Monteggia Fracture Dislocation

Monteggia fracture is the fracture of the proximal third of the ulna with dislocation of the radial head. The fracture is more common in children and rare in adults. Treatment will depend on the age of the patient.The normal position of the radial head and shaft should line up with the capitellum in any position. Dislocation of the radial head may be missed.

normal position

Type I Monteggia fractures occur in the middle or proximal third of the ulna with anterior dislocation of the radial head and characteristic apex anterior angulation of the ulna. This is the most common type and occurs in about 60% of cases. In children, you will immobilize the fracture in flexion and supination. Flex the elbow more than 90 degrees to relax the biceps.

Only 15% of Monteggia fractures are Type II. This fracture occurs in the middle or proximal third of the ulna with posterior dislocation of the radial head and characteristic apex posterior angulation of the ulna. You will need to immobilize this fracture in extension.

type ii

20% of Monteggia fractures are type III. These fractures occur at the ulna just distal of the coronoid process with lateral dislocation of the radial head.

Type IV only occur 5% of the time and is classified as the fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head, and a fracture of the proximal third of the radius below the bicipital tuberosity. This fracture will require surgery, even in children.

TypeIVWith Monteggia Fracture Dislocations, it is important to perform a neurovascular exam. Nerve injury, especially involving the posterior interosseous nerve, is not uncommon. Additionally, you will want to watch the patient for compartment syndrome.

Treatment in adults consists of ORIF of the ulna—when the ulna is properly aligned and fixed, the radial head will reduce by itself. Radial head instability may usually be caused by nonanatomic reduction of the ulna or by interposition of the annular ligament. Fracture of the ulna may need a bone graft for healing.

platingWhen treating pediatric patients, it is important to note that the radial head ossifies around age 4. For Type I-III fractures, you will perform a closed reduction of the ulna to restore the length of the ulna and reduce the radial head. Remember to immobilize in flexion and supination. Type IV fractures or cases where you are unable to reduce the radial head or the length of the ulna in pediatrics will require surgery. Fixation will be done with an IM rod or a plate.

When treating old cases, you will perform an osteotomy of the ulna and an open reduction of the radial head, followed by plating of the ulna.

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Detecting Misleading Patients

How can you tell if a patient is misleading you?

The patient may be malingering, lying, or exaggerating about the extent of their injuries. Detecting the occasional malingering patient can be difficult. malingeringThe physician relies on the patient’s complaints in order to treat the patient. Verbal communication with the patient is important. The patient may attempt to mislead the physician for personal gain such as with workman’s compensation claims or car accidents so they can take more time off or gain more compensation.

Sometimes, patients may allege that they are experiencing a lot of pain and weakness or that they have lost their pain medication in an attempt to get more drugs. The physician may find disparity between the patient’s explanation of the injury or condition and the actual findings during the physical exam.

Overreaction to pain is another finding. The patient may exaggerate the condition and overreact during the exam. This can take the form of extreme facial expressions, sweating, or verbal responses.

Research shows that communication can be verbal or nonverbal and that it is also possible to tell if someone is lying to you based on their body language. Verbal communication accounts for only 7% of the communication. How a person sounds when they are speaking accounts for 38% of communication and body language accounts for 55% of communication. Body language plays a big role in intuition. Body language gives us a message about what the other person is thinking. It is important to interpret the patient’s body language in order to determine if they are misleading us.

Body language involves:

  • Eye contact
  • Facial expressions
  • Gestures
  • Posture and stance
  • Space relationship

Although physicians are very good at interviewing the patient for medical reasons, they may not be good at interpreting a patient’s body language. Verbal communication is important however, nonverbal communication is more important. Facial expressions and gestures can be useful for doctors when they suspect that the patient is not telling the truth. There are many experts who claim they can detect if a person is in fact lying to them.

Here are some of the observational cues if the person is lying:

  1. Hand to Face Gestures
    1. Playing around with their mouth or couch the side of their nose.
    2. They may be actually wanting to cover their mouth which comes from childhood—similar to covering the mouth to cover a lie.
    3. Playing with a shirt collar is also a cue. facegesture
    4. Rubbing the back of the neck—this gesture may be done similar to the way a mother would rub that back of a child’s neck to provide comfort to a hurt child. Questions may cause the patient discomfort and rubbing the neck gives the patient comfort. The patient may not be doing these self-comforting gestures throughout the meeting, rather, only when certain questions are being asked.
  2. Avoiding Eye Contact
    1. Occurs suddenly
    2. May signal that the patient is not telling the truthlegs and feet
  3. How the patient uses their feet and legs
    1. It is also important to take note of when the patient is seated.
    2. The patient has freedom of the use of their legs so watch for rocking or fidgeting motions with their legs in response to certain questions.
    3. The legs and feet are the furthest away for the brain and hardest to control
  4. How the patient uses their hands
    1. The patient will typically remain with the hands open when relaxed
    2. During certain questions the patient may begin to place their hands in their pockets, behind their back, or under their arm pits.hands

Look for these nonverbal signals that the patient is uncomfortable. This may suggest that the person is misleading you. It may not be difficult to notice the signs of a patient lying once you learn to recognize these cues.

Pudendal Nerve Palsy

Damage to the pudendal nerve can occur suddenly as a result of trauma to the pelvic region, prolonged bicycling, fractures, or from falls. The pudendal nerve re-enters the pelvis under the sacrotuberous ligament and gives three branches.

usepudendalThe first branch, the inferior rectal nerve, provides rectal tone and perianal sensation. The second branch, the Perineal Nerve, gives scrotal sensation. The third branch, the dorsal nerve of the penis, give branches to the corpus callosum.

The pudendal nerve arises from S2, S3, and S4. The pudendal nerve carries sensations to the external genitals, the lower rectum, and the perineum.

The symptoms of pudendal nerve palsy can start suddenly or develop over time. Symptoms include the loss of sensation or numbness, burning or stabbing pain, difficulty with bladder and bowel functions, and sexual dysfunction.

morenerves

Causes of pudendal nerve palsy include prolonged sitting exercises such as bicycling or following fracture table traction—the nerve is compressed between the ischium and the hard object.

Treatment options are typically conservative, as the condition is usually transient and will improve over time. Treatment includes:

  • Restbike
  • Physical therapy
  • Stretches and exercises
  • Anti-inflammatory medications
  • Injections/nerve blocks
  • Surgery (as a last resort)

 

Prevention options for bicyclists consists of changing the sitting position while riding the bicycle and changing the seat from a narrow seat to a wider seat.

Unbelievable Bacteria- Part II

Why do open fractures have increased risk for infection?

The presence of bacteria within an open wound increases the risk of colonization when hardware is used. Once the hardware is colonized, the bacteria grows rapidly. During the rapid growth phase, the bacteria secretes a polysaccharide sugar layer, called a “biofilm”, or slime layer that encases the bacteria. This biofilm provides protection to the bacteria against the body’s defenses and antibiotics.

biooo

Within the biofilm, there are channels that allow the bacteria to pass nutrients, messaging signals, and even DNA to each other. The bacteria pass on their DNA by:

passDNA

  1. Transformation
  2. Transduction
  3. Conjugation

Transformation is when a bacterial cell ruptures, releasing its DNA, which is then taken in by another bacteria. Transduction occurs when DNA is transferred from one bacterium to another by a virus. Phage DNA and proteins are made and bacterial chromosomes are broken up, completing the gene transfer. The phage release themselves from the host, carrying either bacterial or phage DNA. Conjugation occurs when two bacteria attach themselves together with a sex pilus and exchange their DNA.

How does the bacteria become resistant to antibiotics?

beta

The bacteria can alter the genes they express by as much as 50-60%. By doing this, the bacteria can produce enzymes such as beta-lactamases, which destroy certain antibiotics before they can reach their target site. They can also make Efflux pumps which expel antibacterial agents from the cell before it can reach its target site. Finally, by expressing different genes, the bacterial cell wall can be altered to no longer contain the binding site of the antibiotic agent. Because the antibiotics cannot break through the biofilm and access the bacteria, the bacterium in the biofilm can become up to a thousand times more resistant to the antibiotics by the different mechanisms previously discussed.

If there is biofilm on the hardware, what can the physician do?

xfix

The only proven treatment, is to remove the hardware and wash the wound. However, removal of the hardware is a problem if the fracture is not healed and the fixation is needed. The physician may decide to suppress the infection, leaving the hardware until the fracture has improved. Or, the physician may decide the remove the hardware and seek an alternative method for stabilizing the fracture, such as an external fixator, and then using a biological material to help heal the fracture.

These are the issues that make infection with hardware so complex!