Monteggia Fracture

Original Editor - Edwina D Souza

Top Contributors - Edwina D Souza and Kirenga Bamurange Liliane  

Introduction

A Monteggia fracture is defined as a one-third fracture of the ulna with radial head dislocation. The term is named after Giovanni Battista Monteggia Who described it in 1814. The forearm is the vital structure of the body. forearm fractures can lead to significant short-term and long-term disability. The technical advances help to identify these fractures easily and have helped to better define, classify and guide in conservative, operative management and also in rehabilitation .

Anatomy

The forearm consists of a radius and ulna forming two radioulnar joints. Proximally, the radius connects the Capitulum of the humerus and radial the notch of the ulna below. This articulation is called the proximal radioulnar joint. The distal radius is articulated with a scaphoid at its lateral part and medially it connects with the lunate. The ulna proximally connects with the trochlea of the humerus and distally it is articulated with the ulna notch of the radius and with the triangular articulate disc in the wrist. the interosseous membrane connects both bones and it is responsible for distributing axial load force to the forearm.

Mechanism of injury

The most common cause of Monteggia fracture is falling on the outstretched arm with a hyper-pronated forearm. The injury can also result from a direct blow to the forearm with the elbow extended and the forearm in hyper pronation. Fall from height, contact sports injuries motorcycle accidents, and osteoporosis are some of the most common causes of this fracture

Classification

Jose Louis Bado reviewed Monteggia's original fracture dislocation and further classified it into 4 types. This defines a set of traumatic injuries having in common a Monteggia fracture with the dislocation of the radial head either in anterior, posterior or lateral directions.

Type I:Anterior radial head dislocation and fracture of ulna diaphysis with anterior angulation.

Type II: Posterior or posterolateral radial head dislocation and fracture of ulna diaphysis with posterior angulation.

Type III: lateral or anterolateral radial head dislocation and fracture of ulna metaphysis.

Type IV: Anterior radial head dislocation and fracture of proximal third of ulna and radius.

Examination and Evaluation

The patients usually come with complaints of pain and swelling at the fracture site. An examination starts with the visual inspection of the skin, soft tissue, visible bony deformity, skin lacerations, muscle contusion and neurovascular damage. Gentle palpation can be done to identify the tenderness around the fracture site. Radio graphs are advised. Anteroposterior and lateral views will help to identify the type of fracture. Along with this An x-ray of the distal radioulnar joint and wrist also should be taken to rule out other fractures and injuries

Complications

• Nerve injuries, Particularly the radial nerve and posterior interosseous nerve are the most commonly injured nerves.
• Ulna Non-union and malunion might occur in conservative as well as operative management through postoperative complications is rare according to a retrospective study of 112 patients
• Most complications arise from a missed diagnosis or delayed treatment of a Monteggia fracture. Untreated or missed diagnosed radial head dislocations over 2-3 weeks might require a more challenging and invasive surgical approach associated with a higher risk of complications which include recurrent radial head dislocations, persistent subluxations and loss of normal elbow range of motion and function.
• Other complications include myositis ossificans, glenohumeral osteoarthritis, compartment syndrome, elbow stiffness and wound infection.

Management

Monteggia fractures need immediate medical attention. orthopaedic consultation is necessary for the diagnosis, and treatment and to rule out any neurological deficit. The initial management includes RICE protocol that is rest, icing, immobilisation and elevation. Most of the time the fracture can be treated with a closed reduction based on the severity, and extent of the fracture. The open fractures, comminuted fractures and long oblique fractures need surgical intervention open reduction and internal fixation with screws and plates. In most cases, a single compression plate is placed with six cortical screws anchored proximally and distally. For a complete fracture with stable length, transverse and short oblique fractures the intramedullary pin fixation can be done and for incomplete fracture with stable length and green stick ulna fracture closed reduction is done. The radial head dislocation can be reduced once the ulna fracture is realigned.

The recovery is based on various factors. The type of Fracture, the severity of the injury treatment approach and the individual's health status vary the length of recovery. Usually, it might take up to 6 weeks for the fracture to heal. Patients can start the mobilise their forearm 2 -3 weeks post-surgery. For conservatively managed fractures rehabilitation should be done once the cast is removed.

Physiotherapy Management

The Rehabilitation begins as soon as the cast is removed for conservative management and 2-3 weeks post-surgically. The goal of rehabilitation is to gain the full range of motion of the joint and fine motor skills with no pain. The return to activity depends on the extent of the injury and the associated factors. Athletes and manual workers might require prolonged rehabilitation. Total return to activity in patients with low physical demands can occur after 8-12 weeks. Patients with high physical demands like athletes and manual workers might require more time to return to their specific field.

The joint is more prone to stiffness after a long period of immobilization. Hence exercises should be started. The exercise aims to gain the range of motion of the joint and to improve the muscle strength of the elbow and forearm.

• Elbow flexion and Extension
• Forearm pronation and supination
• Wrist flexion and extension
• Wrist circumduction
• Shoulder elevation
• Grip strengthening exercises
• Elbow strengthening exercises
• Forearm strengthening exercises

Outcome measures

• Visual analogue scale to evaluate pain
• The Disability oArmm, Shoulder and Hand questionnaire disabilityquestionnaireDisability (DASH)
• Goniometer to assess the range of motion of the elbow and forearm
• Grip straight can be used as an outcome measure to assess the daily functional activities and it can be measured with a dynamo meter.
  • Grip Strength is an important outcome measure because it is an important function in daily activities, it can be measured with a dynamometer. A hand-held dynamometer or Jamar hydraulic hand dynamometer can be used.
• The Michigan Hand Outcomes Questionnaire (MHQ) is a hand-specific outcome instrument divided into six scales:
  1. overall hand function
  2. activities of daily living
  3. pain
  4. work performance
  5. aesthetics
  6. patient satisfaction with hand function