Oblique or comminuted fractures should be treated with open reduction and plate-fixation. 3 Closed reduction can be sufficient for Monteggia fractures in which the involved ulnar fracture is plastic, greenstick, or transverse. 2 The above patient’s injury is a Type I Monteggia fracture, which comprise 14.5% to 30% of all Monteggia fractures and are often the result of high-energy mechanisms. 1 Monteggia fractures are classified using the Bado radiographic classification system, which is based on the direction of the radial head dislocation and angular apex of the ulnar deformity. The ulnar fracture is usually obvious however, the radial head dislocation can be easily overlooked it is estimated that 33% of Monteggia fractures are missed during initial presentation. Discussion:Ī Monteggia fracture is a traumatic ulnar fracture combined with a dislocation of the proximal radioulnar joint. On the anteroposterior forearm X-ray, there is a closed, displaced, comminuted fracture of the ulna (blue arrow). On the axial elbow X-ray, the radial head (red arrow) is dislocated anteriorly from the humerus the humeroulnar articulation is intact. Subsequently, the patient was admitted by orthopedics for reduction of the radial head and open reduction internal fixation (ORIF) of the ulna. Left upper limb radiographs (shown) indicated a fracture of the ulna shaft and dislocation of the radial head consistent with a Monteggia fracture. The patient also reported pain in his right arm, the back of his head, and to his jaw. Sensation and circulation in the affected limb were intact. The patient was unable to move the hand and wrist secondary to pain. The pain in his arm was sharp in nature, did not radiate, and was worse with movement or palpation. The patient reported that two males struck his left arm with a skateboard and punched him in the jaw. A 20-year-old male presented to the emergency department with a closed left forearm deformity and 10/10 pain after being assaulted. Nevertheless, to obtain good treatment results, it is important to accurately diagnose and promptly treat the condition. However, since it was difficult to perform manual reduction owing to a double fracture of the ulna, surgery was the only treatment option available in the presented patient. Therefore, conservative treatment can often be employed in cases with timely diagnosis. Since Monteggia fractures in children are mostly incomplete greenstick fractures, reduction and maintenance are easy to perform. It is important to perform accurate radiography in 2 planes (i.e., frontal and lateral views). Since a child who has sustained such an injury may be experiencing pain and/or anxiety and therefore unable to sufficiently express himself, the presence or absence of any swelling, deformities, abrasions possibly due to direct force, and ROM limitation should be carefully examined. While treating a Monteggia fracture, examination of both the cubital joint and the wrist joint is important because a fracture of the distal forearm may also occur, as in this case. The impact from the fall was subsequently transmitted to the elbow, which was in valgus extension, and resulted in dislocation of the radial head and fractures in the proximal end of the ulna. reported a similar case of an affected child who fell with their forearm pronated and the wrist dorsiflexed, which resulted in distal radius and ulna fractures. In addition, it is difficult to infer the mechanisms of double fractures, as in this case. There is no established theory of the pathogenesis of Monteggia fracture. This is the only case wherein long-term postoperative follow-up evaluation was feasible until adulthood. The observation period in all previous reports of Monteggia injury with ipsilateral forearm fractures has been 2 years or less, except for a 6-year follow-up reported by Biyani. To our knowledge, beyond these cases, only 3 cases of Monteggia fractures with ipsilateral fracture of the distal radius and ulna have been reported, as in the present case. They found that only one out of 33 or 2 out of 102 patients with Monteggia fractures exhibit associated fractures. Fractures of the forearm, including distal radius fractures, have rarely been reported in association with Monteggia fractures, as documented by Letts et al. Nerve injuries, vascular injuries, compartment syndrome, and ipsilateral fractures of the forearm, in the early stages of the injury, as well as redislocation and malunion of the ulna fracture site, in the late stages, have been reported as complications of Monteggia fractures.
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