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Fractures and Dislocations About The Elbow in The Pediatric Patient PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Fractures and Dislocations about the Elbow in the Pediatric Patient" by Amy L. McIntosh, MD.

This medical PowerPoint presentation tells us how fractures and dislocations around the elbow are relatively common in pediatric patients due to their active lifestyles and participation in sports and recreational activities. The elbow joint is particularly vulnerable to injury because it is a hinge joint that allows for flexion and extension, but also some rotation. Injuries to the elbow can be classified based on the type of bone involved, the location of the fracture, and the severity of the injury.

Tags : Fractures, Dislocations, Pediatric Patient, Injuries to the elbow, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 23, 2023 | Views : 1288 | Downloads : 1

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Slide 1-

Fractures and Dislocationsabout the Elbowin the Pediatric Patient Amy L. McIntosh, MD
Slide 2-

Elbow Fractures in Children Very common injuries (approximately 65% of pediatric trauma) Radiographic assessment difficult for non-orthopaedists Complex physeal anatomy and development Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-29
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Elbow FracturesPhysical Examination Children will usually not move the elbow if a fracture is present, although this may not be the case for non-displaced fractures Neurologic exam is essential, as nerve injuries are common neurovascular injuries can occur before and after reduction In most cases, full recovery can be expected
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Elbow FracturesPhysical Examination Neurological exam may be limited by the child’s 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
Slide 5-

Elbow FracturesRadiographs 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
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Anterior Humeral Line Drawn along the anterior humeral cortex Should pass through the middle of the capitellum Variable in very young children -Herman. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188. Elbow FracturesRadiograph Anatomy/Landmarks Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-46
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The capitellum is angulated anteriorly about 30 degrees. The appearance of the distal humerus is similar to a hockey stick. Elbow FracturesRadiograph Anatomy/Landmarks Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-46
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The physis of the capitellum is usually wider posteriorly, compared to the anterior portion of the physis Wider Elbow FracturesRadiograph Anatomy/Landmarks
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Radiocapitellar line should intersect the capitellum in all views Make it a habit to evaluate this line on every pediatric elbow film Elbow FracturesRadiograph Anatomy/Landmarks
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Supracondylar Fractures Most common elbow fx in children & adolescents 50 – 70% of all elbow fx. Frequently seen btw 3-10 yrs. 2 Types Extension Type Flexion Type Courtesy of AL McIntosh
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Appropriate Use Criteria 2014: AAOS adopted appropriate use criteria (AUC) for the management of pediatric supracondylar humerus fractures. 2015 : AUC for pediatric supracondylar humerus fractures with vascular injury These AAOS references should be reviewed prior to engaging in the treatment of a pediatric supracondylar humerus fracture. Appropriate Use Criteria: Management of Pediatric Supracondylar Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons, 2015. 23(10): p. e52-e55.
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Extension Type 95-98% of all SCH fx Mechanism FOOSH Forces the elbow into hyperextension. Olecranon acts as a fulcrum. Force propagates across medial & lateral columns Distal fragment : posterior Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 figure 33-30
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Flexion Type 2- 5% of SCH fx. Mechanism  Direct blow to a flexed elbow. Distal Fragment : Anterior Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-31
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Ulnar n. tented over posterior Margin of prox. Fx.
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Flexion Type Mahan et al: JPO 27(5) 2007 n= 58 (1994- 2004) 3%: SCH II & III = flexion Older (7.5 yrs vs. 5.8 yrs) Increased need for open reduction (31% vs. 10%) Ulnar nerve injury (19% vs. 3%) Need for ulnar nerve decompression (19% vs. 0.5%) Courtesy AL McIntosh
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Gartland Classification (1959) Type I- no displacement Type II- moderate displacement Posterior cortex intact Plastic Deformation Possible Type III- severe displacement Ant & post cortex disruption Type IV: multi-directionally unstable Skaggs: JBJS 88A, 2006 Surg Gyn Obstet 1959 109(2) 145-154.
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Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-34
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Type IV Courtesy of AL McIntosh extension flexion
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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
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Type 1Non-displaced Note the non- displaced fracture (Red Arrow) Note the posterior fat pad (Yellow Arrows)
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Type I Subdivision (1994) Mubarak & Davids: Master Tech- Elbow. Type IA: nondisplaced  cast Type IB: medial comminution  CRPP More unstable Varus/hyperextension malunion Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-38
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Type 2 FracturesTreatment 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 type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.
Slide 23-

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
Slide 24-

Type III  CRPP Courtesy of AL McIntosh
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Ipsilateral Fx of distal radius (5%) Courtesy of TSRH/CMC
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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 Courtesy of TSRH/CMC
Slide 27-

How to perform a CRPP
Slide 28-

Brachialis SignProximal Fragment Buttonholed through Brachialis Courtesty of TSRH/ CMC
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With the elbow in extension, align the distal fragment to the proximal fragment in the coronal plane. 1. Correct coronal plane alignment & re-establish Length Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-49
Slide 30-

3.Correct Angulation and Posterior Displacement Apply longitudinal traction with the elbow semi- flexed, while applying posterior pressure on the proximal fragment. Then, slowly flex the elbow to bring the distal fragment into alignment. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-49
Slide 31-

4. Temporary stabilization and assessment to lock the distal fragment to the proximal fragment. Once the fragments are reduced, hyper-flex the elbow with hyper-pronation Then, confirm the reduction in full external rotation on the monitor. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-49
Slide 32-

Rule of Thumb Thumb should point in the direction of initial displacement. Posterolateral (25%): Supinate  tightens the intact lateral soft tissue sleeve. Posteromedial (75%) : Pronate  tightens the intact medial soft tissue sleeve.
Slide 33-

Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-37 Posteromedial displacement  pronate forearm to tension the intact medial tissues
Slide 34-

Type 3Operative Reduction Closed reduction with flexion AP view with elbow held in flexed position to maintain reduction. Courtesy of AL McIntosh
Slide 35-

Which pin pattern is better?? Courtesy of AL McIntosh
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Brauer et al: JBJS 89A, 2007 Systematic Review N = 2054 35 studies Standard crossed pins: 5.04X higher probability of iatrogenic ulnar n. injury Crossed pins: more stabile (0.58x) less likely to lose reduction
Slide 37-

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).
Slide 38-

Supracondylar Humerus FracturesPin Fixation 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.
Slide 39-

Placement of medial pin w/ulnar nerve protected Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-52
Slide 40-

Supracondylar Humerus Fractures After stable reduction and pinning Elbow can be extended to review the AP radiograph Baumann’s 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.
Slide 41-

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 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
Slide 42-

Supracondylar Humerus Fractures: Indications for Open Reduction Inadequate reduction with closed methods Vascular injury Open fractures Couretsy of TSRH/CMC
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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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-56
Slide 44-

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 . Courtesy of TSRH/CMC
Slide 45-

Lateral Condyle Fractures Common fracture, representing approximately 15% of elbow trauma in children Usually occurs from a fall on an outstretched arm . Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-71
Slide 46-

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. 1975;57:430. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-72
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Lateral Condyle Fractures 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.
Slide 48-

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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-76 A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop. 2009 Sep;29(6):602-5
Slide 49-

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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-75
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Lateral Condyle FracturesComplications 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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-80
Slide 51-

Lateral Condyle FracturesComplications AVN can occur after excessive surgical dissection Cubitus varus can occur, may be because of malreduction or a result of lateral column overgrowth Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-82
Slide 52-

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.
Slide 53-

Medial Epicondyle FracturesClassification No good systematic method of classification Studies vary on how to measure displacement The best x-ray is obatined by positioning the central ray above the shoulder at 15 to 20 degrees from the long axis of the humerus, centered on the distal humerus. J Pediatr Orthop. 2015 Jul-Aug;35(5):449-54. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33- 42
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Medial Epicondyle FracturesTreatment Nondisplaced and minimally displaced Less than 5 mm of displacement May be treated without fixation Early motion to avoid stiffness (3 to 4 weeks) Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-84
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Medial Epicondyle FracturesTreatment 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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-83
Slide 56-

Medial Epicondyle Fracture Elbow dislocation with Medial Epicondyle Avulsion Medial Epicondyle Avulsion After attempted elbow reduction, medial epicondyle avulsion fragment is obvious
Slide 57-

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.
Slide 58-

Olecranon Fractures Olecranon fracture treated with ORIF in 14 year old, with tension band fixation. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-101
Slide 59-

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 intra-articular elbow fractures Medial Condyle Rare Treated with ORIF if displaced . Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33- 104 Medial Condyle Fracture
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Proximal Radius Fractures 1% of children’s 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.
Slide 61-

Proximal Radius FracturesTypes 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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-96
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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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-94
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Proximal Radius Fractures Treatment Unable to reduce closed Percutaneous pin reduction Intramedullary nail reduction Open reduction via lateral approach Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-97 IM nail reduction
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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.
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100% Displaced Failed Closed Reduction Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-96
Slide 66-

Open “closed” reductionBlunt pin to push radial head back onto neck Courtesy of TSRH/CMC
Slide 67-

Pin fixation augmented by cast for 3 weeks Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-96
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Monteggia LesionsUlnar Fracture-Radial Head DislocationBado 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
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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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-109
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Monteggia LesionsInitial 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.
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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 Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-109
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Missed Monteggia LesionsPossible 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.
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Missed Monteggia Lesions Treatment Options Annular ligament reconstructions Bell-Tawse Fascia lata Peterson Ulnar osteotomy Combination Transcapitellar pinning Be wary of possible pin breakage Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-111.
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Ulnar Osteotomy Arthrogram Open reduction radial head Repair annular ligament Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition © Elsevier, 2013 Figure 33-112