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Paediatric Orthopaedic Pathways
Paediatric Orthopaedic Pathways

Monteggia fracture-dislocations

ED Management | Outpatient/Fracture Clinic Management | Operative Management


ED Management

The following information is for use by medical practitioners and trainees in the Emergency Department 

  1. Treatment Pathway 
  2. What are likely findings on history?
  3. What specific information from the patient history should be documented?
  4. What are likely findings on clinical exam?
  5. What specific findings on the physical exam are important to document?
  6. What x-rays should be ordered?
  7. What specific features are found on x-ray?
  8. How should this fracture or dislocation be immobilized in the emergency department?
  9. Should this patient be urgently/emergently referred to the nearest orthopaedic surgery service on call?
  10. Where should this patient be seen for follow-up care?
  11. What discharge prescriptions and instructions should be provided?
  12. What potential complications could result from this injury or its management?

 

1. Treatment Pathway

A Monteggia fracture is a fracture of the proximal ulna coupled with a radial head dislocation.     

Fracture Type

The Bado classification system describes four classic types:

ED management

Follow-up care

Type I (most common)

Anterior dislocation of the radial head with fracture of the ulna shaft

 

1. Analgesia
2. Arm should be splinted (sugar tong) and immobilized
3. Keep NPO
4. For all types, urgent referral to nearest orthopedic surgeon on call for management

 

To be determined by treating orthopaedic surgeon

Type II

Posterior dislocation of the radial head with fracture of the ulna shaft

 

1. Analgesia
2. Arm should be splinted (sugar tong) and immobilized
3. Keep NPO
4. For all types, urgent referral to nearest orthopedic surgeon on call for manageme
nt

 

To be determined by treating orthopaedic surgeon

Type III

Lateral dislocation of the radial head with fracture of ulna shaft

 

1. Analgesia
2. Arm should be splinted (sugar tong) and immobilized
3. Keep NPO
4. For all types, urgent referral to nearest orthopedic surgeon on call for manageme
nt

 

 

To be determined by treating orthopaedic surgeon

Type IV

Anterior dislocation of radial head with fracture of BOTH ulna and radius

 

1. Analgesia
2. Arm should be splinted (sugar tong) and immobilized
3. Keep NPO
4. For all types, urgent referral to nearest orthopedic surgeon on call for manageme
nt

 

 

To be determined by treating orthopaedic surgeon

 

2.  What are likely findings on history?

  • The mechanism of injury is a fall onto an outstretched hand
  • Delayed or missed diagnoses are not uncommon – the radial head dislocation may be missed due to a distracting ulna fracture. However, the ulna injury may be subtle, such as plastic deformation or a greenstick fracture. If an ulna fracture is present, radiographs should be carefully checked to assess for a radial head dislocation.

 

3.  What specific information from the patient history should be documented?

  • Document the date and time of injury
  • Document the time of the last oral intake (all patients should be kept fasting until a decision has been made regarding the need and timing of orthopaedic intervention)

 

4. What are likely findings on clinical exam?

  • Pain, deformity, and swelling at the elbow and forearm. It is always important to use the uninjured arm as a comparison, as swelling and deformity can be subtle in undisplaced fractures.
  • Range of motion of the elbow and forearm may be limited and painful.
  • Posterior interosseous nerve palsy
    •  Posterior interosseous nerve neurapraxia can occur in 10% of acute injuries

 

5. What specific findings on the physical exam are important to document?

  • The presence of skin tenting or fracture blisters
  • The presence of an open fracture or joint (splints placed at outside institutions should be taken down if there is any suspicion of an open fracture to allow adequate inspection of the overlying skin)
  • The presence of a peripheral nerve injury using the SickKids Peripheral Neurovascular Checklist (PDF)
  • The presence of an arterial injury or limb ischemia using the SickKids Peripheral Neurovascular Checklist (PDF)
  • The presence of signs or symptoms of compartment syndrome  
  • The presence of an injury to the joints or bones above and below the injury (two-level injuries are at increased risk of developing compartment syndrome)

 

6. What x-rays should be ordered?

  • After splinting the elbow and providing analgesia, AP and lateral x-rays of the forearm that include the wrist and elbow should be ordered. In addition, a true AP and lateral view of the elbow should be ordered to assess the radiocapitellar joint.

 

7. What specific features are found on x-ray?

  • Monteggia fracture-dislocations can be easily missed on radiographs.
  • If an ulna fracture is present, always look for a radial head dislocation by assessing for disruption of the normal radiocapitellar relationship.

 The radiocapitellar line drawn down the centre of the radius should always intersect the capitellum, regardless of elbow flexion or extension.

 

 

  • In addition, any deformity of the ulna should also be assessed. The posterior border of the ulna should be straight. If it is not straight, it indicates a plastic deformation injury.

 

The ulna should have a straight posterior border on a lateral radiograph (red line)

 

 

If the ulna is not straight, this suggests plastic deformation which can contribute to a radial head dislocation.

         

Monteggia Fracture-Dislocations are classified using the Bado Classification.

 

 

 

Bado Type I (most common): Anterior dislocation of the radial head with fracture of the ulna shaft 

 

      

 

 

 

 

Bado Type II: Posterior dislocation of the radial head with fracture of the ulna shaft
 

These injuries are rare.

 

 

Bado Type III: Lateral dislocation of the radial head with fracture of ulna shaft

 

     

 

 

Bado Type IV: Anterior dislocation of radial head with fracture of BOTH ulna and radius

 

 

8. How should this fracture or dislocation be treated in the emergency department?

  • Analgesia:  
    • Oral: Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed.
    • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
  • Place in long-arm backslab to splint elbow and forearm in position of comfort
  • Keep NPO
  • Urgent referral to nearest orthopaedic surgeon on call for closed reduction
  • For open fractures, tetanus immunization status should be assessed and appropriate IV antibiotics provided.

 

9. Should this patient be urgently/emergently referred to the nearest orthopaedic surgery service on call?

All Monteggia fracture-dislocations require an urgent (within 4 hours) referral to the nearest orthopaedic surgeon on call.

  • Indications for emergent (within 1 hour) referral to the nearest orthopaedic surgeon on call.          
  • Loss of radial pulse or a cool, white hand
  • Signs or symptoms of compartment syndrome
  • Patients awaiting orthopaedic assessment in the emergency department should be kept nil per os (NPO) until a decision about surgery is made.

 

10. Where should this patient be seen for follow-up care?

To be determined by orthopaedic surgical service on call


11. What discharge prescriptions and instructions should be provided?

  •  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg), and/or morphine (0.2-0.5mg/kg/dose). Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
  • Discharge instructions determined by orthopaedic surgical service on call

12. What potential serious complications could result from this injury or its management?

  • If identified early, these injuries typically do well
  • Complications  arise most commonly due to missed injuries or those that are not follow closely
  • Missed Monteggia fracture-dislocations often require more invasive procedures to obtain reduction of the radiocapitellar joint.
  • Posterior interosseous nerve palsy can occur in 10% of acute injuries.
    • Most resolve within three months from injury with no need for intervention.
  • Periarticular ossification
    • Occurs in 5% of Monteggia fracture-dislocations and can result in persistant elbow stiffness.

 

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Outpatient/Fracture Clinic Management

The following information is for use by medical practitioners and trainees in Fracture Clinics or Outpatient Clinics.

  1. When should this patient be seen in fracture clinic/outpatient clinic? 
  2. What should be reviewed at each clinic visit?
  3. What are common reasons to deviate from the treatment pathway?
  4. Does this patient require long-term follow-up?
  5. Instructions for parents and SickKids Parent Information Sheets

 

1. When should this patient be seen in fracture clinic/outpatient clinic ?

Fracture Type

First clinic visit 

Subsequent follow-up

All fracture types

Follow up in Fracture clinic in 1 week with:

Repeat AP, lateral and internal oblique radiographs to assess for interval displacement. If cast material obscures fracture line then consider repeating radiographs after removing backslab.

At 3 weeks with removal of backslab and repeat AP, lateral and internal oblique radiographs to assess for interval displacement and appropriate callus.
At 6 weeks with repeat AP, lateral and internal oblique radiographs to assess for interval displacement and appropriate callus.
Subsequent follow-up at 3 months and then at 3 month intervals until clinically and radiographically united and meet criteria for discharge.

 

First clinic visit

  • Follow up in Fracture Clinic in approximately 1 week with:
  • Repeat AP and lateral radiographs of forearm and elbow to assess for reduction of radiocapitellar joint and union of ulna fracture.
  • Clinical review

Subsequent follow-up at 2 weeks with:

  • Repeat AP and lateral radiographs of forearm and elbow to assess for reduction of radiocapitellar joint and union of ulna fracture.
  • Clinical review

At 3 weeks with:

  • Repeat AP and lateral radiographs of forearm and elbow to assess for reduction of radiocapitellar joint and union of ulna fracture.
  • Clinical Review 

At 6 weeks with:

  • Cast removal
  • Repeat AP and lateral radiographs of forearm and elbow to assess for reduction of radiocapitellar joint and union of ulna fracture.
  • Begin gentle range of motion exercises
  • Clinical Review
  • Begin gentle range of motion exercises
  • Avoid high risk activities for 12-24 weeks

At 3 months with:

  • Repeat AP and lateral radiographs of forearm and elbow to assess for reduction of radiocapitellar joint and union of ulna fracture.
  • Clinical Review to determine need for physiotherapy
  • Avoid high risk activities for 12-24 weeks

Subsequent follow-up to be individually determined

 

2. What should be reviewed at each clinic visit?


 At first clinic (1 week) visit:

  • Obtain repeat AP and lateral radiographs of forearm and elbow
  • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist (PDF)
  • Assess radiographs for reduction of radiocapitellar joint and acceptable alignment of ulna fracture.
  • Check integrity of cast (avoid unnecessary cast changes to decrease loss of reduction).

At 2 week clinic visit:

  • Obtain repeat AP and lateral radiographs of forearm and elbow
  • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist (PDF)
  • Assess radiographs for reduction of radiocapitellar joint and acceptable alignment of ulna fracture.
  • Check integrity of cast (avoid unnecessary cast changes to decrease loss of reduction).

At 3 week clinic visit:

  • Remove cast
  • Obtain repeat AP and lateral radiographs of forearm and elbow
  • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist (PDF)
  • Assess patient for clinical union (i.e. fracture site non-tender to palpation)
  • Assess radiographs for reduction of radiocapitellar joint and union of ulna fracture

At 6 week clinic visit:

  • Remove cast
  • Obtain repeat AP and lateral radiographs of forearm and elbow
  • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist (PDF)
  • Assess patient for clinical union (i.e. fracture site non-tender to palpation)
  •  Assess radiographs for reduction of radiocapitellar joint and union of ulna fracture.

At 3 month clinic visit:

  • Obtain repeat AP and lateral radiographs of forearm and elbow
  • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist (PDF)
  • Assess and document forearm and elbow range of motion to determine need for physiotherapy
  • Assess radiographs for reduction of radiocapitellar joint and union of ulna fracture.


3. What are common reasons to deviate from the treatment pathway?

Common reasons to deviate from the treatment pathway include:

  • Loss of reduction of the radiocapitellar joint.
  • Angulation or displacement of the ulna fracture beyond acceptable limits for continued closed management.
    • May require more frequent follow-up, additional investigations or referral to subspecialist
  • Patient underwent treatment in the operating room
    • These patients should be followed up by their treating surgeon
    • The treating surgeon may want to deviate from the pathway due to patient, fracture or surgical  factors
  • Established neurovascular injury
    • May require more frequent follow-up, additional investigations or referral to subspecialist
  • Decreased elbow and forearm range of motion
    • These patients may require physiotherapy or evaluation by an orthopaedic surgeon


4. Does this patient require long-term follow-up?

Patients with significant elbow stiffness, unresolved nerve palsies or complications from arterial injuries warrant long-term follow-up provided by a pediatric orthopaedic surgeon

A patient can be discharged from future follow up when they have met the  following criteria:

  • concentric reduction of the radiocapitellar joint
  • clinical and radiological evidence of union of the ulna fracture
  • normal elbow and forearm range of motion

 

5. Instructions for parents and SickKids Parent Information Sheets

  •  SickKids Parent Information Sheet- Cast Care: Arm or Leg (PDF)

 

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Operative Management

Until locally specific content is available, we encourage the use of AO Foundation Surgery Reference's Pediatric forearm shaft 22u-D/6 Monteggia lesion surgical treatment guidelines.

 

 References

  1. The Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Monteggia fracture-discloctions- Emergency Department , [Internet,cited August 21, 2018. ]
  2. George, AV, Lawton JN. Management of Complications of Forearm Fractures. Hand Clinics 2015; 31(2):217-33. https://www.ncbi.nlm.nih.gov/pubmed/25934198
  3. Rehim SA, Maynard MA, Sebastin SJ, Chung KC. Monteggia fracture-dislocations: A Historical Review.  J Hand Surg Am 2014; 39(7):1384-94. https://www.ncbi.nlm.nih.gov/pubmed/24792923
  4. Ring D. Monteggia fractures. Orthop Clin North Am 2013; 44(1):59–66. https://www.ncbi.nlm.nih.gov/pubmed/23174326
  5. Beutel, BG. Monteggia Fractures in pediatric and adult populations. Orthopedics 2012; 35(2):138-44. https://www.ncbi.nlm.nih.gov/pubmed/22300997
  6. Waters PM. Monteggia fracture-dislocation in children. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.446-74.
  7. Eathiraju S, Mudgal CS, Jupiter JB. Monteggia fracture-dislocations. Hand Clin 2007; 23(2):165–77, v. https://www.sciencedirect.com/science/article/pii/S0749071207000091
  8. Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J Am Acad Orthop Surg 1998; 6(4):215-24. https://www.ncbi.nlm.nih.gov/pubmed/9682084
  9. Rodgers WB, Waters PM, Hall JE. Chronic Monteggia lesions in children. Complications and results of reconstruction. J Bone Joint Surg Am 1996; 78(9):1322–9. https://www.ncbi.nlm.nih.gov/pubmed/8816646

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Content developed by Dr. Mark Camp and Alexander Tchoukanov on September 1st, 2018.