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Fractures and Dislocations

about the Elbow


in the Pediatric Patient
Joshua Klatt, MD
Original Author: Kevin Shea, MD; March 2004
Revised:
Steven Frick, MD; August 2006
Joshua Klatt, MD; Albert Pendleton, MD ; November 2011

Elbow Fractures in Children


Very common injuries (approximately 65% of
pediatric trauma)
Radiographic assessment - difficult for nonorthopaedists, because of the complexity and
variability of the physeal anatomy and development
A thorough physical examination is essential,
because neurovascular injuries can occur before and
after reduction
Compartment syndromes are rare with elbow
trauma, but can occur

Elbow Fractures
Physical Examination
Children will usually not move the elbow if a fracture is
present, although this may not be the case for nondisplaced fractures
Swelling about the elbow is a constant feature, except for
non-displaced fracture
Complete vascular exam is necessary, especially in
supracondylar fractures
Doppler may be helpful to document vascular status

Neurologic exam is essential, as nerve injuries are


common
In most cases, full recovery can be expected

Elbow Fractures
Physical Examination
Neurological exam may be limited by the childs
ability to cooperate because of age, pain, or fear.
Thumb extension EPL
Radial PIN branch

Thumb flexion FPL


Median AIN branch

Cross fingers/scissors - Ad/Abductors


Ulnar

Elbow Fractures
Physical Examination
Always palpate the arm and forearm for signs of
compartment syndrome
Thorough documentation of all findings is
important
A simple record of neurovascular status is intact is
unacceptable (and doesnt hold up in court)
Individual assessment and recording of motor, sensory,
and vascular function is essential

Elbow Fractures
Radiographs
AP and Lateral views are important initial views
In trauma these views may be less than ideal, because
it can be difficult to position the injured extremity

Oblique views may be necessary


Especially for the evaluation of suspected lateral
condyle fractures

Comparison views frequently obtained by primary


care or ER physicians
Although these are rarely used by orthopaedists

Elbow Fractures
Radiograph Anatomy/Landmarks
Baumanns angle is formed by a line
perpendicular to the axis of the
humerus, and a line that goes through
the physis of the capitellum
There is a wide range of normal for
this value
Can vary with rotation of the radiograph

In this case, the medial impaction and


varus position reduces Baumans
angle
-Baumann E. Beitrage zur Kenntnis der Frakturen am Ellbogengelenk:
Unter besonderer Berucksichtigung der Spatfolgen. I. Allgemeines und
Fractura supra condylica. Beitr Klin Chir 1929;146:1-50.
-Mohammad. The Baumann angle in supracondylar fractures of the
distal humerus in children. J Pediatr Orthop. 1999;19:6569.

Elbow Fractures
Radiograph Anatomy/Landmarks
Anterior Humeral Line
Drawn along the
anterior humeral cortex
Should pass through
the middle of the
capitellum
Variable in very young
children

-Rogers. Plastic bowing, torus and greenstick supracondylar fractures


of the humerus: radiographic clues to obscure fractures of the elbow in
children. Radiology. 1978;128:145.
-Herman. Relationship of the anterior humeral line to the capitellar
ossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188.

Elbow Fractures
Radiograph Anatomy/Landmarks
The capitellum is
angulated
anteriorly about
30 degrees.
The appearance
of the distal
humerus is
similar to a
hockey stick.

30

Elbow Fractures
Radiograph Anatomy/Landmarks
The physis of the
capitellum is
usually wider
posteriorly,
compared to the
anterior portion of
the physis
Wider

Elbow Fractures
Radiograph Anatomy/Landmarks
Radiocapitellar
line should
intersect the
capitellum in all
views
Make it a habit to
evaluate this line
on every pediatric
elbow film

Supracondylar Humerus Fractures


Most common fracture around the elbow in children
60 percent of elbow fractures

95 percent are extension type injuries


Produces posterior angulation/displacement of the distal
fragment

Occurs from a fall on an outstretched hand


Ligamentous laxity and hyperextension of the elbow are
important mechanical factors

May be associated with a distal radius or forearm


fractures
Omid. Supracondylar Humeral Fractures in Children. J Bone Joint Surg.

Supracondylar Humerus Fractures


Classification
Type 1
Non-displaced

Type 2
Angulated/displaced
fracture with intact
posterior cortex

Type 3
Complete displacement,
with no contact between
fragments

Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145-

Type 1
Non-displaced
Note the nondisplaced fracture
(Red Arrow)

Note the posterior


fat pad (Yellow Arrows)

-Skaggs. The posterior fat pad sign in association with occult fracture of
the elbow in children. J Bone Joint Surg Am. 1999;81:1429.
-Bohrer. The fat pad sign following elbow trauma. Its usefulness and
reliability in suspecting invisible fractures. Clin Radiol. 1970;21:90.

Type 2
Angulated/displaced fracture with intact
posterior cortex

Type 2
Angulated/displaced fracture with intact
posterior cortex
In many cases, the type 2
fractures will be impacted
medially
Leads to varus angulation

The varus malposition


must be considered when
reducing these fractures
Apply a valgus force for
realignment

Type 3
Complete displacement, with no contact
between fragments

Supracondylar Humerus Fractures


Associated Injuries
Nerve injury incidence is high, between 7 and 16 %
Median, radial, and/or ulnar nerve

Anterior interosseous nerve injury is most commonly


injured nerve
In many cases, assessment of nerve integrity is limited
Children can not always cooperate with the exam

Carefully document pre-manipulation exam,


Post-manipulation neurologic deficits can alter decision making
Cramer. Incidence of anterior interosseous nerve palsy in supracondylar
humerus fractures in children. J Pediatr Orthop. 1993;13:502.

Supracondylar Humerus Fractures


Associated Injuries
5% have associated
distal radius fracture
Physical exam of distal
forearm
Radiographs if needed
If displaced pin radius
also
Difficult to hold
appropriately in splint

Supracondylar Humerus Fractures


Associated Injuries
Vascular injuries are rare, but pulses should
always be assessed before and after reduction
In the absence of a radial and/or ulnar pulse, the
fingers may still be well-perfused, because of the
excellent collateral circulation about the elbow
Doppler device can be used for assessment
White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric
supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.

Supracondylar Humerus Fractures


Associated Injuries
Type 3 supracondylar
fracture
Absent ulnar and
radial pulses
Fingers had capillary
refill less than 2
seconds.

The pink, pulseless


extremity
White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric
supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.

Supracondylar Humerus Fractures


Anatomy
The medial and lateral columns are
connected by a thin wafer of bone
Approximately 2-3 mm wide in the central
portion

If the fracture is malreduced, it is inherently


unstable
The medial or lateral columns displace easily
into varus or valgus

Supracondylar Humerus Fractures


Treatment
Type 1 Fractures
In most cases, these can be treated with
immobilization for approximately 3 weeks, at
90 degrees of flexion
If there is significant swelling, do not flex to 90
degrees until the swelling subsides

Supracondylar Humerus Fractures


Treatment
Type 2 Fractures: Posterior Angulation
If minimally displaced (anterior humeral line hits part of
capitellum)
Immobilization for 3 weeks.
Close follow-up is necessary to monitor for loss of reduction

Displaced (anterior humeral line misses capitellum)


Reduction may be necessary
The degree of posterior angulation that requires reduction is
controversial
Check opposite extremity for hyperextension

If varus/valgus malalignment exists, most authors


recommend reduction.
Fitzgibbons. Predictors of failure of nonoperative treatment for type2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

Type 2 Fractures
Treatment
Reduction of these fractures is usually not difficult
Maintaining reduction usually requires flexion beyond 90

Excessive flexion may not be tolerated because of


swelling
May require percutaneous pinning to maintain reduction

Most authors suggest that percutaneous pinning is the


safest form of treatment for many of these fractures
Pins maintain the reduction and allow the elbow to be
immobilized in a more extended position

Fitzgibbons. Predictors of failure of nonoperative treatment for type2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

Supracondylar Humerus Fractures


Treatment
Type 3 Fractures
These fractures have a high risk of neurologic and/or
vascular compromise
Can be associated with a significant amount of swelling
Current treatment protocols use percutaneous pin
fixation in almost all cases
In rare cases, open reduction may be necessary
Especially in cases of vascular disruption

Supracondylar Humerus Fractures


OR Setup
The monitor should be
positioned across from
the OR table, to allow
easy visualization of
the monitor during the
reduction and pinning
-Thometz. Techniques for direct radiographic visualization during closed
pinning of supracondylar humerus fractures in children. J Pediatr Orthop.
1990;10:555.
-Tremains. Radiation exposure with use of the inverted-c-arm technique in

Supracondylar Humerus Fractures


OR Setup

The C-Arm fluoroscopy unit can


be inverted, using the base as a
table for the elbow joint
All personnel in the room should be
adequately shielded, as radiation
exposure is significantly increased with
inverted c-arm

Also can use radiolucent board


The child should be positioned
close to the edge of the table, to
allow the elbow to be visualized
by the c-arm
Make sure to secure patients head
and body
-Thometz. Techniques for direct radiographic visualization during closed
pinning of supracondylar humerus fractures in children. J Pediatr Orthop.
1990;10:555.
-Tremains. Radiation exposure with use of the inverted-c-arm technique in

Supracondylar Elbow Fractures


Type 2 with Varus Malalignment
During reduction of
medially impacted
fractures, valgus
force should be
applied to address
this deformity.

Type 3
Supracondylar Fracture

Type 3
Operative Reduction
Closed reduction with
flexion

AP view with elbow held


in flexed position to
maintain reduction.

Brachialis Sign
Proximal Fragment Buttonholed through Brachialis

Milking Maneuver
Milk Soft Tissues over Proximal Spike

Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a


technique of closed reduction and report of initial results. J Pediatr Orthop. 1997;17:298.

Adequate Reduction?
No varus/valgus
malalignment
Anterior humeral line
should be intact
Minimal rotation
Mild translation is
acceptable
From: Rangs childrens fractures. Edited by Dennis R. Wenger, MD,
and Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins,

Medial Impaction Fracture

Type II fracture with medial impaction not


recognized and varus / extension not
reduced

Medial Impaction Fracture

Cubitus varus 2 years later

Lateral Pin Placement


AP and Lateral views with 2 pins

Pin Configuration

Lee. Displaced pediatric supracondylar humerus fractures: biomechanical


analysis of percutaneous pinning techniques. J Pediatr Orthop.

C-arm Views

Oblique views with the C-arm can be useful to help verify the
reduction.
Note slight rotation and extension on medial column (right image).

Supracondylar Humerus Fractures


Pin Fixation
Different authors have recommended different pin
fixation methods
The medial pin can injury the ulnar nerve
Some advocate 2 or 3 lateral pins to avoid injuring the
median nerve

Space pins as widely as possible


If the lateral pins are placed close together at the
fracture site, the pins may not provide much resistance
to rotation and further displacement

Some recommend one lateral, and one medial pin


Sankar. Loss of pin fixation in displaced supracondylar humeral
fractures in children: causes and prevention. J Bone Joint Surg Am.

Pitfalls of Pin Placement

Pins Too Close together


Instability
Fracture displacement
Get one pin in lateral
and one in medial
column

Supracondylar Humerus Fractures


Pin Fixation
Even many children have anterior
subluxation of the ulnar nerve with
hyperflexion of the elbow
Some recommend place two lateral pins,
assess fracture stability
If unstable then extend elbow to take
tension off ulnar nerve and place medial pin
Eberl. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing
of supracondylar humeral fractures in children. Acta Orthop. 2011;82:606.

Supracondylar Humerus Fractures


After stable reduction and pinning
Elbow can be extended to review the AP radiograph
Baumanns angle can be assessed on these radiographs
Remember there can be a wide range of normal values for this
measurement

With the elbow extended, the carrying angle of the


elbow should be reviewed, and clinical
comparison as well as radiograph comparison can
be performed to assure an adequate reduction.

Supracondylar Humerus Fractures

If pin fixation is used, the pins


are usually bent and cut outside
the skin
The skin is protected from the
pins by placing Xeroform and a
felt pad around the pins
The arm is immobilized
The pins are removed in the
clinic 3 to 4 weeks later
After radiographs show periosteal
healing

In most cases, full recovery of


motion can be expected

Supracondylar Humerus Fractures:


Indications for Open Reduction
Inadequate reduction
with closed methods
Vascular injury
Open fractures

Supracondylar Humerus Fractures:


Complications
Compartment syndrome
Vascular injury/compromise
Loss of reduction/malunion
Cubitus varus

Loss of motion
Pin track infection
Neurovascular injury with
pin placement

Bashyal. Complications after pinning of supracondylar


distal humerus fractures. J Pediatr Orthop. 2009;29:704.

Supracondylar Humerus Fractures


Flexion type
Rare, only 2%
Distal fracture fragment anterior
and flexed
Ulnar nerve injury more
common
Reduce with extension
Often requires 2 sets of hands in
OF
Hold elbow at 90 degrees after
reduction to facilitate pinning
Mahan. Operative management of displaced flexion supracondylar
humerus fractures in children. J Pediatr Orthop. 2007;27:551.

Flexion Type

Flexion Type
Pinning

Distal Humeral Complete Physeal


Separation
Often in very young children
May be sign of NAT
Swollen elbow,muffled
crepitance on exam
Through area of wider cross
sectional area than SC
humerus fx
Restore alignment, may need
pinning
Peterson. Physeal injuries of the distal humerus. Orthopedics.
1992;15:799.
Shrader. Pediatric supracondylar fractures and pediatric
physeal elbow fractures. Orthop Clin North Am.

Lateral Condyle Fractures


Common fracture,
representing
approximately 15% of
elbow trauma in children
Usually occurs from a
fall on an outstretched
arm

Landin. Elbow fractures in children. An epidemiological


analysis of 589 cases. Acta Orthop Scand. 1986;57:309.

Lateral Condyle Fractures


Jakob Classification
Type 1
Non-displaced fracture
Fracture line does not cross through the articular surface

Type 2
Minimally displaced
Fracture extends to the articular surface, but the capitellum
is not rotated or significantly displaced

Type 3
Completely displaced
Fracture extends to the articular surface, and the capitellum
is rotated and significantly displaced

Jakob. Observations concerning fractures of the lateral


humeral condyle in children. J Bone Joint Surg Br.

Lateral Condyle Fractures


Jakob Type 1
Oblique radiographs
may be necessary to
confirm that this is not
displaced. Frequent
radiographs in the cast
are necessary to ensure
that the fracture does
not displace in the
cast.

Lateral Condyle Fractures


Jakob Type 2
Displaced more than 2 mm
On any radiograph
(AP/Lateral/Oblique views)
Reduction and pinning
Closed reduction can be attempted,
but articular reduction must be
anatomic

If residual displacement and the


articular surface is not congruous
Open reduction is necessary

Fracture line exiting posterior metaphysis


(arrow) typical for lateral condyle fractures

Flynn. Prevention and treatment of non-union of slightly displaced fractures of the lateral
humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57:1087.

Lateral Condyle Fractures


Jakob Type 3
ORIF is almost always
necessary
A lateral Kocher approach is
used for reduction, and pins or
a screw are placed to maintain
the reduction
Careful dissection needed to
preserve soft tissue attachments
(and thus blood supply) to the
lateral condylar fragment,
especially avoiding posterior
dissection
-Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16.
-Song. Closed reduction and internal fixation of completely displaced and rotated
lateral condyle fractures of the humerus in children. J Orthop Trauma. 2010;24:434.

Lateral Condyle ORIF

Lateral Condyle Fractures


Complications
Non-union
This usually occurs if the
patient is not treated, or the
fracture displaces despite
casting
Well-described in fractures
which were displaced more
than 2 mm and not treated
with pin fixation
Late complication of
progressive valgus and ulnar
neuropathy reported
Skak. Deformity after fracture of the lateral humeral
condyle in children. J Pediatr Orthop B. 2001;10:142.

Lateral Condyle Fractures


Complications
AVN can occur after
excessive surgical
dissection
Cubitus varus can
occur, may be because
of malreduction or a
result of lateral
column overgrowth

Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop.

Medial Epicondyle Fractures


Represent 5% to 10% of pediatric elbow
fractures
Occurs with valgus stress to the elbow,
which avulses the medial epicondyle
Frequently associated with an elbow
dislocation

Landin. Elbow fractures in children. An epidemiological


analysis of 589 cases. Acta Orthop Scand. 1986;57:309.

Medial Epicondyle Fractures


Classification
No good systematic
method of classification
Studies vary on how to
measure displacement
Should take into
consideration
displacement on both the
AP and lateral
Amount of rotational
displacement is also
important
Pappas. Intraobserver and interobserver agreement in the measurement of displaced
humeral medial epicondyle fractures in children. J Bone Joint Surg Am. 2010;92:322.

Medial Epicondyle Fractures


Treatment
Nondisplaced and
minimally displaced
Less than 5 mm of
displacement
May be treated without
fixation
Early motion to avoid
stiffness (3 to 4 weeks)

Medial Epicondyle Fractures


Treatment

Displaced more than 5 mm


Treatment is controversial
Some recommending operative,
others non-operative treatment
Some have suggested that surgery
is indicated in the presence of
valgus instability, or in patients
who are throwing athletes.

Only absolute indication is


entrapped fragment after
dislocation with incongruent elbow
joint
First attempt closed reduction

Long term studies favor


nonoperative treatment

Kamath. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop. 2009;3:345.
Farsetti. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83-A:1299.

Medial Epicondyle Fracture


Elbow dislocation with Medial Epicondyle Avulsion

Medial
Epicondyle
Avulsion

After attempted
elbow reduction,
medial epicondyle
avulsion fragment
is obvious

Medial Epicondyle Fracture


Elbow dislocation with Medial Epicondyle Avulsion

Treated with ORIF

Medial Epicondyle Fracture


Example of Nonoperative Treatment

12 year old female UE


weight bearing athlete
Treated
nonoperatively
Full motion, no valgus
instability at 6 weeks
Returned to
competition at 8 weeks

Olecranon Fractures
Relatively rare fracture in children
Increased incidence in children with OI

May be associated with elbow subluxation/


dislocation, or radial head fracture
The diagnosis may be difficult in a younger child
Olecranon does not ossify until 8-9 years

In older children, the fracture may occur through the


olecranon physis
Anatomic reduction is necessary in displaced fractures
to restore normal elbow extension.
Caterini. Fractures of the olecranon in children. Long-term follow-up of 39 cases. J Pediatr Orthop B. 2002;11:320.

Olecranon Fractures
Olecranon fracture treated with ORIF in 14
year old, with tension band fixation.

Parent. Displaced olecranon fractures in children: a biomechanical


analysis of fixation methods. J Pediatr Orthop. 2008;28:147.

Rare Distal Humeral Fractures


Lateral Epicondyle
Rare
Usually represent a small
avulsion fracture
Treated with early mobilization

T-Condylar fractures
Occur in patients that are almost
skeletally mature
Treatment similar to adult intraarticular elbow fractures

Medial Condyle
Rare
Treated with ORIF if displaced
Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661665.

Proximal Radius Fractures


1% of childrens fractures
90% involve physis or neck
Normally some angulation of head to radial
shaft (0-15 degrees)
No ligaments attach to head or neck
Much of radial neck extraarticular (no
effusion with fracture)
Vocke. Displaced fractures of the radial neck in children: long-term results
and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

Proximal Radius Fractures


Types
Valgus fractures
Salter I or II
Intra-articular fractures
rare

Metaphyseal fractures
Associated with elbow
dislocations or proximal
ulna fractures
Can be completely
displaced, rotated
Vocke. Displaced fractures of the radial neck in children: long-term results
and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

Proximal Radius Fractures


Treatment
Greater than 30
angulation
Attempt manipulation
Usually can obtain
acceptable reduction in
fractures with less than 60
angulation
Traction, varus force in
supination & extension,
flex and pronate
Ace wrap or Esmarch
reduction

Evans. Radial neck fractures in children: a


management algorithm. J Pediatr Orthop B.

Proximal Radius Fractures


Treatment
Unable to reduce
closed
Percutaneous pin
reduction
Intramedullary pin
reduction
Open reduction via
lateral approach
-Vocke. Displaced fractures of the radial neck in children: long-term results and
prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.
-Metaizeau. Reduction et fixation des fractures et decollements piphyssaires de la
tte radial par broche centromedullaire. Rev Chir Ortop 1980;66:47-9.
-Gonzlez-Herranz. Displaced radial neck fractures in children treated by closed
intramedullary pinning (Metaizeau technique). J Pediatr Orthop. 1997;17:325.

Completely Displaced, Malrotated


Radial Neck Fracture

After closed reduction the articular


surface (arrow) is facing distally,
180 degrees malrotated

Proximal Radial Fractures


Complications

Loss of forearm rotation


Radial head overgrowth
Premature physeal closure valgus
Nonunion of radial neck rare
AVN
Proximal synostosis
Vocke. Displaced fractures of the radial neck in children: long-term results
and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

100% Displaced
Failed Closed Reduction

Open closed reduction


Blunt pin to push radial head back onto neck

Pin fixation augmented by cast for 3 weeks

Monteggia Lesions
Ulnar Fracture-Radial Head Dislocation
Bado Classification
Type I anterior radial
head dislocation
Type II posterior radial
head dislocation
Type III lateral radial
head dislocation
Type IV associated
fracture of radius

Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71
86.
Wilkins. Changes in the management of monteggia fractures. J Pediatr

Monteggia Lesions
Most important is to make
the diagnosis initially
Radiocapitellar line
critical
A commonly missed
diagnosis
Every ulna fracture should
have good elbow joint
radiographs to avoid
missing Monteggia lesion

Monteggia Lesions
Be wary of plastic
deformation of ulna or
minimally displaced
ulna fracture with
radial head dislocation
On lateral radiograph
the ulna should be
straight

Note anterior bow of ulnar


shaft, and anterior radial
head dislocation

Monteggia Lesions
Initial Treatment

Closed reduction of ulnar angulation


Direct pressure over radial head
Usually will reduce with palpable clunk
Immobilize in reduced position
Supinate forearm for anterior dislocations
Frequent radiographic follow-up to
document maintenance of reduction
Wilkins. Changes in the management of monteggia
fractures. J Pediatr Orthop. 2002;22:548.

Monteggia Lesions
If unable to obtain or
maintain reduction of
radial head
Operative stabilization of
ulnar fracture to correct
angulation
Oblique fractures may need
plate fixation
Assess radial head stability
Flexion may help for
anterior dislocation
Wilkins. Changes in the management of monteggia
fractures. J Pediatr Orthop. 2002;22:548.

Missed Monteggia Lesion

Anterior radial head


dislocation and
heterotopic ossification

Healed prox ulna fx


with anterior bow

Missed Monteggia Lesions


Possible Long Term Sequelae
Progressive valgus
Proximal radial migration with
disruption of normal forearm
and distal radioulnar joint
mechanics
Posterior interosseous nerve
traction palsy
Collateral ligament instability
Nakamura. Long-term clinical and radiographic outcomes after open reduction for
missed Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.

Missed Monteggia Lesions


Treatment Options
Annular ligament
reconstructions
Bell-Tawse
Fascia lata
Peterson

Ulnar osteotomy
Combination
Transcapitellar pinning
Be wary of possible pin
breakage
-Nakamura. Long-term clinical and radiographic outcomes after open reduction for missed
Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.
-Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.

Missed Monteggia Lesions


Ulnar Osteotomy and Radiocapitellar Pin

Bibliography

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