Endgames Picture Quiz

Forearm injury in a 5 year old boy

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3192 (Published 05 June 2013) Cite this as: BMJ 2013;346:f3192
  1. R Coomber, orthopaedic specialist registrar1,
  2. G Cuffolo, core surgical trainee year 11,
  3. Y Kalairajah, consultant orthopaedic surgeon1,
  4. S Burtt, consultant orthopaedic surgeon1,
  5. R Bhumbra, locum consultant orthopaedic surgeon1
  1. 1Department of Orthopaedics, Luton and Dunstable Hospital, Luton LU4 0DZ, UK
  1. Correspondence to: R Coomber Rosscoomber{at}hotmail.com

A 5 year old right hand dominant boy was brought to the emergency department by his mother because of a painful and deformed left forearm. After slipping in the snow he had landed on his outstretched left hand. He had no relevant medical history. On examination, he was stable and the deformed arm was an isolated injury. There were no symptoms of neurovascular compromise and no evidence of skin compromise or breach.

Plain radiographs were obtained (fig 1).

Fig 1 Anterioposterior (top) and lateral (bottom) radiographs of the forearm and elbow

Questions

  • 1 What abnormality do the radiographs show?

  • 2 What lines should be viewed when assessing forearm radiographs?

  • 3 What are the important parts of the examination?

  • 4 What are the options for managing this patient?

Answers

1 What abnormality do the radiographs show?

Short answer

The radiographs show a minimally displaced proximal third ulna diaphyseal fracture and a radial head dislocation. The eponymous term for this injury is a Monteggia fracture of the forearm.

Long answer

The Monteggia fracture was first described by Monteggia in 1814.1 The radial head can be dislocated anteriorly, laterally, or posteriorly, and these injuries can be found in both adults and children. The Bado classification is used to describe the radiographic appearance of a Monteggia fracture (fig 2).

Fig 2 Bado classification of Monteggia fractures

These injuries are often missed because they are rare, accounting for less than 5% of all forearm fractures. They …

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