OrthoNet

Monteggia Fractures - Approach to Malunion

Consider reconstruction if:
- progressive radiocapitellar subluxation or dislocation, progressive valgus, limited range of elbow or forearm motion
- pain at radiocapitellar or radioulnar articulations

- most kids present with pain and restricted range of motion
- beware the subtle subluxation of the radial head - it might not be so obvious
- carefully scrutinize the ulnar shaft - what is the deformity? Was it fractured or just plastically deformed?
- look closely at the dislocated radial head - will it be congruent if you put it back? If not, you cannot do the reconstruction - wait until skeletally mature and excise it
- decide how to correct the ulnar deformity

Bell Tawse Procedure
- position prone; - Boyd approach
- lateral capsular incision to get into the elbow
- remove interposed soft tissue, including joint capsule, annular ligament
- reduce the radial head
- if cannot reduce the radial head, then osteotomize the ulna at the pre-determined spot
- then reduce the head; usually stable once reduced
- dissect a 1×7 cm strip of fascia off the lateral portion of the triceps; preserve the distal attachment on the olecranon
- pass the strip medial to the olecranon at a point opposite the origin of the annular ligament, then pass it around the neck of the radius, suturing it onto itself. Use a palmaris longus graft if triceps is unsuitable
- fix the ulna
- irrigate aggressively to try to prevent radioulnar synostosis