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.

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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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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.

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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.

Low Back Pain- Disc Herniation

The spine is comprised of bony vertebrae separated by discs. The neural structures of the spine include the spinal cord (T12-L1), The conus medullaris—which is the lower end of the spinal cord, and the Cauda Equina, which is the division of multiple nerve roots beginning at the level of L1. Conditions of the lumbar spine including disc herniation are a main cause of lower back pain.

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The lumbar spine (lower back) consists of five vertebrae numbered L1-L5. These vertebrae are attached to the sacrum at the lower end of the spine. The discs between the vertebrae are round cushioning pads which act as shock absorbers. In a normal disc, there are two layers—the inner disc layer, which is comprised of soft gelatinous tissue and known as the Nucleus Pulposus, and the outer disc layer—which is made up of thick strong tissue, which is known as the Annulus Fibrosis. Behind this disc lies the spinal nerve root and the cauda equina. A major disc herniation of the lumbosacral region could affect the nerve roots.

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In about 95% of all disc herniation cases, the L4-L5 or L5-S1 disc levels are involved. Herniation of the L4-L5 disc will affect the L5 nerve root. Herniation of the L5-S1 disc will affect the S1 nerve root.

spinesections

There are three types of disc herniation:

  1. Protrusion/ Bulge- A bulging disc with intact annular and posterior longitudinal ligament fibers
  2. Disc Herniation
    • Type A—Disruption of inner annular fibers with intact outer annular fibers
    • Type B—Disrupted annulus with tail of disc material extending into the disc space
  3. Sequestration
    • Free fragment without tail extending into disc space
    • Fragment may be reabsorbed spontaneously
    • May get better with the use of an epidural

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There are three typical locations for disc herniation as well:

  1. Central
    • Involves multiple nerve roots
    • Predominantly causes low back pain more than leg pain
    • May cause incontinence of the bladder and bowel
    • Urgent surgical treatment if patient presents with neurological deficits
  2. Posterolateral—usual location, most commonly involving one nerve root (the lower one)
    • For example: L4-L5 posterolateral herniation will involve L5 nerve root
  3. Foraminal
    • Occurs in 8-10% of cases
    • Involves the exiting nerve
    • Example: L4-L5 foraminal herniation will involve the L4 nerve root

Discogenic Back Pain is an internal disc disruption with early disc degeneration. Pain gets worse with flexion and sitting but, gets slightly better with extension. Forward flexion is limited on the exam and there are no radicular symptoms.

Carpal Tunnel Syndrome and Diabetes, A Challenging Problem

Approximately 20% of diabetic patients will develop carpal tunnel syndrome. Peripheral neuropathy makes the condition of the carpal tunnel worse. It is suggested that the never that already has established hypoxia caused by diabetes is more vulnerable to local compression. Other mechanisms and explanations are also involved, so it is a difficult diagnosis). Some people believe that patients with diabetic neuropathy will have a high prevalence of carpal tunnel syndrome.

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Electrodiagnostic testing (EMG and nerve studies) cannot distinguish patients with clinical carpal tunnel syndrome from patients with diabetic polyneuropathy. The decision to treat these patients should be made independently of the electrodiagnostic findings. When treating the patient, try to figure out the patient’s blood sugar level. There may be difficulty in determining if the blood sugar is under control.

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HBA1C (the glycosylated hemoglobin test) is an important blood test that shows how well the diabetes is being controlled. The test provides an average blood sugar control over the last 2-3 moths. The normal range of hemoglobin A1c is between 4% and 5.6%. When the level is 6.5% or higher, this indicated diabetes. The goal of treatment is to make sure that the patient with diabetes has hemoglobin A1c less than 7%. The higher the levels of Hemoglobin A1c, the higher the risk of developing complications. People should have the test done every three months to check and see that their blood sugar is under control. At least, the test should be done twice a year.

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The difficulty in carpal tunnel syndrome in diabetic patients is the difficulty of diagnosis, the difficulty in determining if the diabetes is being controlled or not, and if there will be surgery needed, will the patient have complications or not.

Patients who develop complications in orthopedics include: diabetics, obese patients, heavy smokers and patients taking blood thinners.

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If the condition is acute or an emergency, we have to do surgery. If the condition is elective, then surgery can wait. If the patient has poor glycemic control, then you probably don’t want to perform elective surgery on the patient such as carpal tunnel release. Remember, elective surgery can wait.

High blood sugar is linked to increased wound complications after surgery. Hemoglobin A1c is used to monitor the patient’s blood sugar level. The higher preoperative Hemoglobin A1c level, the more there is a risk factor for surgical site infection. Elective surgery can be delayed until HBA1c level becomes normal or better. Joint replacement surgery for example is delayed until HBA1c levels are less than 7%.

Since carpal tunnel syndrome is common in patients with diabetes, we need to take time to sort things out with these conditions. We need to know that the patient has better control of their diabetes. Carpal tunnel syndromes is a small surgery, but it can have catastrophic effect if we do not have a good control of the patient’s diabetes. Hemoglobin A1c will help us monitor the patient. Carpal tunnel surgery can cause complications and infection providing that high levels of HBA1c levels is a true risk factor for infection postoperatively.

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