Fractures of antebrachium. Fracture – dislocation of Galeatzi and Montegia. Flashcards
what is monteggia fracture ?
proximal 1/3of ulnar fracture with radial HEAD dislocation and instability
the treatment of monteggia fracture depends on what ? and how will the treatment differ ?
the age of the patient
in children and adults (rare in adults)
what is used to classify monteggia ?
bado classification - going from most common to least
type 1 - fracture at proximal or middle third of ulna
with anterior dislocation of the radial head
most common in children and young adults
type 2 - fracture of the proximal or middle third of the ulna with posterioir dislocation of the radial head = most common in adults
type 3 - fracture of ulna metaphysis distal to the coronoid process with lateral dislocation of radial head
type 4
fracture of the proximal and middle third of ulna and radius with dislocation of the radial head in any direction
the radial head has two articulation points what are they ?
with capitellum
and the proximal radioulnar joint
when the radial head dislocate dislocation of BOTH of these joints
what is the treatment for monteggia fracture ?
type 1
children - closed reduction
must ensure stabilty and anatomic alignment of ulna fracture
w/ forarm in full supination
Place the thumb on the radial head and the fingers at the epicondyles and grasp the distal ulna to provide longitudinal traction. Simultaneously reduce the ulnar angulation and the radial head dislocation.
Direct thumb pressure on the apex of the ulnar deformity may help.
immobilise the elbow in flexion (90-100 degrees) and supination
Tubular bandage - from the axillary crease to just distal to the MCP
padding = Apply a single layer of padding from the MCP joints of the fingers and thumb to the axillary crease.
Overlap each layer by 1/2.
Apply extra padding over pressure areas, including the olecranon.
plaster of paris / synthetic fibreglass appendages
Apply a slab the width of the forearm over the ulnar aspect and the posterior humerus.
in adults - open reduction and internal fixation with ulna head properly aligned and dorsal preconutred compression plate fixation with lag screw
the radial head should reduce by itself
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type 2
in children - closed reduction
applying traction to forearm w/ the forearm in full extension;
immobilise the elbow in full extension
in adults open reduction and internal fixation of ulna head properly aligned which is very important and dorsal precontured compression plate fixation with lag screw
the radial head will reduce by itself
the radial head is still not reduced then asses the ulnar alignment it can also be due to interposed annular ligament
progress to open reduction of the radial head when failure to reduce radial head with ORIF of ulnar shaft
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type 3
in children - closed reduction and immobilise in full extension and valgus mould
adults = open reduction and internal fixation with plate as in type 2
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type 4
will need surgery even in children
reduce the radial head
reduce the ulna fracture so the radioulnar joint is anatomic
when the radioulnar joint is anatomic we can temporarily pin it with k wires
then use a dorsal ulnar compression plate
and radial compression plate fixation
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we can also fix with intrameduillry rod for transverse or short oblique fracture
what is the clinical presentaton of the monteggia fracture ?
neuromuscular examination for posterior interossues nerve injury which is adjacent to the radial neck
- supplies the extensors of the wrist causing a floppy wrist
weakness of thumb extension
weakness of MCP extension
loss of ROM at elbow due to dislocation
signs
radial deviation
what is complication of monteggia fracture ?
posterior interossues nerve injury
malunion with radial head dislocation = ulnar osteotomy
how can we see monetggaie fracture on x ray ?
ap view
lateral elbow , wrist and forarm view
anterior radial line should dissect the capitellum at any point
what causes monteggia fracture ?
fall on outreached hand with the forearm in excessive pronation
what causes radial and ulna shaft fracture ?
Radial and ulnar shaft fractures, also known as adult both bone fractures, are common fracture of the forearm caused by either direct trauma (hit by bat) or indirect trauma (fall).
Isolated ulnar shaft fractures are rare fractures of the forearm caused by either direct blow to the forearm (“nightstick” fracture) or indirect trauma (fall).
what is the classification of radial or ulna shaft fracture ?
OTA classification
radius /ulna / radius and ulna
type a - simple
spiral
transverse
oblique
wedge
wedge spiral
bending wede
segmented wedge
complex
spiral complex
segmented
comminuted
if it closed or open
amount of displacement
angulation
what are the indication and non operative treatment in ulnar shaft fractures ?
ISOLATED non displaced
distal 2/3 of ulnar shaft fracture with :
less than 50 percent displacement
and less than 10 degree angulation
put a functional brace with good INTEROSSEOUS MOLD - oval cross section - helps to maintain tension in interosseous membrane
or casting
Muenster cast with good interosseous mold
soft compression dressings
allowing immediate mobilization
what are the non operative indications and treatmnet for radius and ulna shaft fractures ?
COMPLETE NON DISPLACED ULNAR AND RADIUS FRACTURE
bracing
functional fracture brace
casting
Muenster cast with good interosseous mould
should extend just above elbow to control forearm rotation
outcomes
high rates of non-union associated with non-operative management
operative management of isolated ulnar shaft fracture ?
external fixation
severe soft tissue injury
open reduction with internal fixation with DYNAMIC COMPRESSION PLATE WITHOUT bone grafting :
displaced distal 2/3 of ulna
proximal 1/3 isolated ulna fractures
for proximal 1/3 of ulnar fractures place plate posterior act as a tension band plate
comminution : open reduction internal fixation with a bridge plate
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open reduction internal fixation WITH bone grafting
if the defect is more than 5 cm long and significant bone loss or non union use vascularized fibula grafts
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IM nailing
indications
poor soft-tissue integrity
outcomes recent studies have shown similar union rates compared to ORIF for isolated ulnar shaft fractures
what are the indication for operation for ulnar and radial shaft fractures ? and treatmnet
subcutaneous approach to ulna shaft
RADIUS AND ULNA
1) external fixation
when severe soft tissue injury
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2) ORIF with dynamic compression plating
- all both bone fractures in surgical candidates
separate approaches due to risk of synostosis
volar (Henry) approach to radius
best for distal 1/3 and middle 1/3 radial fractures
dorsal (Thompson) approach to radius
can be utilized for proximal 1/3 radial fractures
3) ORIF with bone grafting
open fractures with significant bone loss or nonunions
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4) IM nailing
poor soft-tissue integrity
not preferred due to lack of rotational and axial stability and difficulty maintaining radial bow
high nonunion rate
even if non displaced
ALL radial shaft fractures = plate placed anteriorly
