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We recently treated a 27-year-old woman who sustained a closed left Bado type 1 Monteggia fracture-dislocation during a fall. In the emergency department, the patient was noted to have a posterior interosseous nerve (PIN) palsy before and after closed reduction and splinting. Operative intervention was undertaken. We initially stabilized the ulna near-anatomically with compression plate fixation. Intraoperative fluoroscopy demonstrated reduction of the radiocapitellar joint in the neutral and supinated forearm positions, but anterior subluxation was evident in pronation (Fig. 1). Subtle proximal radioulnar joint widening was also noted on anterior-posterior imaging. Lateral exposure between the extensor carpi radialis brevis and extensor digitorum communis revealed an annular ligament tear and an entrapped PIN posterior to the radial neck. To free the PIN, we removed the ulna fixation, dislocated the radiocapitellar joint, and restored the PIN to its native anterior position using a Freer elevator. The ulna fixation was revised, and fluoroscopy demonstrated a stable radiocapitellar joint throughout forearm rotation.
Figure 1A Radiocapitellar joint reduced in neutral forearm rotation and B subluxed in pronation. C Intraoperative photograph of the PIN entrapped posterior to the radial neck. D, E Reduction of the radiocapitellar joint in both neutral and pronation. F Intraoperative photograph demonstrating reduction of the PIN to its native position. White arrows indicate the PIN.
Persistent posterior interosseous nerve palsy associated with a chronic type 1 Monteggia fracture-dislocation in a child: a case report and review of the literature.
described the case of an 8-year-old boy who sustained a Bado type 1 Monteggia fracture-dislocation and subsequently developed a PIN palsy. Nine months later, at surgery, the PIN was noted to be subluxed posterior to the radial head and located in the proximal radioulnar joint. Morris
reported the case of a 17-year-old girl who similarly sustained a Bado type 1 Monteggia fracture-dislocation. Through a Boyd approach, Morris noted that the PIN had subluxed posteriorly. Li et al
reported 8 pediatric Monteggia fracture-dislocations presenting with PIN palsies. Four of 5 Bado type 3 fractures were associated with PIN subluxation into the radiocapitellar joint. They recommended immediate surgical exploration in all Bado type 3 pediatric Monteggia fracture-dislocations with a PIN palsy and an irreducible radial head. Cho et al
described the case of a 46-year-old woman who had sustained an elbow injury when she was 6 years of age and now had a tardy PIN palsy. At surgery, the PIN was wrapped around the medial side of the radial neck and stretched by the supinator.
This case highlights several points regarding treatment of Monteggia fracture-dislocations. First, a preoperative PIN palsy should alert to the surgeon to this possibility of nerve subluxation. Second, a cross-table fluoroscopic examination with the forearm in supination, neutral, and pronation should be performed. In this case, radiocapitellar subluxation was notable only in pronation. Therefore, it is important that fluoroscopic radiocapitellar reduction be confirmed throughout forearm range of motion. Finally, an entrapped PIN under tension can appear similar to the annular ligament and capsule, so there should be a low threshold for exposing the PIN (distal to proximal) within the supinator.
References
Ruchelsman D.E.
Pasqualetto M.
Price A.E.
Grossman J.A.
Persistent posterior interosseous nerve palsy associated with a chronic type 1 Monteggia fracture-dislocation in a child: a case report and review of the literature.
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