paediatric injuries around the elbow supracondylar elbow injuries pulled elbow in paediatric age r radiological signs around elbow in supracondylar fracture humerus

1. Department of Orthopaedics
Chairperson& Moderator: Prof. & HOD: Dr. Kiran Kalaiah
Presenter : Dr. Yashavardhan .T.M
SEMINAR PRESENTATION ON: Injuries
around elbow in pediatric age group.

2. Paediatric elbow fractures
1. Anatomy
2. Ossification
3. Supracondylar Fractures
4. Lateral Condyle Fractures
5. Medial Epicondyle Avulsion
6. Proximal Radius Fractures
7. Radial head & neck fracture dislocation
8. Olecranon fracture
9. Nursemaid’s elbow
10. Elbow dislocation
11. Monteggia fracture dislocation.

3. Stability of the elbow - static and
dynamic constraints
 3 primary static constraints
1) Ulno-humeral articulation,
2) the anterior bundle of the MCL
3) the lateral collateral ligament (LCL) complex
 4 Secondary constraints
1) Radio-capitellar articulation,
2) the common flexor tendons,
3) the common extensor tendons,
4) the capsule.
 Dynamic stabilizers - Muscles that cross the elbow joint

4. Osteo-articular anatomy
The articular surfaces of the elbow joint
1. distal humerus,
2. the proximal ulna,
3. proximal radius
The elbow -trochleogingylomoid joint
hinged (ginglymoid) motion in flexion and extension
at the ulno-humeral and radio-capitellar articulations
radial (trochoid) motion in pronation and supination
at the proximal radio-ulnar joint

5. Osseous stability - enhanced in flexion
1) coronoid process locks into the coronoid fossa of the distal humerus
2) radial head is contained in the radial fossa of the distal humerus
Osseous stability - enhanced in extension
1) the tip of the olecranon rotates into the olecranon fossa.
2) The sublime tubercle is the attachment site for the anterior bundle
of the MCL.

6. The MCL complex
3 components:
1) the anterior bundle or anterior MCL
2) the posterior bundle
3) the transverse ligament
The origin of the MCL is at the antero-inferior surface of the medial
epicondyle.

7. AMCL
most discrete structure inserts on the antero-medial aspect of the coronoid
process, the sublime tubercle. Provide significant stability against valgus
force
• one of the primary static constraints of the elbow
• The anterior bundle - divided into
1. anterior band
2. Posterior band
The transverse ligament
Runs between the coronoid and the tip of the olecranon
consists of horizontally oriented fibers that often cannot be separated from
the capsule

8. The LCL complex
four components
1) radial collateral ligament,
2) the lateral ulnar collateral ligament,
3) the annular ligament,
4) the accessory collateral ligament
 The LCL complex originates along the inferior surface of the
lateral epicondyle.

9. Blood supply around elbow.

17. CARRYING ANGLE
It is the angle at which the humerus and forearm articulate, with the
elbow in full extension, and the palms facing forward.
The carrying angle permits the arm to be swing without contacting the
hips.
Normal values.
Males=15
Female=20 deg

18. A line in the longitudinal axis of proximal end of radius passes to the
centre of capitulum.
A line in the Anterior cortex of distal end of humerus passes to the
centre of capitulum
Distruption from this indicates Fracture or Dislocation.

19. SUPRACONDYLAR FRACTURES
OF THE DISTAL HUMERUS
1. Supracondylar fractures of the humerus are the most common
type of elbow fracture in children and adolescents.
2. They account for 50% to 70% of all elbow fractures and are seen
most frequently in children between the ages of 3 and 10 years.
3. The high incidence of residual deformity and the potential for
neurovascular complications make supracondylar humeral
fractures a serious injury.
4. When forced into hyperextension, the olecranon can act as a
fulcrum through which an extension force can propagate a
fracture across the medial and lateral columns.
5. Similarly, a force applied posteriorly with the elbow in flexion can
create a fracture originating at the level of the olecranon fossa

20. Mechanism of Injury
Supracondylar humeral fractures may be the result of an extension or
flexion force on the distal humerus. Usually they are the result of a fall
on an outstretched hand, which causes hyperextension of the elbow.
These extension type supracondylar humeral fractures account for 95%
to 98% of all supracondylar fractures. With hyperextension injuries the
distal fragment will be displaced posteriorly.
Flexion-type supracondylar fractures are rare and occur in only 2% to 5%
of cases. The mechanism of flexion supracondylar fractures is usually a
direct blow on the posterior aspect of a flexed elbow that results in
anterior displacement of the distal fragment.

21. Classification
Supracondylar humeral fractures are usually initially classified as
extension or flexion injuries and then according to the amount of
radiographic displacement.
This three-part classification system was first described by Gartland in
1959.
There have been several modifications of this scheme. Wilkins
subdivided type III injuries according to the coronal plane displacement
of the distal fragment.

22. HISTORY – MECHANISM OF
INJURYDescribes falling on an outstretched hand ( FOOSH injury) or other traumatic event
SYMPTOMS
• Severe pain • swelling, • inability to bend the arm • Loss or abnormal sensation and pulse •
inability of normal distal arm functions • Children with nursemaid's elbow will not bend due to
pain and hold arm slightly bent.
CLINICAL EXAMINATION
1) Pulse
2) Touch sensation of digits
3) Motor function -abduction and adduction
4) strength of the digits (ulnar nerve)
5) opposability of the thumb (median nerve).
• Posterior elbow dislocations -prominent olecranon and foreshortened forearm
• Anterior elbow dislocations elongated forearm, arm is held in extension

23. Radiographic Findings◦ The diagnosis of a supracondylar humeral fracture is confirmed radiographically.
Obtaining good-quality radiographs is complicated by the fact that the elbow is painful
and difficult to move.
Imaging
obtain AP and lateral of humerus and elbow.
include entire length of humerus and forearm.
additional views obtain wrist radiographs if elbow injury present or distal tenderness
oblique radiographs may assist in surgical planning, traction radiographs may assist in
surgical planning
specifically evaluate if there is continuity of the trochlear fragment to medial
epicondylar fragment, this can influence hardware choice
CT
often obtained for surgical planning.
helpful when shear fractures of the capitellum and trochlea are suspected.
3D CT scan.
MRI
◦ usually not indicated in acute injury.

24. Radiograph Anatomy/Landmarks
Fat pad sign.
-Note the un- displaced fracture (Red Arrow).
-Note the posterior fat pad (Yellow Arrows).

25. Baumann’s angle
Baumann’s angle is formed by a line
perpendicular to the axis of the
humerus, and a line that goes through
the physis of the capitellum.
A normal angle is approximately 8-9°,
and so when reducing paediatric
supracondylar humerus fractures, a
deviation of more than 5° from the
contralateral side should not be
accepted.

26. Ant.humeral line
Anterior Humeral Line
– Drawn along the anterior humeral
cortex
– Should pass through the middle of the
capitellum
– Variable in very young children

27. Humerocapitellar angle
The capitellum is angulated anteriorly
about 30 degrees.
• The appearance of the distal humerus is
similar to a hockey stick.

28. Radiocapitellar line
Radiocapitellar line should intersect the capitellum in all views.
• Make it a habit to evaluate this line on every paediatric elbow film

29. Treatment
the goal of treatment of supracondylar humeral fractures is to “avoid catastrophes”
(vascular compromise, compartment syndrome) and “minimize embarrassments”
(cubitus varus, iatrogenic nerve palsies).

30. Treatment of Nondisplaced Fractures
Treatment of nondisplaced fractures is straightforward and
noncontroversial. It consists of long-arm cast immobilization for 3
weeks. often initially treat the patient in the emergency department
with a posterior splint, with figure eight reinforcement. The position of
the forearm in the long-arm cast has been the subject of a great deal
of speculation.
For truly non-displaced fractures there is no theoretic advantage to
pronation or supination. We generally immobilize non-displaced
fractures with the forearm in neutral position.
The patient returns 5 to 10 days after injury for removal of the splint.
Radiographs are repeated to ensure that no displacement has
occurred, and the patient is placed in a long-arm cast for an additional
2 to 3 weeks, at which time immobilization is discontinued.

31. Treatment of Displaced Fractures
Several treatment options are available for the management of
displaced fractures (types II and III). By definition, all these fractures
require reduction. Usually, even for severe type III injuries, reduction
can be accomplished in a closed fashion. Options exist in regard to the
method of maintaining the reduction until the fracture has healed,
including cast immobilization, traction, and percutaneous pin fixation.
If adequate closed reduction cannot be achieved, open reduction
should be performed; this is almost universally followed by pin
fixation.

32. Supracondylar Humerus
Fractures: Complications
Immediate:-
1. Vascular injury to brachial artery.
2. Nerve injury to radial nerve, median nerve (AIN) and ulnar nerve(in flexion type).
Early:-
1. Volkmann’s ischemia and
2. Compartment syndrome.
Late:-
1. Malunion-Cubitus varus
2. Myositis ossificans,
3. Volkmann’s ischemic contracture.

33. Transphyseal Fractures
Transphyseal fractures are most common in children younger than 2
years. They have been reported to result from abuse in up to 50% of
children younger than 2 years.
In children of this age, the distal humerus is entirely cartilaginous or
almost so, thus making interpretation of radiographs difficult and
making diagnosis the most difficult aspect of this fracture.

34. Mechanism of Injury
The mechanism of injury depends on the age of the patient.
In newborns and infants, there is usually a rotatory or shear force
associated with birth trauma or child abuse.
In older children, the mechanism is usually a hyperextension force from
a fall on an outstretched hand.

35. Classification
DeLee and colleagues separated transphyseal fractures into
three groups based on their radiographic appearance.
Their criteria included the presence or absence of the secondary
ossification center of the radial head and the presence and size of the
metaphyseal fragment (Thurston-Holland sign).
These radiographic parameters correspond to the age of the patient but
add little to clinical management. These fractures may also be classified
according to the Salter-Harris classification of physeal injuries.
In infants these injuries are usually Salter-Harris type I fractures. In
older children they are usually type II injuries.

36. Toniolo and Wilkins proposed a simple classification based on
the degree of displacement and comminution of the fracture fragments
for pediatric T-condylar fractures.
Type I fractures are minimally displaced.
Type II fractures are displaced but do not have comminution of the
metaphyseal fragments.
Type III fractures are displaced fractures with comminution of the
metaphyseal fragments

37. Treatment of T-Condylar
Distal Humerus Fractures
Indications/Contraindications

38. ELBOW DISLOCATIONS
Disruptions of the elbow joint represent a spectrum of injuries involving
three separate articulations:
The radiocapitellar, the ulnohumeral, and the proximal radioulnar joints.
Dislocations of the elbow joint in children are not common.
Of all elbow injuries in skeletally immature patients, Henrikson65 found that
only about 3% of all were dislocations. The peak incidence of pediatric
elbow dislocations typically occurs in the second decade of life, usually
between 13 and 14 years of age when the physes begin to close.
Based on the National Electronic Injury Surveillance System database, the
calculated incidence of elbow dislocations in adolescents aged 10 to 19
years old was 6.87 dislocations per 100,000 person years with an almost 2:1
ratio of injuries in males compared to females (incidence 8.91 vs. 4.72 per
100,000 person years).

39. POSTERIOR ELBOW DISLOCATIONS
O’Driscoll et al. have proposed that most posterior elbow dislocations begin
with disruption of the lateral ligaments and proceed along the anterior
capsular structures to the medial ligaments.
Although this is likely the mechanism for the more rarely seen
posteromedial elbow dislocation, for the more common posterior and
postero lateral elbow dislocations, this notion has been challenged.

40. Associated Injuries with
Posterior Elbow Dislocations
Fractures Associated with Posterior Elbow Dislocations:
A. medial epicondyle,
B. the coronoid process,
C. the radial head and the neck.
Soft Tissue Injuries Associated with Posterior Elbow Dislocations:

41. Signs and Symptoms of
Posterior Elbow Dislocations
1. Crepitus is usually absent in children with a dislocation and the
forearm appears shortened.
2. The prominence produced by the distal humeral articular surface is
more distal and is palpable as a blunt articular surface.
3. The tip of the olecranon is displaced posteriorly and proximally so
that its triangular relationship with the epicondyles is lost.
4. The skin may have a dimpled appearance over the olecranon fossa.
5. If the dislocation is postero-lateral, the radial head also may be
prominent and easily palpable in the subcutaneous tissues.

42. Anteroposterior (AP) and lateral x-rays
Anteroposterior (AP) and lateral x-rays usually are diagnostic of a
posterior elbow dislocation.
There is a greater superimposition of the distal humerus on the
proximal radius and ulna in the AP view.
The radial head may be proximally and laterally displaced, or it may be
directly behind the mid-distal humerus, depending on whether the
dislocation is postero-lateral, posterior, or posteromedial

43. Management.
Nonoperative Treatment of Posterior Elbow Dislocations.

44. Operative Treatment of Posterior
Elbow Dislocations

45. MANAGEMENT OF EXPECTED ADVERSE OUTCOMES
AND UNEXPECTED COMPLICATIONS RELATED TO
POSTERIOR ELBOW DISLOCATIONS

46. Recurrent Posterior Dislocations
Recurrent posterior elbow dislocation is rare. In the combined series of
dislocations, only 2 of 317 patients (0.6%) experienced recurrent
dislocations.
Approximately 80% of recurrent dislocations are in males.
Three investigators have reported bilateral cases.
Pathology Contributing to Recurrent Posterior Dislocations
1) Osborne and Cotterill126 suggested that articular changes are
secondary and that the primary defect is a failure of the posterolateral
ligamentous and capsular structures to become reattached after
reduction.
2) With recurrent dislocations, the radial head impinges against the
posterolateral margin of the capitellum, creating an osteochondral
defect.

47. Management
Because nonsurgical management is so often unsuccessful, the
treatment of recurrent posterior elbow dislocations is predominately
surgical.
Various surgical procedures have been described to correct bone and
soft tissue abnormalities

48. ANTERIOR ELBOW DISLOCATIONS
Mechanisms of Injury for Anterior Elbow Dislocations:
Anterior elbow dislocations usually are caused by a direct blow to the
posterior aspect of the ɻexed elbow.
Hyperextension of the elbow also has been implicated in one study.
Associated Injuries with Anterior Elbow Dislocations
Associated fractures are common.
In children, the triceps insertion may be avulsed from the olecranon
with a small piece of cortical bone. This fragment usually reduces to the
olecranon after reduction.

49. Signs and Symptoms of Anterior Elbow Dislocations
The elbow is held in extension upon presentation.
There is a fullness in the ante-cubital fossa.
Swelling usually is marked because of the soft tissue disruption
associated with this type of dislocation.
There is severe pain with attempted motion. A careful neurovascular
examination is mandatory.

50. MEDIAL AND LATERAL ELBOW
DISLOCATION
Signs and Symptoms of Medial and Lateral Elbow Dislocations
In an incomplete lateral dislocation, the semilunar notch articulates
with the capitulo-trochlear groove, and the radial head appears more
prominent laterally.
There is often good ɻexion and extension of the elbow, increasing the
likelihood that a lateral dislocation will be overlooked. In a complete
lateral dislocation, the olecranon is displaced lateral to the capitellum.
This gives the elbow a markedly widened appearance

51. DIVERGENT ELBOW DISLOCATION
Divergent dislocation represents a posterior elbow dislocation with
disruption of the interosseous membrane between the proximal radius
and ulna with the radial head displaced laterally and the proximal ulna
medially.

52. TREATMENT OPTIONS FOR
DIVERGENT ELBOW DISLOCATIONS
Closed Reduction in Divergent Elbow Dislocations
Divergent dislocations are typically easily reduced using closed
reduction under general anesthesia.
Reduction is achieved by applying longitudinal traction with the elbow
semiextended and at the same time compressing the proximal radius
and ulna together.

53. MEDIAL EPICONDYLE APOPHYSIS
FRACTURES
Mechanisms of Injury for Medial Epicondyle Apophysis Fractures:
A direct blow, avulsion mechanisms, and association with elbow
dislocation.
Among more recent investigators, however, only Watson-Jones described this
injury as being associated with a direct blow to the posterior medial aspect of the
elbow.
Smith proposed that when a child falls on his outstretched upper extremity with
the elbow in extension, the wrist and fingers are often hyperextended as well,
placing an added tension force on the epicondyle by the forearm flexor
muscles

54. TREATMENT OPTIONS FOR MEDIAL
EPICONDYLE AVULSION FRACTURES
Nonoperative Treatment of Medial Epicondyle Avulsion Fracture.

55. PULLED ELBOW SYNDROME
(NURSEMAID’S ELBOW)
Subluxation of the annular ligament, or pulled elbow syndrome, is a
common elbow injury in young children.
The term “nursemaid’s elbow” and other synonyms have been used to
describe this condition.
The mean age at injury is 2 to 3 years, with the youngest reported
patient 2 months of age.
Mechanisms of Injury for Pulled Elbow Syndrome
Longitudinal traction on the extended elbow is the usual mechanism of
injury. Cadaver studies have shown that longitudinal traction on the
extended elbow can produce a partial slippage of the annular ligament
over the head of the radius and into the radio-capitellar joint,
sometimes tearing the subannular membrane.

56. Lateral Condyle Fractures
Fractures of the lateral humeral condyle are transphyseal, intraarticular injuries.
As such, they frequently require open reduction and fixation.
They are the second most common operative elbow injury in children, second in
frequency only to supracondylar fractures.
The capitellum is the first secondary ossification center of the elbow to appear,
usually around 2 years of age. The lateral epicondyle is the last, often not appearing
until 12 or 13 years of age.
The two ossification centers fuse at skeletal maturity.
Mechanism of Injury
Lateral condylar fractures are generally the result of a fall on an outstretched arm.
The fall may produce a varus stress that avulses the lateral condyle or a valgus force
in which the radial head directly pushes off the lateral condyle.

58. Complications
1) cubitus varus,
2) lateral spur formation,
3) delayed union, and
4) nonunion with or without cubitus valgus.
5) Growth Arrest:Although lateral condyle fractures cross the germinal layer of the
physis and are classified as Salter-Harris type IV injuries, growth arrest is a rare
complication.
6) Fishtail Deformity and Avascular Necrosis: The cause of fishtail deformity of the
distal humerus is uncertain.
oRutherford noted this deformity in 9 of 10 patients who had unreduced lateral
condyle fractures and hypothesized that malunion at the medial extent of the
fracture results in growth arrest of the lateral trochlea
oHowever, Morrissey and Wilkins noted it after a variety of fractures of the distal
humerus and attributed it to AVN

59. Radial Head and Neck Fractures
In children, the cartilaginous radial head is resistant to fracture, and
children are more likely to sustain fractures of the radial neck than
fractures of the head.
The secondary ossification center of the proximal radius appears as a
small sphere between the third and fifth years of life and fuses with the
shaft between the ages of 16 and 18 years.
Mechanism of Injury
Fractures of the radial head or neck may occur as a result of two
different mechanisms.
1. Usually they result from a fall onto an outstretched hand, with the
elbow in extension and valgus.
2. Fracture of the radial neck may also occur as a result of dislocation
of the elbow

60. Classification

61. Radiographic Findings.

62. Percutaneous and
Intramedullary Reduction.
1) In type II (30 to 60 degrees of angulation) and type III (>60 degrees of
angulation) radial neck fractures, we first attempt closed reduction
under conscious sedation or general anesthesia. If we are unable to
reduce the angulation to less than 30 degrees, we usually attempt
percutaneous or intramedullary reduction.
2) A number of authors have described using a K-wire to joystick the
proximal fragment into position percutaneously.
3) When attempting a percutaneous joystick reduction, it is important to
avoid injury to the posterior interosseous nerve.
Métaizeau and colleagues described reducing the radial
neck by passing an intramedullary pin in a distal to proximal
Direction.

63. Radial Head Excision
The role of radial head excision is poorly defined. Classically, radial head
excision has not been advocated in children because of concern
regarding growth disturbance and wrist and elbow deformity.
Complications of radial head and neck fracture.
1. Loss of motion may be caused by joint incongruity (malunion),
2. enlargement of the radial head (overgrowth),
3. AVN,
4. fibrous adhesions, or proximal radioulnar synostosis.

64. Olecranon Fractures
Fractures of the olecranon are relatively uncommon and account for only
approximately 5% of elbow fractures.
They are associated with other elbow injuries (usually the medial
epicondyle) in 20% to 50% of cases.
Surgical treatment is required for 10% to 20% of olecranon fractures.
Several anatomic factors make olecranon fractures less common and less
severe in children than in adults.
First, because the olecranon is predominantly cartilage, particularly in
younger children, there is a smaller chance of a fracture occurring with a
direct blow to the olecranon.
Second, the thick periosteum and relatively thin metaphyseal cortex of the
olecranon predispose it to minimally displaced greenstick fractures

65. Mechanism of Injury
Olecranon fractures are usually the result of a hyperextension injury.
However, they may also be caused by a direct blow to the flexed elbow,
hyperflexion injury, or shear force.
A varus hyperextension injury may be associated with lateral dislocation
of the radial head, a Bado type III Monteggia lesion.

66. Metaphyseal Fractures of the Olecranon:
1. Flexion type
2. Extension type
3. Shear injures
a) Flexion shearing
b) Extension shearing

67. Nonoperative Treatment of
Fractures of the Coronoid Process
in Fractures of the Proximal Ulna

68. Operative Treatment of Fractures Involving the Proximal
Apophysis and Olecranon Metaphysis in
Fractures of the Proximal Ulna
Closed Reduction and Percutaneous Pinning

69. Open Reduction and Tension-Band Fixation

70. Open Reduction and Compression Screw Fixation

71. MONTEGGIA FRACTURE-
DISLOCATIONS
Monteggia fracture-dislocations are a rare but complex injury usually
involving a fracture of the ulna associated with proximal radio-ulnar
joint dissociation and radio-capitellar dislocation.
These injuries comprise less than 1% of all pediatric forearm fractures
and typically aʃect patients between 4 and 10 years of age.
Classification of Monteggia Fracture-Dislocations

72. E-story.
1814 Giovanni Batista Monteggia, a surgical pathologist and public
health official in Milan, Italy
“a traumatic lesion distinguished by a fracture of the proximal third of
the ulna and an anterior dislocation of the proximal epiphysis of the
radius.”
1967 Jose Luis Bado, while director of the Orthopedic and Traumatology
Institute in Montevideo, Uruguay, classification of Monteggia lesions.

73. TYPE I
DEFINITION: A type I lesion is an anterior dislocation of the radial head
associated with an ulnar diaphyseal fracture at any level. This is the
most common Monteggia lesion in children.
ULNAR FRACTURE SITE: metaphysis or diaphysis INJURY MECHNISMS:
direct trauma, hyperpronation, and hyperextension

74. TYPE I
SIGNS AND SYMPTOMS:, swelling about the elbow, significant pain and
limted elbow flexion and extention an forearm supination and
pronation, mild valgus, ecchymosis on the volar aspect, PIN pulsy,
fullness in the cubital fossa
RADIOGRAPHIC EVALUATION: maybe normal on AP despite obvius
disruption on lateral view. Line drawn through the center of the radial
neck and head should extend directly through the center of the
capitellum, and remain intact regardless of the degree of flexion or
extension of the elbow

75. TREATMENT: An anatomic, stable reduction of the ulnar fracture
Percutaneous intramedullary fixation of complete transverse and short
oblique ulna fractures is standard. Open reduction and internal fixation
with plate and screws of the rarer long oblique and comminuted
fracture is also standard
stable reduction of the radial head dislocation Irreducible or unstable
radial head approached surgically usually involves repairing
entrapped soft tissues.
This aggressive approach avoids late complications.

76. A long-arm cast
4 to 6 weeks
forearm in slight supination and the elbow flexed 90 to 110 degrees
depending on the degree of swelling.
Radiographs are obtained every 1 to 2 weeks until fracture healing.

77. TYPE II
DEFINITION: A type II lesion is a posterior dislocation of the radial head
associated with an ulnar diaphyseal or metaphyseal fracture. This is the
most common lesion in adults but very rare in children
ULNAR FRACTURE SITE: metaphysis or diaphysis
INJURY MECHNISMS: direct force and sudden rotation and supination
CLINICAL FINDINGS: The elbow region is swelling, posterior angulation
of the proximal forearm, marked prominence in the area posterolateral
to the normal location of the radial head.

78. RADIOGRAPHIC EVALUATION: The typical finding is a proximal
metaphyseal fracture of the ulna with possible extension into the
olecranon. Midshaft fractures also occur, with an oblique fracture
pattern. The radial head is dislocated posteriorly or posterolaterally and
should be carefully examined for other injuries.
Accompanying fractures of the anterior margin of the radial head have
been noted.

79. TREATMENT: Ulnar reduction
longitudinal traction.
Radial head reduction spontaneously or with gentle, anteriorly
directed force over the radial head.
If the ulnar fracture is stable cast immobilization with the elbow in
extension. If the ulnar fracture is unstable percutaneous
intramedullary K-wire
Comminuted or very proximal fractures open reduction and internal
fixation with plate and screws or tension band fixation.

80. The Boyd approach can be used to obtain reduction of the radial head if
it cannot be obtained through closed manipulation.
Associated compression fractures of the radial head require early
detection to avoid late loss of alignment. Open reduction and internal
fixation may be required to maintain radiocapitellar joint stability.
Cast immobilization
usually 6 weeks
Longitudinal traction and pronation of the forearm and immobilization
in 60 degrees flexion or complete extension

81. Type 3
DEFINITION: A type III lesion is a lateral dislocation of the radial head
associated with an ulnar metaphyseal fracture. This is the second most
common pediatric Monteggia lesion.
ULNAR FRACTURE SITE: metaphysis INJURY MECHNISMS: varus stress
at the level of the elbow
CLINICAL FINDINGS: Lateral swelling, varus deformity of the elbow, and
significant limitation of motion, especially supination, are the hallmarks
of lateral (type III) Monteggia fracture-dislocations. Again, these signs
can be subtle and missed by harried clinicians.
RADIOGRAPHIC EVALUATION: Radiographs of the entire forearm should
be obtained because of the association of distal radial and ulnar
fractures with this complex elbow injury

82. TREATMENT: As with any Monteggia lesion, treatment is aimed at
obtaining and maintaining reduction of the radial head, either by open
or closed technique. This is usually performed by anatomic, stable
reduction of the ulnar fracture that in turn leads to a stable reduction of
the proximal radioulnar and radiocapitellar joints.
Immobilization: If radial head dislocated in straight lateral or
anterolateral 100 to 110 degree
If there is posterolateral component for dislocation 70 to 80 degree

83. TYPE IV
DEFINITION: A type IV lesion is an anterior dislocation of the radial head
associated with fractures of both the ulna and the radius. The original
description was of a radial fracture at the same level or distal to the
ulna fracture.
ULNAR FRACTURE SITE: diaphysis
INJURY MECHNISMS: hyperpronation and direct blow
CLINICAL FINDINGS: More swelling and pain are present, Particular
attention to the neurovascular status, increased risk for a compartment
syndrome.
Failure to recognize the radial head dislocation is the major
complication of this fracture.

84. RADIOGRAPHIC EVALUATION: The radial and ulnar fractures usually are
in the middle third, with the radial fracture usually distal to the ulnar
injury. They may be complete or greenstick.
TREATMENT: Stabilization of the radial fracture converts a type IV lesion
to a type I lesion Closed reduction ,intramedullary or plate fixation
fallow type I protocol.
Immobilized in a long-arm cast 4 to 6 weeks in 110 to 120 degrees of
flexion with the forearm in neutral rotation.
A short-arm cast is used thereafter if additional fracture protection is
necessary.
Reduction schematic for type IV Monteggia fracture

85. Monteggia Equivalent Lesions
Type I Equivalents
Isolated dislocation of radial head
Radial neck fracture (isolated)
Radial neck fracture in combination with a fracture of the ulnar
diaphysis
Radial and ulnar fractures with the radial fracture above the junction
of the middle and proximal thirds
Fracture of ulnar diaphysis with anterior dislocation of radial head and
an olecranon fracture

86. Type II Equivalents Fractures of the proximal radial epiphysis or radial
neck.
Type III and Type IV Equivalents Fractures of the distal humerus
(supracondylar, lateral condylar) in association with proximal forearm
fractures.

87. Thank you every for “patience listening”