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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1 General considerations top

Open reduction; plate fixation (ulna) - Plating the ulna and ESIN of the radial head enlarge


Plating is the standard technique for treating forearm fractures in adults and is also appropriate for children approaching skeletal maturity.

Children with open physes have thick active periosteum favoring stability and rapid healing with ESIN techniques. In more proximal ulnar fractures plating may be used in younger children.

Combination with other treatment options

Plating the ulna may be combined with ESIN of the proximal radial fracture.

This allows for stable anatomical restoration of the forearm axis and early motion.

K-wire fixation of the radial fracture may be performed but is not recommended. This provides less stability and requires additional immobilization.

2 Order of reduction and fixation top

Open reduction; plate fixation (ulna) - Order of reduction and fixation enlarge

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 be fixed with an intramedullary nail to prevent redisplacement and to allow early joint mobilization.

3 Patient preparation top

Patient preparation enlarge

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

4 Choice of approach top

Open reduction; plate fixation (ulna) - Approaches to the ulna enlarge

The ulna is exposed through a posterior approach.

An alternative is the posterolateral approach, which provides access to both the proximal ulna and the radial head. A disadvantage of this approach is the potential for cross-union.

Open reduction; plate fixation (ulna) - Approaches to the ulna enlarge

If there is residual displacement of the radial neck fracture after optimization of the ulnar correction, a closed reduction using ESIN or an open reduction should be performed.

Open reduction may also be necessary if an image intensifier is not available or if soft-tissue structures are trapped between the fragments.

A lateral approach centered on the epicondyle may be used to visualize the radial neck fracture.

5 Reduction and fixation of the ulna top

Open reduction; plate fixation of the ulna enlarge

The proximal ulnar fracture should be reduced and stabilized anatomically. The type of plate fixation depends on the fracture pattern.

Ensure that the ulna is out to length and rotationally aligned. With Monteggia equivalents an overreduction of the ulna is not required.

6 Reduction and fixation of radial head/neck top

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).

ESIN of the radial neck enlarge

ESIN procedure

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.

7 Final assessment top

Open reduction; plate fixation (ulna) - 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 plate is at the correct location, the screws and the nail are of appropriate length and the desired reduction has been achieved.

Open reduction; plate fixation (ulna) - Checking forearm rotation enlarge

Check the forearm rotation.

v1.0 2019-08-28