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Failure to repair the annular ligament
11%
106/953
Failure to identify a radial head fracture
1%
13/953
Failure to repair the lateral collateral ligament
3%
33/953
Failure to restore appropriate ulnar length
82%
783/953
Failure to create internal fixation with sufficient rigidity
12/953
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Figure A demonstrates persistent dislocation of the radial head after fixation of the ulna in a Monteggia fracture pattern. Most often this is due to failure to restore the length or alignment of the ulna.Monteggia fractures are proximal or middle one-third ulna fractures with concomitant radial head dislocation. Typically the head and ulnar angulation are in the same direction; most often in the anterior direction in children and posterior in adults. In adults, these fractures often require open reduction and internal fixation, while in pediatric patients these can often be treated with closed reduction and casting. Treatment of persistently dislocated radio-capitellar joints is with revision of ulnar fixation or ulnar osteotomy and closed versus open reduction of the radial head. To prevent shortening through the fracture during fixation, it is recommended that you use the dorsal cortex to determine anatomic reduction and in the setting of comminution a distractor device.Eathiraju, Mudgal, and Jupiter reviewed Monteggia fracture-dislocations. Within the review, they thoroughly discuss the complex anatomy of the articular, ligamentous, and osseous anatomy. Further discussion covers the Bado classification and the Jupiter sub-classification. Finally, they cover operative fixation and pearls for proper treatment to include using the dorsal cortex for determining appropriate reduction, restoration of length, proper plate conformity to the proximal ulna, and how the radial head should spontaneously reduce. If it does not, that indicates inadequate ulna reduction or possible soft tissue interposition.Delpont, Louahem, and Cottalorda reviewed Monteggia injuries as well. This review focuses on why Monteggia fractures are missed. This includes seemingly insignificant ulnar displacement on radiographs and the overall rarity of the injury. Missed Monteggia fractures can be a difficult problem to treat, as fibrosis within the elbow joint can start in 2-3 weeks resulting in the inability to close reduce the radial head. Long-term dislocation of the radial head in pediatric patients can result in overgrowth of the proximal radius, requiring more significant operative treatments. Figure A demonstrates a lateral forearm radiograph with anterior dislocation of the radial head. Appropriate reduction of the radial head is when the radial head is in line with the capitellum on all radiographic views.Incorrect Answers:Answer 1: Typically with Monteggia fractures, repair of the annular ligament is not required. Additionally, congruence of radial head and capitellum would likely keep the radial head reduced if the proper ulnar length and therefore appropriate radio-capitellar joint forces were present.Answer 2: Radial head fractures occur in approximately 5% of Monteggia fractures and a radial head fracture alone does not create radio-capitellar instability. A more likely etiology is malreduction of the ulna.Answer 3: Incompetence of the lateral collateral ligament would result in overall elbow instability affecting the ulnohumeral joint as well. Isolated radial head dislocation in the setting of LCL tear and incompetence is not common.Answer 5: Internal fixation rigidity would affect the healing of the ulna fracture, which on this imaging appears to be healing. The long-term effect of improper fixation rigidity would be hardware failure.
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