Executive Editor: James Hunter General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric proximal forearm 21u-M/6.1 Monteggia lesion

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Glossary

General considerations

Congruent and stable reduction of radiocapitellar joint dislocation requires correction of angulation and restoration of length of any ulnar fracture distal to the coronoid.

If this is not achieved, the radial head can remain dislocated and if reduced can redislocate or sublux.

This may lead to permanent loss of forearm function and operative treatment is recommended.

Overcorrection of the ulna may be necessary to stabilize the radial head. An osteotomy should be considered in the presence an incomplete fracture or established deformity.

Treatment of Monteggia lesions with more distal ulnar fractures is discussed in the forearm shaft section of Pediatric Surgery Reference.

Closed reduction; cast immobilization
Main indication Skill Equipment
Young child, fracture manipulation leading to stable ulnar fracture and reduced and stable radiocapitellar joint possible Some specialized surgical experience Basic equipment only

A well-molded cast is recommended to ensure maintenance of satisfactory ulnar reduction with stable and congruent radiocapitellar joint reduction.

Early radiological follow-up is necessary to check radial head position. If there is any doubt about reduction, operative treatment of the ulna is recommended.

Reduction of bowing and greenstick injuries of the ulna, whilst simultaneously maintaining stable reduction of the radial head is difficult to achieve.

Contraindications

  • Radial head not perfectly reduced

Advantages

  • No requirement for implant removal

Disadvantages

  • Unstable radiocapitellar joint reduction
  • High risk of displacement requiring surgical treatment
ESIN
Main indication Skill Equipment
Any unstable or displaced fracture Some specialized surgical experience Simple surgical and imaging resources

If elastic nails are not available, the ESIN method can be performed with long stainless-steel K-wires.

If closed reduction is not possible, an open reduction may be necessary.

This treatment can be performed if image intensifier is not available with fracture reduction under direct vision.

Advantages

  • Cast-free rehabilitation
  • Minimally invasive treatment
  • Good alignment of fracture fragments
  • Predictably good functional outcome
  • Sufficient radial head stability

Disadvantages

  • Image intensifier recommended
  • Risk of nerve or tendon injury at entry point
  • Risk of infection
  • General anesthesia required
  • Second anesthetic required for implant removal
Open reduction; plate fixation
Main indication Skill Equipment
Insufficient stability to hold radial head reduced, unstable injury in adolescents and young adults Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Advantages

  • Cast-free rehabilitation
  • Anatomical reduction of joint (may require overcorrection of the ulna)
  • Absolute stability

Disadvantages

  • Risk of infection
  • Neurovascular injury
  • General anesthesia required
  • Second anesthetic required for implant removal
  • Scar(s)
  • Bulk of implant
  • Demanding technique
  • Image intensifier or arthrotomy necessary for radiocapitellar joint visualization
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2019-08-28