Slide 124 — Bell tawse

Clean FRCS notes with inline figures

Monteggia fracture dislocation

•Proximal 1/3 ulnar fracture with associated radial head dislocation / instability

Bado classification

**Fig 2.** Classification / diagrammiddle left

**Fig 4.** Classification / diagram - visible label: Bell tawsemiddle centre

Type / group	Definition / note
I	Anterior dislocation + mid-prox 1/3 ulna #, apex anterior.

•Mechanism: Hyperpronation or hyperextension

•Reduce with flexion

Type / group	Definition / note
II	Posterior dislocation + mid-prox 1/3 ulna #, apex posterior.

•Mechanism: Axial load of forearm with flexed elbow

•Reduce with extension

Type / group	Definition / note
III	Lateral dislocation + ulnar metaphyseal #.

•Mechanism: Extension + varus stress

Type / group	Definition / note
IV	Fracture both radius and ulna, anterior dislocation. Type 1 + radial shaft additional fail

•(children I, adult II)

•Type 1 equivalent (“Monteggia variant”)

Type / group	Definition / note
Type I	isolated radial head dislocation
Type II	radial neck fracture + ulna fracture
Type III	isolated radial neck fracture
Type IV	elbow dislocation

•Ulnar bow line – plastic deformity of ulna

•Ulna should be very straight!

•Line joining proximal and distal ulna on lateral XR, increase ulnar bow if >1cm from apex

•Lateral humeral line

•Line along axis of humerus, shift to lateral epicondyle, normally it lines lateral to proximal radial metaphysis (medial to it in bado 3)

Acute Management: assess other injury, neurovascular, open wound

•Reduction of ulna fracture (flexion, traction, supination + direct pressure on radial head), maintain length, alignment, radius reduced after ulna reduced + length restored

•Immobilize in supination (tighten IOM) and flexion for type I, extension (<60) in type II

Definitive mx:

•Aim: concentric RCJ, anatomical fixation of ulnar (length, angulation, rotation)

•Fix with plate or K wire + cast (supination in I/ III) for <10yo

•ORIF if >10yo or if fracture is very comminuted or length unstable

•Radial head will usually automatically reduce if ulnar reduction is achieved

•If greenstick fracture of ulna + radial head dislocation

•Try reduce ulna greenstick by sustained force, make use of viscoelastic property of paediatric bone (difficult)

•IM Kwire to fix reduced ulna

•Osteotomy at metaphyseal region to procedure apex dorsal (closer to CORA of radius, not ulna)

•If radial head not reduce

•Confirm ulnar fixation anatomical

•Rule out annular ligament or radial nerve interposition

•Plastic deformity of ulnar

•+/- Bell Tawse for annular ligament reconstruction

+/- Transcapitellar pin (last resort, for subacute case)

•Cx

•Nerve injury

•Most common Bado Type II & III, radial or median nerve, PIN (10%), AIN, observe 3m, if no recovery → explore

•Radial head instability

•< 6 wk + non anatomical ulna reduction → revise fixation + radial head OR

•> 6 wk → osteotomy

Management of late presentation

Sequelae:

•Cubital valgus

•Valgus/ PLRI instability

•Ulnar nerve and PIN palsy

•Heterotopic ossification

•OA

OT indication:

•All <12yo

•Normal concave radial head + convex capitellum

•Ulna osteotomy + open reduction of radial head +/- annular ligament reconstruction

•Cut at ulnar metaphyseal area, closer to site where radius is out; overcorrect due to plastic deformity

Kocher approach for radial head management (protect PIN)

•Check stability

•- Reconstruct annular ligament Bell tawse (lateral strip of triceps fascia wind around radial neck then back onto itself)

•- +/- Transcapitellar Kwire

•- Cast 6w

Complication:

•Residual radial head dislocation

•Ulnar nerve palsy

•Heterotopic ossification

•Radioulnar synostosis

•Nakamura JBJS 2009 showed good long term outcomes after acute recon for chronic missed monteggia fracture under 12yo, within 2 years of initial injury

•JBJS review paper Hubbard 2018

•Timing: duration of dislocation <3yr, patient age <12yo

•Osteotomy: crescentic osteotomy without ulnar lengthening

•Radial head reduction: into native annular ligament, if failed, piecrust, if still fail, incise and repair

•Reinforcement with triceps fascia

•0.4% of all fracture, peak incidence 4-10 yr

Delayed treatment > 2w with much increased complication

•Stabilizers of radial head

Static:

•ligament: IOL (proximal oblique cord) + annular ligament + quadrate ligament

•Bone: RCJ

•Dynamic: Anconeus

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Monteggia fracture dislocation
2	0	None	None	0	Proximal 1/3 ulnar fracture with associated radial head dislocation / instability
3	0	None	None	0	Bado classification
4	0	None	None	0	I: Anterior dislocation + mid-prox 1/3 ulna #, apex anterior.
5	1	None	None	1	Mechanism: Hyperpronation or hyperextension
6	1	None	None	1	Reduce with flexion
7	0	None	None	0	II: Posterior dislocation + mid-prox 1/3 ulna #, apex posterior.
8	1	None	None	1	Mechanism: Axial load of forearm with flexed elbow
9	1	None	None	1	Reduce with extension
10	0	None	None	0	III: Lateral dislocation + ulnar metaphyseal #.
11	1	None	None	1	Mechanism: Extension + varus stress
12	1	None	None	1	Reduce with flexion
13	0	None	None	0	IV: Fracture both radius and ulna, anterior dislocation. Type 1 + radial shaft additional fail
14	1	None	None	1	Reduce with flexion
15	0	None	None	0	(children I, adult II)
16	0	None	None	0	Type 1 equivalent (“Monteggia variant”)
17	1	None	None	1	Type I: isolated radial head dislocation
18	1	None	None	1	Type II: radial neck fracture + ulna fracture
19	1	None	None	1	Type III: isolated radial neck fracture
20	1	None	None	1	Type IV: elbow dislocation
21	0	None	None	0	Ulnar bow line – plastic deformity of ulna
22	0	None	None	0	Ulna should be very straight!
23	0	None	None	0	Line joining proximal and distal ulna on lateral XR, increase ulnar bow if >1cm from apex
24	0	None	None	0	Lateral humeral line
25	0	None	None	0	Line along axis of humerus, shift to lateral epicondyle, normally it lines lateral to proximal radial metaphysis (medial to it in bado 3)
26	0	None	None	0	Acute Management: assess other injury, neurovascular, open wound
27	0	None	None	0	Reduction of ulna fracture (flexion, traction, supination + direct pressure on radial head), maintain length, alignment, radius reduced after ulna reduced + length restored
28	0	None	None	0	Immobilize in supination (tighten IOM) and flexion for type I, extension (<60) in type II
29	0	None	None	0	Definitive mx:
30	0	None	None	0	Aim: concentric RCJ, anatomical fixation of ulnar (length, angulation, rotation)
31	0	0	0	0	Fix with plate or K wire + cast (supination in I/ III) for <10yo
32	0	0	0	0	ORIF if >10yo or if fracture is very comminuted or length unstable
33	0	None	None	0	Radial head will usually automatically reduce if ulnar reduction is achieved
34	0	None	None	0	If greenstick fracture of ulna + radial head dislocation
35	0	228600	-228600	1	Try reduce ulna greenstick by sustained force, make use of viscoelastic property of paediatric bone (difficult)
36	0	228600	-228600	1	IM Kwire to fix reduced ulna
37	0	228600	-228600	1	Osteotomy at metaphyseal region to procedure apex dorsal (closer to CORA of radius, not ulna)
38	0	None	None	0	If radial head not reduce
39	0	228600	-228600	1	Confirm ulnar fixation anatomical
40	0	228600	-228600	1	Rule out annular ligament or radial nerve interposition
41	0	228600	-228600	1	Plastic deformity of ulnar
42	0	0	0	0	+/- Bell Tawse for annular ligament reconstruction
43	0	0	0	0	+/- Transcapitellar pin (last resort, for subacute case)
44	0	None	None	0	Cx
45	0	None	None	0	Nerve injury
46	0	None	None	0	Most common Bado Type II & III, radial or median nerve, PIN (10%), AIN, observe 3m, if no recovery → explore
47	0	None	None	0	Radial head instability
48	0	None	None	0	< 6 wk + non anatomical ulna reduction → revise fixation + radial head OR
49	0	0	0	0	> 6 wk → osteotomy
50	0	0	0	0	Management of late presentation
51	0	0	0	0	Sequelae:
52	0	171450	-171450	1	Cubital valgus
53	0	171450	-171450	1	Valgus/ PLRI instability
54	0	171450	-171450	1	Ulnar nerve and PIN palsy
55	0	171450	-171450	1	Heterotopic ossification
56	0	171450	-171450	1	OA
57	0	0	0	0	OT indication:
58	0	171450	-171450	1	All <12yo
59	0	171450	-171450	1	Normal concave radial head + convex capitellum
60	0	0	0	0	Ulna osteotomy + open reduction of radial head +/- annular ligament reconstruction
61	0	None	None	0	Cut at ulnar metaphyseal area, closer to site where radius is out; overcorrect due to plastic deformity
62	0	None	None	0	Kocher approach for radial head management (protect PIN)
63	0	None	None	0	Check stability
64	0	0	0	0	- Reconstruct annular ligament Bell tawse (lateral strip of triceps fascia wind around radial neck then back onto itself)
65	0	0	0	0	- +/- Transcapitellar Kwire
66	0	0	0	0	- Cast 6w
67	0	None	None	0	Complication:
68	0	None	None	0	Residual radial head dislocation
69	0	None	None	0	Ulnar nerve palsy
70	0	None	None	0	Heterotopic ossification
71	0	None	None	0	Radioulnar synostosis
72	0	None	None	0	Nakamura JBJS 2009 showed good long term outcomes after acute recon for chronic missed monteggia fracture under 12yo, within 2 years of initial injury
73	0	None	None	0	JBJS review paper Hubbard 2018
74	0	171450	-171450	1	Timing: duration of dislocation <3yr, patient age <12yo
75	0	171450	-171450	1	Osteotomy: crescentic osteotomy without ulnar lengthening
76	0	171450	-171450	1	Radial head reduction: into native annular ligament, if failed, piecrust, if still fail, incise and repair
77	0	171450	-171450	1	Reinforcement with triceps fascia
78	0	None	None	0	=============================
79	0	None	None	0	0.4% of all fracture, peak incidence 4-10 yr
80	0	None	None	0	Delayed treatment > 2w with much increased complication
81	0	None	None	0	Stabilizers of radial head
82	0	None	None	0	Static:
83	0	171450	-171450	1	ligament: IOL (proximal oblique cord) + annular ligament + quadrate ligament
84	0	171450	-171450	1	Bone: RCJ
85	0	0	0	0	Dynamic: Anconeus

#	semantic level	section?	rewritten line
1	0		Monteggia fracture dislocation
2	1		Proximal 1/3 ulnar fracture with associated radial head dislocation / instability
3	0	yes	Bado classification
4	1		I: Anterior dislocation + mid-prox 1/3 ulna #, apex anterior.
5	1		Mechanism: Hyperpronation or hyperextension
6	1		Reduce with flexion
7	1		II: Posterior dislocation + mid-prox 1/3 ulna #, apex posterior.
8	1		Mechanism: Axial load of forearm with flexed elbow
9	1		Reduce with extension
10	1		III: Lateral dislocation + ulnar metaphyseal #.
11	1		Mechanism: Extension + varus stress
12	1		IV: Fracture both radius and ulna, anterior dislocation. Type 1 + radial shaft additional fail
13	1		(children I, adult II)
14	1		Type 1 equivalent (“Monteggia variant”)
15	1		Type I: isolated radial head dislocation
16	1		Type II: radial neck fracture + ulna fracture
17	1		Type III: isolated radial neck fracture
18	1		Type IV: elbow dislocation
19	1		Ulnar bow line – plastic deformity of ulna
20	1		Ulna should be very straight!
21	1		Line joining proximal and distal ulna on lateral XR, increase ulnar bow if >1cm from apex
22	1		Lateral humeral line
23	1		Line along axis of humerus, shift to lateral epicondyle, normally it lines lateral to proximal radial metaphysis (medial to it in bado 3)
24	0	yes	Acute Management: assess other injury, neurovascular, open wound
25	1		Reduction of ulna fracture (flexion, traction, supination + direct pressure on radial head), maintain length, alignment, radius reduced after ulna reduced + length restored
26	1		Immobilize in supination (tighten IOM) and flexion for type I, extension (<60) in type II
27	0	yes	Definitive mx:
28	1		Aim: concentric RCJ, anatomical fixation of ulnar (length, angulation, rotation)
29	1		Fix with plate or K wire + cast (supination in I/ III) for <10yo
30	1		ORIF if >10yo or if fracture is very comminuted or length unstable
31	1		Radial head will usually automatically reduce if ulnar reduction is achieved
32	1		If greenstick fracture of ulna + radial head dislocation
33	1		Try reduce ulna greenstick by sustained force, make use of viscoelastic property of paediatric bone (difficult)
34	1		IM Kwire to fix reduced ulna
35	1		Osteotomy at metaphyseal region to procedure apex dorsal (closer to CORA of radius, not ulna)
36	1		If radial head not reduce
37	1		Confirm ulnar fixation anatomical
38	1		Rule out annular ligament or radial nerve interposition
39	1		Plastic deformity of ulnar
40	1		+/- Bell Tawse for annular ligament reconstruction
41	0	yes	+/- Transcapitellar pin (last resort, for subacute case)
42	1		Cx
43	1		Nerve injury
44	1		Most common Bado Type II & III, radial or median nerve, PIN (10%), AIN, observe 3m, if no recovery → explore
45	1		Radial head instability
46	1		< 6 wk + non anatomical ulna reduction → revise fixation + radial head OR
47	1		> 6 wk → osteotomy
48	0	yes	Management of late presentation
49	0	yes	Sequelae:
50	1		Cubital valgus
51	1		Valgus/ PLRI instability
52	1		Ulnar nerve and PIN palsy
53	1		Heterotopic ossification
54	1		OA
55	0	yes	OT indication:
56	1		All <12yo
57	1		Normal concave radial head + convex capitellum
58	1		Ulna osteotomy + open reduction of radial head +/- annular ligament reconstruction
59	1		Cut at ulnar metaphyseal area, closer to site where radius is out; overcorrect due to plastic deformity
60	0	yes	Kocher approach for radial head management (protect PIN)
61	1		Check stability
62	1		- Reconstruct annular ligament Bell tawse (lateral strip of triceps fascia wind around radial neck then back onto itself)
63	1		- +/- Transcapitellar Kwire
64	1		- Cast 6w
65	0	yes	Complication:
66	1		Residual radial head dislocation
67	1		Ulnar nerve palsy
68	1		Heterotopic ossification
69	1		Radioulnar synostosis
70	1		Nakamura JBJS 2009 showed good long term outcomes after acute recon for chronic missed monteggia fracture under 12yo, within 2 years of initial injury
71	1		JBJS review paper Hubbard 2018
72	1		Timing: duration of dislocation <3yr, patient age <12yo
73	1		Osteotomy: crescentic osteotomy without ulnar lengthening
74	1		Radial head reduction: into native annular ligament, if failed, piecrust, if still fail, incise and repair
75	1		Reinforcement with triceps fascia
76	0		——
77	1		0.4% of all fracture, peak incidence 4-10 yr
78	0	yes	Delayed treatment > 2w with much increased complication
79	1		Stabilizers of radial head
80	0	yes	Static:
81	1		ligament: IOL (proximal oblique cord) + annular ligament + quadrate ligament
82	1		Bone: RCJ
83	1		Dynamic: Anconeus

124. Bell tawse

Clean FRCS notes with inline figures

Monteggia fracture dislocation

Bado classification

Acute Management: assess other injury, neurovascular, open wound

Definitive mx:

+/- Transcapitellar pin (last resort, for subacute case)

Management of late presentation

Sequelae:

OT indication:

Kocher approach for radial head management (protect PIN)

Complication:

Delayed treatment > 2w with much increased complication

Static:

Direct Q&A

Aim: concentric RCJ, anatomical fixation of ulnar (length, angulation, rotation)

Cx

Check stability

Residual radial head dislocation

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes