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Monteggia Fractures in Children

- See: Monteggia Fractures in Adults

- Discussion:
    - all four types of Monteggia frx dislocation are pertinent to children, including Monteggia equivalents;
    - diff dx: Monteggia equivalent (w/ fracture of proximal radius rather than dislocation of the radial head);

- Classification:
    - type I:
          - anterior dislocation of the radial head w/ apex anterior angulation of the ulnar frx;
          - is most common type of this frx;
    - type II frx:
          - posterior dislocation of the radial head w/ posterior angulation of the ulnar frx; 
          - ref: Pediatric posterior monteggia lesion: a greenstick fracture of the proximal ulnar metaphysis with radial neck fracture. A case report.
    - type III:
          - lateral dislocation of radial head w/ ulnar metaphyseal fracture, usually a greenstick type of frx;
          - commonly assoc w/ radial nerve injuries & is 2nd most common type of Monteggia frx (approx 1/4 of lesions);
          - frx of ulna may be complete or incomplete (greenstick frx), w/ bowing of ulna due to plastic deformation;
          - occasionally there is persistent ulnar bowing, occurring most often w/ type III lesions;
                - this can produce subluxation of radial head w/ subsequent pain;
          - ref: Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children.  
    - type IV:
          - anterior radial head dislocation and fractures of both the proximal radius and ulna;

- Radiographs: (radiology of pediatric elbow)
    - radial head does not ossify until age 4;
    - ultrasound or MRI may be helpful with the diagnosis;
    - be sure that radiographs include the distal radius, since upto 24% of these injuries may be associated with distal frx;
    - also remember that the "isolated" ulnar green stick frx may actually represent a Monteggia equivalent lesion in which there has
            been spontaneous reduction of the radial head;

- Treatment:
     - in contrast to adults, most of these injuries are treated closed;
     - reduction of the radial head, however, must be confirmed;
     - for type I, III, and IV Monteggia injuries, immobilize elbow in 100 deg of flexion w/ forearm fully supinated for 6 weeks;
     - for type II injuries, immobilize w/ elbow extended for four weeks;
     - inability to achieve reduction;
           - improper position of elbow ( < 110 deg of flexion)
           - infolded annular ligament;
           - radial head buttonholed thru capsule;
     - open reduction is indicated if it is necessary to reduce radial head;
     - if reduction of radial head is not maintained, IM fixation of ulna frx; 
     - post op:
            - forearm immobilized within a cast with full supination and 110º of elbow flexion for 6 weeks.   
            - position relaxes biceps and tenses the interosseous membrane, and both stabilizes the reduction.
     - references:
             - Pediatric Monteggia Fractures: A Single-Center Study of the Management of 40 Patients 

- Complications:
    - misdiagnosis:
           - chronic radial head dislocation;
                 - consider the Bell Tawse procedure (slip of triceps fascia is used to reconstruct the annular ligament); 
           - references:
                 - Missed Pediatric Monteggia Fractures
                 - The treatment of malunited anterior Monteggia fractures in children
                 - Long-term outcome after ulnar osteotomy for missed Monteggia fracture dislocation in children.
                 - Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children
                 - Missed radial head dislocations associated with ulnar deformation: treatment by open reduction and ulnar osteotomy
                 - Treatment of the missed Monteggia fracture in the child.
                 - Open Reduction and Annular Ligament Reconstruction With Fascia of the Forearm in Chronic Monteggia Lesions
                 - Open Reduction and Annular Ligament Reconstruction With fascia of the Forearm in Chronic Monteggia Lesions in Children.
                 - Angular remodeling of midshaft forearm fractures in children.

Pediatric monteggia fractures: a multicenter examination of treatment strategy and early clinical and radiographic results.

The Monteggia lesion

Acute Monteggia lesions in children.

Treatment of the missed Monteggia fracture in the child.

Monteggia fracture-dislocations in children.

Forearm fractures in children. Cast treatment with the elbow extended.

Monteggia-type elbow fractures in childhood.

Fracture of the upper end of the ulna associated with dislocation of the head of the radius in children.

The Monteggia lesion in children. Fracture of the ulna and dislocation of the radial head.

Monteggia injuries in children.    

Operative treatment of Monteggia fractures in children.  

The Pediatric Monteggia Fracture.  

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