Isolated fractures of the ulna most often result from direct blows to the forearm. The natural response to raise the forearm in defense of a blow from a club is why it is often referred to as a nightstick fracture. Undisplaced fractures are immobilized in a long-arm cast and closely followed for subsequent displacement of the fracture.
Displaced fractures are those with greater than 10° of angulation or displacement of more than 50 percent of the width of the bone at the site of the fracture. Open reduction and internal fixation with a compression plate and screws are necessary to prevent angulation, loss of length, and rotational deformity. These injuries should be closely scrutinized for any possible radius fracture or dislocation.
Fracture of the ulnar shaft with a radial head dislocation is often referred to as Monteggia fracture-dislocation (Fig 261-8). It is typically a diaphyseal fracture in the proximal third of the ulna with an anterior dislocation of the radial head (60 percent of cases). Anterolateral and posterolateral dislocation of the radial head or a metaphyseal ulna fracture are other possibilities. Clinically, there are considerable pain and swelling at the elbow. The radial head may be palpable in an anterolateral or posterolateral location. The forearm may appear shortened and angulated. The ulnar fracture is clearly visible and may overshadow the less obvious radial head dislocation. As a rule, the radial head normally points to the capitellum in all radiographic views of the elbow. In a Monteggia fracture, the apex of the ulna fracture points in the direction of the radial head dislocation.
FIG. 261-8. Monteggia fracture-dislocation. The angulation of the comminuted fracture of the proximal ulna ( arrow) points in the direction of the radial head dislocation (.arrowhead).
Monteggia fracture-dislocations are treated with open reduction and internal fixation of the ulna and closed reduction of the radial head dislocation. Children may be treated adequately by closed reduction of both bones and long-arm cast immobilization. Complications include nonunion, redislocation, infection, and paralysis of the posterior interosseus nerve. Remember that the nerve wraps around the proximal radius.
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