Introduction:
A Monteggia fracture is a particular kind of forearm fracture that affects the ulna bone and is frequently accompanied by a radial head dislocation. The Italian surgeon Giovanni Battista Monteggia, who initially documented this fracture in the early 19th century, is honored with the name of this fracture. The ulna bone, the largest bone in the forearm, is commonly broken in the proximal (near the elbow) or middle third of the bone in a Monteggia fracture. The fracture may have a straightforward pattern or a more intricate one.
What Is Montegia Fracture and Its Types?
A Monteggia fracture consists of an ulna fracture together with radiocapitellar dislocation and disruption of the proximal radio-ulnar joint (PRUJ). A fall onto an outstretched hand or a direct hit to the forearm are common causes of Monteggia fractures. Ulna fracture and radial head dislocation can both result from the force being applied to the forearm.
Based on the precise position and pattern of the ulna fracture, there are various forms of Monteggia fractures.
-
Type I: Ulnar shaft fracture with anterior radial head dislocation.
-
Type II: Anterior dislocation of the radial head along with an ulnar metaphysis (proximal portion) fracture.
-
Type III: Ulnar neck fracture with lateral (posterolateral) radial head dislocation.
-
Type IV: Ulnar metaphysis fracture with posterior radial head dislocation.
What Is Monteggia Fracture in Children?
Since children's bones are still growing and developing, pediatric patients, usually those under the age of 16 or 18, are more likely to experience pediatric Monteggia fractures than adults. A Monteggia fracture in children involves a fracture of the ulna bone in the forearm, just like in adults, and is frequently accompanied by a radial head dislocation. Children of all ages can develop Monteggia fractures, but older kids and teenagers tend to have them more frequently. The suggested course of treatment may vary depending on the child's age because younger children may have a greater capacity for bone remodeling and repair.
The existence of growth plates in children's bones is one important distinction between pediatric and adult fractures. Growth plates are articular regions near the ends of bones that permit bone extension and growth. In order to prevent any disturbance in bone growth in children with Monteggia fractures, the integrity of the growth plates must be carefully evaluated and taken into account throughout therapy.
The Bado classification method, which divides Monteggia fractures into four kinds depending on the position and pattern of the ulna fracture and radial head dislocation, can still be used to classify Monteggia fractures in children. The treatment plan may be influenced by the particular type of fracture. Four basic categories of Monteggia fractures are recognized by the Bado classification system:
-
Type I: In a Type I Monteggia fracture, the ulnar shaft, the bigger forearm bone, is broken, and the radial head, the forearm's smaller bone, is dislocated anteriorly (forward). The most typical Monteggia fracture in both children and adults is this one.
-
Type II: An anterior dislocation of the radial head and a fracture of the ulnar metaphysis (the proximal section of the ulna) characterize a Type II Monteggia fracture. Children frequently experience this fracture, which typically occurs at the metaphyseal-diaphyseal intersection.
-
Type III: In a Type III Monteggia fracture, the ulnar neck—the portion of the ulna close to the elbow joint—is broken, and the radial head is laterally (posterolaterally) dislocated. Children are also more likely to sustain type III fractures.
-
Type IV: Type IV Monteggia fractures are uncommon and involve an ulnar metaphysis fracture that is comparable to a Type II fracture but also involves a posterior dislocation of the radial head. The least prevalent of the four is this variety.
How Is Monteggia Fracture Managed in Children?
The presence of growth plates in children's bones adds specific considerations to the treatment of Monteggia fractures, which necessitates a thorough evaluation by a pediatric orthopedic specialist. The type and severity of the Monteggia fracture, the child's age and size, and the health of the growth plates will all affect the precise course of treatment. The general guidelines for treatment are as follows:
-
Initial Evaluation: A thorough assessment by a healthcare expert, including a clinical examination and imaging tests like X-rays, is the first step. The objective is to identify the kind and degree of the Monteggia fracture precisely and to evaluate the health of the growth plates in the involved bones.
-
Closed Reduction: A closed reduction may be tried in some circumstances, particularly when the fracture is not substantially displaced, and the radial head is not locked in a dislocated position. By manipulating the bones, the correct alignment of the bones can be restored without surgery. To ensure that the youngster is at ease throughout this surgery, sedation or anesthesia may be administered.
-
Surgery: The majority of Monteggia fractures in children require surgical intervention, particularly when the fracture is displaced or when there is a locked dislocation of the radial head. The type of fracture and the child's particular anatomy will determine the precise surgical approach. Surgical options could consist of:
-
Open Reduction: The procedure known as "Open Reduction and Internal Fixation" (ORIF) involves the surgeon making an incision to get access to the fracture site, realigning the ulna, and maybe using plates, screws, or other fixation devices to stabilize the broken bone pieces. During the treatment, the surgeon will also address the dislocation of the radial head.
-
Radial Head Reduction: In cases where the radial head has been dislocated, the surgeon may need to decrease it and maybe stabilize it with pins or screws to keep it from moving around while the patient heals.
-
Growth Plate Protection: In order to avoid affecting a child's ability to grow, it is essential to safeguard the growth plates in the child's bones during surgery. When organizing and carrying out the procedure, the surgeon will take the growth plates very careful consideration.
Conclusion:
Preventing a neglected Monteggia injury is the best course of action. The primary choice should be ulna angulation and elongation osteotomies at the proximal third. Reconstruction of the annular ligament and transcapitellar fixation is not advised if stable reduction of the radial head is attained following ulnar osteotomy. Open reduction and joint debridement are recommended if the radial head reduction is impossible or unstable. A progressive reduction of the radial head and lengthening of the ulna using an external fixator (unilateral or circular) may be taken into consideration for patients with long-lasting dislocation and overgrowth of the radius rather than a shortening osteotomy of the radius.
