Anterior Elbow Dislocations

The elbow is held in extension upon presentation.

There is a fullness in the ante-cubital fossa.

Swelling usually is marked because of the soft tissue disruption associated with this type of dislocation.

There is severe pain with attempted motion. A careful neurovascular examination is mandatory.

MEDIAL AND LATERAL ELBOW DISLOCATION

Signs and Symptoms of Medial and Lateral Elbow Dislocations

In an incomplete lateral dislocation, the semilunar notch articulates with the capitulo-trochlear groove, and the radial head appears more prominent laterally.

There is often good ɻexion and extension of the elbow, increasing the likelihood that a lateral dislocation will be overlooked. In a complete lateral dislocation, the olecranon is displaced lateral to the capitellum.

This gives the elbow a markedly widened appearance

DIVERGENT ELBOW DISLOCATIONDivergent dislocation represents a posterior elbow dislocation with disruption of the interosseous membrane between the proximal radius and ulna with the radial head displaced laterally and the proximal ulna medially.

TREATMENT OPTIONS FOR DIVERGENT ELBOW DISLOCATIONSClosed Reduction in Divergent Elbow Dislocations

Divergent dislocations are typically easily reduced using closed reduction under general anesthesia.

Reduction is achieved by applying longitudinal traction with the elbow semiextended and at the same time compressing the proximal radius and ulna together.

MEDIAL EPICONDYLE APOPHYSIS FRACTURES

Mechanisms of Injury for Medial Epicondyle Apophysis Fractures:A direct blow, avulsion mechanisms, and association with elbowdislocation.Among more recent investigators, however, only Watson-Jones described this injury as being associated with a direct blow to the posterior medial aspect of the elbow.Smith proposed that when a child falls on his outstretched upper extremity with the elbow in extension, the wrist and fingers are often hyperextended as well, placing an added tension force on the epicondyle by the forearm flexormuscles

TREATMENT OPTIONS FOR MEDIAL EPICONDYLE AVULSION FRACTURESNonoperative Treatment of Medial Epicondyle Avulsion Fracture.

PULLED ELBOW SYNDROME (NURSEMAID’S ELBOW)Subluxation of the annular ligament, or pulled elbow syndrome, is a common elbow injury in young children.

The term “nursemaid’s elbow” and other synonyms have been used to describe this condition.

The mean age at injury is 2 to 3 years, with the youngest reported patient 2 months of age.

Mechanisms of Injury for Pulled Elbow Syndrome

Longitudinal traction on the extended elbow is the usual mechanism of injury. Cadaver studies have shown that longitudinal traction on the extended elbow can produce a partial slippage of the annular ligament over the head of the radius and into the radio-capitellar joint, sometimes tearing the subannular membrane.

Lateral Condyle FracturesFractures of the lateral humeral condyle are transphyseal, intraarticular injuries.

As such, they frequently require open reduction and fixation.

They are the second most common operative elbow injury in children, second in frequency only to supracondylar fractures.

The capitellum is the first secondary ossification center of the elbow to appear, usually around 2 years of age. The lateral epicondyle is the last, often not appearing until 12 or 13 years of age.

The two ossification centers fuse at skeletal maturity.

Mechanism of Injury

Lateral condylar fractures are generally the result of a fall on an outstretched arm. The fall may produce a varus stress that avulses the lateral condyle or a valgus force in which the radial head directly pushes off the lateral condyle.

Complications1) cubitus varus,

2) lateral spur formation,

3) delayed union, and

4) nonunion with or without cubitus valgus.

5) Growth Arrest:Although lateral condyle fractures cross the germinal layer of the physis and are classified as Salter-Harris type IV injuries, growth arrest is a rare complication.

6) Fishtail Deformity and Avascular Necrosis: The cause of fishtail deformity of the distal humerus is uncertain.

oRutherford noted this deformity in 9 of 10 patients who had unreduced lateral condyle fractures and hypothesized that malunion at the medial extent of the fracture results in growth arrest of the lateral trochlea

oHowever, Morrissey and Wilkins noted it after a variety of fractures of the distal humerus and attributed it to AVN

Radial Head and Neck FracturesIn children, the cartilaginous radial head is resistant to fracture, and children are more likely to sustain fractures of the radial neck than fractures of the head.

The secondary ossification center of the proximal radius appears as a small sphere between the third and fifth years of life and fuses with the shaft between the ages of 16 and 18 years.

Mechanism of Injury

Fractures of the radial head or neck may occur as a result of two different mechanisms.

1. Usually they result from a fall onto an outstretched hand, with the elbow in extension and valgus.

2. Fracture of the radial neck may also occur as a result of dislocation of the elbow

Classification

Radiographic Findings.

Percutaneous and Intramedullary Reduction.

1) In type II (30 to 60 degrees of angulation) and type III (>60 degrees of angulation) radial neck fractures, we first attempt closed reduction under conscious sedation or general anesthesia. If we are unable to reduce the angulation to less than 30 degrees, we usually attempt percutaneous or intramedullary reduction.

2) A number of authors have described using a K-wire to joystick the proximal fragment into position percutaneously.

3) When attempting a percutaneous joystick reduction, it is important to avoid injury to the posterior interosseous nerve.

Métaizeau and colleagues described reducing the radial

neck by passing an intramedullary pin in a distal to proximal

Direction.

Radial Head ExcisionThe role of radial head excision is poorly defined. Classically, radial head excision has not been advocated in children because of concern regarding growth disturbance and wrist and elbow deformity.

Complications of radial head and neck fracture.1. Loss of motion may be caused by joint incongruity (malunion),

2. enlargement of the radial head (overgrowth),

3. AVN,

4. fibrous adhesions, or proximal radioulnar synostosis.

Olecranon Fractures

Fractures of the olecranon are relatively uncommon and account for only approximately 5% of elbow fractures.

They are associated with other elbow injuries (usually the medial epicondyle) in 20% to 50% of cases.

Surgical treatment is required for 10% to 20% of olecranon fractures.

Several anatomic factors make olecranon fractures less common and less severe in children than in adults.

First, because the olecranon is predominantly cartilage, particularly in younger children, there is a smaller chance of a fracture occurring with a direct blow to the olecranon.

Second, the thick periosteum and relatively thin metaphyseal cortex of the olecranon predispose it to minimally displaced greenstick fractures

Mechanism of Injury

Olecranon fractures are usually the result of a hyperextension injury. However, they may also be caused by a direct blow to the flexed elbow, hyperflexion injury, or shear force.

A varus hyperextension injury may be associated with lateral dislocation of the radial head, a Bado type III Monteggia lesion.

Metaphyseal Fractures of the Olecranon:

1. Flexion type

2. Extension type

3. Shear injures

a) Flexion shearing

b) Extension shearing

Nonoperative Treatment of Fractures of the Coronoid Process in Fractures of the Proximal Ulna

Operative Treatment of Fractures Involving the Proximal Apophysis and Olecranon Metaphysis inFractures of the Proximal Ulna

Closed Reduction and Percutaneous Pinning

Open Reduction and Tension-Band Fixation

Open Reduction and Compression Screw Fixation

MONTEGGIA FRACTURE-DISLOCATIONS

Monteggia fracture-dislocations are a rare but complex injury usually involving a fracture of the ulna associated with proximal radio-ulnar joint dissociation and radio-capitellar dislocation.

These injuries comprise less than 1% of all pediatric forearm fractures and typically aʃect patients between 4 and 10 years of age.

Classification of Monteggia Fracture-Dislocations

E-story.1814 Giovanni Batista Monteggia, a surgical pathologist and public health official in Milan, Italy

“a traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius.”

1967 Jose Luis Bado, while director of the Orthopedic and Traumatology Institute in Montevideo, Uruguay, classification of Monteggia lesions.

TYPE I

DEFINITION: A type I lesion is an anterior dislocation of the radial head associated with an ulnar diaphyseal fracture at any level. This is the most common Monteggia lesion in children.

ULNAR FRACTURE SITE: metaphysis or diaphysis INJURY MECHNISMS: direct trauma, hyperpronation, and hyperextension

TYPE I

SIGNS AND SYMPTOMS:, swelling about the elbow, significant pain and limted elbow flexion and extention an forearm supination and pronation, mild valgus, ecchymosis on the volar aspect, PIN pulsy, fullness in the cubital fossa

RADIOGRAPHIC EVALUATION: maybe normal on AP despite obviusdisruption on lateral view. Line drawn through the center of the radial neck and head should extend directly through the center of the capitellum, and remain intact regardless of the degree of flexion or extension of the elbow

TREATMENT: An anatomic, stable reduction of the ulnar fracture

Percutaneous intramedullary fixation of complete transverse and short oblique ulna fractures is standard. Open reduction and internal fixation with plate and screws of the rarer long oblique and comminutedfracture is also standard

stable reduction of the radial head dislocation Irreducible or unstable radial head approached surgically usually involves repairing entrapped soft tissues.

This aggressive approach avoids late complications.

A long-arm cast

4 to 6 weeks

forearm in slight supination and the elbow flexed 90 to 110 degrees depending on the degree of swelling.

Radiographs are obtained every 1 to 2 weeks until fracture healing.

TYPE II

DEFINITION: A type II lesion is a posterior dislocation of the radial head associated with an ulnar diaphyseal or metaphyseal fracture. This is the most common lesion in adults but very rare in children

ULNAR FRACTURE SITE: metaphysis or diaphysis

INJURY MECHNISMS: direct force and sudden rotation and supination

CLINICAL FINDINGS: The elbow region is swelling, posterior angulation of the proximal forearm, marked prominence in the area posterolateralto the normal location of the radial head.

RADIOGRAPHIC EVALUATION: The typical finding is a proximal metaphyseal fracture of the ulna with possible extension into the olecranon. Midshaft fractures also occur, with an oblique fracture pattern. The radial head is dislocated posteriorly or posterolaterally and should be carefully examined for other injuries.

Accompanying fractures of the anterior margin of the radial head have been noted.

TREATMENT: Ulnar reduction

longitudinal traction.

Radial head reduction spontaneously or with gentle, anteriorly directed force over the radial head.

If the ulnar fracture is stable cast immobilization with the elbow in extension. If the ulnar fracture is unstable percutaneous intramedullary K-wire

Comminuted or very proximal fractures open reduction and internal fixation with plate and screws or tension band fixation.

The Boyd approach can be used to obtain reduction of the radial head if it cannot be obtained through closed manipulation.

Associated compression fractures of the radial head require early detection to avoid late loss of alignment. Open reduction and internal fixation may be required to maintain radiocapitellar joint stability.

Cast immobilization

usually 6 weeks

Longitudinal traction and pronation of the forearm and immobilization in 60 degrees flexion or complete extension

Type 3DEFINITION: A type III lesion is a lateral dislocation of the radial head associated with an ulnar metaphyseal fracture. This is the second most common pediatric Monteggia lesion.

ULNAR FRACTURE SITE: metaphysis INJURY MECHNISMS: varus stress at the level of the elbow

CLINICAL FINDINGS: Lateral swelling, varus deformity of the elbow, and significant limitation of motion, especially supination, are the hallmarks of lateral (type III) Monteggia fracture-dislocations. Again, these signs can be subtle and missed by harried clinicians.

RADIOGRAPHIC EVALUATION: Radiographs of the entire forearm should be obtained because of the association of distal radial and ulnar fractures with this complex elbow injury

TREATMENT: As with any Monteggia lesion, treatment is aimed at obtaining and maintaining reduction of the radial head, either by open or closed technique. This is usually performed by anatomic, stable reduction of the ulnar fracture that in turn leads to a stable reduction of the proximal radioulnar and radiocapitellar joints.

Immobilization: If radial head dislocated in straight lateral or anterolateral 100 to 110 degree

If there is posterolateral component for dislocation 70 to 80 degree

TYPE IV

DEFINITION: A type IV lesion is an anterior dislocation of the radial head associated with fractures of both the ulna and the radius. The original description was of a radial fracture at the same level or distal to the ulna fracture.

ULNAR FRACTURE SITE: diaphysis

INJURY MECHNISMS: hyperpronation and direct blow

CLINICAL FINDINGS: More swelling and pain are present, Particular attention to the neurovascular status, increased risk for a compartment syndrome.

Failure to recognize the radial head dislocation is the major complication of this fracture.

RADIOGRAPHIC EVALUATION: The radial and ulnar fractures usually are in the middle third, with the radial fracture usually distal to the ulnar injury. They may be complete or greenstick.

TREATMENT: Stabilization of the radial fracture converts a type IV lesion to a type I lesion Closed reduction ,intramedullary or plate fixation fallow type I protocol.

Immobilized in a long-arm cast 4 to 6 weeks in 110 to 120 degrees of flexion with the forearm in neutral rotation.

A short-arm cast is used thereafter if additional fracture protection is necessary.

Reduction schematic for type IV Monteggia fracture

Monteggia Equivalent Lesions

Type I Equivalents

Isolated dislocation of radial head

Radial neck fracture (isolated)

Radial neck fracture in combination with a fracture of the ulnar diaphysis

Radial and ulnar fractures with the radial fracture above the junction of the middle and proximal thirds

Fracture of ulnar diaphysis with anterior dislocation of radial head and an olecranon fracture

Type II Equivalents Fractures of the proximal radial epiphysis or radial neck.

Type III and Type IV Equivalents Fractures of the distal humerus(supracondylar, lateral condylar) in association with proximal forearm fractures.

Thank you every for “patience listening”