MONTEGGIA FRACTURE

“Man in Armor”, oil on canvas, Edwin Lord Weeks, (1849 - 1903) “In the ensuing spring five thousand veterans and volunteers were embarked under the command of Tarik, a dauntless and skilful soldier…The Saracens landed at the pillar or point of Europe; the corrupt and familiar appellation of Gibraltar”.

Edward Gibbon, “The History of the Decline and Fall of the Roman Empire”, volume 5, 1786.

Until the second quarter of the Seventh century, the land of Arabia was terra incognita to the Christian world. Remote and inhospitable, productive of nothing to tempt the sophisticated merchants of the West, it had made no contribution to civilization and seemed unlikely ever to do so. Its people insofar as anyone knew anything about them, were presumed to be little better than savages, periodically slaughtering each other in violent outbreaks of tribal warfare, falling mercilessly on any traveller foolhardy enough to venture among them, making not the slightest attempt towards unity or even stable government. Apart from a few scattered Jewish colonies around the coast and in Medina, and a small Christian community in the Yemen, the overwhelming majority practiced a sort of primitive polytheism, which in the city of Mecca - their commercial centre - appeared to be somehow focused on the huge black stone that stood in their principle temple, the Ka'aba. Where the outside world was concerned, they showed no interest, made no impact, and certainly posed no threat.

Then in the twinkling of an eye, all was changed. In 633, showing a discipline and singleness of purpose of which they had previously given no sign, and which therefore was totally unexpected by their victims, they suddenly burst out of Arabia. After three years they had taken Damascus, after five Jerusalem, after six all Syria. Within a decade Egypt and Armenia had alike fallen to the Arab sword; within twenty years the whole Persian Empire, within thirty Afghanistan and most of the Punjab. Then after a brief interval for consolidation, the victorious armies turned their attention to the West. In 711, after having occupied the entire coast of North Africa, they invaded Spain; and by 732, less than a century after their first eruption from their desert homeland, they had crossed the Pyrenees and driven north to the banks of the Loire where, after a week long battle, they were checked at last.

History provides few parallels for so dramatic a saga of conquest, and only one explanation: the Arabs were carried forward on a great surge of religious enthusiasm, implanted in them by their first and greatest leader, the Prophet Mohammad. So, indisputably, they were; it is worth remembering, however, that this enthusiasm contained scarcely any missionary zeal. Throughout their century of advance, their attempts at the mass - or even individual - conversion of their defeated enemies were remarkably few, and they tended at times to show an almost embarrassing respect for the religion of the Jews and Christians who, as “people of the book”, could normally count on their toleration and goodwill. What their faith gave to them was, above all, a feeling of brotherhood, of cohesion, and of almost limitless self- confidence, knowing as they did that Allah, was with them, and that if it were His will that they should fall in battle they would be immediately rewarded in Paradise - and a delightfully sensual paradise at that, whose promised delights were, it must be admitted, a good deal more alluring than those of its Christian counterpart. In this world, on the other hand, they willingly adopted a disciplined austerity that they had never known before, together with an unquestioning obedience whose outward manifestations were abstinence from wine and strong drink, periodic fasting and the five times daily ritual of prayer.

John Julius Norwich, Byzantium, The Early Centuries, Viking, 1988.

In 633 A.D the old Emperor Heraclius, could feel well pleased with himself. After many years locked in a desperate struggle with the Persian Empire, that had seen a kaleidoscopic shifting of fortunes first to one side then to other and back again, final victory had come at last. Heraclius, now once again, held supreme suzerainty over the lands of the Mediterranean east, Syria and Judea. His quest to restore the integrity of a failing empire had been bloody and hard fought - the Persian invaders had finally been driven back from the Byzantine provinces to within the old pre-war borders. Now it would be time to sit back, relax and savour the sweet fruits of his immense labours....or so he thought!

Just at this time, one of the most astonishing military forces in history burst forth onto a completely off guarded Heraclius, and it came from an utterly unexpected source, the desert wastelands of Arabia. The old emperor watched in horror - as decades of hard fought victories were wiped away in just a few short years - his armies seemingly powerless in the face of the new enemy. All the Syria cities and provinces fell in quick order. As drastic as the Byzantine losses were however they were nothing compared to what befell their old adversaries - the Persians, whose empire quickly collapsed in the face of the fanatical onslaught and was completely subsumed into to the new Arabic hegemony. The astonishing onslaught swept into Afghanistan and even into India, where foreign invaders had not been seen since the time of Alexander the Great. Following the swift victories in the east, next was the turn of Africa, and within a century the entire north African coast had come under the sway of the sword of Islam, the new religion of the invaders. Finally thwarted at the gates of Constantinople itself, by a terrifying new weapon known as the “Greek-fire”, the invader's attention turned to the Iberian peninsula, as a place of unexploited vulnerability in the west. In 711 AD a reconnaissance force of Arabs and Berbers under the charismatic warrior Tariq crossed over from Morocco and landed on the shores of Gibraltar with an eye to the conquest of the Iberian kingdom of the Visigoths. The subsequent progress of conquest of Tariq was Napoleonic. He defeated the Visigothic King Roderic at the battle of Guadalete which essentially delivered the vast majority of the Peninsula into the Islamic hegemony - a hegemony which now stood at the foot of the Pyrenees, with its attention turned threateningly to the very heartland of the West - the kingdom of the Franks.

The expansion of the Islamic empire of Arabia in the Seventh century had few parallels in history, perhaps matched on only half a dozen or so occasions in 3000 years - in antiquity by Alexander the Great and the armies of the old Roman republic under Julius Caesar and in Medieval times by Genghis Khan, and in modern times by Napoleon Bonaparte in the Nineteenth century and the German Nazis and Imperial Japan in the Twentieth century. One of the greatest historians who ever lived, Edward Gibbon, strove to seek the underlying causes of the great events in history - what made this astonishing scale of conquest possible, he thought was an idea - not just any old idea of course - a very powerful one - something no less than the birth of new world religion. For the first time in history soldiers were driven by an ideal of reward in paradise - a reward it must be said - as the magisterial John Julius Norwich pointed out, a good deal more alluring than the Christian one! This new religion took many aspects of the older religions of Judaism and Christianity - indeed some say it is merely one view of the one true religion - whatever that may be - the Islamic armies held great respect for all religions of “the book” - Islam, Christianity and Judaism. What they could not countenance was anything outside of these or worse still - the Godless. Although the Islamic sword of the Seventh century was formidable, the old adage that the “pen (- or word - or idea -) is yet mightier than the sword” gives us the explanation of the miraculous Arabic conquests of the Seventh century. Although Constantine’s latter armies would “conquer by this sign”, (the Christian cross), in the early Fourth century, in truth they conquered far more by dint of superior leadership, military skill, lust for glory and booty; whereas in the Seventh century, for the first time in history, an army conquered on the back of the fanatical religious fervour of each and every individual soldier. In just over a century the Umayyad Caliph would rule over a new Islamic empire that stretched from the Pyrenees, across Northern African, through Syria and Persia to the Punjab of India.

History repeatedly records the stories of astonishing victories of a novel and powerful idea over that of the sword, one of the prime examples being that of the Islamic onslaught from the desolate sands of Arabia in the Seventh century. When we assess our patients with a fracture of the proximal ulnar, we do well to keep in mind a powerful idea of our own - that any such fracture should immediately and always raise suspicion for an associated dislocation of the head of the radius.

“The Goths Fleeing from the Berber Cavalry at the Battle of Guadalete”, oil on canvas, Salvador Martínez Cubells (1845-1914. MONTEGGIA FRACTURE

Introduction

This fracture is defined as a fracture of the proximal third of the shaft of the ulna with an associated dislocation of the radial head.

Whenever an apparent isolated fracture of the proximal third of the shaft of the ulnar is found, the alignment of the radio-capitellar line should always be carefully checked as well to determine whether or not there is an associated dislocation of the radial head.

Missing the dislocated radial head will result in long term pain and disability.

All cases should be referred to the Orthopaedic Unit

History

This injury was first described by Giovanni Monteggia (1762-1815) in 1814.

Epidemiology

These fractures are more commonly seen in children (4-10 years), than in adults.

Mechanism

Severe angulation of a forearm bone is normally accompanied by a fracture or dislocation of the other.

In the Monteggia fracture-dislocation, there is a fracture of the ulna with dislocation of the radial head.

The injury may result from:

● A direct blow.

● A fall on the outstretched arm with forced pronation.

Classification

The Bado classification of Monteggia fractures recognizes 4 main types: 1

Type I Type II Type III Type IV

Type I, (about 70 % of cases):

● Fracture of the ulna shaft (diaphysis)

With

● Anterior dislocation of the radial head with

Type II, (about 5 % of cases):

● Fracture of the ulna shaft (diaphysis or metaphysis)

With

● Posterior dislocation of the radial head

Type III, (about 25 % of cases):

● Fracture of the ulna metaphysis

With

● Lateral dislocation of the radial head

Type IV, (these are very uncommon):

● Fracture of the diaphyseal shafts of both the ulna and radius

With

● Anterior dislocation of the radial head

Complications

1. Radial head dislocation:

● This is the most important complication.

If the radial head dislocation is not initially recognized, then non-union and persistent displacement will result with secondary degenerative changes and chronic pain and disability.

2. Vascular compromise:

3. Nerve compromise:

● In particular the radial nerve, (10-20 % incidence) from displacement of radial head, usefully in type or type III injuries.

● Less commonly the posterior interosseous nerve may be affected.

3. Compartment syndrome.

4. Myositis ossificans.

Clinical assessment

● Swelling and deformity is usually obvious when there is displacement of the ulna

If there is minimal displacement however, as in greenstick type fractures, then these features may not be readily apparent.

● Check the neurovascular status

● Check that the injury is not compound

Investigations

Plain Radiography:

A-P and lateral radiographs should be done.

These must be true A-P and laterals, so as to allow for accurate assessment of the important radio-capitellar line, especially in more subtle cases of injury, which may be missed otherwise.

The radio-capitellar line:

The key to picking the radial head dislocation is checking that the line drawn through the centre of the radial shaft and head passes directly through the centre of the capitellum.

This is called the radio-capitellar line.

Normally this should be the case in all standard views, but particularly on the lateral projection.

If this line is disrupted, then there is dislocation of the radial head.

Whenever an apparent isolated fracture of the proximal third of the shaft of the ulnar is found, the alignment of the radio-capitellar line should always be carefully checked as well to determine whether or not there is an associated dislocation of the radial head.

Beware of the diagnosis of “isolated” proximal ulnar fracture. Similarly when an obvious radial head dislocation is seen look carefully for a proximal ulna fracture.

The radio-capitellar line is an important radiological feature when assessing for possible fractures around the elbow. The radial head should always align with the capitellum in all true A-P and lateral). (RCH Fracture Guidelines).

Left: Normal radio-capitellar lines on true A-P and lateral radiograph of the elbow.

Right: Alignment of landmarks: N = normal alignments, 1 = Posterior Monteggia, 2 = Anterior Monteggia, 3 = Lateral Monteggia

Management

1. Analgesia, as required

2. Splint and elevate.

3. Reduction:

All Monteggia fractures require timely reduction.

● Children are usually managed with a closed reduction under GA and an above elbow plaster with broad arm sling.

● Adults will generally be treated with ORIF.

4. Nerve injury:

● Nerve injury is usually a neuropraxia, (and is treated expectantly, with recovery expected by 9 weeks).

Disposition:

All Monteggia fracture-dislocations should be referred to the Orthopaedic Unit.

Following reduction check radiographs should be taken at 1, 3 and 6 weeks.

Return to any full contact sports is at 2-3 months.

Appendix 1

Type I Monteggia fracture with anterior radial dislocation, (this is the most common type)

References

1. Bado JL. The Monteggia lesion. Clin Orthop Relat Res. Jan-Feb 1967; 50:71-86.

2. McRae, R. Practical Fracture Management 3rd ed 1994, p.162-163.

3. Pitfalls in Orthopaedic Radiography Interpretation. Michelle Lin, MD FAAEM Assistant Clinical Professor of Medicine, UC San Francisco San Francisco General Hospital Emergency Services 2008.

4. RCH Paediatric Fracture Guidelines.

Dr J. Hayes Dr Peter Papadopoulos. Reviewed February 2013.