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Clinical Practice Guidelines

Monteggia fracture-dislocations - Fracture clinics

  • Fracture Guideline Index

    See also: Monteggia fracture-dislocations - Emergency Department  

    1. How often should these fractures be followed up in fracture clinics?
    2. What should I review at each appointment?
    3. What are the potential complications associated with this injury?
    4. When should I refer for an orthopaedic consultant opinion?
    5. What are the indications for discharge?

    1. How often should these fractures be followed up in fracture clinics?

    Table 1: Recommended follow-up schedule for Monteggia fracture-dislocation.

    Fracture type

    First appointment

    Subsequent review appointments

    Discharge advice to parents

    All types

    7 days post-reduction with x-ray dependent on stability of the injury

    At 2 weeks post-reduction with x-ray

    At 3 weeks post-reduction with x-ray. Change of plaster may be required

    At 6 weeks post-reduction with x-ray

    Attend GP if the child develops pain or has deterioration in elbow/forearm range of movement (ROM)

    2-3 months for return to full contact sports

     

    2. What should I review at each appointment?

    Assessment of reduction of the radiocapitellar joint and position. It should be concentric on both AP and lateral x-ray views of the elbow.

    The position of the ulna fracture should also be assessed.

    3. What are the potential complications associated with this injury?

    Complications include:

    • Nerve injury - the radial nerve is the most commonly injured nerve (10-20%). It is most commonly associated with type I and III injuries. The posterior interosseous nerve can also be injured due to its proximity to the radial head. The injury is usually a neuropraxia. Peripheral nerve examination needs to be documented. The nerve injury is usually treated expectantly. Return of nerve function would be expected by approximately 9 weeks. Electromyography (EMG) assessment should be done at 12 weeks if nerve function is not returning.
    • Periarticular ossification - this can occur in 3-7% of Monteggia fracture-dislocations. This can be around the radial head or the annular ligament. It is associated with higher energy injuries, fractures of the radial head, and multiple attempts at manipulation. This can affect elbow ROM.

    4. When should I refer for an orthopaedic consultant opinion?

    Indications for a consultant orthopaedic surgeon opinion are:

    • any concern with concentric reduction of the radiocapitellar joint.
    • loss of position of the ulna fracture
    • persistent neurologic injury

    5. What are the indications for discharge?

    Healed fracture, with full elbow ROM and no persistent neurologic injury.

    References (Outpatient setting)

    Waters PM. Monteggia fracture-dislocation in children. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.446-74.

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    Content developed by Victorian Paediatric Orthopaedic Network. 
    To provide feedback, please email rch.orthopaedics@rch.org.au