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اصفهان پزشکی دانشکده استادیار

Forearm,Monteggia&Galleazzi Fracture Dislocations

Common 12 to 16y

Most common site for refracture

Fx suspected >>child has not returned all

normal arm function within 1 to 2 days of

injury

Forearm Both Bone Fracture

Practical classification2 bones3 levels

4fracture patterns(Bow,Greenstick,Compelet&Comminuted)

Classification

Closed Reduction still remains the gold standard for closed isolated pediatric

forearm fractures

Treatment

Non or minimally displaceLong arm cast(except above 4 y with stable

distal third fx)1 and 2 week visit

6-8 week castAfter that splint until union compelet

Displaced fracturesManipolation with sedation

Contorol with fluroscopySugar tong splint(7-10 layers 3inch plaster)

Next week x-ray and change splint to cast2 next weeks follow up4 weeks after reduction can chang short cast

Except under 4 yReturn to sport now if…

Distal third< 20 degreeMiddle third< 15 degreeUpper third <10 degree100% translation with <1cm shorteningRotation< 45 degree.difficult to measure

Bicipital tuberisity and radial styloid

Acceptable limits of angulation

Open fractureFracture with unacceptibale reductionFx in assosiated supracodylar fx(to avoid

risk of compartement syn)

Surgery

Interamedullary fixation is preferredIf one bone fixation Fix ulna

If both bone should be fix,radius first2-2.5 mm nail

brace or cast6-12 mo nail removal

RedisplacementForearm stiffnessRefractureMalunionNonunionCross union(synostosis)Infection…

Complications

Monteggia Fracture Dislocation InChildren

Type 1Ant dis radial head associated with ulnar

diaphyseal fx at any level(most common)

Classification(Bado)

Ant radial head dislocasion(include pulled elbow)

No plastic deformity of ulnaAnt dis radial head with radial neck fxAnt dis radial head with fx of radial

diaphyseal fx proximal to ulnar fx.…

Type 1 Equivalents

direct blow theoryHyperpronation theoryHyperextention theory

Mechanism of injury

Fusiform swelling elbowPain &limit ROM elbow

clinic

Three steps:Correcting the ulnar deformityStable reduction of radial headMaintaining ulnar length and fx stability

Treatment

A bivalved long arm cast 4-6 w slight supination and elbow 90 to 110 flex

Radiography every 1 to 2 wHardware remove

Postoperative care

CongenitalPosteriorBilateral

Can be associated with various syndromesTraumatic

Isolated ant. Or ant lateral dislocationUnless congenital or systemic difference

Traumatic versus Congenital dislocation

Posterior monteggia fx dxRare in children usully older patientMechanism

Direct force,sudden rotation and supinationSuddenly loaded in longitodinal direction

elbow at 60 flex

Type 2

Incomplete fx ulna>>close reduction casting in extension

If doubt>>interamedullary fixationComminuted or very proximal ulnar

fx>>open reduction plate screw

treatment

Lat swelling,varus,significant limitation of ROM

Mechanism>>hyperextesion of elbow combined with pronation

Monteggia type 3

Incomplete or plastic deformation of ulnaClose reduction>>

Elbow in extension longitudinal traction valgus sterss test

Long arm cast elbow 70 to 80 flex

treatment

Ant dis with fx both radius and ulna Radial fx level same or distal too ulnar fx

Fx unstablefixation

Type 4

Chronic Monteggia InjuryUnder 12 years old

MRI

Determine congruency radial head and capitellum

Compelications

SurgeryRadial nerve identify

Anconeous-extansor carpiulnaris intervalRepair or reconsteraction of annular lig

Radius head unreduceable >>ulnar osteotomy

After radial head redauction>>anullar lig repi

Fracture of the distal radius with DRUJ disruption

Mechanism >>axial load ,forearm rotationSigns &symptoms>>pain,limitation of

forearm rotation,wrist flex ext

Pediatric Galeazzi Fractures

Type 1 dorsal (apex volar)displacmentType 2 volar(apex dorsal)displacmentGaleazzi equivalent

Distal radius fx with distal ulnar physis disruption

Classification

Volar apex Radius fx greenstick or incomplete

Close reduction and long arm cast in supinationComplete fx

Open reduction and fix with plate

Treatment

Incompelet radius fxClose reduction

Compelet fxOpen reduction

Dorsal apex