Monteggia fracture is a fracture of the forearm bone. Monteggia fracture usually results from falls on the forearm while the elbow is bent. In the course of a Monteggia fracture, mainly the proximal part of the ulna (medical name Ulna) breaks. In addition, the radial head is dislocated.
What is a Monteggia fracture?
Monteggia fracture, like Galeazzi fracture, is a dislocation fracture. This refers to a fracture in which the forearm is dislocated. The forearm is composed of two bones, the ulna and the radius. While in a Galeazzi fracture the radius breaks, in a Monteggia fracture the ulna breaks near the elbow joint. Not only does the bone break, but the fragments of the ulna shift against each other. The radial head is usually dislocated ventrally and laterally. Monteggia fracture received its name after the Milanese surgeon Giovanni Monteggia, who was the first to describe this special type of forearm fracture.
Causes
There are several possible causes of a Monteggia fracture. In most cases, the fracture represents the result of an accident in which strong forces act on the bone. Often such injuries occur in the context of traffic accidents. In addition, a Monteggia fracture can result from a fall on the forearm. In this case, the elbow is usually in a bent position, making it particularly susceptible to the fracture. In many cases, the forearm is probably turned inward. In children, Monteggia fractures usually occur from falls onto the outstretched arm.
Symptoms, complaints, and signs
Monteggia fractures may present with various signs and symptoms in the patient. In many cases, the condition begins with “falling asleep” and the resulting sensation of tingling at the tip of the middle finger. The discomfort is often triggered by one-sided postures of the wrist during certain activities. After a short time, the person feels that the hand is swollen. Pain is felt, which usually extends over the whole hand and sometimes also to the forearm. It is characteristic of Monteggia fractures that the pain occurs preferentially at rest, which is why it is particularly common at night. As the disease progresses, the symptoms of Monteggia fracture increasingly extend beyond nocturnal pain and discomfort. The symptoms also become increasingly apparent during the day. In connection with this, patients often report some clumsiness and a feeling of sudden weakness in the hand. In addition, the sensitivity of the skin on the fingers is increasingly reduced. Later, there may even be a loss of the muscles of the ball of the thumb.
Diagnosis and course of the disease
Monteggia fracture is usually diagnosed in the conventional way by X-ray examination. During this examination, the forearm and elbow are x-rayed from the side and from the front. The lateral view in particular allows conclusions to be drawn about how far the small head of the radius has dislocated. It is important that the elbow is adequately imaged for assessment, otherwise the diagnosis of Monteggia fracture is complicated. In young children, the radial head is not yet bony, so correct centering can be demonstrated here by ultrasound examination. For detailed diagnoses, the affected patient must present all complaints, also with regard to various concomitant diseases, such as diabetes mellitus, dysfunctions of the thyroid gland or previous fractures of the wrists. Differential diagnostics are also relevant in order to reliably differentiate the Monteggia fracture from other possible diseases. Here, for example, the presence of compression in the median nerve or carpal tunnel syndrome must be excluded.
Complications
In most cases, the Monteggia fracture leads to the typical falling asleep of the arm and thus to significant limitations in the patient’s daily life. The affected region tingles and there is a very unpleasant sensation. Especially when the region is moved, the tingling sensation is not further intensified. Likewise, pain may also occur when the joint is moved.If the pain also occurs at night in the form of pain at rest, it can lead to sleep complaints and thus to a lack of sleep. The pain usually also spreads over the entire hand, so that it can no longer be used without further ado. In the further course, the Monteggia fracture leads to paralysis and to other insensations, which make the daily life of the affected person more difficult. The affected person appears clumsy and the affected hand is weak. The sensitivity in the fingers is also greatly reduced. In most cases, the symptoms of the Monteggia fracture can be reconstructed so that the limitations and symptoms disappear completely. As a rule, there are no special restrictions. The affected arm is then dependent on rest and recovery. After treatment, however, it can be used again in the usual way.
When should you go to the doctor?
If discomfort and discomfort of the forearm occurs after a fall or accident, a doctor should be consulted. Limitations in usual range of motion or general mobility, as well as decreased physical strength of the arm, should be presented to a physician. Pain or perceptual disturbances must be investigated and treated. Use of analgesic medications should be completely discontinued until consultation with a physician has occurred. Alternatively, complications and side effects may occur, which have a negative impact on the general health of the affected person. If there are sensory disturbances in the arm, a feeling of numbness or tingling on the skin, and hypersensitivity to touch, they should be investigated and treated. They indicate internal injuries to nerves, muscles or tendons that need to be clarified. If existing symptoms spread to the arm, a visit to the doctor should be made as soon as possible. A particular indication of the presence of the Monteggia fracture is the characteristic pain at rest. Affected persons complain of an increase in the existing complaints, especially if they adopt a resting posture or do not move the arm. Without early treatment, the affected person is at risk of permanent impairment of the muscles in the hand. Therefore, a visit to the doctor is recommended as soon as possible so that comprehensive medical care can be initiated.
Treatment and therapy
A Monteggia fracture can be treated with different methods, and the choice of measures depends on the individual clinical picture. A metal plate may be used to rejoin the two fractured pieces of the ulna. In the first step, the fracture pieces must be put back into their correct position (medical term reduction). If the fracture of the ulna is near the elbow joint, a plate osteosynthesis is used. This allows osteosynthesis to occur, restoring the bone structure. For this purpose, the bone fracture pieces are rejoined by means of a plate fixed to the bone by screws. The exact reduction of the fracture on the ulnar bone takes place during a surgical procedure, usually under general anesthesia. In children, the Monteggia fracture is stabilized by intramedullary splinting. It may be necessary to suture the ligaments of the radius. Surgical therapy is followed by immobilization of the arm in a cast for a period of three to four weeks. A Monteggia fracture can also damage the radial nerve and the vessels in the elbow, which can promote the development of compartment syndrome. Consequently, this must be subjected to appropriate treatment.
Outlook and prognosis
A correct and early diagnosis of Monteggia fracture leads, among other things, to the fact that the quality of life does not suffer. In contrast, a shortening of life expectancy is not to be expected. In practice it happens again and again that the disease is misinterpreted as a forearm shaft fracture. Scientific surveys even assume every tenth case. Complications can result from improper treatment. Those who forego therapy altogether even risk permanent movement restrictions. According to the current state of medical knowledge, early setting is considered to guarantee a favorable prognosis. The type of fracture also determines the prospects for a complete recovery. In general, a fracture that is true to the axis has a good outlook.In contrast, malpositions of the radial head often lead to instabilities and obstacles in the course of movement. This results in a mixed outlook. Long-term physiotherapy becomes necessary. If necessary, private and professional changes have to be arranged. The therapeutic approach depends on the age at diagnosis. In children, conservative treatment is often sufficient. Adults, on the other hand, require surgery. With increasing age, the prospect of a symptom-free healing of the Monteggia fracture diminishes.
Prevention
Since Monteggia fracture is a bone fracture, risky activities should be avoided or special attention should be paid to one’s own movements as well as the surroundings, such as during sports activities. In sports where falls may occur more frequently, appropriate techniques should be practiced to mitigate falls.
Aftercare
Stabilization of the Monteggia fracture with metal implants is done in a surgical procedure if the radial head cannot be set. For follow-up care, the arm is immobilized in a cast. X-ray controls are used to monitor the healing process. Early functional physiotherapy should begin as soon as possible. Even while the forearm is in a cast, light range-of-motion exercises of the shoulder and fingers are recommended. The chances of a symptom-free, complete recovery depend on the type and severity of the fracture. In the case of a combination fracture that is true to the axis, the prognosis is generally favorable. Intensive physiotherapeutic treatment is necessary to avoid functional limitations, postural changes or instabilities in a Monteggia fracture. With proper therapy and individualized physiotherapy follow-up, the function of the forearm, wrist and fingers can usually be completely restored after four to six weeks. It is important to avoid overuse due to abrupt movements. Complicated Monteggia fractures require a healing period of six months or longer. If the radial head becomes malpositioned again and blood vessels are affected or nerves of the musculature and bones are affected, patients suffer from restricted movement, sensory disturbances or pain. In addition to targeted physiotherapeutic measures, medicinal pain therapy can be used in a supportive manner to alleviate symptoms at the site of injury or in close proximity.
Here’s what you can do yourself
Depending on the individual’s condition, sufferers can take a number of steps to aid recovery from a Monteggia fracture. In children, splinting is usually done. Parents of affected children should watch out for any deformities and correct them immediately. The splint must be adjusted regularly during the course of the disease, which is why regular visits to the doctor are indicated. After surgical therapy, rest and avoidance of external stimuli such as heat or cold apply. The area around the surgery must be cared for according to the doctor’s instructions to avoid wound healing disorders, infections and other problems. In addition, a physician should be consulted regularly to monitor the healing process. Should pain, movement disorders or other complications develop, the physician must be informed in any case. Other self-help measures are limited to protecting the affected body part from overexertion and taking preventive measures. Individuals who have previously suffered a Monteggia fracture or other bone fracture should avoid risky activities and pay special attention to their movements and surroundings during sports. In sports where there is an increased risk of falling, appropriate techniques should be practiced to cushion any falls.
