MONTEGGIA AND GALEAZZI FRACTURES

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MONTEGGIA AND GALEAZZI FRACTURES
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ANATOMY-ELBOW

• Hinge joint.
• Three bones form the elbow joint the humerus of
  the upper arm, and the paired radius and ulna of
  the forearm.
• The bony prominence at the very tip of the elbow
  is the olecranon process of the ulna, and the
  inner aspect of the elbow is called the
  antecubital fossa.

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• Humeroulnar joint-
• from trochlear notch of the ulna
• to trochlea of humerus
• Is a simple hinge-joint, and allows of movements
  of flexion and extension only.

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• Humeroradial joint-
• from head of the radius
• to capitulum of the humerus
• Is a hinge-joint

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• Proximal radioulnar joint.
• From-head of the radius
• to radial notch of the ulna
• pronation and supination.

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• Ligaments-
• Ulnar collateral ligament,
• Radial collateral ligament, and
• Annular ligament.

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• The muscles 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
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Movements

• The hinge-like bending and straightening (flexion
  and extension) between the humerus and the ulna.
• The complex action of turning the forearm over
  (pronation or supination) happens at the
  articulation between the radius and the ulna
  (this movement also occurs at the wrist joint).
• The hinge moves in only one plane.

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• The Arteries supplying the joint are derived from
  the anastomosis between the profunda and the
  superior and inferior ulnar collateral branches
  of the brachial, with the anterior, posterior,
  and interosseous recurrent branches of the ulnar,
  and the recurrent branch of the radial. These
  vessels form a complete anastomotic network
  around the joint.
• The Nerves of the joint are a twig from the
  ulnar, as it passes between the medial condyle
  and the olecranon a filament from the
  musculocutaneous, and two from the median.

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Monteggia fracture

• of upper third of ulna with dislocation of head
  of radius.
• Head of radius is dislocated both from the
  radioulnar articulation and from elbow joint.
• It may be displaced Ant,post,or laterally acc to
  angulature of ulnar fracture.

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DIAGNOSIS

• Every of upper shaft of ulna without of
  radial shaft should be considered to be monteggia
  unless otherwise proved.
• first X ray may show head of radius in its
  correct position, but serial X rays have to be
  taken over 1st few weeks bcoz if dislocation has
  occurred and there is instability ,head of radius
  may redisplace later.

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Displacement-3 types

• Monteggia dislocations can take place from 3
  forces and corresponding injuries seen.
• FLEXION INJURY
• EXTENSION INJURY
• ADDUCTION INJURY
• Hume fracture

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• FLEXION INJURY-10-15
• ulna is angulated
• with the convexity
• posteriorly and the
• head of radius is
• dislocated
• backwards.

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EXTENSION INJURY-85-90

• Commonest type.
• ulna is angulated with covexity ant. and
  laterally.
• With head of radius dislocated forwards and
  laterally.

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Adduction injury

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

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HUME FRACTURE

• High Monteggia injury.
• 1957 Hume described --fracture of the olecranon
  with an associated anterior dislocation of the
  radial head .
• Seen in Children.

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MECHANISM OF INJURY.

• Mervyn Evans suggested this mech.
• 1Fall on outstretched hand with twisting of the
  trunk,forcibly pronating the forearm.
• 2Direct injury-Africa-Direct blow on the back
  of forearm with a stickwhile arm is raised
  warding off an attacker.

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TREATMENT

• CONSERVATIVE
• OPERATIVE

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CONSERVATIVE-

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

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Redn. of extension injury.

• Longitudinal traction of forearm with with the
  elbow flexed as much as possible without
  compromising the blood supply.
• Forearm is stable in supination
• Plaster windowed for radial pulse

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Redn of adduction injury.

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

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Redn of flexion injury

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

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OPERATIVE TREATMENT.

• Advisable in adults.
• Open redn of ulna and rigid int. fixation
  preferable with a plate..
• Dislocation of head of radius red. spontaneously
  when the deformity of ulna has been reduced.

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OPERATIVE TECHNIQUE.

• of ulna is exposed ,reduced and fixed by a
  compression plate,or IM nail.
• Intraop take xray elbow in 2 planes.
• If head of radius is perfectly reduced, the
  position is accepted and well padded plaster cast
  is applied from metacarpals to axilla- with elbow
  at right angles and forearm supinated.

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• If X ray shows head of radius is not reduced,
  then it must be exposed and reduced under direct
  vision.
• Annular lig. --usually cause obstruction-incised.

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COMPLICATIONS

• 1.UNREDUCED DISLOCATION OF HEAD OF RADIUS.
• 2.TRAUMATIC OSSIFICATION AROUND RADIAL HEAD.
• 3.PIN PALSY
• 4.CROSS UNION B/W RADIUS AND ULNA.
• 5.DISLOCATION OF LOWER END OF ULNA
• 6.UN-UNITED OF ULNA.

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Unred. disl. of head of radius.

• Rx
• Excision of displaced head of radius.
• Prod inc. elbow flexion and good range of
  pronation and supination.
• NOT done in CHILDREN.removal of upper radial
  epiphysisinequality of length of forearm bones
  and cause further disl. of RU joints both sup.
  and inf.

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Traumatic ossi. around radial head.

• Excision of radial head and the block of bone
  attached to it.
• Recurrence.
• Can be reduced by Sx delayed 6-12 months after
  injury with elbow immobilised for atleast 2
  weeks.
• NO Physiotherapy,manipulation and passive excs
  during rehab period.

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PIN PALSY

• Common with Adduction dislocation.
• Prognosis good in early complete reduction of
  head of radius.
• Late PIN palsy due to inadequate redn of radial
  head.

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Cross union b/w radius and ulna.

• Bony fusion b/w neck of radius and 3 site of
  upper 3rd of ulna.
• Difficult to Rx.
• B coz proximity of elbow jt and PIN.
  Recurrence is high.
• Perm limitation of Radioulnar movt.

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Dislocation of lower end of ulna

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

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Un united of ulna

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

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