Monteggia Fracture

Definition

This is an arm fracture in which the joint with the radial head at your elbow becomes dislocated and the ulna, one of the bones in your forearm is broken. When a person has this type of fracture it is normally very evident because it causes extreme pain. Your range of motion will also be limited. It is named after Giovanni Battista Monteggia. He is the one who described this fracture in the early 1800’s. It is rare for an adult to have a Monteggia fracture but is most common in children between the ages of four and ten.

Relevant anatomy

The radial head is a bone that makes up part of your elbow. Your ulna is a bone in your forearm that is broader near your elbow and tapers as it approaches your wrist. It is on the pinky-finger side of your arm near the radius bone, which is the lateral bone of your forearm between your elbow and hand. The radius bone is always aligned with your thumb.

Pictures : How Monteggia Fracture Looks like?

Classification

There are four classifications of a Monteggia fracture. What classification they fall into depends on the displacement of the radial head. They are referred to as Bado classifications.

• Type 1 — fracture of the middle third of your ulna with the anterior, or front, dislocation of your radial head. This accounts for approximately sixty percent of these types of fractures and is referred to as an extension type. This is most common in adults and children.
• Type 2 — fracture of your middle third of your ulna with posterior, or back, dislocation of your radial head. This accounts for approximately fifteen percent of fractures and is referred to as a flexion type. This is more commonly seen in adults.
• Type 3 — fracture of the wide portion of your ulna, referred to as the metaphysis with the lateral, or the side, dislocation of your radial head. This accounts for approximately twenty percent of these fractures and are referred to as a lateral type.
• Type 4 — fracture of the middle third of your ulna and radius with the anterior, or front, dislocation of your radial head. This accounts for approximately five percent of these fractures and is referred to as a combined type.

Symptoms

• The only general symptoms of having a Monteggia fracture are swelling and pain at the elbow joint
• You may also have pain in your arm that gets worse every time you move your elbow or wrist
• When looking at it you may or may not see any obvious dislocation but you may notice that there may be loss of range of motion at the elbow because of the dislocation
• You may also have swelling in your hand, wrist, and forearm
• Forearm tenderness
• Numbness

Causes

A Monteggia fracture can be caused by:

• A blow to the back of your upper forearm
• Hyperextension, which is when you move your tendons, muscles, or joints beyond the normal range of motion
• Falling on an outstretched hand to break your fall. This is referred to as a hyperpronation injury.

Diagnosis

To diagnosis a Monteggia fracture the radiographer will use an x-ray machine to visualize the joints and bones in your arm. They will take several angles so they can tell the full extent of your injury.

Treatment

Although the exact treatment used depends on how severe the fracture is the conservative treatment for a Monteggia fracture is to cast it in order to immobilize the arm so the joint and the ulna have a chance to heal. After your arm has been in a cast for several weeks your physician will order more x-rays to confirm that the healing is even and the bones are knitting together. If they have pulled out of position or not healing the cast will be remove to correct the situation. Unless the fracture appears problematic casting is often sufficient for younger patients. Many times the Monteggia fracture will have to be treated using surgery. How long a cast will stay on depends on the classification of the fracture.

• Type 1 — three weeks in a cast above your elbow and then another three weeks with a cast on the area below your elbow. This type rarely requires surgery.
• Type 2 — three weeks in a cast
• Type 3 — four weeks in a long arm cast
• Type 4 — three to four weeks for the lower part of your arm past your elbow and three week for the area above your elbow

The casting is done by an orthopedic physician who is trained in the branch of medicine that deals with your musculoskeletal system.

Other treatments can include:

• Resting your arm by elevating it higher than your heart
• Cold compresses but you have to be careful not to get the cast wet. Put the ice pack into a plastic bag and wrap in a towel before you put it on the cast so the cast will not get wet
• Use a shoulder sling
• Taking either a prescription medication or over-the –counter medication for the pain.

Surgery

If the Monteggia fracture is severe you may need to have surgery. The surgery is done to pin the fractured ulna and to stabilize the joint if necessary. This type of surgery is referred to as open reduction internal fixation. The surgery is done by an orthopedic surgeon, who is a surgical specialist that has received special training working with injuries to the bone, especially this type of fracture. Because it is a very complex surgery you may need several surgeries to correct a Monteggia fracture. After the surgery is finished a cast will normally be applied to give it stability during healing. Depending on the patient, healing time can take six weeks or longer. For children who have a type four classification they may use intramedullary wires or plate fixation to stabilize the fracture.

Complications after surgery

After surgery there could be complications or long range problems such as:

• Nerve palsy and damage
• Muscle damage
• Tendonitis
• Infection
• Arthritis
• Loss of range of motion and stiffness
• Audible snapping or popping
• Compartment syndrome, which is an increase in pressure in one of your body’s compartments that contains nerves and muscles.
• Deformity
• Chronic pain that is associated with surgical hardware like the plates, pins, and screws

Problems if not healing correctly

If the fracture does not heal correctly you could have one arm that is shorter than the other arm. It can also predispose you to another fracture. A big risk with an open fracture, which means that your skin has been damaged during the injury or the bone has broken through your skin, is necrosis. This is when the tissue and bone die because they are not being supplied with blood or there is an infection.

Management

A Monteggia fracture is often managed with resetting and casting in children. After having surgery there will be a restriction on range of motion on the elbow but that is normally lifted after three months. In three months after the cast is removed the orthopedic physician or surgeon will have you start rehabilitation. Rehabilitation is necessary in order for your muscles to become stronger.