![]() The capsule was also found interposed within the joint and these findings explained the failed attempts at closed reduction.The interposed tissue was freed from the joint, the radial head reduced and the position confirmed using XRII. A posterolateral approach revealed a radial head which had buttonholed through the capsule, associated with a ruptured annular ligament. A decision was made to carry out an open reduction of the RCJ. A 2 mm Kirschner wire (K-wire) was then inserted across the ulnar fracture site via the olecranon apophysis (Figure 3c), but again the RCJ was not reducible. Despite successful reduction of the radial fracture, the RCJ remained dislocated (Figure 3b). ![]() Closed reduction of the forearm fractures was unsuccessful at reducing the radiocapitellar joint (RCJ) dislocation so a 2 cm radial incision was made over the distal radius and a 2 mm titanium elastic nail (TEN) was inserted under X-ray image intensifier (XRII) guidance across the radial fracture site. After immobilisation, further radiographs of the elbow revealed a Bado type IV Monteggia lesion – fractures of both radius and ulna with an associated anterior dislocation of the radial head (Figure 2).The following day, the injury was treated with manipulation of the forearm fractures under general anaesthesia (Figure 3a). There was no history of previous fractures, dislocations or any medical conditions.Initial radiographs showed diaphyseal fractures of both radius and ulna (Figure 1). However, the patient was upset and uncooperative and therefore the neurological status of the affected limb was impossible to assess comprehensively. His peripheral pulses and capillary refill time were normal. There was deformity of the right forearm with a small abrasion over the proximal ulna. Here we have described the management of a rare type IV lesion in which there was buttonholing of the radial head through the anterior capsule, causing the radiocapitellar dislocation to be irreducible (even after fixation of the radial and ulnar fractures).Ī 3-year-old Caucasian boy presented with his mother to the emergency department complaining of pain and deformity in his right arm following an unwitnessed fall whilst playing in the garden. Accurate reduction of the radiocapitellar joint is crucial to prevent significant long-term consequences and failed closed reduction requires open reduction. Monteggia lesions of the paediatric elbow, albeit uncommon, should be considered in all forearm fractures. Follow-up at five months showed a full range of elbow movement with no adverse symptoms. Subsequently, alignment was maintained with fracture healing. The block to reduction was due to a buttonholing of the radial head through the anterior joint capsule, with interposition of the capsule in the radiocapitellar joint. After failed attempts at closed reduction, open reduction of the radial head was required. The patient was treated with closed manipulation and percutaneous fixation of both bone forearm fractures with intra-medullary wires. Clinical and radiological examination revealed a Monteggia type IV fracture-dislocation. We present the case of a 3-year-old Caucasian boy who attended the emergency department following an un-witnessed fall, resulting in right elbow and forearm pain, swelling and deformity. Early recognition and appropriate management are essential to prevent long-term consequences of loss of forearm rotation, cubitus valgus, elbow instability and chronic pain. Fractures of the proximal third of the ulna and radius with associated anterior radial head dislocation are uncommon in children. ![]()
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