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.


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.


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:


  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?


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?


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!

Galeazzi Fracture

Galeazzi Fractures are a type of fracture of the radial shaft which is associated with dislocation of the distal radio-ulnar joint (DRUJ). This particular fracture is name after Ricardo Galeazzi who was an Italian surgeon in Milan. This injury is uncommon and only accounts for about 7% of all forearm fractures in adults.


A radius fracture may be short, oblique, or transverse and involves a fractures at the junction of the middle third and distal third of the radius with associated injury to the distal-ulnar joint. The closer the fracture is to the DRUJ, the more likely that it will be unstable. Dislocation of the DRUJ is usually dorsal. It may be associated with either a ligamentous injury or fracture of the styloid process of the ulna.

styloid fx

A fracture is usually located above the proximal border of the pronator quadratus muscle. The distal fragment usually moves towards the ulna. Galeazzi fractures are best treated with open reduction and internal fixation of the radius and assessment of the distal radio-ulnar joint.


Surgery is necessary. Nonsurgical treatment in adults usually results in recurrent dislocations of the distal ulna and a bad outcome. Surgery is done by a volar plate fixation. Followed by assessment of the Distal Radio Ulnar Joint (DRUJ), if stable, the forearm will be splinted in supination for six weeks. If the joint is unstable, reduce and pin the distal radio-ulnar joint in supination for about four weeks. If the joint is not reducible, open and explore the joint. Check for entrapment of the ECU.




Child Abuse

Child abuse most often occurs under 3 years of age, and if it is not recognized and reported, repeat abuse may occur in 40% of the cases. Death can occur in up to 5% of cases.

Risk factors for Child Abuse include:

  • Being the first born child
  • Single Parent
  • Stepchild
  • Disabled Child
  • Parents were abused

It is important to rule out osteogenesis imperfecta and metabolic bone disease.


Suspect Child abuse if:

  • There is a fractured femur in an infant before walking age
    • The most common orthopaedic injury associated with child abuse is a femur fracture
  • Multiple fractures in different stages of healing
    • Callus and periosteal reaction is seen
  • Unwitnessed spiral fracture
    • Spiral fractures are not a good criteria because most of them are accidental
  • Multiple soft tissue bruising
    • Skin lesions are the most common
    • Bone fracture is the second most common

skin lesions

  • Corner fracture
    • Metapheseal fracture especially in the distal femur and proximal tibia
    • Child abuse should be considered when health care providers see cornercornerfx fractures in children before they are of walking age.
  • Posterior rib fracture from a squeezing injury
  • If there is a transepiphyseal separation in the humerus
    • In Newborns
      • The olecranon moves posteriorly
      • Looks like an elbow dislocation
    • Older Child
      • Separation of the distal humerus usually occurs in younger ages

Discrepancy in the history is a clue. It is hard to explain the injury and match it with the given mechanism of the injury. Injuries in abuse mostly occur at the humerus, tibia, and femur (more in the diaphysis). When child abuse is suspected in a patient it is important to recognize the symptoms, be non-judgmental, and obtain a skeletal survey. If you suspect abuse and a skeletal survey is negative, obtain a bone scan to verify. Then consult protective services. The most frequent cause of long-term morbidity in an abused child is a head injury.