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
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