Caseortho ext.bodin

1. Case Conference
Ext. Bodin Chokdamrongsuk
4/8/2017

2. Case History
•ผู้ป่วยเด็กชายไทย 8 ปี ภูมิลาเนา อ.จักราช จ.นครราชสีมา
•CC : ปวดแขนขวา 1 hr.
•PI : 1 hr. ขณะเล่นโหนเสา พลาดล้ม แขนขวากระแทกพื้น มีอาการปวด
แขนขวา แขนขวาบวม ผิดรูป ไม่มีบาดแผลภายนอก ไม่ชา ไม่อ่อนแรง
•PH : - ปฎิเสธประวัติโรคประจาตัว
- ปฎิเสธประวัติแพ้ยา แพ้อาหาร
- ปฎิเสธประวัติรับประทานยาประจา

3. Physical Examination
• A-B-C-D-E : ok
• V/S
- BT : 36 c
- BP : 126/70 mmHg
- RR : 20 /min
- PR : 110 bpm
• Effected part : Rt. Forearm defomity, sweling , marked tender. Limit
ROM of Rt. elbow, no external bleeding, neurovascular intacted. Full
ROM of Rt. thumb

5. Investigation
•Film Rt. Forearm AP, Lat.
•Film Rt. Elbow AP, Lat.
•Rt. Proximal ulnar fracture with radial head
dislocation.

8. •Dx : Monteggia fracture Rt. forearm
(proximal 1/3 ulnar fracture with associated radial head
dislocation/instability)

12. Epidemiology
- rare in adults
- more common in children with peak incidence between 4 and 10
years of age

13. Presentation
•Pain and swelling at elbow joint
•Limit ROM due to dislocation
•PIN neuropathy
- Radial deviation of hand with wrist extension
- Weakness of thumb extension
- Weakness of MCP extension

14. Bado classification

15. Type 1
•Fracture ulna with anterior dislocation of the radial head (most common in
children and young adults)
•Direct blow to post. aspect of elbow

16. Type 2
•Fracture ulna with posterior dislocation of the radial head (70 to 80% of
adult Monteggia fractures)
•Longitudinal direction force on partially flexed elbow

17. Type 3
•Fracture ulna with lateral dislocation of the radial head
•Varus stress on extended elbow

18. Type 4
•Fracture ulna with anterior dislocation of the radial head with radial shaft fracture.
•Poorly understood but presumed to be similar to Type 1

19. Treatment - Pediatric patient
•Non-operative
• Closed reduction of ulna and radial head dislocation and long arm
casting
- Indication : Bado type 1-3
- Type 1,3 : immobilize in 110° of flexion and full supination
- Type 2 : immobilize in 70° of flexion and full supination

20. •Operative
• plating of ulna + reduction of radial head ± annular ligament
repair/reconstruction
- Indication :
1. Bado Types I-III with
- radial head is not stable following reduction
- ulnar length is not stable (unable to maintain ulnar length)
2. Acute Bado Type IV
3. Open fractures

21. Treatment in adult patient
•ORIF of ulna shaft fracture ± open reduction of radial head

22. Complication
•PIN or radial nerve palsy from anterior displacement of radial head
- spontaneous recovery is usual
•Non-union of fracture of ulnar shaft
•Mal-union of fracture of ulnar shaft
•Recurrent radial head dislocation
•Myositis ossificans