MONTEGGIA AND GALEAZZI FRACTURES

ANATOMY-ELBOW Hinge joint. Hinge joint. Three bones form the elbow joint: the humerus of the upper arm, and the paired radius and ulna of the forearm. Three bones form the elbow joint: the humerus of the upper arm, and the paired radius and ulna of the forearm.humerusradius ulnahumerusradius ulna The bony prominence at the very tip of the elbow is the olecranon process of the ulna, and the inner aspect of the elbow is called the antecubital fossa. The bony prominence at the very tip of the elbow is the olecranon process of the ulna, and the inner aspect of the elbow is called the antecubital fossa.olecranon antecubital fossaolecranon antecubital fossa

Humeroulnar joint- Humeroulnar joint-umeroulnar jointumeroulnar joint **from trochlear notch of the ulna rochlear notchulnarochlear notchulna **to trochlea of humerus trochlea of humerustrochlea of humerus Is a simple hinge-joint, and allows of movements of flexion and extension only. Is a simple hinge-joint, and allows of movements of flexion and extension only.hinge-joint

Humeroradial joint- Humeroradial joint-umeroradial jointumeroradial joint **from head of the radius head of the radiushead of the radius **to capitulum of the humerus capitulum of the humeruscapitulum of the humerus Is a hinge-joint Is a hinge-jointhinge-joint

Proximal radioulnar joint. Proximal radioulnar joint.roximal radioulnar jointroximal radioulnar joint **From-head of the radius head of the radiushead of the radius **to radial notch of the ulna radial notchulnaradial notchulna pronation and supination. pronation and supination. pronationsupination pronationsupination

Ligaments:- Ligaments:- Ulnar collateral ligament, Ulnar collateral ligament,lnar collateral ligamentlnar collateral ligament Radial collateral ligament, and Radial collateral ligament, andadial collateral ligamentadial collateral ligament Annular ligament. Annular ligament.nnular ligamentnnular ligament

The muscles in relation with the joint are: The muscles in relation with the joint are:muscles in front, the Brachialis, the BrachioradialisBrachialisBrachioradialis behind, the Triceps brachii and AnconæusTriceps brachiiAnconæus laterally, the Supinator,Supinator and the common tendon of origin of the Extensor muscles medially, -common tendon of origin of the Flexor muscles, and the Flexor carpi ulnarisFlexor carpi ulnaris

Movements The hinge-like bending and straightening (flexion and extension) between the humerus and the ulna. The hinge-like bending and straightening (flexion and extension) between the humerus and the ulna.flexion and extensionflexion and extension The complex action of turning the forearm over (pronation or supination) happens at the articulation between the radius and the ulna (this movement also occurs at the wrist joint). The complex action of turning the forearm over (pronation or supination) happens at the articulation between the radius and the ulna (this movement also occurs at the wrist joint).pronationsupinationpronationsupination The hinge moves in only one plane. The hinge moves in only one plane.

The Arteries supplying the joint are derived from the anastomosis between the profunda and the superior and inferior ulnar collateral branches of the brachial, with the anterior, posterior, and interosseous recurrent branches of the ulnar, and the recurrent branch of the radial. These vessels form a complete anastomotic network around the joint. The Arteries supplying the joint are derived from the anastomosis between the profunda and the superior and inferior ulnar collateral branches of the brachial, with the anterior, posterior, and interosseous recurrent branches of the ulnar, and the recurrent branch of the radial. These vessels form a complete anastomotic network around the joint.rteriesprofundainferior ulnar collateralbrachialulnarrecurrent branch of the radialanastomoticrteriesprofundainferior ulnar collateralbrachialulnarrecurrent branch of the radialanastomotic The Nerves of the joint are a twig from the ulnar, as it passes between the medial condyle and the olecranon; a filament from the musculocutaneous, and two from the median. The Nerves of the joint are a twig from the ulnar, as it passes between the medial condyle and the olecranon; a filament from the musculocutaneous, and two from the median.ervesulnarolecranonmusculocutaneousmedianervesulnarolecranonmusculocutaneousmedian

Monteggia fracture # of upper third of ulna with dislocation of head of radius. # of upper third of ulna with dislocation of head of radius. Head of radius is dislocated both from the radioulnar articulation and from elbow joint. Head of radius is dislocated both from the radioulnar articulation and from elbow joint. It may be displaced –Ant,post,or laterally acc to angulature of ulnar fracture. It may be displaced –Ant,post,or laterally acc to angulature of ulnar fracture.

DIAGNOSIS Every # of upper shaft of ulna without # of radial shaft should be considered to be monteggia # unless otherwise proved. Every # of upper shaft of ulna without # of radial shaft should be considered to be monteggia # unless otherwise proved. first X ray may show head of radius in its correct position, but serial X rays have to be taken over 1 st few weeks –bcoz if dislocation has occurred and there is instability,head of radius may redisplace later. first X ray may show head of radius in its correct position, but serial X rays have to be taken over 1 st few weeks –bcoz if dislocation has occurred and there is instability,head of radius may redisplace later.

Displacement-3 types Monteggia # dislocations can take place from 3 forces and corresponding injuries seen. Monteggia # dislocations can take place from 3 forces and corresponding injuries seen. FLEXION INJURY FLEXION INJURY EXTENSION INJURY EXTENSION INJURY ADDUCTION INJURY ADDUCTION INJURY ***Hume fracture ***Hume fracture

FLEXION INJURY-10-15% FLEXION INJURY-10-15% # ulna is angulated # ulna is angulated with the convexity posteriorly and the head of radius is dislocatedbackwards.

EXTENSION INJURY-85-90% Commonest type. Commonest type. # ulna is angulated with covexity ant. and laterally. # ulna is angulated with covexity ant. and laterally. With head of radius dislocated forwards and laterally. With head of radius dislocated forwards and laterally.

Adduction injury Caused by adduction strain at the elbow. Caused by adduction strain at the elbow. Ulna is angulated laterally and radial head is displaced laterally. Ulna is angulated laterally and radial head is displaced laterally.

HUME FRACTURE “High Monteggia injury”. “High Monteggia injury” Hume described --fracture of the olecranon with an associated anterior dislocation of the radial head Hume described --fracture of the olecranon with an associated anterior dislocation of the radial head.fracture olecranonanterior dislocationradial headfracture olecranonanterior dislocationradial head Seen in Children. Seen in Children.

MECHANISM OF INJURY. Mervyn Evans suggested this mech. Mervyn Evans suggested this mech. 1**Fall on outstretched hand with twisting of the trunk,forcibly pronating the forearm. 1**Fall on outstretched hand with twisting of the trunk,forcibly pronating the forearm. 2**Direct injury-Africa-Direct blow on the back of forearm with a stickwhile arm is raised warding off an attacker. 2**Direct injury-Africa-Direct blow on the back of forearm with a stickwhile arm is raised warding off an attacker.

TREATMENT CONSERVATIVE CONSERVATIVE OPERATIVE OPERATIVE

CONSERVATIVE:- Children. Children. manipulation and plaster immobilisation. manipulation and plaster immobilisation. But close watch needed-recurrence of deformity. But close watch needed-recurrence of deformity.

Redn. of extension injury. Longitudinal traction of forearm with with the elbow flexed as much as possible without compromising the blood supply. Longitudinal traction of forearm with with the elbow flexed as much as possible without compromising the blood supply. Forearm is stable in supination Forearm is stable in supination Plaster windowed for radial pulse Plaster windowed for radial pulse

Redn of adduction injury. Traction of the forearm with elbow extended and pressure over the head of radius, and after redn.this # dislocation is stable with the elbow flexed.and with forearm supinated. Traction of the forearm with elbow extended and pressure over the head of radius, and after redn.this # dislocation is stable with the elbow flexed.and with forearm supinated.

Redn of flexion injury Traction on forearm with elbow extende and as the redn is stable only in the extended position –not advisable in adults. Traction on forearm with elbow extende and as the redn is stable only in the extended position –not advisable in adults.

OPERATIVE TREATMENT. Advisable in adults. Advisable in adults. Open redn of # ulna and rigid int. fixation preferable with a plate.. Open redn of # ulna and rigid int. fixation preferable with a plate.. Dislocation of head of radius red. spontaneously when the deformity of ulna has been reduced. Dislocation of head of radius red. spontaneously when the deformity of ulna has been reduced.

OPERATIVE TECHNIQUE. # of ulna is exposed,reduced and fixed by a compression plate,or IM nail. # of ulna is exposed,reduced and fixed by a compression plate,or IM nail. Intraop take xray elbow in 2 planes. Intraop take xray elbow in 2 planes. If head of radius is perfectly reduced, the position is accepted and well padded plaster cast is applied from metacarpals to axilla- with elbow at right angles and forearm supinated. If head of radius is perfectly reduced, the position is accepted and well padded plaster cast is applied from metacarpals to axilla- with elbow at right angles and forearm supinated.

If X ray shows –head of radius is not reduced, then it must be exposed and reduced under direct vision. If X ray shows –head of radius is not reduced, then it must be exposed and reduced under direct vision. Annular lig. --usually cause obstruction- incised. Annular lig. --usually cause obstruction- incised.

COMPLICATIONS 1.UNREDUCED DISLOCATION OF HEAD OF RADIUS. 2.TRAUMATIC OSSIFICATION AROUND RADIAL HEAD. 3.PIN PALSY 4.CROSS UNION B/W RADIUS AND ULNA. 5.DISLOCATION OF LOWER END OF ULNA 6.UN-UNITED # OF ULNA.

Unred. disl. of head of radius. Rx Rx Excision of displaced head of radius. Excision of displaced head of radius. Prod inc. elbow flexion and good range of pronation and supination. Prod inc. elbow flexion and good range of pronation and supination. NOT done in CHILDREN.—removal of upper radial epiphysis—inequality of length of forearm bones and cause further disl. of RU joints both sup. and inf. NOT done in CHILDREN.—removal of upper radial epiphysis—inequality of length of forearm bones and cause further disl. of RU joints both sup. and inf.

Traumatic ossi. around radial head. Excision of radial head and the block of bone attached to it. Excision of radial head and the block of bone attached to it. Recurrence. Recurrence. Can be reduced by Sx delayed 6-12 months after injury with elbow immobilised for atleast 2 weeks. Can be reduced by Sx delayed 6-12 months after injury with elbow immobilised for atleast 2 weeks. NO Physiotherapy,manipulation and passive excs during rehab period. NO Physiotherapy,manipulation and passive excs during rehab period.

PIN PALSY Common with Adduction # dislocation. Common with Adduction # dislocation. Prognosis good in early complete reduction of head of radius. Prognosis good in early complete reduction of head of radius. Late PIN palsy due to inadequate redn of radial head. Late PIN palsy due to inadequate redn of radial head.

Cross union b/w radius and ulna. Bony fusion b/w neck of radius and 3 site of upper 3rd of ulna. Bony fusion b/w neck of radius and 3 site of upper 3rd of ulna. Difficult to Rx. Difficult to Rx. B coz proximity of elbow jt and PIN. ***Recurrence is high. B coz proximity of elbow jt and PIN. ***Recurrence is high. ***Perm limitation of Radioulnar movt. ***Perm limitation of Radioulnar movt.

Dislocation of lower end of ulna REDUCES with redn of ulnar shaft #. REDUCES with redn of ulnar shaft #. WORSENS if head of radius is excised. WORSENS if head of radius is excised. Rx excise distal inch of ulnar-if wrist symptoms. Rx excise distal inch of ulnar-if wrist symptoms.

Un united # of ulna Notorious for that. Notorious for that. Rigid internal fixation and cancellous onlay grafting. Rigid internal fixation and cancellous onlay grafting.

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