MONTEGGIA AND MONTEGGIA AND GALEAZZI FRACTURESGALEAZZI FRACTURES

ANATOMY-ELBOWANATOMY-ELBOW

Hinge joint.Hinge joint. Three bones form the elbow joint: the Three bones form the elbow joint: the humerushumerus

of the upper arm, and the paired of the upper arm, and the paired radiusradius and and ulnaulna of the forearm. of the forearm.

The bony prominence at the very tip of the The bony prominence at the very tip of the elbow is the elbow is the olecranonolecranon process of the ulna, and process of the ulna, and the inner aspect of the elbow is called the the inner aspect of the elbow is called the antecubital fossaantecubital fossa..

HHumeroulnarumeroulnar joint joint- -

**from t**from trochlearrochlear notch notch of the of the ulnaulna

**to **to trochleatrochlea of of humerushumerus

Is a simple Is a simple hinge-jointhinge-joint, and allows of , and allows of movements of flexion and extension only.movements of flexion and extension only.

HHumeroradialumeroradial joint joint--

**from **from head of the radiushead of the radius

**to **to capitulumcapitulum of the of the humerushumerus

Is a Is a hinge-jointhinge-joint

PProximal roximal radioulnarradioulnar joint joint..

**From-**From-head of the radiushead of the radius

**to **to radial notchradial notch of the of the ulnaulna

pronationpronation and and supinationsupination..

Ligaments:-Ligaments:- UUlnar collateral ligamentlnar collateral ligament, , RRadial collateral ligamentadial collateral ligament, and , and AAnnular ligamentnnular ligament. .

The The musclesmuscles in relation with the joint are: in relation with the joint are:

in front, the Brachialis, the Brachioradialis

behind, the Triceps brachii and Anconæus

laterally, the Supinator, and the common tendon of origin of the Extensor

muscles medially, -common tendon of origin of the Flexor

muscles, and the Flexor carpi ulnaris

MovementsMovements

The hinge-like bending and straightening (The hinge-like bending and straightening (flexion and extensionflexion and extension) between the humerus ) between the humerus and the ulna. and the ulna.

The complex action of turning the forearm The complex action of turning the forearm over (over (pronationpronation or or supinationsupination) happens at the ) happens at the articulation between the radius and the ulna articulation between the radius and the ulna (this movement also occurs at the wrist joint). (this movement also occurs at the wrist joint).

The hinge moves in only one plane. The hinge moves in only one plane.

The AThe Arteriesrteries supplying the joint are derived from the supplying the joint are derived from the anastomosis between the anastomosis between the profundaprofunda and the superior and the superior and and inferior ulnar collateralinferior ulnar collateral branches of the branches of the brachialbrachial, , with the anterior, posterior, and interosseous recurrent with the anterior, posterior, and interosseous recurrent branches of the branches of the ulnarulnar, and the , and the recurrent branch of the radialrecurrent branch of the radial. These vessels form a . These vessels form a complete complete anastomoticanastomotic network around the joint. network around the joint.

The NThe Nerveserves of the joint are a twig from the ulnar, as it of the joint are a twig from the ulnar, as it passes between the medial condyle and the olecranon; passes between the medial condyle and the olecranon; a filament from the musculocutaneous, and two from a filament from the musculocutaneous, and two from the median.the median.

Monteggia fractureMonteggia fracture

# of upper third of ulna with dislocation of # of upper third of ulna with dislocation of head of radius.head of radius.

Head of radius is dislocated both from the Head of radius is dislocated both from the radioulnar articulation and from elbow joint.radioulnar articulation and from elbow joint.

It may be displaced –Ant,post,or laterally acc It may be displaced –Ant,post,or laterally acc to angulature of ulnar fracture.to angulature of ulnar fracture.

DIAGNOSISDIAGNOSIS

Every # of upper shaft of ulna without # of Every # of upper shaft of ulna without # of radial shaft should be considered to be radial shaft should be considered to be monteggia # unless otherwise proved.monteggia # unless otherwise proved.

first X ray may show head of radius in its first X ray may show head of radius in its correct position, but serial X rays have to be correct position, but serial X rays have to be taken over 1taken over 1stst few weeks –bcoz if dislocation few weeks –bcoz if dislocation has occurred and there is instability ,head of has occurred and there is instability ,head of radius may redisplace later.radius may redisplace later.

Displacement-3 typesDisplacement-3 types

Monteggia # dislocations can take place from Monteggia # dislocations can take place from 3 forces and corresponding injuries seen.3 forces and corresponding injuries seen.

FLEXION INJURYFLEXION INJURY EXTENSION INJURYEXTENSION INJURY ADDUCTION INJURYADDUCTION INJURY ***Hume fracture***Hume fracture

FLEXION INJURY-10-15%FLEXION INJURY-10-15% # ulna is angulated # ulna is angulated

with the convexity with the convexity

posteriorly and the posteriorly and the

head of radius is head of radius is

dislocated dislocated

backwards.backwards.

EXTENSION INJURY-85-90%EXTENSION INJURY-85-90%

Commonest type.Commonest type. # ulna is angulated with covexity ant. and # ulna is angulated with covexity ant. and

laterally.laterally. With head of radius dislocated forwards and With head of radius dislocated forwards and

laterally.laterally.

Adduction injuryAdduction injury

Caused by adduction strain at the elbow.Caused by adduction strain at the elbow. Ulna is angulated laterally and radial head is Ulna is angulated laterally and radial head is

displaced laterally.displaced laterally.

HUME FRACTUREHUME FRACTURE

““High Monteggia injury”.High Monteggia injury”.

1957 Hume described --fracture of the 1957 Hume described --fracture of the olecranon with an associated anterior olecranon with an associated anterior dislocation of the radial head .dislocation of the radial head .

Seen in Children.Seen in Children.

MECHANISM OF INJURY.MECHANISM OF INJURY. Mervyn Evans suggested this mech.Mervyn Evans suggested this mech.

1**Fall on outstretched hand with twisting of 1**Fall on outstretched hand with twisting of the trunk,forcibly pronating the forearm.the trunk,forcibly pronating the forearm.

2**Direct injury-Africa-Direct blow on the 2**Direct injury-Africa-Direct blow on the back of forearm with a stickwhile arm is raised back of forearm with a stickwhile arm is raised warding off an attacker.warding off an attacker.

TREATMENTTREATMENT

CONSERVATIVECONSERVATIVE OPERATIVEOPERATIVE

CONSERVATIVE:-CONSERVATIVE:-

Children.Children. manipulation and plaster immobilisation.manipulation and plaster immobilisation. But close watch needed-recurrence of But close watch needed-recurrence of

deformity.deformity.

Redn. of extension injury.Redn. of extension injury.

Longitudinal traction of forearm with with the Longitudinal traction of forearm with with the elbow flexed as much as possible without elbow flexed as much as possible without compromising the blood supply.compromising the blood supply.

Forearm is stable in supinationForearm is stable in supination Plaster windowed for radial pulsePlaster windowed for radial pulse

Redn of adduction injury.Redn of adduction injury.

Traction of the forearm with elbow extended Traction of the forearm with elbow extended and pressure over the head of radius, and after and pressure over the head of radius, and after redn.this # dislocation is stable with the elbow redn.this # dislocation is stable with the elbow flexed.and with forearm supinated.flexed.and with forearm supinated.

Redn of flexion injuryRedn of flexion injury

Traction on forearm with elbow extende and Traction on forearm with elbow extende and as the redn is stable only in the extended as the redn is stable only in the extended position –not advisable in adults.position –not advisable in adults.

OPERATIVE TREATMENT.OPERATIVE TREATMENT.

Advisable in adults.Advisable in adults. Open redn of # ulna and rigid int. fixation Open redn of # ulna and rigid int. fixation

preferable with a plate..preferable with a plate.. Dislocation of head of radius red. Dislocation of head of radius red.

spontaneously when the deformity of ulna has spontaneously when the deformity of ulna has been reduced.been reduced.

OPERATIVE TECHNIQUE.OPERATIVE TECHNIQUE.

# of ulna is exposed ,reduced and fixed by a # of ulna is exposed ,reduced and fixed by a compression plate,or IM nail.compression plate,or IM nail.

Intraop take xray elbow in 2 planes.Intraop take xray elbow in 2 planes. If head of radius is perfectly reduced, the If head of radius is perfectly reduced, the

position is accepted and well padded plaster position is accepted and well padded plaster cast is applied from metacarpals to axilla- with cast is applied from metacarpals to axilla- with elbow at right angles and forearm supinated. elbow at right angles and forearm supinated.

If X ray shows –head of radius is not reduced, If X ray shows –head of radius is not reduced, then it must be exposed and reduced under then it must be exposed and reduced under direct vision.direct vision.

Annular lig. --usually cause obstruction-Annular lig. --usually cause obstruction-incised.incised.

COMPLICATIONS COMPLICATIONS

1.UNREDUCED DISLOCATION OF HEAD 1.UNREDUCED DISLOCATION OF HEAD OF RADIUS.OF RADIUS.

2.TRAUMATIC OSSIFICATION AROUND 2.TRAUMATIC OSSIFICATION AROUND RADIAL HEAD.RADIAL HEAD.

3.PIN PALSY3.PIN PALSY

4.CROSS UNION B/W RADIUS AND ULNA.4.CROSS UNION B/W RADIUS AND ULNA.

5.DISLOCATION OF LOWER END OF ULNA5.DISLOCATION OF LOWER END OF ULNA

6.UN-UNITED # OF ULNA.6.UN-UNITED # OF ULNA.

Unred. disl. of head of radius.Unred. disl. of head of radius.

RxRx Excision of displaced head of radius.Excision of displaced head of radius. Prod inc. elbow flexion and good range of Prod inc. elbow flexion and good range of

pronation and supination.pronation and supination. NOT done in CHILDREN.—removal of upper NOT done in CHILDREN.—removal of upper

radial epiphysis—inequality of length of radial epiphysis—inequality of length of forearm bones and cause further disl. of RU forearm bones and cause further disl. of RU joints both sup. and inf.joints both sup. and inf.

Traumatic ossi. around radial head.Traumatic ossi. around radial head.

Excision of radial head and the block of bone Excision of radial head and the block of bone attached to it.attached to it.

Recurrence.Recurrence. Can be reduced by Sx delayed 6-12 months Can be reduced by Sx delayed 6-12 months

after injury with elbow immobilised for atleast after injury with elbow immobilised for atleast 2 weeks.2 weeks.

NO Physiotherapy,manipulation and passive NO Physiotherapy,manipulation and passive excs during rehab period.excs during rehab period.

PIN PALSYPIN PALSY

Common with Adduction # dislocation.Common with Adduction # dislocation. Prognosis good in early complete reduction of Prognosis good in early complete reduction of

head of radius.head of radius. Late PIN palsy due to inadequate redn of Late PIN palsy due to inadequate redn of

radial head.radial head.

Cross union b/w radius and ulna.Cross union b/w radius and ulna.

Bony fusion b/w neck of radius and 3 site of Bony fusion b/w neck of radius and 3 site of upper 3rd of ulna.upper 3rd of ulna.

Difficult to Rx.Difficult to Rx. B coz proximity of elbow jt and PIN. B coz proximity of elbow jt and PIN.

***Recurrence is high.***Recurrence is high. ***Perm limitation of Radioulnar movt.***Perm limitation of Radioulnar movt.

Dislocation of lower end of ulnaDislocation of lower end of ulna

REDUCES with redn of ulnar shaft #.REDUCES with redn of ulnar shaft #. WORSENS if head of radius is excised.WORSENS if head of radius is excised. Rx excise distal inch of ulnar-if wrist Rx excise distal inch of ulnar-if wrist

symptoms.symptoms.

Un united # of ulnaUn united # of ulna

Notorious for that.Notorious for that. Rigid internal fixation and cancellous onlay Rigid internal fixation and cancellous onlay

grafting.grafting.

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