Normally, the annular ligament ensures the stability of the radiocapitellar joint by surrounding the radial head. As a result, the unmatched humeroradial joint becomes painful and may eventually develop osteoarthritis ( 1, 3, 4, 8, 60). Dislocated PRUJ also results in the degeneration of the radial notch, which could block the reduction of the radial head ( 3, 27, 55, 56, 62). With the radial head unreduced, the capitellar facet becomes atrophic and flattened, and the radial head loses its crateriform facet due to its growth without the limitation of the humeral facet. Typical pathological changes of NMF include malunion and angulation of the ulna, refractory dislocation of the radial head, and soft tissue injury ( 1, 2, 3, 33, 39, 43, 58, 59, 60, 61). ( 56, 57) which accommodates the unique features of pediatric Monteggia lesions. Another alternative classification system was proposed by Letts et al. The biomechanics of this subset is similar to subset I, while the radial fracture could be a secondary injury ( 50, 52, 55). (IV) Concomitant fracture of the radius with dislocation of the radial head in any direction, with or without dislocation of the PRUJ. Subset III is mainly due to a strike from the medial aspect of the elbow. (IIIa) Apex posterior fracture of ulna, and posterior dislocation of the radial head without dislocation of the PRUJ (IIIb) apex posterior fracture of ulna and posterior dislocation of the radial head with dislocation of the PRUJ. Longitudinal force during elbow flexion may be the cause of this subset, similar to the mechanism of posterior dislocaiton of the elbow, though the humeroulnar ligament is often intact. (II) Metaphyseal fracture of ulna with posterior angulation, and posterior dislocation of the radial head without dislocation of the PRUJ. The biomechanics of this subset of Monteggia fracture is that a direct blow to the posterior ulna, or extreme pronation of the forearm or over-extension of the elbow during the fall induces contract of biceps muscle and consequent fracture and dislocation. Thus, subsets of the Monteggia fracture were reestablished as follows: (I) diaphyseal fracture of ulna with anterior angulation, and anterolateral dislocation of the radial head without dislocation of the PRUJ. However, the injury of the proximal radioulnar joint (PRUJ) is ignored under this classification system, which leads to limited prognostic prediction ( 1, 3, 31, 35, 54). 2009 34(9):1618–24.Classification and biomechanics of Monteggia injuryīado classification was once the most widely utilized classification for Monteggia fracture, whose occurrence is shown in Table 1 ( 52, 53). Long-term evaluation of surgically treated anterior monteggia fractures in skeletally mature patients. The posterior Monteggia lesion with associated ulnohumeral instability. Strauss EJ, Tejwani NC, Preston CF, Egol KA. The surgical treatment of isolated mason type 2 fractures of the radial head in adults: comparison between radial head resection and open reduction and internal fixation. Zarattini G, Galli S, Marchese M, Mascio LD, Pazzaglia UE. Comparison between radial head arthroplasty and open reduction and internal fixation in patients with radial head fractures (modified Mason type III and IV): a meta-analysis. Surgical treatment of the radial head is critical to the outcome of Monteggia-like lesions. Klug A, Konrad F, Gramlich Y, Hoffmann R, Schmidt-Horlohe K. Monteggia fractures in adults: long-term results and prognostic factors. Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP. Monteggia fractures in children and adults. Pediatric monteggia fractures: a multicenter examination of treatment strategy and early clinical and radiographic results. Monteggia fractures and variants: review of distribution and nine irreducible radial head dislocations. Management of adult elbow fracture dislocations. “Isolated” traumatic radial-head dislocation. Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs. Kunkel S, Cornwall R, Little K, Jain V, Mehlman C, Tamai J. A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows. Disruption of the radiocapitellar line in the normal elbow. Nerve injuries complicating Monteggia lesions. Neglected Monteggia fracture dislocations in children: a systematic review. Goyal T, Arora SS, Banerjee S, Kandwal P. Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. Givon U, Pritsch M, Levy O, Yosepovich A, Amit Y, Horoszowski H. Monteggia fracture dislocations: a historical review. Rehim SA, Maynard MA, Sebastin SJ, Chung KC. Unstable fracture-dislocations of the forearm.
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