Monteggia Fracture Presentation

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Monteggia Fracture:

Monteggia Fracture Aug 11, 2012 Chad Carlson, Maria Milhous, Lana Hall, Pamela Heise, Katelyn Hodges, Abbey McClanahan, Megan Vail, Ben Wood

Monteggia Fracture:

Monteggia Fracture Constituted by: Fracture of the proximal third of the shaft of the ulna Concurrent dislocation of the radial head Monteggia’s fracture. Duke Orthopaedics website. 2012. Available at: http://www.wheelessonline.com/ortho/monteggias_fracture Photo courtesy of: http://images.radiopaedia.org/images/590909/7c4f11abbf1e51e5241eeacdf23dca_gallery.jpeg

Clinical Presentation:

Clinical Presentation Pain and swelling at the elbow Range of motion extremely limited Elbow flexion and forearm supination especially limited and painful Tender to palpation over radial head in an anterior, antero -lateral, or postero -lateral location Weakness or paralysis of extension in the fingers or thumb Deep branch of radial nerve may be injured, as assessed by a positive pinch grip test Sensory involvement is uncommon Perron et al. Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation. American Journal of Emergency Medicine. 2001; 19: 225-228

Bado System of Classification:

Bado System of Classification Type I: anterior dislocation of the radial head Type II: posterior dislocation of the radial head Type III: lateral dislocation of the radial head Type IV: anterior dislocation of the radial head with fractures of the radius and ulna at the same level Monteggia fractures. British Medical Journal. 1981; 282: 1994

Type I:

Type I Most common in children Typically results from direct trauma Blow to posterior elbow or pronation on an outstretched arm Fracture occurs at the proximal or middle third of the ulna with anterior dislocation of the radial head (anterior apex) Represents 59% of all incidences of Monteggia fractures

PowerPoint Presentation:

Photo courtesy of: http://radiographics.rsna.org/content/20/3/819/F2.large.jpg

Type II:

Type II Most common in adults Typically results from an axial load being placed on a partially flexed elbow Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (apex posterior) Only 5% of Monteggia fractures

PowerPoint Presentation:

Photo courtesy of: http://radiographics.rsna.org/content/20/3/819/F3.large.jpg

Type III:

Type III Varus stress on extended elbow More common in children Represents 26% of all Monteggia fractures Fracture of the ulna distal to the coronoid process with lateral dislocation of the radial head

PowerPoint Presentation:

Photo courtesy of: http://radiographics.rsna.org/content/20/3/819/F4.large.jpg

Type IV:

Type IV Mechanism of injury poorly understood Thought to be similar to that of type I Rarest type (1%) Fracture of the proximal third of the radius with anterior dislocation of the radial head Perron et al. Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation. American Journal of Emergency Medicine. 2001; 19: 225-228

PowerPoint Presentation:

Photo courtesy of: http://radiographics.rsna.org/content/20/3/819/F5.large.jpg

Monteggia in Children:

Monteggia in Children Pediatric presentation is very unique Characteristics include: Plastic deformation Associated with anterior radial head dislocation (31%) Poor recognition can lead to recurrent dislocation Incomplete fracture (i.e. greenstick fracture) Complete transverse or short oblique fracture Comminuted or long oblique fracture Putigna F et al. Monteggia Fracture. Medscape Reference website. 2010. http://emedicine.medscape.com/article/1231438-overview#a0101. Accessed August 8, 2012.

Role of Imaging in Diagnosis:

Role of Imaging in Diagnosis The fracture of the proximal ulna often goes undetected by physical examinations and radiographs because the anteriorly dislocated radius is more obvious 11 Radiographs locate the fracture, determine the extent of damage, and aide with classification 11

Best Type of Imaging and Views :

Best Type of Imaging and Views Monteggia fractures are usually confirmed with radiograph AP, lateral, and oblique views of a fully extended and supinated forearm if possible 1,13 Internal oblique view is best to view the coronoid process 11 When dislocations about the elbow are discovered, wrist and hand radiographs should ensue to rule out further damage 11

Best Type of Imaging and Views:

Best Type of Imaging and Views Computed Tomography (CT) is rarely employed 3-Dimensional CT is well apt to view heterotopic bone deposits 14 Magnetic resonance imaging (MRI) is sometimes used for children with Epiphyseal plates that are still growing 1,13

Goals of Therapy Following Immobilization/Reduction13:

Goals of Therapy Following Immobilization/Reduction 13 Both children and adults are often referred to physical therapy following immobilization in order to: Prevent stiffness Minimize loss of forearm supination/pronation Restore flexion/extension of the wrist and elbow

PT applying imaging following immobilization :

PT applying imaging following immobilization Indicates which joints are involved, especially at wrist and elbow Indicates site of ulnar fracture and direction of radial head dislocation Indicates if complications are present and helps to identify prognosis 11

Role of Imaging in Diagnosis:

Role of Imaging in Diagnosis Nerve damage is a common complication. Imaging helps confirm suspected nerve involvement. Identifies/confirms which muscle groups may be causing the patient problems and how to individualize treatment Physical therapy can decrease the likelihood of nerve complications, notably from the posterior interosseous nerve, by promoting early mobilization and nerve gliding 13

What Imaging Does Not Detect15:

What Imaging Does Not Detect 15 Undetected/untreated ulnar fractures often result in non unions Any mal-unions or non unions of the ulna in Monteggia Fractures can cause: Decreased stability Decreased ranges of motion Pain and discomfort Indicating the use of PT Motion is able to be restored through therapy

“Pre-hab” Before the Cast Comes Off:

“Pre- hab ” Before the Cast Comes Off Soft tissue damage/atrophy can be identified via imaging A weak elbow can inappropriately transmit forces up and down the kinetic chain. Therefore, core, shoulder, forearm, and wrist musculature should also be strengthened before elbow surgery, if possible. M ore proximal muscles, especially those surrounding the GH joint, are often strained 16

ABCs Search Pattern: Alignment:

ABCs Search Pattern: Alignment Image source: http://emedicine.medscape.com/article/1231438-overview

PowerPoint Presentation:

Alignment : General Architechture : Size and appearance: The size of the bone appears normal, with no abnormalities present(other than the obvious ulnar fracture and the proximal radial head dislocation). General Contours: Cortical outlines: The cortical outlines of the bones are clear, with no abnormalities. Alignment of adjacent bones: Bone and joint positions: There is a dislocation apparent at the proximal radial head. The proximal one-third of the ulna is fractured and anteriorly displaced. There is an ossification center that may be mistaken for an extra- articular fracture of the olecranon process that could show up on x-rays in patients 9 year old or younger.

ABCs Search Pattern: Bone Density:

ABCs Search Pattern: Bone Density

PowerPoint Presentation:

Bone Density : General Density: Contrast bone to soft tissue and within bones: The bones appear to have normal general densities. There appears to be density changes at the distal humerus that may indicate a crush fracture of the condyle . Textural Abnormalities: Trabeculae appearance: The trabeculae seem to have normal pattern, and appearance. The thickness of trabeculae goes from the middle shaft, distal, which appears normal as well. Local Density: Defined areas(sclerosis): There are no areas of sclerosis apparent in the radiograph.

ABCs Search Pattern: Cartilage:

ABCs Search Pattern: Cartilage

PowerPoint Presentation:

Cartilage : Joint Space- Articular and hyaline cartilage: There are signs of disturbance in the cartilage at humeral attachment sites of the radius. The radius is dislocated and trauma is apparent in the ulno -humeral joint. There seems to be some signs anterior to the ulna and humerus articulation illustrating a darker shade. This shows signs of inflammation at the joint. Subchondral Bone- bone along joint surface: The joint surface is in tact at the distal humerus, but there is a crush fracture of the condyle that can be visualized in the image. Epiphyseal Plates- Size and position: Growth plates are seen and seem normal in size for a child.

ABCs Search Pattern: Soft Tissue:

ABCs Search Pattern: Soft Tissue

PowerPoint Presentation:

Soft Tissues : Muscles- Size and Shape: Muscles cannot be seen well in this radiograph, but there is apparent swelling of the forearm. Fat Pads- Displacement: The fat pads are not seen in this radiograph. Joint Capsules- Distension: The radial joint capsule has been disturbed from the dislocation and cannot be visualized in this image. As provided above, there are some signs of swelling in the ulno -humeral joint anteriorly . Periosteum- Reaction: The fracture of the ulna is displaced enough to have disturbed the periosteum of the bone. Miscellaneous- Calcifications & foreign bodies NA

Biomechanical and Physical Impairments:

Biomechanical and Physical Impairments

PowerPoint Presentation:

Biomechanical and physical impairments : Some nerves and arteries that can be damaged in Monteggia fractures and cause long-term damage or even loss of the extremity. Fracture/dislocations can be misdiagnosed and not detected in the clinic. Instability in the radialulnar and radialhumeral joints can become an chronic issue. If the nerves are injured, motor and sensory loss distal to the injury may ensue. If there is an avulsion of the olecranon it will need to be fixed to the bone to assist stabilization of the joint. This is a site for many tendon and ligament attachments that extend and stabilize the joint(triceps, anconeus , ulnar collateral ligament).

Ultrasound:

Ultrasound Image source: http://openi.nlm.nih.gov/

PowerPoint Presentation:

This Ultrasound shows radial head malalignment in a patient who sustained a Monteggia fracture as a child. The patient is now in her 40’s and has a palsy of the posterior interosseus nerve suspected to be due to compression from repeated supination/pronation . The malalignment of the radius led to increased stress on the interosseus membrane and the nerve associated with it. This is one of the many issues that can arise from an untreated radial head dislocation that often occurs with Monteggia fractures. The arrows indicate the dislocated radial head and swelling associated with the injury. The radiograph represents, from top to bottom, the lateral to medial views of the tissue at the radial articulation at the humerus . The lateral dislocation of the radial head can be visualized with associated swelling. The tendons are also visualized, running lateral over the radius to the proximal attachment site on the lateral epicondyle of the humerus .

References:

References 1. http://www.wheelessonline.com/ortho/monteggias_fracture 2. ttp://images.radiopaedia.org/images/590909/7c4f11abbf1e51e5241eeacdf23dca_gallery.jpeg 3. Perron et al. Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation. American Journal of Emergency Medicine. 2001; 19: 225-228 4. Monteggia fractures. British Medical Journal. 1981; 282: 1994 5. http://radiographics.rsna.org/content/20/3/819/F2.large.jpg 6. http://radiographics.rsna.org/content/20/3/819/F3.large.jpg 7. http://radiographics.rsna.org/content/20/3/819/F4.large.jpg 8. http://radiographics.rsna.org/content/20/3/819/F5.large.jpg 9. Putigna F et al. Monteggia Fracture. Medscape Reference website. 2010 10. http://emedicine.medscape.com/article/1231438-overview#a0101. Accessed August 8, 2012. 11. McKinnis LN. Fundamentals of Musculoskeletal Imaging. Philidelphia , PA: FA Davis Co, 2010 12. http://www.ortho.hyperguides.com/multimedia/lectureContent.asp?rID=5619 13. www.ncbi.nlm.nih.gov/pubmed/22300997 14. Casavant et al. Heterotopic ossification about the elbow: a therapist’s guide to evaluation and management. Journal of Hand Therapy. 2006; 19: 255-266 15. Papagelopoulos P, Morrey B. Treatment of nonunion of olecranon fractures. Journal of Bone and Joint Surgery-British Volume . 1994; 76 (4): 627 16. Broady L, Hall, C. Therapeutic Exercise: Moving toward function. Lippincott Williams and Wilkins; 3 rd edition, 2010; 723. 17. http://emedicine.medscape.com/article/1231438-overview 18. Image source: http://openi.nlm.nih.gov/

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