A type of Monteggia fracture, highly susceptible to misdiagnosis

Dear Editor,

Monteggia fracture, which was first described by Giovanni Battista Monteggia, consists of the fracture of ulna accompanied by radial head dislocation.[1] This definition was later modified by Bado, who included a group of injuries under the term of Monteggia fracture.[1] Bado also proposed a system of classification based on the mechanism of injury [Table 1]. Based on this classification, Type 1 lesion is an anterior dislocation of radial head associated with an ulnar diaphyseal fracture at any level. This is the most common type in children. Bado also suggested some equivalents to true Monteggia lesions, as their mechanism of injury is similar. One of the most conflicting diagnostic clues is determining the true Type 1 fracture due to a plastic deformation of ulna and subsequently anterior radial head dislocation.[2,3] Misdiagnosis of Monteggia fracture could be catastrophe.[2,3] In addition, misdiagnosis of Type 1 equivalent in which the isolated radial head dislocation occurs is possible.[4] Misdiagnosis and untreatment cause impairment in elbow function, and reports on the results of delayed repair are conflicting, especially if these procedures are done after 40 months.[3] The most important diagnostic clue in the radiography is radiocapitellar line. This line which is drawn down to the long axis of radius bisects the capitellum of the humerus, regardless of the degree of elbow flexion or extension.[5] This rule is also applicable in the anteroposterior (AP) radiographic view. In addition, attention to ulnar bowing is crucial. The radiographs in this letter are of a 4-year-old girl who was admitted to our center after falling from a sofa [Figure 1]. Our patient after diagnosis was transferred to the operating room, and reduction was done by the correction of ulnar bowing under anesthesia.

Table 1.

Bado classification for moneggia fracture

Figure 1.

(a and b) The anteroposterior and lateral view of elbow in a 4-year-old girl with Bado Type 1 Monteggia fracture, the red line in both radiographs shows the radiocapitellar line and the white line indicates a line drawn beneath the ulnar line and shows bowing of ulna in this patient

Such simple traumas are common, and the general practitioners (GPs) are the first line in the management and diagnosis of these patients, especially in rural areas. These traumas need reduction under anesthesia, and timely management is crucial. Availability of GPs at the community level makes them ideal as the first contact for emergency care. Timely and effective management is needed in such cases, which needs knowledge and proper training.[6] There are numerous cases of misdiagnosis by GPs and even by orthopedic surgeons. Because that the radiography seems normal at the first look, the injury might be missed and the physician may try to manage the patients by a splint with the diagnosis of a simple trauma to arm. Then, we notify the simple but important radiographic signs which could help general physicians to the diagnosis and referring the patient to a trauma center.

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