Forearm Case #1

HPI- 21 y/o female presents to the ED post mvc c/o left arm pain. She was an unrestrained driver and her arm struck the steering wheel.

PMX- Herpes type IISocial- ETOHAllergies- SeasonalPSX- Elective abortion

H & P

P- 120 BP 130/86 RR- 14 T 98.7HEENT – NCAT, EOMICardio- S1 S2Lungs- CTABExt- Left upper extremity is swollen and deformed.

No evidence of open fx. Distal sensation and pulses intact

Physical exam

X-ray

Monteggia Fracture/Dislocation

Pain Control Reduction and Splint     - Reduction:

           - achieved w/ forarm in full supination, & longitudinal traction;           - then elbow is gently flexed to > 90 deg to relax biceps;           - radial head is gently repositioned by direct manual pressure

anteriorly on the bone;           - following reduction, radial head will be stable if left in flexion;           - angulated ulnar shaft is reduced by firm manual pressure;

Contact Orthopedics to discuss arranging Urgent Operative Repair

ED management

Background Giovanni Monteggia (1814) first described frx

of proximal 1/3 of ulna in association w/ anterior dislocation of radial head;

Mechanism:Proposed mechanisms include direct blow &

hyper-pronation injuries as well- as the hyperextension theory

Pearls

   Associated Injuries   Tear of the annular ligament

  Nerve Damage Paralysis of deep branch of the radial nerve is most common.

The posterior interosseous nerve may be wrapped around neck of radius, preventing reduction;

Note: that patients whose operative treatment is delayed may be found to have a progressive PIN palsy from constant pressure exerted by the dislocated radial head           

Pearls