5
Management of Forearm Fractures
and Acute Monteggia Fractures in
Children and Adolescents
Chapter Outline
Forearm Fractures
♦♦ Introduction
♦♦ Diagnosis
♦♦ Classification
♦♦ Nonsurgical Management
♦♦ Surgical Treatment
FOREARM FRACTURES
INTRODUCTION
Forearm fractures, defined as diaphyseal fractures of the
radius and ulna, are some of the most common types
of injuries encountered by the orthopedist treating
fractures in children. These fractures are most common
in the United States of America in children under
15 years of age. The ratio of boys to girls increases steadily
until the age of 13 years, after which the incidence is
nearly twice as common in boys as girls.1,2 Most of these
fractures heal uneventfully with complete return of
function with cast immobilization. These fractures often
occur from a fall on the outstretched hand and trampolines
have become a very common source of these injuries.3
A recent Finnish study demonstrated that pediatric
forearm fractures have been increasing over the last
Kerwyn C Jones
Monteggia Fracture-Dislocations
♦♦ Introduction
♦♦ Diagnosis
♦♦ Classification
♦♦ Nonsurgical Management
♦♦ Surgical Management
♦♦ Outcomes
♦♦ Complications
decade and that trampolines appear to be the most
common reason for this.4 Direct blows to the forearm can
result in forearm fractures as well.
DIAGNOSIS
Clinical
A fracture should be suspected in any child that falls
onto an outstretched hand and has pain in the fore-
arm, difficulty with pronation and supination, swelling
or obvious deformity. Inspection of the elbow, forearm
and hand is first undertaken to determine the presence
of deformity and swelling. The forearm compartments
should be examined by palpation to check for extreme
tautness or swelling along the forearm compartments
98 Contemporary Surgical Management of Fractures and Complications: Pediatrics
that may be indicative of an impending or actual com-
partment syndrome. Extreme pain with passive flexion
and/or extension of the fingers may also indicate a
possible compartment syndrome. Skin lacerations and
abrasions must be carefully assessed to determine if the
fracture is open. Neurologic status should be assessed
to determine the sensation in the hand as well as motor
strength in the radial, median and ulnar nerve distribu-
tions. Some diminution of strength is expected due to
pain but the patient should still have some ability to fire
all muscles despite discomfort. The radial pulse and capil-
lary refill of the injured arm should be similar in character
to the noninjured arm.
Imaging
Anteroposterior (AP) and lateral radiographs of the
entire forearm, including the elbow and wrist are obtained
to confirm the presence of a fracture. Abnormal bone
appearance is noted to rule out a pathologic fracture.
Fracture location, the fracture pattern and the amount of
deformity are also carefully determined. The degree of
angular deformity of forearm fractures can be misjudged
on typical orthogonal views. The angle of deformity of
either bone is at least equal to and often significantly
greater than the maximal angle measured on the AP or the
lateral radiograph because the maximal angle of deformity
is often out of the plane of either of the standard views.
Possible rotational malalignment must also be carefully
determined. In the normal radius, the radial styloid and
radial tuberosity point directly opposite each other on
the AP view. Similarly, the normal relationship of the ulna
reveals an ulnar styloid that is directed opposite to the
coronoid process on the lateral view. A mismatch of the
diameters of the bone measured proximal and distal to the
fracture site is another way to identify malrotation. Care
should also be taken to confirm on the radiographs that
the normal bony relationships are present at the wrist and
elbow. For example, even subtle fractures of the ulna may
be associated with radial head dislocations (Monteggia
fracture), which is sometimes missed when inadequate
views of the elbow are not obtained.
CLASSIFICATION
Fracture Location and Type
Forearm fractures are classified by fracture location and
fracture type. These are typically described as the proximal
third, the middle third and the distal third of both the
radial and ulnar shafts as measured on forearm radio-
graphs. Fractures that occur from high-energy mecha-
nisms commonly occur at or near the same location within
the forearm and are generally more unstable compared to
forearm fractures in which the fracture locations are not
at the same level. Many forearm fractures, however, occur
from falls onto an outstretched hand and have a torsional
component to the mechanism of injury, causing fractures
that occur at different locations within the forearm. If the
forearm is positioned in supination, the radius fracture is
proximal to the ulna fracture. If the forearm is supinated
at the time of impact, the ulna fracture is proximal to the
radius fracture. Fracture patterns include complete and
incomplete fractures. Complete fractures, which are typi-
cally transverse or short oblique patterns, are generally
less stable than incomplete fractures because the degree
of periosteal stripping and soft tissue injury is greater in
complete fractures. Incomplete fracture types include
greenstick fractures, buckle fractures and plastic defor­
mity. Significant comminution is uncommon in children’s
forearm fractures. Although the majority of forearm
fractures include both the radius and ulna, it is possible to
sustain isolated fractures to the radial shaft or the ulnar
shaft. These are typically caused by a direct blow to the
forearm. Monteggia fractures (ulnar fractures associated
with dislocations of the radial head), and Galeazzi fractures
(radius fractures associated with disruption of the distal
radioulnar joint) must be ruled out before the diagnosis
of an isolated fracture of either bone can be made.
Open Fractures
Open forearm fractures typically have only either radius
or ulna breaching the soft tissue; infrequently, both the
radius and ulna fractures are open. The severity of the
soft tissue injury is classified by the Gustilo and Ander-
son grading system. Most open forearm fractures are
grade 1 or 2 injury types.5 It is our practice to administer
intravenous antibiotics upon admission to the emergency
department and to perform and irrigation and debride-
ment of all open fractures in the operating room within
24 hours of injury.6 After surgery, antibiotics are conti­
nued for an additional 24–48 hours as prophylaxis against
infection and repeat irrigation and debridement is done as
necessary until the wound is clean. Repeat surgery, how-
ever, is uncommonly required for open forearm injuries.
NONSURGICAL MANAGEMENT
The majority of forearm fractures in children and adoles-
cents can be managed nonoperatively in a well-molded
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents
cast.7 The primary goal of any treatment of forearm frac-
tures is to achieve a healed fracture in an alignment that
yields little or no functional deficit and minimal cosmetic
deformity. Displaced fractures are typically managed in
the emergency by closed reduction and casting. For the
comfort of the patient, intravenous sedation or regional
anesthesia, such as a Bier block, are most commonly used.
Emergency department personnel skilled in cardiovascular
monitoring and equipped with advanced resuscitative and
life support capabilities is mandatory when applying these
techniques for analgesia.
Closed Reduction
Complete displaced fractures may be reduced by exag-
gerating the deformity and applying longitudinal traction
while using manually applied three-point bending forces
to realign the fracture. For fractures that are significantly
shortened, traction may be necessary to restore fracture
length. Chinese finger traps applied to the hand may be
suspended from an IV pole while traction is manually
applied or by a 2–5 pound weights suspended on the
upper arm through a padded sling. The arm can hang with
this traction for 5–10 minutes to permit gradual distraction
of the fracture fragments, allowing for a gradual closed
reduction with maintenance of bone length.
Greenstick fractures and plastic deformities of the
forearm present can be particularly difficult to achieve
a proper reduction that can be maintained in the cast.
Controversy exists over the best treatment of these
incomplete fractures. Because the intact cortex tends to
cause the fracture to displace into the direction of the
initial deformity, some clinicians recommend completing
the fracture in order to avoid this type of recurrent
angulation. However, many incomplete fractures may be
adequately reduced and held in a cast if proper casting
techniques are followed. Generally, incomplete fractures
with an apex of deformity directed volar are reduced
with forearm pronation while fractures with apex dorsal
displacement are reduced by supinating the forearm.
Cast Technique
It is imperative that proper cast application techniques
be employed in order to maintain good alignment of
unstable fractures after reduction (Box 5.1). The cast
must be applied with an interosseous mold between
the radial and ulnar shafts while maintaining a flattened
ulnar border. After application, the cast should not appear
cylinder-shaped on the arm, but instead should have an
99
oval contour when viewed axially, and appear flat along
the ulna side of the forearm when viewed from the side.
This type of cast molding is necessary for maintain-
ing alignment of the entire forearm axis and prevents
displacement of the fracture fragments as the swelling
in the forearm resolves. The recommended rotational
position of the forearm in the cast is dependent on the
location of the radius fracture. The biceps muscle imparts
a supination force to the proximal fracture fragment in
proximal third radius fractures. Therefore, proximal third
radial shaft fractures are best casted with the hand in a
supinated position in order to rotationally realign the
distal fragment with the proximal fragment. Fractures in
the middle one-third of the radius are best casted with
the hand in a neutral rotation. Distal third fractures are
best rotationally realigned by pronating the forearm in
the cast. Extremes of either supination or pronation are
not recommended to minimize the risk of stiffness after
fracture healing.
Box 5.1: Proper forearm cast application
• Good interosseous mold
• Avoid pressure areas by molding with palms of hands
• Shift hands while fiberglass is setting
• Avoid excessive cast padding around fracture
While applying the cast, the surgeon should always be
aware of hand position while molding the fiberglass or
plaster to avoid pressure points that may be caused by the
finger tips, sites for potential pressure ulcers and discom-
fort for the patient. It is best to use the palm of the hands
while applying molds and to make small, frequent shift in
the hands in order to avoid any indentations in the cast.8
Also, cast padding should be adequate to prevent pressure
sores over bony prominences but never excessive as this
may result in loss of maintenance of alignment. Long arm
casts should always be used for nonoperative manage-
ment of all proximal and middle-third forearm fractures.
While a well-molded short arm cast may be applied for
some distal third fractures, it is the author’s opinion that
most displaced diaphyseal forearm fractures that undergo
reduction are best treated by long arm cast immobiliza-
tion. While some believe that Plaster of Paris casts are
better for obtaining effective cast molding compared to
fiberglass, in our hands the technique of application is
more important than the cast material used. The choice
of material for cast immobilization is best chosen by the
surgeon applying the cast, based on experience as well
as availability and cost of materials (Figs 5.1 and 5.2).
100 Contemporary Surgical Management of Fractures and Complications: Pediatrics
Fig. 5.1: Proper cast molding demands that the surgeon applies
a good interosseous mold over the forearm. Notice the position of
the hands. They constantly change positions while the fiberglass or
plaster is setting. Also notice that the surgeon is molding with the
palm of the hands and is avoiding direct pressure with the fingertips
Acceptable Reduction
It is important for the treating physician to understand
the remodeling potential of the fracture. This remodeling
potential is dependent upon the age of the patient, the
proximity of the fracture to the rapidly growing distal
physis and the direction of the deformity. Fractures in
younger children have a greater remodeling capacity than
fractures in adolescents who are closer to skeletal matu-
rity. Fractures in the distal forearm remodel more reliably
than fractures in the proximal portion of the forearm due
to their close proximity to the rapidly growing physes of
the distal radius and ulna. Angular deformities typically
remodel better than rotational deformities. Fortunately,
significant rotational deformities are well-tolerated in the
forearm of children even though they have poor remod-
eling potential.9
Because of remodeling potential, acceptable reduction
parameters have been established, albeit with some
controversy because of differing opinions on what is
termed acceptable. The authors utilize these guidelines.9
Complete bayonet apposition of the fracture fragments
with up to 1 cm of shortening can be acceptable provided
Fig. 5.2: It is important to make the cast sturdy around the thumb
but to avoid direct pressure in the thenar area that will eventually
cause discomfort for the patient
Table 5.1: Acceptable alignment of forearm fractures in children
Eight Years Older than
and Younger Eight Years
Angulation 20°* 10°
Malrotation 45° 30°
Bayonet Yes Yes
*Proximal third - 10°
that the angular alignment is appropriate for the patient’s
age and type of fracture. For children 8 years of age
or younger, middle and distal third forearm fractures
with angular deformities of up to 20° and up to 45° of
malrotation are acceptable. Fractures in proximal third
of the forearm in all ages and fractures at all locations in
children older than 8–10 years of age do no not have as
much capacity to remodel. Acceptable angulation is 10°
and less than 30° of malrotation (Table 5.1).
Care after Closed Reduction
After closed reduction and casting, most children are
discharged after postreduction X-rays are assessed and
found to be acceptable. The child and the parents are
given instructions to maintain 24 hours of arm elevation
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents
Table 5.2: Signs and symptoms of compartment syndrome
Six “Ps” Three “As”
Pain Agitation
Pressure Anxiety
Paresthesia Analgesia (increasing need)
Paresis
Pallor
Pulselessness
if possible to diminish swelling, to monitor pain and
assess function of the hand. They are asked to contact
the physician or to return to the emergency department
for significant changes that may signal the development
of a compartment syndrome (Table 5.2).
Repeat radiographs and an examination should be
performed within 5–7 days as the swelling resolves.
Fractures that are potentially at risk to lose reduction,
such as those that are complete, occurring at the same
level or are reduced with bayonet apposition or residual
angulation, require follow-up X-rays weekly for 2–3 weeks
until early callus formation is visualized on the radio-
graphs. Unacceptable reangulation can be treated with
cast wedging or repeat anesthesia and closed reduction
under anesthesia (Figs 5.3A and B). Repeat manipulation
can often be successfully performed up to 3 weeks after
A B
Figs 5.3A and B: A radius and ulna shaft fractures with unaccep-
table alignment of the ulna. Alignment of the fractures is markedly
improved after cast wedging
101
the injury in most cases, except for fractures in younger
children. Most pediatric fractures are maintained in a cast
for 6–12 weeks, depending on age of the child, fracture
characteristics and radiographic healing. Stiffness of
the elbow and wrist occur infrequently in children after
immobilization.
Parent Counseling
Children with some residual acceptable angulation for
age and who have at least 2 years of growth remaining
will remodel over the course of 1–3 years in most cases.
Because parents often do not understand the concept
of remodeling, they are therefore frequently concerned
about fractures that are not in anatomic alignment. It
is the author’s belief that it is important to counsel the
parents prior to the closed reduction about the goals of
the closed reduction. It is also helpful to maintain a copy
of serial radiographs of other children who have success-
fully remodeled so that parents can see the expected
progression (Figs 5.4A and B).
Outcomes of Closed Reduction and Casting
Most forearm fractures can be treated successfully
with cast immobilization, or closed reduction and cast
immobilization. When acceptable reduction parameters
are achieved, and even in many cases where successful
reduction could not be achieved, most children have
restoration of normal function.9
Complications of Closed Reduction
Malunion
Malunions can occur with pediatric forearm fractures and
may potentially be avoided by understanding the remod-
eling potential for each fracture, proper cast application
and close follow-up for early treatment of unacceptable
loss of alignment. Most forearm fractures that redisplace
following a closed reduction will do so in the first 2 weeks
after the closed reduction. Therefore close follow-up with
serial AP and lateral radiographs in the first 2 weeks after
closed reduction is critical to prevent this complication.
For healing fractures, cast wedging in the office,
performed by creating an opening wedge at the
deformity apex to prevent skin injury that can occur with
closed wedging techniques, may be useful to improve
unacceptable angulation. Once significant callus
102 Contemporary Surgical Management of Fractures and Complications: Pediatrics

A B
Figs 5.4A and B: (A) This 5-year-old girl sustained a metaphyseal-diaphyseal fracture that was reduced and placed into a poorly molded
cast which slid down on her arm. A new cast was applied without a repeat reduction; (B) The images show the alignment of the fractured
forearm 8 months after the injury

formation is seen on radiographs, however, closed or open
fracture osteoclysis is an option. Repeat manipulation
under fluoroscopy, sometime facilitated by percutaneous
drilling with a smooth wire or small drill bit at the fracture
site, can be successful as long as 4–6 weeks after injury
in some cases. After realignment, a well-molded cast
may then be reapplied. Open reduction with fixation is
recommended when this technique does not achieve
adequate realignment of the fracture.
Healed fractures with residual angulation, which is
greater than can be expected to remodel, or has failed to
remodel after 1–2 years of observation, are best treated
with osteotomies of the radius and ulna. Careful preopera-
tive planning, meticulous surgical technique and stable
fixation with plate-screw constructs yield the most reliable
results.10
Refracture
Refractures occur in less than 5% of forearm fractures.
This complication is seen most commonly after proximal
and middle third diaphyseal forearm fractures and may
occur up to one year after fracture healing.11 Parents
should be cautioned that refracture of diaphyseal
forearm fractures may occur. Children with fractures in
the proximal or middle third of the forearm may benefit
from the use of a forearm brace and restriction of sports
activities until early remodeling occurs, usually within
6–9 months of injury.
Many refractures may be successfully treated with
closed reduction and casting. Some refractures, especially
those that occur through a site of incomplete healing or
those that occur in fractures that healed with residual
angulation, benefit from open reduction and fixation. It
is also important that the surgeon carefully assess the
radiographs to assure that the refracture did not occur
through pathologic bone.
Compartment Syndrome
Compartment syndromes are devastating but fortunately
rare events after pediatric forearm fractures. While Jones
and Weiner had no reported compartment syndrome in
730 fractures7 treated with casting alone, this complica-
tion may occur secondary to severe swelling after injury,
excessive manipulation or tight casting in patients who
undergo closed reduction of displaced forearm fractures.
Young patients and patients with limited verbal abilities
should be monitored closely with serial exams and use
of compartment pressure checks when any suspicion of a
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents
compartment syndrome is entertained. Splinting instead
of casting after reduction, careful casting technique that
avoids excessive stretching of the casting material while it
is applied and bivalving of casts in patients with excessive
swelling or who cannot communicate symptoms are some
ways to avoid this potentially devastating complication.
Cast Complications
In addition to tight casting leading to a compartment
syndrome, other complications can occur from casts. Skin
breakdown may occur from improperly applied molding
or cast imprints from poor technique. Skin burns can occur
from using cast material dipping water that is too warm
or by applying fiberglass over a plaster mold before the
plaster has dried and cooled. Removal of casts has a risk
of cast saw burns of approximately 0.72%.12 Maintaining
sharp blades on cast saws and avoiding unnecessarily
thick casts may reduce the incidence of cast saw injury.
Proper technique for removal involves alternating firm
pressure with relaxation and withdrawal of the blade from
the cast before advancing it to the next spot.8
SURGICAL TREATMENT
Indications
Indications for surgical treatment of forearm fractures
vary amongst surgeons and are based on many factors.
As for all operative techniques, careful consideration
should always be given to weighing the risks and benefits
of surgical versus nonsurgical management. Indications
for surgical management include open fractures, severely
comminuted fractures, those that cannot be reduced
into acceptable alignment utilizing closed reduction
techniques and fractures that have lost reduction after
a previously acceptable reduction. Primary operative
treatment of forearm fractures that have a high risk of
failure of closed treatment may also be indicated. These
include displaced fractures in children greater than
10 years of age, displaced proximal third radius fractures
with greater than 10° angulation and mid-diaphyseal
fractures with initial ulna angulation greater than 15°.13
Preoperative Considerations
High-quality AP and lateral radiographs of the forearm
including the elbow is typically all that is necessary
for surgical planning of both bone forearm fractures.
Computed tomography (CT) scans and magnetic resonance
103
imaging (MRI) are not beneficial except if fracture through
pathologic bone is suspected. Options for surgical fixation
include intramedullary fixation of one or both bones, plate
fixation of one or both bones, and the use of pins and
plaster to maintain length and alignment. The choice of
fixation is dependent upon the physician’s experience with
the various techniques, availability of implants and cost.
Intramedullary Fixation
Intramedullary fixation of forearm fractures is the most
commonly used method of stabilization of forearm frac-
tures in children and adolescents.5 The type of intramedul-
lary implants used depends on the surgeon’s preference
as well as experience and includes elastic intramedullary
nails, long Steinman pins or K-wires and Rush rods. Unlike
the femur, in which two nails are used, the radius and ulna
only require one intramedullary implant for stabilization.
Similar to plate fixation, intramedullary fixation may be
undertaken for both bones in the forearm or for only
one of the two bones when the nonstabilized bone is in
adequate alignment and is deemed stable without implant
fixation14 (Box 5.2).
Box 5.2: general steps of intramedullary
implant placement in the radius and ulna
• Pass the nail (or pin) up to the fracture sight
• Reduce the fracture
• Pass the nail one centimeter past the fracture sight
• Check AP and Lateral films to confirm distal intramed-
ullary placement of the nail
• Advance nail to one centimeter short of final position
(beware of physis)
• Cut nail just outside of skin
• Advance nail final centimeter so that the proximal
tip is just outside of the canal
• Reconfirm placement of the nail with anteroposterior
and lateral fluoroscopic films
Compared to open reduction and plate fixation, the
technique most commonly used in adults, intramedullary
fixation may be sometimes done without fracture site
exposure (closed) or with a limited exposure, yielding
more cosmetically pleasing scars with less soft tissue
dissection and providing easier implant removal. The
major disadvantage of this technique is the fact that
intramedullary nails are flexible. Because of this, nails must
be supplemented with postoperative immobilization in
104 Contemporary Surgical Management of Fractures and Complications: Pediatrics
a cast or splint and have a higher risk of malunion and
nonunion compared to plating. Another disadvantage is
the risk of neurovascular or tendon injury at the nail inser-
tion site. Injuries to the dorsal sensory branch of the radial
nerve and rupture of the extensor pollicis longus (EPL)
tendon have been associated with nail insertion in the
distal radius. In addition, it is difficult to use this technique
in partially healed fractures that have become malaligned
because callus formation within the medullary canal
may prevent passage of the nails. Complication rates for
surgical stabilization of diaphyseal forearm fractures in
children and adolescents may be as high as 14%.15
Patient Positioning
The procedure should be performed under general
anesthesia with the patient positioned supine. A sterile
tourniquet is applied to the upper arm but is not inflated
unless necessary. Most surgeons place the arm on a
hand table but some clinicians prefer to simply place the
forearm over the chest.
The implant should be sized to fit the intramedullary
canal of the bone so that it does not need to be force-
fully placed. One common mistake is to attempt to pass
a nail that approximates the inner diameter of the canal.
As the nail is placed into its final position, an excessively
large implant may bind in the canal and not advance,
causing distraction at the fracture site. Elastic nails made
of titanium measuring 2.0–2.5 mm in diameter or K-wires
measuring 0.062 inches or 5/64th inches are most com-
monly used. The radial implant should be pre-contoured
prior to insertion to match the normal radial bow. The
ulna is a straight bone and therefore no pre-contouring
is necessary. It is my preference to stabilize the bone that
reduces the easiest first because doing this often makes
reduction of the second bone easier.
Approach and Relevant Surgical Anatomy
The radius is approached from its distal aspect because
approaching the proximal radius may cause injury to
posterior interosseous nerve. In addition, the wide meta-
physeal flare of the distal radius makes it more amenable
to easy entry into the medullary canal. The radial implant
may be placed either through a starting point made dor-
sally just ulnar to Lister’s tubercle or through a starting
point made in the radial side of the mid-metaphysis just
proximal to the physis. There are, however, inherent risks
to this distal radius entry point. One risk is injury to the
superficial branch of the radial nerve which has several
small, diverging branches on the dorsal-lateral side of
the radius. The second risk associated with the dorsal
approach is injury to the tendons of the dorsal compart-
ments of the wrist, particularly the EPL. The third risk is
injury to the distal radial physis, the result of drilling too
close the physis of the distal radius from either approach.
The ulnar implant is placed through the proximal ulna.
The starting point may be made directly through the tip of
the olecranon apophysis or through the lateral metaphysis
of the ulna just distal to the tip utilizing a small incision.
Surgical Technique
The safest method to avoid inadvertent injuries to these
structures is as follows. Fluoroscopy is used to identify
and mark the distal radial physis on the skin. For radial
sided placement of the radial implant, a small, 7–10 mm
skin incision is made directly radially starting at the level
of the physis and continuing proximally. A small hemostat
is used to develop a soft tissue plane down to the first
dorsal compartment of the wrist. The tendons may then
be retracted dorsally to expose the underlying bone. A
drill bit sized slightly larger than the diameter of the nail
is used to make a cortical window starting approximately
1 cm proximal to the distal radial physis marked out
under direct fluoroscopic vision. A soft tissue guide or
two small retractors are be used to protect the branches
of the superficial radial nerve and the tendons of the first
dorsal interosseous compartment. Upon entry of the drill
bit into the canal, the surgeon should direct the drill from
the position perpendicular to the cortex to a position
more parallel with it, thereby making the cortical hole
oval-shaped. An oval window makes it easier to pass the
nail into the canal.
An appropriately sized nail is then gently bent to match
the expected radial bow (Figs 5.5A and B). When elastic
intramedullary nails are used, the bent “shovel tip” portion
of the nail should enter first. When using Steinman pins
or K-wires, it is necessary to remove the sharp tip of the
device prior to attempting entry into the canal. It can be
helpful to attach a chuck from a drill or a ratcheting plier
to the implant in order to have control of the implant
as it is advanced. Alternatively, many elastic intramedul-
lary nail sets are available with an implant holder that
accomplishes the same goal. Care should be taken, as
the implant is placed into the canal, to avoid penetrating
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents
A B
Figs 5.5A and B: Very unstable radius and ulna midshaft fractures
stabilized with Steinman pins utilized as intramedullary implants
the opposite cortex. This can be done by watching the
progression of the device under intermittent fluoroscopic
imaging and keeping the device in line with the radial shaft
while advancing it. When using a precontoured elastic
intramedullary nail, the shovel should be directed away
from the intramedullary metaphyseal cortex as the nail
enters the canal. If the nail does not pass the metaphyseal
flare easily, the implant tip may be bent slightly more at
the tip or a smaller nail may be selected.
Once the nail passes the intramedullary metaphyseal
cortex and is advanced to the fracture, it may be rotated to
reduce the fracture and to reconstitute the normal radial
bow. Care should be taken to use small, light taps with the
hammer to avoid passing the implant past the unreduced
fracture and penetrating the surrounding soft tissue in the
forearm compartments. Frequent fluoroscopic images can
be helpful in preventing this. The implant is then moved
slowly in a proximal direction until it is just at the fracture
site but not past it. A closed reduction of the radius and
ulna is now performed by an assistant. With the fracture
held aligned, the surgeon may then advance the implant
across the fracture site. AP and lateral views are then taken
to confirm placement of the implant in the intramedul-
lary canal of the radius. Yuan and Mubarak, et al.16 have
reported an increase risk of compartment syndrome with
multiple attempts at closed passage of the nail across the
fracture site. Therefore, it is our practice to make only three
attempts to pass the implant across the fracture. If this
cannot be accomplished after these three attempts, then
the fracture is opened through a limited volar approach
105
that is used to assist in passage of the nail under direct
visualization.
Once the implant is across the fracture site, it is passed
proximally within 2 cm of the proximal radial physis. The
implant is then cut and advanced to its final position
beneath the skin with a bone tamp. Prior to skin closure,
rods placed dorsally must be inspected at the bone entry
site to ensure that the dorsal tendons are not entrapped
by the implant or at risk for laceration from the end of
the rod.
At this point a decision can be made, based on remod-
eling criteria, on the necessity of implant placement in
the ulna. If the ulna is reduced into acceptable alignment,
then it is not always necessary to fix the ulna. The child
may then be placed into a long arm cast and the reduc-
tion confirmed with forearm radiographs. Ulna fixation is
indicated if the reduction is not acceptable or is not stable
with only single-bone fixation.
Ulna Fixation
Ulnar fixation is most commonly placed from proximal to
distal. The implant can be placed through the olecranon
apophysis without concern for growth arrest causing
a limb-length discrepancy because this growth center
contributes to appositional growth of the olecranon, not
longitudinal growth. However, this technique can cause
irritation at the tip of the olecranon that may require
early removal of the implant. Because of this, it is our
practice to place the nail through the lateral side of the
olecranon through a small 5–7 mm skin incision just
distal to the coronoid process. After the incision is made,
a small hemostat is used to gently spread the fibers of
the anconeus muscle, exposing the underlying lateral
cortex of the proximal ulna. An implant that is smaller
than the smallest diameter of the intramedullary canal
of the ulna is then selected and introduced through a
small cortical hole made with a drill bit with a diameter
slightly larger than the implant diameter. Because the
ulnar shaft is straight, there is no need to pre-contour the
implant. As with the radius, the sharp end of the K-wire
or Steinmann pin should be removed prior to placement.
When a pre-contoured elastic intramedullary nail is
used, the shovel end should be turned away from the
opposite intramedullary canal of the ulna to allow for easy
passage. The ulnar implant is carefully advanced across
the fracture with the fracture held aligned. If the ulna
106 Contemporary Surgical Management of Fractures and Complications: Pediatrics
cannot be reduced in a closed fashion, then a standard
approach to the ulna can be performed though a small
incision between the extensor carpi ulnaris and the flexor
carpi ulnaris tendons, typically on the lateral border of the
ulna. After fluoroscopic confirmation of reduction and
intramedullary placement, the implant is advanced 2 cm
proximal of the distal ulnar physis, cut and tamped into
its final position beneath the skin.
Postoperative Management
Following intramedullary fixation, the arm should be place
into an anterior-posterior sugar-tong splint or a bivalved
long arm cast and admitted to the hospital overnight
for pain control and observation for development of a
compartment syndrome. Approximately 7–10 days after
surgery, AP and lateral radiographs are performed to
check maintenance of alignment and implant position.
The splint is then converted to a cast or the bivalved cast
is overwrapped with casting material. After 4–6 weeks,
when some callus is present on follow-up radiographs,
the cast is removed and early gentle motion is started. The
patient should still be restricted from any sports activities
or activities that place the patient at a risk for falling on
the arm until complete radiographic healing, generally
12–16 weeks (Box 5.3).
Box 5.3: postoperative management
• Following closed reduction, fracture alignment
should be assessed at least weekly until callus
formation to assess maintenance of reduction
• Cast wedging can be a useful tool to realign mild
angular deformities in fractures without callus
formation in older patients
• Instruction given to parents regarding monitoring of
compartment syndrome and its signs and symptoms
It is our practice to remove all implants after the
fracture has healed and intramedullary remodeling of
the canal occurs, typically a minimum of 8–12 weeks
after surgery. Removing implants too early can result in
a refracture. Implants may require early removal if they
are causing local sensory nerve or skin irritation, interfer-
ing with EPL or other tendon function, or infection has
occurred. Nail removal with conversion to plating may be
necessary for delayed unions or nonunions.
Plate Fixation
Open reduction and plate fixation has been utilized for
decades for the treatment of adult forearm fractures with
good success. There are many reports of excellent out-
comes utilizing this technique in children and adolescents
as well.17 Anatomic alignment of the fracture with very little
chance of loss of alignment, reliable healing and earlier
initiation of rehabilitation compared to casting alone and
intramedullary nailing are the major advantages of plate
fixation. Disadvantages of this technique compared to
intramedullary nailing include a larger operative exposure
and longer operative time, and the possible need for
hardware removal after which immobilization is required
to prevent refracture.
Plate fixation is a reliable technique for any age but
in practice is utilized mainly for children with fracture
patterns not amenable to nail fixation, such as those with
severe comminution and for those approaching skeletal
maturity. Intramedullary nail fixation yields worse out-
comes in children older than 10 years of age compared
to those younger than 10 years of age.5 Increased healing
time and the occurrence of nonunions are more likely in
older children. For children and adolescents older than
10 year of age or near skeletal maturity regardless of
chronological age, plate fixation may be a better tech-
nique compared to intramedullary nail fixation.
Patient Positioning
The patient should be placed in the supine position on the
operating room table with arm placed on a hand table. A
tourniquet is placed proximally on the upper arm. For plate
fixation, either a nonsterile tourniquet prepped out of the
field or a sterile one applied in the sterile field is utilized.
Approaches and Relative Surgical Anatomy
The radius is typically approached through a standard
anterior (volar) approach utilizing the interval between
the brachioradialis and the flexor carpi radialis muscles.
Care should be taken to protect the superficial radial nerve
that lies deep to the brachioradialis. When exposing the
proximal third of the radius, it is imperative to supinate the
forearm, thereby moving the posterior interosseous nerve,
which lies deep to the supinator muscle, posteriorly and
laterally away from the surgical dissection. The supinator
muscle can then be incised at its medial border of the
proximal radius and reflected laterally. Retraction of this
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents
muscle must be gentle to avoid neurapraxia of the nerve.
Dissection distally can be continued onto the insertion of
the pronator teres on the lateral border of the radius. This
muscle should be divided at this insertion and retracted
medially. Continuing distally, the flexor digitorum superfi-
cialis origin on the radius can be divided to be mobilized
medially as well to allow almost complete exposure of the
radius through a single incision.
The ulna is approached through a skin incision along its
lateral border. Once through skin, the interval between the
flexor carpi ulnaris and the extensor carpi ulnaris muscles
is identified and divided. Because the ulna is essentially
subcutaneous in this interval, the entire diaphyseal shaft
can be exposed.
Plating Technique
The radius fracture is typically stabilized with a 3.5 mm
compression plate in older children and adolescents. For
smaller children, a 2.7 mm plate may be required to bet-
ter accommodate the smaller width of the bone. Optimal
fixation includes three bicortical screws proximal and
three screws distal to the fracture. Lag screw compression
outside of the plate can be beneficial when the fracture
pattern allows for this. This is typically easier with oblique
fractures. The screws in the plate should also be placed
to provide some degree of compression across the frac-
A B
Figs 5.6A to C: A radius and ulna shaft fracture in an athletic male treated open reduction and fixation of only the radius. The ulna
reduced spontaneously and was stable once the radius was stabilized. Notice the lag screw placed across the radius fracture to apply
compression to the fracture
107
ture. This can be performed by placing two screws either
distal or proximal to the fracture first. This is followed by
placement of a third screw on the opposite side of the
fracture by placing the screw in a non-centered fashion
in the portion of the hole away from the fracture. Prior to
final seating of this screw, the first two screws should be
loosened slightly to allow the plate to slide and thereby
apply compression to the fracture sight. The initial two
screws can then be tightened to a final tightness. Locked
plate-screw combinations are typically not necessary
in healthy children with normal bone quality. They may
occasionally be beneficial, however, in fractures with signi­
ficant comminution or in children with abnormal bone
quality due to osteogenesis imperfecta or other systemic
causes of osteoporosis.
The same principles apply to plate fixation of the ulna.
The ulna plate can be applied to the direct subcutaneous
border of the ulna or to the volar side of the bone
beneath the flexor muscles to avoid plate prominence
when the patient is resting the forearm on a hard surface.
It is possible, especially in younger children, to achieve
reduction by stabilizing only one of the two forearm
bones with plate fixation. As with single bone fixation with
intramedullary nails, in some circumstances in children the
bone that is not fixated may be held in alignment with
long arm application (Figs 5.6A to C).
C
108 Contemporary Surgical Management of Fractures and Complications: Pediatrics
Postoperative Management
When plate fixation is used for both bones, an anterior-
posterior sugar-tong splint is applied for patient comfort.
After 1–2 weeks the splint is removed and the patient is
permitted to begin gentle range of motion activities as
well as to use the arm for normal activities of daily living
that do not involve any heavy lifting or impact loading
of the forearm. When only one bone is stabilized, a long
arm cast is applied and maintained until the nonstabilized
bone shows callus formation on plain radiographs, typi-
cally 6 weeks after surgery. Plate removal is recommended
for any patient who wishes to return to contact sports
or impact activities that involve the forearm in order to
reduce the risk of refracture at the stress riser near the
top and bottom of the plates. This generally cannot be
performed until one year after plate placement. After plate
removal, the arm should be casted for 4–6 weeks minimum
to reduce the risk of refracture through the screw holes.
Outcomes
Outcomes following plate fixation and intramedullary
implant fixation of forearm fractures in children are
generally good. Most patients return rapidly to full
function.17 As mentioned previously, plate fixation of both
bones allows for return to normal nonimpact activities
of daily living in 1–2 weeks with return to sports once
complete healing occurs in 3–4 months.
Complications of Forearm Fixation
Hardware-Related Complications
Hardware failure typically occurs because the nail or plate
chosen was not of sufficient strength or fixation was
inadequate. For intramedullary nail fixation, use of
implants that are too small or inadvertent distraction with
too large a rod are some reasons for failure. Use of third
tubular plates and reconstruction plates are associated
with failure compared to stiffer plates. It is the author’s
practice to use 3.5 mm or 2.7 mm compression plates
when utilizing this technique. Removal of hardware solves
the problem of painful hardware. While all nails should
be removed, plates are not routinely removed unless they
are causing soft tissue or skin irritation. Fracture around
the plates may occur after forearm loading or contact
when plates are left in place. Patients and families must
be counseled about the risk of fracture around the plates
and advised to remove them if the child is planning to
return to contact or collision sports and other activities
at risk for falling onto the affected arm.
Intramedullary nail fixation of the radius has two im-
portant complications associated with it. Dorsally placed
radial nails may cause attritional rupture of the EPL at
the nail insertion site. This is diagnosed typically several
weeks after the nail is inserted. Early nail removal and
exploration of the tendon is indicated. If the tendon is
incompletely torn, casting the wrist including the thumb
may promote healing. Direct repair may be attempted but
is often unsuccessful because of attritional damage and
dysvascularity of the tendon. The simplest and most ef-
fective solution is transfer of the extensor indicis proprius
to the EPL tendon,18 a procedure that improves thumb
extension without significant patient morbidity. Radially
placed radial nails may irritate, or in extreme cases cause
neuromas of the dorsal sensory branch of the radial
nerve. In most cases, nail removal solves this problem. In
cases of nerve irritation not improved after nail removal,
exploration and neurolysis may be necessary.
Nonunion
Nonunion of forearm fractures is rare and occurs most
commonly in the ulna in older patients between the ages
of 13 years and 16 years.19 The most common location
is in the mid-diaphyseal region in what is thought to be
a watershed zone of perfusion with poor intraosseous
blood supply.19 The etiology of nonunion after either
intramedullary nail fixation or plating may be multifacto-
rial. Inadequate stability of fixation and infection of the
bone and implants are the most important consideration
when evaluating a nonunion. Laboratory studies, such as
white blood cell (WBC) count, erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP), may be useful to
identify an infection. Implant removal, bone debridement,
and culturing of the implant and bone may be necessary
to identify infection. Repeat fixation, often with bone
grafting, is typically done in the same surgery if infection
is not proven. Nonunion after intramedullary nail fixation
is best managed with plate fixation while a change in plate
size for improvement of fixation is sometimes necessary
when nonunion occurs after plating.
Compartment Syndrome
In one study, placement of intramedullary implants for
both bones fractures is associated with a risk of forearm
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents
compartment syndrome in 10%16 of patients. This risk
appears to directly relate to the duration of the surgery,
with the authors hypothesizing that excessive manipula-
tion contributed to compartment syndrome develop-
ment. In another study, an increased risk was seen in
older children who had intramedullary nail surgery within
24 hours of injury.5 Because of these findings, it is the
author’s practice to limit the time spent attempting closed
passage of intramedullary nails to 3–4 passes or a to an
overall manipulation time of 10 minutes. When the limits
109
are exceeded, the fracture is open reduced. In addition,
intramedullary nail surgery is delayed if possible for a
minimum of 48 hours after injury.
Forearm compartment syndrome is managed by
emergent fasciotomy of the volar forearm in most cases.
An extensile volar exposure allows decompression of
the superficial and deep muscle groups, generally the
compartments most involved, and the carpal tunnel.
Decompression of the anterior forearm and the mobile
wad muscles in necessary only in rare cases.

MONTEGGIA FRACTURE-DISLOCATIONS

INTRODUCTION a suspected Monteggia fracture. It is especially important

to visualize the entire elbow when an isolated ulna fracture
The Monteggia fracture-dislocation is an uncommon type of is seen on forearm radiographs, a common mistake made
forearm injury, making up only 3% of all forearm fractures.20 that leads to missed Monteggia lesions. To diagnose the
It is a combination of an ulnar shaft fracture and a dislocated radial head dislocation, a line is drawn through the center
radioulnar joint, with or without a radius fracture (Fig. 5.7).
of the shaft proximal radius and across the elbow joint to
The mechanism of injury for Monteggia fractures typically
the capitellum on all radiographs. In normal elbows, this
involves a fall on an outstretched arm while the forearm is
line intersects the center of the capitellum of the distal
in a supinated position. Early recognition of this injury is the
humerus on all views regardless of the positioning of the
key to success because acute treatment is easier and more
reliable than treatments used to reconstruct Monteggia elbow and forearm. Other subtle radiographic signs as-
fractures that are diagnosed late. sociated with these injuries include ulnar bowing without
fracture, incomplete ulna fractures and metaphyseal ulna
fractures with angulation. Also, fractures of the radial neck
DIAGNOSIS
and shaft may also occur in association with Monteggia
fractures. CT scan and MRI are rarely indicated to diagnose
Clinical Presentation these injuries.
Children with Monteggia fracture often present with
forearm pain and deformity. Elbow swelling, how-
ever, may not be obvious. Tenderness along the lateral
elbow and prominence of the radial head are some signs
that may distinguish this from a both bones forearm
fracture. A careful neurovascular exam is necessary to
detect abnormalities. Neurological and vascular injuries
are uncommon after Monteggia fractures. Posterior
interosseous nerve neuropraxia is the most common
nerve injury, detected when the patient is unable to extend
the thumb and fingers but has intact sensation. Tense,
firm forearm compartments should alert the clinician to
the possibility of compartment syndrome, also rare after
a Monteggia fracture.

Imaging
Fig. 5.7: Forearm views that reveal an isolated ulna shaft
Anteroposterior and lateral radiographs of the elbow and fracture should alert the physician that a Monteggia fracture is likely.
the forearm should be obtained for all children who have Additional X-rays of the elbow should be ordered
110 Contemporary Surgical Management of Fractures and Complications: Pediatrics
CLASSIFICATION
Monteggia fractures have been historically classified on
the basis of the direction of the radial head dislocation
and on the presence of a radial neck fracture. The original
classification system was first described by Bado in 1958.21
This system, based on the work of Monteggia, includes
four types of injuries (Box 5.4). Type I Monteggia fracture-
dislocations involve an ulna fracture with a proximal radius
that is dislocated anteriorly relative to the capitellum. The
ulna is most commonly angulated anteriorly. Type II inju-
ries are characterized by an ulna fracture with a posteriorly
dislocated proximal radius. In this type of injury, the ulna is
most commonly angulated posteriorly. In type III injuries,
the ulna is fractured and the radial head is dislocated in
the lateral direction. These occur often with incomplete
fractures of the proximal ulna when the ulna is angulated
in a radial direction. Type IV Monteggia fracture-disloca-
tions include an ulna fracture seen in association with a
proximal radius dislocation and a radial neck fracture. Type
I and Type III injuries are the most common types while
Type II injuries are the least common. Types I, III, and IV
generally result from a fall on an outstretched hand with
the forearm in a pronated position. Type II injuries occur
with a fall on an outstretched hand with the forearm in
a supinated position. Understanding the mechanism of
injury is necessary for reduction of the fracture.
Box 5.4: Monteggia Fracture
classification
• Type I Ulna fracture with Anterior radial head disloca-
tion
• Type II Ulna fracture with Posterior radial head
dislocation
• Type III Ulna fracture with Lateral radial head dislocation
• Type IV Ulna fracture with Radial neck fracture with
or without radial head dislocation
An additional classification system, developed by Letts
et al. described these injuries on both the direction of the
radial head dislocation and the ulna fracture pattern. This
classification divided the Bado Type I injuries into three
sub-types based on the ulna fracture. These included the
plastic deformity, greenstick and complete proximal ulna
fractures.22
NONSURGICAL MANAGEMENT
Monteggia injuries are best reduced under intravenous
sedation in the emergency department or under gen-
eral anesthesia in the operating room in order to obtain
alignment, to assess of the stability of the fracture and to
allow effective casting. In the vast majority of the cases,
the proximal radius will reduce once the ulna is anatomi-
cally aligned. This is achieved by first manipulating the
forearm to reduce the ulna. For Types I, III and IV injuries,
this is followed by a combination of elbow flexion and
forearm supination, reversing the mechanism of injury of
elbow extension and forearm pronation. Type II lesions
may require elbow extension combined with forearm
supination to reduce. While performing the reduction
maneuver, the surgeon places a thumb on the radial head
and attempts to relocate it with a gentle force. With the
forearm held reduced, the elbow is taken through a range
of gentle motion to assess the stability of the radial head;
for stable fractures, a long arm cast is then applied. Type
I, III, and IV injuries are typically casted with the elbow
flexed approximately 100° with forearm in supination.
However, excessive elbow flexion greater than 120° should
be avoided in order to prevent compartment syndrome
of the forearm. Type II fractures are typically casted with
the elbow in extension and the forearm in supination.
The casting in extension is complicated by the tendency
for cast to slide down the arm after application. Encom-
passing the thumb with a thumb spica component and
applying a supracondylar mold just above the elbow will
help prevent this problem.
Management after Closed
Reduction and Casting
Clinical and radiographic follow-up weekly for the first
3 weeks after injury is recommended after closed
reduction to ensure maintenance of reduction of the ulna
fracture and the radiocapitellar joint (Figs 5.8A and B).
Loss of anatomic alignment of this joint on any view is
an indication for repeat reduction and implant fixation of
the ulna (Figs 5.9 and 5.10). Cast immobilization should
be continued for 4–6 days to weeks. Fractures which are
not completely united at that point may be placed into a
removable posterior splint that is removed two to three
times daily to allow elbow and forearm motion. Most
fractures are healed after 8–10 weeks of immobilization.
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents 111

A B
Figs 5.8A and B: (A) AP view alone is inadequate for assessing the radiocapitellar joint; (B) A Lateral X-ray of
the elbow should be ordered to assess alignment because the forearm view is inadequate to define the injury

Fig. 5.9: This lateral view of the forearm shows the minimal plastic Fig. 5.10: In this patient the lateral elbow view demonstrates slight
deformity of the ulna and an anterior radiocapitellar dislocation anterior subluxation of the radial head relative to the capitellum

SURGICAL MANAGEMENT Box 5.5: Treatment Recommendation for

Indications
Unlike most pediatric both bone forearm fractures, many
Monteggia fracture-dislocations require surgical treat-
ment (Box 5.5). Fractures which are unstable clinically
after closed reduction, those that require greater than
120° of flexion to maintain radial head reduction, and
length-unstable ulna fractures, such as those with com-
minution or oblique fracture patterns are best treated
primarily with operative fixation of the ulna. Fractures that
lose reduction after casting, open Monteggia fractures,
most Type IV Monteggia fracture-dislocations and the
rare acute injury with an irreducible radial head are other
indications for surgery.
Monteggia Fracture-Dislocatinos
• Monteggia fracture dislocations should be reduced
under IV sedation or general anesthesia to assure
anatomic reduction and the opportunity to assess
stability.
• Type I, II and IV Monteggia fracture-dislocations
should be immobilized in elbow flexion and forearm
supination.
• Type II Monteggia fracture-dislocations require
immobilization in extension.
• Monteggia fracture-dislocations should be moni-
tored weekly for 3 weeks after reduction for assess-
ment of ulnar and the radiocapitellar alignment.
112 Contemporary Surgical Management of Fractures and Complications: Pediatrics

Contemporary Techniques the radiocapitellar joint is not reducible or is unstable after

ulnar fixation.
Surgical Management of
Acute Monteggia Fractures
Ulnar Fixation
Patient positioning: Patient positioning and preparation
are similar to that used for intramedullary nail or plate Patient positioning and the techniques of ulna fixation
fixation of both bones forearm fractures. are identical to those described above for fixation of the
ulna. The choice of intramedullary nail or plate fixation is
Technique: Surgical treatment for Monteggia fractures is
based on fracture pattern and age of the child. Children
initially directed at correcting the alignment of the ulna
with noncomminuted fractures are generally managed
fracture. Reduction of the ulna often allows closed reduction
with intramedullary nail fixation. Patients near skeletal
of the radiocapitellar joint while flexing the elbow and
maturity or those of any age with severe ulnar comminu-
applying a gentle force on the radial head. Stabilization
tion or length-instability after intramedullary fixation are
of the ulna is then accomplished by intramedullary nail or
best treated with plate fixation.
most commonly by plate fixation of the ulna (Figs 5.11 and
5.12). The rare olecranon fracture associated with radial
Radial Head Reduction
head dislocations in children23 may be treated with a tension
band technique utilizing K-wires and 18 gauge wire or After ulna fixation, the radial head reduction is carefully
sutures. Open reduction of the radial head is performed if assessed with live fluoroscopic evaluation of the elbow.

Figs 5.11A and B: (A) These elbow and forearm films together
demonstrate a Type I Monteggia fracture dislocation with an
unstable, oblique ulna fracture that typically requires open reduction
and internal fixation; (B) A lateral view demonstrating stable fixation
with a dynamic compression plate (DCP) and anatomic reduction
B of the radiocapitellar joint
 Management of Forearm Fractures and Acute Monteggia Fractures in Children and Adolescents
Fig. 5.12: A Monteggia fracture-dislocation with an unstable oblique
ulna shaft fracture stabilized with an Ender’s nail in the ulna. Once
the ulna was stabilized the radiocapitellar joint was found to be
very stable
If the proximal radius is anatomically aligned with the
capitellum on all radiographic views of the elbow and
forearm, a long arm cast or sugar-tong splint is applied
with the elbow flexed to 90–100° and the forearm in
supination (Fig. 5.13).
If the radiocapitellar joint is not reducible after ulna
fixation, open reduction is then performed, typically
through a Kocher posterior-lateral approach to the elbow.
After skin incision, the interval between the anconeus and
the extensor carpi ulnaris muscles is identified and split.
The forearm should be pronated during this dissection to
protect the posterior interosseous nerve from inadvertent
injury. The radiocapitellar joint is then identified and the
impediments to reduction are addressed. Structures that
may be an impediment to reduction include the annular
or orbicular ligament, the capsule of the radiocapitellar
joint and bony or cartilaginous fragments of the radial
head or the capitellum. Soft tissue structures should be
gently removed from within the joint. Occasionally a small
incision will need to be made in the capsule or inverted
ligament to allow reduction of the radial head past the
constriction. Osteocartilaginous fragments with adequate
bone for fixation should be reduced into their anatomic
position and stabilized with sutures, headless bioabsorb-
able implants or headless stainless steel screws counter-
sunk into bone. Small fragments are discarded. Typically
after reduction, the radial head is stable. Repair of the
113
Fig. 5.13: Position of stability for Type I, III and IV Monteggia
fractures with the elbow flexed 90° and the forearm in supination
annular ligament or torn capsule may be necessary but in
many instances is not required as the tissues fall into their
anatomic position after the radial head is reduced and
heal after immobilization in a cast. After wound closure,
a long arm cast or sugar-tong splint is applied as above.
Postoperative Management
Radiographs of the elbow and forearm are taken 5–7 days
after surgery to confirm alignment. A cast is placed for
patients who were initially treated with a splint. Immobi-
lization is continued until adequate healing of the ulna
is seen on radiographs, usually 4–6 weeks after surgery.
Elbow and forearm range of motion exercises are then
begun, often under the supervision of a physical therapist.
Return to activities is permitted when range of motion
returns to normal, typically 3–4 months after surgery. The
same guidelines for hardware removal, described above
for forearm fractures that undergo fixation, apply for
Monteggia fractures that undergo fixation.
OUTCOMES
When detected early and treated adequately, outcomes
for Monteggia fractures are generally good.24 Return of
motion of the forearm axis with pronation and supination
can be slow but full active and passive return of motion
is to be expected in 3–4 months. Risk of redislocation
is a significant concern but complete healing of the
114 Contemporary Surgical Management of Fractures and Complications: Pediatrics
ulna in anatomic alignment gives the best chance of a
stable forearm axis.
COMPLICATIONS
Poor outcomes from Monteggia fractures most commonly
occur when the radial head redislocates in a cast follow-
ing closed or open reduction and the dislocation is not
detected until healing of the ulna occurs or the radiocapi-
tellar dislocation is missed by the initial treating physician.
Loss of Reduction
If the radial head redislocates after reduction and the
dislocation is detected within 4–6 weeks of injury, repeat
reduction is indicated. If the child had been previously
treated with closed reduction alone, ulnar fixation and
radial head reduction as described above is often all that
is needed to achieve and maintain radiocapitellar reduc-
tion. Subtle plastic deformation of the ulna or loss of ulnar
reduction are the most common reasons that redislocation
occurs after closed reduction. Radial head redislocation
after ulnar fixation and closed or open reduction warrants
re-exploration of the radiocapitellar joint. Repair of the
annular ligament after 4–6 weeks from injury is difficult
because the tissue planes cannot be identified easily and
the integrity of the soft tissues is compromised. Annular
ligament reconstruction may be necessary to achieve a
stable radiocapitellar joint (discussed below).
Missed Monteggia Fractures
Missed or chronic Monteggia fractures in children lead to
loss of elbow motion, pain and cubitus valgus. Treatment
for missed injuries is technically difficult and should only
be performed by surgeons with training and experience,
because ulnar remodeling and soft tissue contracture
make anatomic restoration impossible and demand
reconstructive techniques. In general, factors associated
with better outcomes include younger patients (< 12 years
old) and early treatment of these injuries before defor­
mity of the radial head occurs (< 3 years after injury),25
and children without changes in radial head shape such
as a convex articular surface.26 In the authors’ experi-
ence, however, achieving a satisfactory outcome is more
likely when the injury is diagnosed and treated within
6–9 months of its occurrence.
Detailed description of Monteggia reconstructive
techniques is beyond the scope of this chapter. To sum-
marize, the first step is an ulnar osteotomy through the
old fracture or, if remodeling has occurred, through the
proximal third of the shaft. The radiocapitellar is then
open reduced after removal of fibrous tissue and release
of capsular contractures. To facilitate ligament reconstruc-
tion, the radiocapitellar joint may be provisionally pinned
with a radioulnar or radiocapitellar wire. Annular ligament
reconstruction is then performed to provide stabilization.
Many annular ligament reconstructive techniques have
been described with variable results. Choices for recon-
struction include forearm fascia, triceps fascia,26-28 and
umbilical tape or other surgical material. The goal is to
create a ligament tether that allows for centered rotation
of the radius in the radiocapitellar joint. The final step is
fixation of the ulnar osteotomy. Overcorrection or slight
lengthening of the osteotomy and stable plate fixation in
this non-anatomic position may be necessary to facilitate
radial head reduction. Because results for surgical recon-
structions are so variable,29 patients and family members
should be counseled regarding the risks of surgical recon-
struction including injuries to the radial and ulnar nerves
and persistent stiffness with limited forearm rotation.
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2. Landin L. Epidemiology of children’s fractures. J Pediatr
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3. Black B, Amadio R. Orthopedic injuries associated with
backyard trampoline use in children. J Pediatr Surg.
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4. Sinikumpu J, Lautamo A, Serlo W. The increasing incidence
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