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paediatric monteggia fracture dr mohamed ashraf alleppey kerala india.pptx

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paediatric monteggia fracture is often missed especially by less experienced orthopaedic surgeon. once missed ,it can lead to progressive deformity of the elbow,restricted elbow and forearm movements. subsequent management is often less satisfactory and give inferior results. a high degree of suspicion is often needed in all pediatric elbow injuries brought to the emergency department. the presentation is by prof.mohamed ashraf ,head of the department of orthopaedics. govt TD MEDICAL COLLEGE,ALLEPPEY,KERALA, INDIA

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paediatric monteggia fractures Dr Mohamed Ashraf Prof and Head Govt Medical College Alleppey Kerala,india drashraf369@gmail.com
GIOVANNI BATTISTA MONTEGGIA 1814 EPONYMOUSLY NAMED BY PERRIN,1909
Why important? Rapid recovery of elbow mobility Prevention of late complications Symptomatic radial head pain flexion block cubitus valgus neurological supination limitation
How often missed 1.5-3 % of all pediatric elbow injuries Peak age- 4 to 10 years Missed- upto 20 % Radial head unreduced for 4 weeks or more- NEGLECTED
Why missed Clinical suspicion Proper interpretation of well exposed properly centered x-rays. Redisplacement of fracture or radial head Plastic deformation-often missed Bae-2016 Most missed by non-pediatric ortho,ER person,residents
Patho mechanics
Patho anatomy Shortened or angulated ulna leads to radial head dislocation. Interosseous membrane contracted and shortened.[hence corrective osteotomy proximal] Untreated- progressive elbow instability,progressive deformity and stiffness of elbow and forearm. Missed case -multiple procedures with inferior outcome
types 4 types 3 variants-isolated rad head,#ulna and rad neck,bb#with radius proximal Letts-green stick ulna
Classification JOSE LUIS BADO 1958
BADO TYPE Type depends on injury mechanism Neurodeficite in 10-20 % cases Bado 2 -ulnar nerve Bado 3 -PIN waters 2012
Bado 1 70-75 % apex anterior, anterior dislocation pronated FA fall
Bado 2 rare in children 3-6 % axial load on partly flexed elbow direct trauma to mid-supinated FA penrose 1951
Bado 3 15-20 % apex lateral lateral dislocation fall on pronated FA with varus stress
Bado 4 high energy trauma FA pronated fall
LETTS CLASSIFICATION
Clinical
radiology
radiology greenstick plastic genetic
Never miss this line!!!
X-ray Doubtful-take contralateral elbow Dynamic imaging with fluroscopy
X-ray mimicker Congenital head dislocation Hypoplastic capitellum Convex radial head Radial shaft bowing and too long No trauma Difficult reduction Usually post dislocation Opposite elbow affected Waters 2012
management Closed reduction and casting[ under C-arm] Open reduction and nailing [ESIN] Open reduction and plating
Current principles RING and WATERS Restoration of length and alignment of ulna Closedreduction-lengthstable fractures [transverse and short oblique] Unstable radial head in stable#- nail plating-length unstable fractures [long oblique and comminuted] Osteotomy Plating ,radial head stabilisation- neglected#
Treatment RING AND RAMSKI Depends on fracture pattern Plastic deformation-closed manipulation Greenstick injury-closed manipulation Unstable radial head even @100-ulna fixation Stable radial head-close observation Transverse/short oblique-CMR +/_ fixation Long oblique/comminuted- ORIF/plate fixation ORIF- upto 4-6 weeks
Plastic deformity Cosmetic and Functional aspects 10 yr - 15 deg 6-10 yrs- 20 deg correction 5 yrs-remodelling Under GA ,3-5 mts transverse force over the apex Avoid epiphysis INJURY
missed If elbow not included in xray If radial head position overlooked
Late cases DCP or LCP preferred for neglected cases. More chance of radial head dislocation More chance of forearm restriction. Plastic deformation difficult to identify later. Dysplastic radial head may be the only sign
Radial head Closed reduction Open-clear soft tissue,repair annular,elbow 120 deg,transarticular pin.
missed Radial head Can be open reduced -6 months After 6 months-1 year-leave till skeletal maturity-excision later Late annular reconstruction- Extensor aponeurosis[boyd], Triceps middle fascia[bell tawse] Triceps lateral fascia[lloyd roberts]
Late cases problem solving Annular ligament reconstruction- 1]palmaris longus 2]pedicled forearm fascia 3]pedicled triceps fascia. 4]remnant repair 5]synthetic annular ligament levin et al cureus
Late cases surgical tips Speed and boyd -boyd approach -Osteotomy ulna, -radial head reduction, -R-C or R-U pin stabilisation -FA or triceps muscle facia 1.3x 11.5 cm around neck and suture to itself,if stable pin can be removed -fix ulna- transverse,oblique or step-cut osteotomy chetan peshin 2020
Thank you delegates and team palakkad

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paediatric monteggia fracture dr mohamed ashraf alleppey kerala india.pptx

  • 1. paediatric monteggia fractures Dr Mohamed Ashraf Prof and Head Govt Medical College Alleppey Kerala,india drashraf369@gmail.com
  • 3. Why important? Rapid recovery of elbow mobility Prevention of late complications Symptomatic radial head pain flexion block cubitus valgus neurological supination limitation
  • 4. How often missed 1.5-3 % of all pediatric elbow injuries Peak age- 4 to 10 years Missed- upto 20 % Radial head unreduced for 4 weeks or more- NEGLECTED
  • 5. Why missed Clinical suspicion Proper interpretation of well exposed properly centered x-rays. Redisplacement of fracture or radial head Plastic deformation-often missed Bae-2016 Most missed by non-pediatric ortho,ER person,residents
  • 7. Patho anatomy Shortened or angulated ulna leads to radial head dislocation. Interosseous membrane contracted and shortened.[hence corrective osteotomy proximal] Untreated- progressive elbow instability,progressive deformity and stiffness of elbow and forearm. Missed case -multiple procedures with inferior outcome
  • 8. types 4 types 3 variants-isolated rad head,#ulna and rad neck,bb#with radius proximal Letts-green stick ulna
  • 10. BADO TYPE Type depends on injury mechanism Neurodeficite in 10-20 % cases Bado 2 -ulnar nerve Bado 3 -PIN waters 2012
  • 11. Bado 1 70-75 % apex anterior, anterior dislocation pronated FA fall
  • 12. Bado 2 rare in children 3-6 % axial load on partly flexed elbow direct trauma to mid-supinated FA penrose 1951
  • 13. Bado 3 15-20 % apex lateral lateral dislocation fall on pronated FA with varus stress
  • 14. Bado 4 high energy trauma FA pronated fall
  • 19. Never miss this line!!!
  • 20. X-ray Doubtful-take contralateral elbow Dynamic imaging with fluroscopy
  • 21. X-ray mimicker Congenital head dislocation Hypoplastic capitellum Convex radial head Radial shaft bowing and too long No trauma Difficult reduction Usually post dislocation Opposite elbow affected Waters 2012
  • 22. management Closed reduction and casting[ under C-arm] Open reduction and nailing [ESIN] Open reduction and plating
  • 23. Current principles RING and WATERS Restoration of length and alignment of ulna Closedreduction-lengthstable fractures [transverse and short oblique] Unstable radial head in stable#- nail plating-length unstable fractures [long oblique and comminuted] Osteotomy Plating ,radial head stabilisation- neglected#
  • 24. Treatment RING AND RAMSKI Depends on fracture pattern Plastic deformation-closed manipulation Greenstick injury-closed manipulation Unstable radial head even @100-ulna fixation Stable radial head-close observation Transverse/short oblique-CMR +/_ fixation Long oblique/comminuted- ORIF/plate fixation ORIF- upto 4-6 weeks
  • 25. Plastic deformity Cosmetic and Functional aspects 10 yr - 15 deg 6-10 yrs- 20 deg correction 5 yrs-remodelling Under GA ,3-5 mts transverse force over the apex Avoid epiphysis INJURY
  • 26. missed If elbow not included in xray If radial head position overlooked
  • 27. Late cases DCP or LCP preferred for neglected cases. More chance of radial head dislocation More chance of forearm restriction. Plastic deformation difficult to identify later. Dysplastic radial head may be the only sign
  • 28. Radial head Closed reduction Open-clear soft tissue,repair annular,elbow 120 deg,transarticular pin.
  • 29. missed Radial head Can be open reduced -6 months After 6 months-1 year-leave till skeletal maturity-excision later Late annular reconstruction- Extensor aponeurosis[boyd], Triceps middle fascia[bell tawse] Triceps lateral fascia[lloyd roberts]
  • 30. Late cases problem solving Annular ligament reconstruction- 1]palmaris longus 2]pedicled forearm fascia 3]pedicled triceps fascia. 4]remnant repair 5]synthetic annular ligament levin et al cureus
  • 31. Late cases surgical tips Speed and boyd -boyd approach -Osteotomy ulna, -radial head reduction, -R-C or R-U pin stabilisation -FA or triceps muscle facia 1.3x 11.5 cm around neck and suture to itself,if stable pin can be removed -fix ulna- transverse,oblique or step-cut osteotomy chetan peshin 2020