[5] The ulna provides a stable platform for rotation of the radius and forearm. J Hand Surg Am. there may be slow and progressive shortening and angulation; Radial head dislocation may lead to radial nerve injury. Monteggia fractures are one third as common as the more familiar Galeazzi fractures. (5/8), Level 4 J Hand Surg Am. Philadelphia: JB Lippincott; 1991. In his classic 1943 text, Watson-Jones stated that "no fracture presents so many problems; no injury is beset with greater difficulty; no treatment is characterized by more general failure." Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. Monteggia fracture-dislocations in children. Clin Orthop Relat Res. 36 (2):65-73. The key to a good outcome after a Monteggia-type fracture-dislocation of the forearm remains early recognition of proximal radioulnar dissociation. 40 (3):e216-e221. 3rd ed. Orthopedics. - spontaneous recovery is usual & exploration is not indicated; Does a Monteggia variant lesion result in a poor functional outcome? (OBQ10.240) The eponym Monteggia fracture is most precisely used to refer to a dislocation of the proximal radioulnar joint (PRUJ) in association with a forearm fracture, most commonly a fracture of the ulna. The Monteggia lesion in children. Are you sure you want to trigger topic in your Anconeus AI algorithm? Are you sure you want to trigger topic in your Anconeus AI algorithm? Philadelphia: Lippincott Williams & Wilkins; 2012: 351-65. Thank you. 2009 Jun. This allows the radius to rotate around the ulna. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. 91 (6):1394-404. Undecided The present multicenter retrospective study compared results for the Bouyala procedure with versus without plasty of the annular ligament of the radial head in evolved radial head lesion (Monteggia lesion), assessing the benefit of associating ligamentoplasty to ulnar osteotomy. [15] The mean postoperative increase in MEPI score was 30. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Monteggia fractures account for fewer than 5% of forearm fractures, with published literature supporting figures in the range of 1-2%. 4 (2):167-72. 2016 Jun. The ulna fracture is usually noted, commonly in the proximal third of the ulna. J Pediatr Orthop. Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique. Bado type II lesion after open reduction and internal fixation. 2. Indications for treatment of Monteggia fractures (seeTreatment) are based on the specific fracture pattern and the age of the patient (ie, pediatric or adult). for: Medscape. It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes. (0/8), Level 2 If the elbow is flexed, the chance of a type II or III lesion is greater. 1967; 50:71-86. Trauma10531822MonteggiaFracturesAuthor:Tracy JonesIntroductionInjury defined asproximal 1/3 ulnar fracture with associated radial head dislocation/instabilityEpidemiologyrare in adultsmore common in childrenwith peak incidence between 4 and 10 years of agedifferent treatment protocol for childrenAssociated injuriesmay be part of complex injury 32 (4):352-6. The distal ulna and radius also articulate at the DRUJ. Application of this eponym to all injuries with radiocapitellar subluxation or dislocation has led to some confusion. [8] : The Bado classification is based on the recognition that the apex of the fracture is in the same direction as the radial head dislocation. We present an unreported configuration of a traumatic olecranon fracture with a concomitant medial radial head dislocation in a 3-year-old male.. Bado type I lesion. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). You can rate this topic again in 12 months. (0/1). A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. Surgical Management of Complex Adult Monteggia Fractures. Pediatric Monteggia fractures: a single-center study of the management of 40 patients. The treating physician may reduce an unrecognized dislocation while reducing or immobilizing the ulna fracture. (1/7), Level 5 The poor re-sults usually relate to intraarticular damage, coronoid frac-tures and comminution of the ulna and radial head fractures. The mean Broberg and Morrey score increased from 89 points to 94 points, and the median Disabilities of the Arm, Shoulder, and Hand (DASH)score was 7 points at long-term follow-up. [QxMD MEDLINE Link]. Separate radiographs should be taken of the elbow. This eponym is among the most widely recog nized by orthopaedic surgeons, largely because of the notoriously poor results associated with the treatment of these injuries, particularly in adults83948. 1967 Jan-Feb. 50:71-86. Vol 2: 520. Hand Clin. - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory; (OBQ09.264) 19 (74):164-167. Evans EM. - proposed mechanisms include direct blow & hyperpronation injuries as well-as the Monteggia fractures are one third as common as the more . of flexion; Orthopedics. If you log out, you will be required to enter your username and password the next time you visit. Li H, Cai QX, Shen PQ, Chen T, Zhang ZM, Zhao L. Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children. It is the character of the ulnar fracture, rather than the direction of radial head dislocation, that is useful in determining the optimal treatment of Monteggia fractures in both children and adults. Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India Baltimore: Williams & Wilkins; 1943. - frx of ulna just distal to coronoid process w/ lateral dislocation of radial head; - Type IV (5%) [QxMD MEDLINE Link]. (0/7), Level 2 Unstable (complete) ulnar fractures are prone to residual or recurrent displacement and may require operative fixation. - dislocation of radial head may be missed, eventhough frx of ulna is obvious (need AP, lateral and olbique X-rays of elbow) This article describes the diagnosis, treatment, and potential pitfalls encountered in the treatment of Monteggia fractures. Clinical effect of manual reduction of humeroradial joint in the treatment of type - fresh Monteggia fracture in children. - See: 2023 Lineage Medical, Inc. All rights reserved. - Type III - 20% Removal of forearm plates. - immobilization is continued until there is union of the ulna; and radial deviation of head; - Complications: 39 (4):451-5. J Bone Joint Surg Br. Are you sure you want to trigger topic in your Anconeus AI algorithm? Richard L Ursone, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Society of Military Orthopaedic SurgeonsDisclosure: Nothing to disclose. Canton G, Hoxhaj B, Fattori R, Murena L. Annular ligament reconstruction in chronic Monteggia fracture-dislocations in the adult population: indications and surgical technique. Monteggia-type elbow fractures in childhood. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTIzMTQzOC1vdmVydmlldw==, Type I - Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (see the first and second images below), Type II - Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (see the third and fourth images below), Type III - Fracture of the ulnar metaphysis with lateral dislocation of the radial head (see the fifth and sixth images below), Type IV - Fracture of the proximal or middle third of the ulna and radius with anterior dislocation of the radial head (see the seventh image below), Excellent - Union with less than 10 loss of elbow and wrist flexion/extension and less than 25% loss of forearm rotation, Satisfactory - Union with less than 20 loss of elbow and wrist flexion/extension and less than 50% loss of forearm rotation, Unsatisfactory - Union with greater than 30 loss of elbow and wrist flexion/extension and greater than 50% loss of forearm rotation, Failure - Malunion, nonunion, or chronic osteomyelitis. - key is to obtain length and alignment, which then allows the radial head to be reduced; Kopriva J, Awowale J, Whiting P, Livermore A, Siy A, Hetzel S, et al. 2022 Feb 1. 1949 Nov. 31B (4):578-88, illust. - r/o tear of the annular ligament Evans in 1949 [11, 12] Of the Monteggia fractures, Bado type I has been reported to be the most common (59%), followed by type III (26%), type II (5%), and type IV (1%). - Mechanism: Treatment may be closed reduction and casting for length stable ulna fractures with a stable radiocapitellarjoint. Monteggia fractures in pediatric and adult populations. Tan JW, Mu MZ, Liao GJ, Li JM. Reckling FW. - anterior dislocation of radial head (or frx) and fracture of ulnar diaphysis at any level w/ - Discussion: J Orthop Trauma. ROM increased by an average of 30. Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. 9 (8):[QxMD MEDLINE Link]. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. Kathmandu Univ Med J (KUMJ). In a study evaluating long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in 22 children (14 boys, 8 girls; age range, 4 y to 15 y 11 mo), Nakamura et al noted that the postoperative Mayo Elbow Performance Index (MEPI) at follow-up ranged from 65 to 100, with 19 excellent results, two good results, one fair result, and zero poor results. (1/1), Level 4 (3/76), Level 1 [QxMD MEDLINE Link]. The Monteggia fracture with posterior dislocation of the radial head. - following reduction, radial head will be stable if left in flexion; : A retrospective study, Mortons Neuroma: Interdigital Perineural Fibrosis, Orthopaedic Specialists of North Carolina. [10] studied the etiology of Monteggia fractures on cadavers by stabilizing the humerus in a vise and subjecting different forces to the forearm. 2020 Sep. 40 (8):387-395. The end result is a disrupted interosseous membrane proximal to the fracture, a dislocated PRUJ, and a dislocated radiocapitellar joint. - see: nerve injuries - apex of angular deformity of ulna usually indicates direction of radial head dislocation; - Reduction: Prompt recognition of this injury is imperative. [QxMD MEDLINE Link]. The Monteggia lesion. Pediatric hand and upper limb surgery: a practicalguide. J Pedtiatr Orthop 2016; 35:S67-S70. 2013. For patient education resources, see theBreaks, Fractures, and Dislocations Center, as well asBroken Arm,Broken Elbow, andElbow Dislocation. Zivanovic D, Marjanovic Z, Bojovic N, Djordjevic I, Zecevic M, Budic I. Neglected Monteggia Fractures in Children-A Retrospective Study. Fractures of the shafts of the radius and ulna. plastic deformation of the ulna without obvious fracture, pain, swelling, and deformity about the forearm and elbow, isolated radial head dislocations almost never occur in pediatric patients, a line down the radial shaft should pass through the center of the capitellar ossification center, radial head is stable following reduction, radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length, for Type I, elbow flexion is the main reduction maneuver, if reduction of radiocapitellar joint is unsuccessful, annular ligament is most common block to reduction, radial head is not stable following reduction, ulnar length is not stable (unable to maintain ulnar length), older patients 10y if closed reduction is not stable, symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity) who had delayed treatment or missed diagnosis, open reduction of radial head through a lateral approach if needed in chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave structure, annular ligament reconstruction almost never required for acute fractures, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Acta Orthop Belg. A good radiographic result was seen in all patients who underwent open reduction within 3 years after injury or before reaching 12 years of age. In: Beaty JH, Kasser JR,eds. The original description is of a "traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius"" [1]. Pronation injuries of the forearm, with special reference to the anterior Monteggia fracture. Bado type III lesion with lateral displacement of the radial head. Datta et al conducted a prospective, longitudinal study of 21 children with Monteggia fracture with dislocation (18 type I, three type III), all of whom were treated by modified Hirayama corrective osteotomy of the ulna with wedge bone grafting, restoration of bone length, reconstruction of the anular ligament using the Bell Tawse method, and fixation of the radial head with transcapitellar Kirschner wire (K-wire). Stitgen A, McCarthy JJ, Nemeth BA, Garrels K, Noonan KJ. Robert J Nowinski, DO Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio More than 150 years later, in 1967, Bado coined the term Monteggia lesion and classified the injury into the following four types Modified technique for correction of isolated radial head dislocation without apparent ulnar bowing: a retrospective case study. Radiographically, there were 15 good results, seven fair results, and zero poor results. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). Forearm fractures in children. Foran, I., Upasani, V., Wallace, C., et.al. Epub 2012 Oct 10. Floriano Putigna, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic AssociationDisclosure: Nothing to disclose. anterior dislocation of radial head; A Monteggia fracture-dislocation, or proximal ulnar fracture with associated radial head dislocation, is a complex injury of the forearm and elbow that can destabilize the elbow leading to poor functional outcomes. - ref: Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique. [1] The injury is typically caused by axial loading on a partially flexed metacarpal and may be associated with other carpal bone fractures or ligament injuries. If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. Monteggia fracture-dislocation is rare in children 2,3,4. - note: that patients whose operative treatment is delayed may be found to have a progressive PIN palsy from The ulna fracture is usually clinically and radiographically apparent. [QxMD MEDLINE Link]. A Monteggia fracture involves a fracture of the ulna with disruption of the proximal radio-ulnar joint (PRUJ) and radiocapitellar dislocation (Bado, 1967). Soni JF, Valenza WR, Pavelec AC. - this is esp true on the lateral projection; - radial head is gently repositioned by direct manual pressure anteriorly on the bone; (1/7), Level 1 Hume fracture - fracture of the olecranon accompanied by anterior dislocation of the radial head. Take great care to avoid injury to the underlying skin. The ulna was fixed with a tension band-wire construct supplemented with screws in three patients (all of whom had a Bado type-II fracture). [14]. Most nerve injuries are neurapraxias and typically resolve over a period of 4-6 months. - achieved w/ forarm in full supination, & longitudinal traction; - then elbow is gently flexed to > 90 deg to relax biceps; The eponymous term "Monteggia fracture" is most precisely used to refer to dislocation of the proximal radioulnar joint in association with a forearm fracture. History Mystery: Did Subdural Hematoma Kill Thomas Aquinas? Monteggia fractures account for fewer than 5% of forearm fractures, with published literature supporting figures in the range of 1-2%. [14]. [1], The first challenge is correctly assessing the extent and nature of the injury. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. This may occur in the field spontaneously or as a result of manipulation by emergency responders. A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Chin J Traumatol. J Pediatr Orthop. Speed JS, Boyd HB: Treatment of fractures of ulna with dislocation of head ofradius (Monteggia fracture). [4] The radial head articulates with the humeral capitellum and the radial notch of the proximal ulna. J Bone Joint Surg Am. J Bone Joint Surg Br. An Alternative to the Traditional Radiocapitellar Line for Pediatric Forearm Radiograph Assessment in Monteggia Fracture. (0/7), Level 3 Successful Strategies for Managing Monteggia Injuries. The character of the ulnar fracture is useful in determining optimal treatment. [13] : Pain, nerve dysfunction, and cosmetic deformity are other factors to consider in evaluating the outcome of treatment in Monteggia fracture-dislocations. Ulnar fracture with late radial head dislocation: delayed Monteggia fracture. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. The keys to successful diagnosis of a Monteggia fracture are clinical suspicion and radiographs of the entire forearm and elbow. Whenever a fracture of a long bone is noted, the joints above and below should be evaluated with radiographs in orthogonal planes (planes at 90 angles to each other). The mechanism of injury is most often a fall on an outstretched hand. - type I, III, and IV lesions are held in 110 deg. [QxMD MEDLINE Link]. The radial head dislocation may not be apparent and will possibly be missed if the elbow is not included in the radiograph. Towson, MD 21204 The olecranon, midshaft, and distal shaft may be involved. 2008 Apr. 2018 Oct. 102 (Suppl 1):93-102. 7th ed. Undecided The Galeazzi fracture is a fracture of the middle to distal one-third of the radius associated with dislocation or subluxation of the distal radioulnar joint (DRUJ). - type II lesions with posterior dislocations should be maintained in about 70 deg. Fracture of the upper end of the ulna associated with dislocation of the head of the radius in children. Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). Beutel BG. The investigators evaluated outcomes on the basis of the 100-point MEPI, radiology, and questionnaire. Curr Opin Pediatr. J Bone Joint Surg Am. Orthop Traumatol Surg Res. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. Children (Basel). Ramski, D., Hennrikus, W., Bae, D., et. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. What are Monteggia fractures and how are they classified and treated? Events Search Events ; All Events List All Events Calendar Trauma Spine Shoulder & Elbow Knee & Sports Pediatrics Recon Hand . 2012 Mar 7. - recurrent radial head dislocation Splinting of the wrist in extension and finger range-of-motion (ROM) exercises help prevent contractures from developing while the patient awaits resolution of the nerve injury. Anderson LE, Meyer FN. 8 (10):18197-202. [11, 12] Of the Monteggia fractures, Bado type I has been reported to be the most common (59%), followed by type III (26%), type II (5%), and type IV (1%). The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. encoded search term (Monteggia Fracture) and Monteggia Fracture. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee SurgeonsDisclosure: Nothing to disclose. Advances in radiography and fracture research have helped define, classify, and guide operative management. Monteggia GB. [QxMD MEDLINE Link]. - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity. Events. - PIN palsy is most common in type I frx and may occur in a delayed fashion if theradial - frx of proximal ulnar diaphysis with posterior angulation; (8/80), Level 2 Leonidou A, Pagkalos J, Lepetsos P, Antonis K, Flieger I, Tsiridis E, et al. Dhoju D, Parajuli B. Functional Outcome of Pediatric Monteggia Fracture Dislocation Treated Surgically in a Tertiary Care Centre of Nepal. ORTHOBULLETS; Events. (16/80), Level 5 He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. [5] The mean arc of forearm rotation increased from 145 to 149. Data Trace Publishing Company 2021 Apr-Jun. 2021 Nov. 46 (11):1006-1015. The forearm structures are intricately related, and any disruption to one of the bones affects the other. anteriorangulation (usually proximal third); Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment, Removal of forearm plates. - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; Kevin Strohmeyer, MD Consulting Surgeon, Department of Orthopedic Surgery, Darnall Army Community Hospital, Kevin Strohmeyer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons. A high index of suspicion, therefore, should be maintained with any ulna fracture. 2020 Aug. 23 (4):233-237. 2020 Oct 1. Bruce HE, Harvey JP, Wilson JC Jr. Monteggia fractures. Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture. - radiohumeral ankylosis Van Tongel A, Ackerman P, Liekens K, Berghs B. Angulated greenstick fractures of the distal forearm in children: closed reduction by pronation or supination. "A Monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation. 35 (3):e434-7. - line drawn thru radial shaft and radial head should align w/ capitellum in any position if the radial head is in normal position Wheeless' Textbook of Orthopaedics. Compartment Syndrome in Operatively Managed Pediatric Monteggia Fractures and Equivalents. In 1991, Anderson and Meyer used the following criteria to evaluate forearm fractures and their prognosis Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment. Clin Orthop Relat Res. A review of the complications. J Pediatr Orthop. Injury. [QxMD MEDLINE Link]. [Full Text]. - Plating Techniques - radioulnar synostosis - associated nerve injury: PENROSE JH. - fracture of ulnar metaphysis; [Full Text]. Treatment may be closed reduction and casting for length stable ulna fractures with a stable radiocapitellar joint. - ulnar frx is treated w/ compression plate (esp in proximal third) - angulated ulnar shaft is reduced by firm manual pressure; - Type II (flexion type) - 15% 2013 Jan;44(1):59-66. A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. Steven I Rabin, MD, FAAOS Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic - this ordinarily requires 6-10 wks depending on the age of pt; Monteggia Fracture } Drake LeBrun MD Experts 3 Bullets 65 3.4 ( 5 ) 3 Images Snapshot A 35-year-old man presents to the emergency room for severe right elbow and forearm pain after sustaining a blunt injury to his right arm. Wong JC, Getz CL, Abboud JA. Must have high index of suspicion high incidence of missed injuries (Waters, 2010), Appropriate radiographic imaging is essential to making the correct diagnosis, Be aware of plastic deformation of the ulna. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patients, a proximal radioulnar synostosis in one, a malunited fracture of the coronoid process and a proximal radioulnar synostosis in one, a malunion of the ulna in one, and painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head in one.

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