Davos Courses

Executive Editor: James Hunter General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric proximal forearm 21r-E/M, 21u-M Monteggia equivalent

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Glossary

1 General considerations top

The ESIN method involves closed reduction and internal fixation with an elastic nail. enlarge

Most ulnar fractures are in the proximal 1/3 and retrograde nailing of both bones is therefore recommended.

The ESIN method involves closed reduction and internal fixation of both fractures with elastic nails or K-wires.

It can be used in any age group and any combination of fracture types.

Note: The risk of avascular necrosis of the radial head is higher after open reduction, which should be avoided if possible.

2 Patient preparation top

Patient preparation enlarge

This procedure is normally performed with the patient in a supine position.

3 Entry points top

ESIN - Entry point to the ulna enlarge

Entry point to the ulna

In the ulna use the distal medial entry point.


ESIN - Entry points to the radius enlarge

Entry points to the radius

The distal lateral entry point is in common use and shown in this example.

The dorsal entry point ((Lister’s tubercle)) is also well established and offers more versatile nail manipulation.

Find more details in ESIN entry points (radius).

4 Reduction and fixation top

ESIN (Monteggia equivalent) - Order of reduction and fixation enlarge

Order of reduction and fixation

The ulnar fracture (1) is treated first.

The radial neck fracture (2) may spontaneously reduce after anatomical reduction and fixation of the ulna.

The radial neck fracture should also be fixed with an intramedullary nail to prevent redisplacement and to allow early joint mobilization.


ESIN of the ulna enlarge

Reduction and fixation of the ulna

The steps for ulnar fracture fixation are described in the ESIN procedure (retrograde nail insertion).


ESIN of the radial neck enlarge

Reduction and fixation of radial head/neck

The steps required for proximal radial fracture fixation are described in the ESIN procedure, illustrated with a 21r-E/1.1 fracture.

This technique is also appropriate for reduction and fixation of other proximal radial fracture types.


ESIN of the radial neck – Open reduction enlarge

If an open reduction of the radial neck fracture is necessary a lateral approach to the proximal radius may be used.

5 Final assessment top

ESIN (Monteggia equivalent) - Final radiological assessment enlarge

Check the completed osteosynthesis with image intensification. These images should be retained for documentation.

If an image intensifier is not available an x-ray should be obtained before discharge.

Make sure that the desired reduction has been achieved and the nails are of appropriate length.

v1.0 2019-08-19