Pediatric Forearm | Ulnar Fracture + Radial Head Dislocation | Bado Classification | Missed Diagnosis Risk
BADO CLASSIFICATION
Critical Must-Knows
- Definition: Fracture of the ulna (proximal third usually) with dislocation of the radial head
- Missed Diagnosis: High rate of missed diagnosis (up to 50%) - always check radiocapitellar line in ALL forearm fractures
- Radiocapitellar Line: Line drawn through radial neck shaft must bisect capitellum in ALL views
- Plastic Deformation: Ulnar fracture may be subtle plastic deformation (bowing) only - requires reduction to reduce radial head
- Nerve Injury: Posterior Interosseous Nerve (PIN) most commonly injured (neurapraxia)
Clinical Pearls
- "MUGR: Monteggia (Ulna # / Radial Head dislocation), Galeazzi (Radius # / DRUJ dislocation)
- "Radial head points to the direction of the ulnar fracture apex (and creates the Bado type)
- "If ulnar length is not restored, radial head will not reduce/stay reduced
- "In chronic missed cases, ulnar osteotomy is required to lengthen ulna and reduce head
Critical Monteggia Exam Points
The Missed Monteggia
Most common malpractice case in pediatric orthopaedics. 50% are missed on initial presentation. Any "isolated" ulnar shaft fracture MUST have the elbow (radiocapitellar line) and wrist (DRUJ) checked meticulously. Look for ulnar plastic deformation if no frank fracture.
Radiocapitellar Line
Must bisect the capitellum on ALL views. On lateral view, if the line passes anterior to capitellum = Anterior dislocation (Type I). If posterior = Posterior dislocation (Type II).
Nerve at Risk: PIN
PIN palsy (unable to extend fingers/thumb, wrist extension weak/deviates radial) is common especially in Type I and III. Usually neuropraxia and resolves spontaneously in 6-12 weeks. Don't rush to explore.
Reduction Principle
"You must reduce the ulna to reduce the radius." Anatomical reduction and length restoration of the ulna is key. The radial head reduces indirectly once the ulna is corrected. Cast in position of stability (Type I: flexion/supination).
Quick Decision Guide - Bado Classification
| Type | Deformity Direction | Frequency | Reduction Strategy |
|---|---|---|---|
| Type I | Anterior (Head & Ulna Apex) | 70% (Most common) | Traction + Flexion + Supination |
| Type II | Posterior (Head & Ulna Apex) | 6% (Rare in children) | Extension + Pronation (rarely needs ORIF) |
| Type III | Lateral (Head & Ulna Apex) | 23% (Second most common) | Valgus/Varus correction |
| Type IV | Both bones + Dislocation | 1% (Rare) | ORIF usually required for stability |
MUGRMUGR - Forearm Fracture-Dislocations
| M | Monteggia Ulna fracture + PRUJ (In proximal forearm) |
| U | Ulna Bone fractured in Monteggia |
| G | Galeazzi Radius fracture + DRUJ (In distal forearm) |
| R | Radius Bone fractured in Galeazzi |
| M | Monteggia Ulna fracture + PRUJ (In proximal forearm) | G | Galeazzi Radius fracture + DRUJ (In distal forearm) |
| U | Ulna Bone fractured in Monteggia | R | Radius Bone fractured in Galeazzi |
Hook:MU = Monteggia Ulna (Proximal). GR = Galeazzi Radius (Distal). 'M comes before G in alphabet, proximal comes before distal'.
PINPIN - Nerve Examination
| P | Posterior Interosseous Nerve Motor branch of radial nerve |
| I | Index finger extension Test extensor indicis |
| N | No sensory loss Pure motor nerve (unlike superficial radial) |
| P | Posterior Interosseous Nerve Motor branch of radial nerve |
| I | Index finger extension Test extensor indicis |
| N | No sensory loss Pure motor nerve (unlike superficial radial) |
Hook:PIN injury: Hand drops (wrist extension weak), fingers drop (MCP extension lost), thumb drops (IP extension lost). Sensation intact.
Overview and Epidemiology
Monteggia fracture-dislocation is a fracture of the ulnar shaft with dislocation of the radial head at the radiocapitellar joint. It is named after Giovanni Monteggia (1814).
Epidemiology:
- Peak age 4-10 years
- Rare injury (less than 2% of pediatric forearm fractures)
- Bado Type I (Anterior) is by far the most common in children
- Often associated with high-energy trauma but can occur from simple falls
Plastic Deformation Trap
The ulnar fracture is not always a clean break. In children, it often presents as plastic deformation (bowing) of the ulna. If you see a radial head dislocation but no obvious ulnar fracture lines, look for bowing! The radial head cannot dislocate without ulnar pathology or annular ligament rupture (rare in isolation).
Pathophysiology and Mechanisms
The Forearm Ring Concept
The forearm and elbow function as a ring structure containing the radius, ulna, PRUJ, and DRUJ. Disruption of one part of the ring (fracture) often leads to disruption of another (joint dislocation).
- Radius and ulna are bound by interosseous membrane
- Ulna shortening/angulation forces radius to dislocate if linked
Ligamentous Stabilizers
- Annular Ligament: The primary stabilizer of the proximal radioulnar joint (PRUJ). It encircles 4/5ths of the radial head. In Monteggia fractures, it usually ruptures or becomes interposed, blocking reduction.
- Interosseous Membrane (IOM): The central band is a stout structure that transfers load from radius to ulna and prevents excessive proximal migration of the radius.
- Quadrate Ligament: Connects the neck of the radius to the supinator crest of the ulna.
- LCL Complex: Provides varus stability to the elbow. Often injured in Type III (Varus) patterns.
Radiocapitellar Joint
- Normal alignment: Radiocapitellar line must pass through the center of the capitellum on ALL views (AP, Lateral, Oblique)
- Ossification: Radial head ossifies at 3-5 years, Capitellum at 1 year. In younger children, bisect the radial neck shaft.
Topographic Anatomy: MUGR
| Feature | Monteggia | Galeazzi |
|---|---|---|
| Bone Fractured | Ulna (Proximal) | Radius (Distal/Middle) |
| Joint Dislocated | PRUJ (Radial Head) | DRUJ (Ulnar Styloid/Head) |
| Nerve at Risk | PIN (Radial) | AIN (Median) or Ulnar |
| Mechanism | Direct blow or fall (Pronation) | Fall (Hyperextension/Pronation) |
| Treatment (Paeds) | Closed Reduction usually possible | Closed Reduction usually possible |
Radiocapitellar Joint
- Normal alignment: Radiocapitellar line must pass through the center of the capitellum on ALL views (AP, Lateral, Oblique)
- Ossification: Radial head ossifies at 3-5 years, Capitellum at 1 year. In younger children, bisect the radial neck shaft.
Check the Line!
Always draw the radiocapitellar line. On lateral view:
- Anterior to capitellum = Anterior dislocation (Type I)
- Posterior to capitellum = Posterior dislocation (Type II)
- Centered = Normal
Classification Systems
Bado Classification (1967)
Based on direction of radial head dislocation and ulnar fracture apex.
| Type | Direction | Frequency | Mechanism |
|---|---|---|---|
| I | Anterior | 70% | Forced pronation + extension |
| II | Posterior | 6% | Axial load + flexion (rare in kids) |
| III | Lateral | 23% | Varus force (adduction) |
| IV | Combined | 1% | Complex force (both bones #) |
Key Concept: The radial head points in the direction of the ulnar fracture apex.
- Type I: Ulna apex anterior → Head dislocates anterior
- Type II: Ulna apex posterior → Head dislocates posterior
- Type III: Ulna apex lateral (varus) → Head dislocates lateral
Classification dictates the reduction maneuver and the position of immobilization.
Clinical Assessment
Diagnostic Steps
- Mechanism of injury
- Pain location (elbow AND forearm)
- "Wrist" pain may be referred or Galeazzi (check both!)
- Deformity: Angulation of forearm
- Prominence: Radial head may be palpable anteriorly (Type I) or posteriorly (Type II) in antecubital fossa/posterior elbow
- Swelling: Around elbow and fracture site
- Tenderness along ulnar shaft
- Palpate radial head position relative to lateral epicondyle
- PIN Examination (Critical):
- Thumbs up (EPL)
- Hitchhiker sign
- Finger extension (MCP joints)
- Sensation is intact!
- Ulnar nerve: Less common, assess interossei
Red Flag Checklist:
- Open fracture (Gustilo I usually)
- Compartment syndrome signs (pain out of proportion)
- Skin tenting (impending open)
- Polytrauma (e.g. Monteggia + Femur fracture)
Documentation Template
Example ED Note: "6yo female, fall on outstretched hand. Isolated injury. O/E: Deformity L forearm. Closed neurovascularly intact. PIN function normal (thumbs up). X-ray: Midshaft ulna fracture with anterior radial head dislocation (Bado I). Plan: Ketamine procedural sedation for closed reduction. Discussed risks (PIN palsy, loss of reduction, cast issues) with parents. Consented."
Nerve Injury 10-20%
PIN neuropraxia is the most common complication (10-20% of cases), particularly with Type III (lateral) or Type I. It almost always resolves spontaneously. Document pre-reduction function!
Investigations
Radiographic Rules
- Include elbow and wrist: Dedicated elbow views, not just forearm views.
- True Lateral: Essential for checking radiocapitellar line.
- Ulnar Bow: Look for plastic deformation (compare to other side if unsure - normative ulna has slight posterior bow, NEVER anterior).
Radiographic Checklist
| Finding | Significance | Action |
|---|---|---|
| Radiocapitellar line deviation | Dislocated radial head | Identify Direction (I, II, III) |
| Ulnar shaft fracture | Obvious pathology | Assess angulation |
| Ulnar bowing | Plastic deformation | Requires straightening to reduce head |
| Ulnar length | Shortening | Must restore length to reduce head |
Management Algorithm
Monteggia Reduction Tips
| Phase | Tip | Reason |
|---|---|---|
| Preparation | Go to theatre | Muscle relaxation is key. ED sedation often fails due to spasm. |
| Ulnar Length | Get length first | You cannot reduce the head if the ulna is short. Pull hard! |
| Supination | Supinate fully (Type I) | Tightens membrane, relaxes biceps. Neutral is NOT enough. |
| Molding | Interosseous Mold | Squeeze radius and ulna apart to open the space. |
| Imaging | True Lateral | Don't accept obliques. The line is only valid on true lateral. |
Acute Monteggia Treatment
Goal: Anatomic reduction of the ulna (length and angulation) → Indirect reduction of radial head.
Bado I (Anterior):
- Closed Reduction: Traction + Extension (to correct length) → Flexion of elbow to 100-110° + Supination.
- Molding: Correct ulnar angulation (mold valgus/varus if needed).
- Immobilization: Long arm cast in Flexion (100-110°) and Supination.
- Why Supination? Relaxes biceps (main deforming force).
- Why Flexion? Relaxes biceps and pushes radial head back.
- Indications for Surgery (ORIF/IM Nail): Failure to maintain ulnar reduction, unstable fractures, Letts B/C types (complete/comminuted).
Bado III (Lateral):
- Closed Reduction: Traction + Extension → Valgus stress to correct ulnar varus.
- Immobilization: Long arm cast in Extension or slight flexion + Valgus mold.
- Surgery: Often need IM nail for ulna as varus is hard to hold.
Bado II (Posterior):
- Closed Reduction: Extension of elbow (reduces posterior head) + Pronation.
- Immobilization: Cast in Extension (uncommon/awkward) or surgery.
Post-Reduction Check: Ensure radiocapitellar line is restored in all views.
Surgical Technique
Flexible IM Nailing of Ulna
Indication: Unstable Type I/III fractures, failure of closed reduction.
Surgical Preparation:
- Position: Supine, arm on radiolucent hand table.
- C-Arm: Comes from head or across from surgeon (monitor at foot of bed).
- Draping: Tourniquet high on arm (sterile), drape to include shoulder to allow rotation.
- Instruments: Small frag set, flexible nails (TENs), wire driver, oscillating saw (if osteotomy needed).
- Consent Risks: Infection, nerve injury (PIN), loss of reduction, need for removal of hardware.
Tourniquet Safety
Limit tourniquet time to 90 minutes. If reduction is difficult and time is expiring, deflate for 20 minutes before re-inflating. Ensure the limb is exsanguinated but avoid excessively tight Esmarch banding over the fracture site.
Steps
- Olecranon tip (proximal to distal).
- Stab incision, awl.
- Advance appropriately sized TEN nail (2.0-3.0mm).
- Cross fracture site.
- Reduce fracture manually while advancing nail.
- Critical: Must restore LENGTH and alignment.
- Once ulna is rigidly fixed and length restored, check radial head.
- Should spontaneously reduce.
- Verify with image intensifier (rotation/flexion/extension).
Complications
Complications
| Complication | Cause | Management |
|---|---|---|
| Loss of Reduction | Casting error, untreated plastic deformation | Early recognition → Redo/ORIF |
| PIN Palsy | Nerve stretch (Type I/III) | Observation (resolves 6-12w), EMG if no recovery greater than 3mo |
| Compartment Syndrome | High energy, tight cast in hyperflexion | Fasciotomy |
| Redislocation (Late) | Failure to restore ulnar length | Ulnar osteotomy |
| Synostosis | Trauma to interosseous space | Excision if limiting rotation (late) |
Postoperative Care and Rehabilitation
Rehab Protocol
- Long arm cast (position depends on Bado type)
- Weekly X-rays for first 3 weeks (check ulnar alignment and radial head)
- Shoulder motion allowed
- Monitor for cast looseness (as swelling subsides)
- Keep Dry: Use a bag when showering. Wet cast = skin sores.
- No Poking: Do not put rulers/knitting needles down the cast.
- Wiggle Fingers: Encourage finger movement to prevent stiffness.
- Elevation: Keep hand above heart level for the first 3 days.
- Return to ED if: Pain out of proportion, fingers blue/white, cast feels too tight, or cast cracks/softens.
- Remove cast/splint
- Remove IM nail if used (typically 6-12 weeks when united)
- Begin Active ROM (Flexion/Extension, Pro/Supination)
- No passive stretching which may cause myositis
- Progressive strengthening
- Return to non-contact sports
- Monitor for heterotopic ossification (rare but possible)
- Full contact sports when radiographic union solid and full ROM
- Monitor for growth disturbance (rare)
- Assess for any residual PIN deficit
Cast Removal
Check the X-ray before removing the cast. Ensure the ulna is healing and radial head is reduced. If the ulna has angulated, the radial head may have subluxated.
Differential Diagnosis
The key differential is anything that produces radial head malalignment or proximal forearm injury on a paediatric radiograph. The discriminator is almost always the radiocapitellar line plus the state of the ulna.
Differential Diagnosis of the Malaligned Radial Head / Proximal Ulna Injury
| Diagnosis | Distinguishing Feature | Pitfall / Action |
|---|---|---|
| Monteggia fracture-dislocation | Ulnar fracture OR plastic deformation + radial head dislocated (line off) | Look for subtle ulnar bowing if no frank fracture |
| Isolated ulnar shaft fracture | Radiocapitellar line normal in ALL views, radial head congruent | Only call 'isolated' after a true lateral elbow view |
| Congenital radial head dislocation | Dome-shaped/hypoplastic radial head, convex capitellum, NO ulnar fracture, often bilateral | Compare both elbows; do not attempt reduction |
| Nursemaid's elbow (pulled elbow) | Toddler, axial-pull history, no fracture, normal radiographs | Clinical diagnosis; reduces with supination/flexion or pronation |
| Radial neck fracture | Fracture through radial neck, radiocapitellar line may still pass head | Distinct from dislocation; can be a Monteggia equivalent |
| Olecranon / proximal ulna fracture without dislocation | Ulnar fracture present but radial head congruent | Still scrutinise the line - proximal ulnar fractures are high-risk for occult Monteggia |
Congenital vs Traumatic Dislocation
A convex (dome-shaped) capitellum, hypoplastic/dome-shaped radial head, and an intact, non-deformed ulna point to a CONGENITAL dislocation - especially if bilateral. A traumatic Monteggia always has an ulnar abnormality (fracture or plastic deformation). Mistaking congenital for acute leads to unnecessary attempted reductions.
Controversies & Areas of Uncertainty
Annular Ligament: Repair, Reconstruct, or Ignore?
In chronic reconstruction, repairing the native annular ligament has been associated with better stability, whereas formal reconstruction (e.g. Bell-Tawse) and radiocapitellar pinning have not reliably reduced redislocation. Many surgeons now prioritise accurate ulnar osteotomy over routine ligament reconstruction.
Time Window for Chronic Surgery
Delay to surgery is the most consistent predictor of redislocation. Most evidence favours operating within the first year; beyond this the radiocapitellar joint and ulnar geometry remodel unfavourably, but exact cut-offs remain debated.
Fixation Choice for Complete Ulna
Complete ulnar fractures need stabilisation, but the choice between elastic intramedullary nailing, plating, and external fixation is institution-dependent. ESIN is increasingly favoured over external fixation for lower residual pain and better cosmesis.
Managing the Asymptomatic Missed Case
Whether to operate on an older child with a chronically dislocated but pain-free, well-functioning elbow is unsettled. Some advocate observation given surgical morbidity and stiffness risk; others reconstruct to prevent late pain, instability, and tardy PIN palsy.
Outcomes
Prognosis:
- Acute Treated: Excellent prognosis. Most children regain full ROM.
- Missed/Chronic: Guarded prognosis. Reconstruction (osteotomy) improves pain and stability but often leaves some stiffness.
- Nerve Injury: PIN neurapraxia has excellent prognosis (90%+ recover spontaneously).
- Recurrence: Rare if ulnar length maintained.
Evidence Base
Ulnar-Pattern Treatment Algorithm (Landmark)
- Multicentre retrospective review of 112 acute paediatric Monteggia fractures, mean age 6.9 years
- Strategy by ulnar pattern: closed reduction for plastic/greenstick, IM pin for transverse/short-oblique, ORIF for long-oblique/comminuted
- 0 of 57 patients treated per strategy failed; 6 of 18 (33%) complete ulnar fractures treated NON-operatively failed
- All treatment failures were complete fractures managed without surgical stabilisation
Missed Monteggia Injuries (Plastic Deformation Trap)
- Retrospective series of 39 Monteggia injuries; 8 were missed at presentation (mean age 6.3 years)
- 7 of the 8 missed injuries were the variant type with ulnar plastic deformation rather than a frank fracture
- Mean interval from injury to diagnosis in missed cases was 33.5 weeks
- 2 cases diagnosed within 4 weeks were treated successfully by closed manipulation; the rest needed ulnar osteotomy plus annular ligament repair
Reconstruction of Missed Monteggia Lesions
- 52 children reconstructed for missed Monteggia, median age 6.8 years, median injury-to-surgery 12.9 weeks
- Median flexion improved from 108 to 140 degrees; congruent radiocapitellar alignment maintained in 75%
- 9 of 52 (17%) re-dislocated; 6 of these were salvaged with early revision
- Repair of the NATIVE annular ligament gave better stability than reconstruction or leaving it unaddressed (p=0.03)
Risk Factors for Redislocation After Reconstruction
- 62 children reconstructed for chronic Monteggia, mean follow-up 6 years; ulnar osteotomy in all
- 16.1% redislocated after surgery
- Time from injury to surgery was the independent predictor of redislocation on multivariate analysis
- Annular ligament reconstruction and radiocapitellar pinning did not reduce redislocation
Outcomes of Surgically Treated Missed Cases
- 22 children with chronic radial head dislocation, mean age 7.2 years, mean injury-to-surgery 15.7 months
- Radial head stayed reduced in 15 of 22; one frank redislocation
- Kim elbow score excellent/good in 18 of 22 (mean 91); all but five were pain-free
- Clinical outcome was generally better than radiographic radiocapitellar congruency
Elastic Nailing vs External Fixation (Acute)
- 26 children with acute Monteggia: closed reduction plus external fixation vs elastic stable intramedullary nailing (ESIN)
- Both achieved similar excellent healing and functional (Quick DASH) outcomes
- Residual pain / cosmetic dissatisfaction higher with external fixation (40%) than ESIN (9.1%)
- Heterotopic ossification in 2 of 26 (7.6%) overall
Original Description of the Lesion (Historic)
- Defined the four-type classification still used worldwide, based on direction of radial head dislocation
- Established the principle that the radial head dislocates in the direction of the ulnar apex
- Described Monteggia 'equivalents' (e.g. isolated radial head dislocation, radial neck fracture variants)
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
"A 6-year-old girl falls on an outstretched hand. X-rays show a greenstick fracture of the proximal ulna. The radial head does not point to the capitellum on the lateral view."
"You see a 12-year-old boy in clinic who injured his elbow 2 months ago. He has limited flexion and a 'bump' on the front of his elbow. X-rays show a healed ulnar fracture and a dislocated radial head."
"A junior registrar calls you about a 5-year-old with a 'proximal ulnar fracture' and a 'swollen elbow'. They represent the X-rays describing a 'Greenstick proximal ulna fracture' but say the elbow looks 'a bit out'."
MCQ Practice Points
Radiocapitellar Line Question
Q: A 5-year-old presents with a forearm fracture. On the lateral view, the radiocapitellar line passes posterior to the capitellum. What is the diagnosis? A: Bado Type II (Posterior) Monteggia fracture-dislocation. (Anterior line = Type I).
Nerve Injury Question
Q: Which nerve is most commonly injured in Monteggia fractures and what is the presentation? A: Posterior Interosseous Nerve (PIN). Presents with loss of finger extension (MCP) and thumb extension. Wrist extension is preserved (radial deviation) due to ECRL innervation (proximal to PIN). Sensation is INTACT.
Mechanism of Reduction
Q: Why is supination used for Type I Monteggia reduction? A: Supination tightens the interosseous membrane (pulling bones together) and relaxes the biceps tendon (which is an anterior deforming force on the radial tuberosity and proximal radius).
CASTCAST - Immobilization Positions
| I | Type I (Anterior) Flexion + Supination |
| II | Type II (Posterior) Extension |
| III | Type III (Lateral) Extension + Valgus |
| IV | Type IV Surgery (IM Nail) |
| I | Type I (Anterior) Flexion + Supination | III | Type III (Lateral) Extension + Valgus |
| II | Type II (Posterior) Extension | IV | Type IV Surgery (IM Nail) |
Hook:Know the position: I = Flex/Sup. II = Extend. III = Extend/Valgus.
Type III Associations
Q: A 7-year-old sustains a varus injury to the elbow (Bado III). What associated ligamentous injury is most likely? A: Lateral Collateral Ligament (LCL) injury or avulsion. This contributes to the instability and may require repair in chronic cases.
Radial Head Ossification
Q: At what age does the radial head ossification center appear, and why does this matter for diagnosis? A: It appears at 3-5 years. Before this, you must rely on the radial neck alignment with the capitellum. Don't mistake the unossified head for a "dislocation" if the neck points centrally, but be very suspicious of any misalignment.
Bado IV Management
Q: What characterizes a Bado IV fracture and how is it managed? A: Fracture of the proximal ulna AND radius shaft with radial head dislocation. It is highly unstable and almost always requires operative fixation of both bone fractures to maintain reduction.
Guidelines, Registries & Global Practice
Global epidemiology:
- Monteggia fracture-dislocations account for less than 2% of paediatric forearm fractures, with a peak incidence at 4-10 years of age and a slight male predominance in most reported series.
- Common mechanisms worldwide are falls onto the outstretched hand, falls from playground equipment (monkey bars, trampolines) and direct blows to the forearm; in lower-resource settings, road traffic and fall-from-height injuries contribute a higher proportion of high-energy Bado IV patterns.
- Bado Type I (anterior) predominates in children (roughly 70%), with Type III (lateral) the second most common; Types II and IV are uncommon in the paediatric population.
Side-by-side practice and guidance:
| Body / Source | Key message for paediatric Monteggia |
|---|---|
| AAOS / POSNA (US) | Emphasise the radiocapitellar line on every paediatric forearm radiograph; ulnar-pattern-based treatment (closed for incomplete, fixation for complete) per multicentre data |
| BOA / BSCOS (UK) | Dedicated elbow views in all forearm injuries; urgent senior review of any radial head malalignment; manage missed cases in a paediatric specialist centre |
| AO Foundation | Restore ulnar length and alignment first; the radial head reduces indirectly; ESIN is the workhorse fixation for unstable complete ulnar fractures |
| EFORT / European consensus | Early recognition is the priority; chronic reconstruction (ulnar osteotomy +/- annular ligament repair) should be performed as early as possible after diagnosis |
Registry and outcome notes:
- There is no dedicated paediatric Monteggia registry; the strongest comparative evidence comes from multicentre cohorts (e.g. the multi-institution ulnar-pattern study) rather than national arthroplasty/trauma registries, which capture implant-based adult injuries.
- Outcome data consistently show that the dominant modifiable risk factor across health systems is delay to diagnosis, not the choice of reconstruction technique.
High- vs limited-resource practice variation:
- Well-resourced settings: Routine theatre reduction under image intensifier, ready access to elastic nails, MRI/ultrasound for occult plastic deformation, and early specialist referral pathways.
- Limited-resource settings: Higher rates of missed/late presentation; greater reliance on careful clinical examination and contralateral comparison radiographs; external fixation or open ulnar osteotomy may be used where elastic nails are unavailable.
Handover principles (universal):
- Splint for comfort during transfer (does not usually reduce the injury).
- Imaging - transfer dedicated elbow and wrist views (or PACS access) so the radial head can be reassessed.
- Neurovascular - document PIN function clearly before and after any manipulation.
- Fasting - keep fasted if early reduction under anaesthesia is anticipated.
Clinical summary
Bado Types
- •I: Anterior (70%) - Flexion/Supination cast
- •II: Posterior (6%) - Extension cast
- •III: Lateral (23%) - Im nail / Valgus mold
- •IV: Combined (1%) - ORIF
Key Exam Steps
- •Check Radiocapitellar Line (Every view)
- •Check Ulnar Bow (Plastic deformation)
- •Check PIN (hitchhiker thumb)
- •Check Wrist (Galeazzi screen)
Reduction Mantra
- •Restore Ulnar Length
- •Correct Ulnar Angulation
- •Radial head reduces itself
- •Check radiocapitellar line on ALL views