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Monteggia fracture
MONTEGGIA FRACTURE G. J. C URRY, <:hirf, Section
of Traunw,
FLINT,
MICHIGAN
T
HE combination of a fracture of the upper end of the ulna with radial head dislocation was first described by Monteggia in 1814. Two cases were reported and the terminology of “ hlonteggia fracture” has been used quite universally since. J. S. Speeds stated in 1940, that during the prexrious tweIve years thirty-four articles on this subject appeared in the literature, and onIy two of them were in EngIish. His series of sixty-two is 64 far the Iargest on record. In another series of 257 consecutive fractures of the ulna the condition occurred fourteen times, representing about 5 per cent.” The Monteggia fracture may be produced by indirect or direct violence, the basic reason being that the radius and ulna form mutual splints, each bound to the other at the top and bottom b;\ strong ligaments and attached almost throughout by the strong interosseous membrane. The ulna fractures and shortens thereby putting stress and strain on the radial head which dislocates. A dislocated radial head should, therefore, be suspetted when there is a fracture of the ulnar shaft four to five inches from the elbow. Neglect of this observation resuIts in a severe disability.” The dislocation f,‘ir out-shadows the fractured ulna in importance.” Dislocation of the radial head anteriorly is present in the large percentage of cases (84 per cent). The injury is more often produced by a direct blow on the forearm, and the head of the radius pulls out of the annular ligament, which also ruptures. The condition occurs in childhood in which better resuIts have been obtained, compared with frequent failures in adults. * I’ro~nthe Fracture
Scrvicc,
M.D.
for Surgcq
Section
for Surgery 613
I lurlcy
I Iw+itaI
Two types of dispkcement are described: (I) The flexion type, rare, and occurring in IO to 13 per cent of cases, in which the radial heatI is disIocated backwards and the ulnar fracture angulation is in the same direction. (2) Extension type, presenting anterior angulation of the ulnar fracture site and a radia1 head dispIacement upwards and outwards. This is the common type. Many compIications have resulted, i.e., non-union of the fracture, maI-reduction of the radial head, myositis ossificans, ankylosis of the radiaI-uInar joint, and cross union between the radia1 and ulnar shafts.‘” The angIe of the uInar fracture is usualI?- toward the radius, probabIy due to pull of the supinator muscle. DisIocation of the radia1 head may occur in fractures of both bones of the forearm in the upper third.” The management of the Monteggia fracture, extension type, is a difficuIt mechanical problem. EarIy operation is recommended, consisting of uInar plating, radia1 head reduction and orbicular Iigament reconstruction. lj8 Open reduction is done more often in North American than in the British clinics. The Iatter claim that repair of the orbicular ligament is unnecessary when accurate reduction of the radia1 head is done.’ ManipuIation of the forearm with fixation at a 44 degree in supination, is recomflexion angle, mended when considering the non-operative management.” This maneuver is more successfu1 in children and aImost never in adults. Fixation in pIaster of paris should extend over a six to eight weeks’ period. Operative management is indicated in the non-reducible radial head cases, and excision in the old cases has produced of Trauma,
IIurIey
IIospitnl,
Flint,
AIichigan.
614
American
Jcn~rnnl 01 Surgery
Curry-Monteggia
the radial fairly good results, However, head shouId be saved if possible.” There is a strong tendencyto the recurrence of the deformity and dislocation of the radial head, and it seems Iogical to advise primary internal fixation for the fractured ulna with reduction
Fracture
of the radial head dislocation, and an of associated reconstruction or repair the orbicular Iigament.8 Some authors”’ oppose earIy reconstruction of the orbicuIar ligament, stating this can be done two to three months later, after the essential hematoma has absorbed and the tendency
FIG. 2. lateral view taken three ycnrs after reduction, internal fixation of the fr:ictured ulna and replacement of disIocated radial head. Thcrc has been some calcificntion 01 the reconstructed orbicular Iigamcnt. Union is firm nt the ulnar fracture site. FIG. 3. Same as Figure 2; anterior posterior view. RlinimnI I:rtcraI displnccmrnt of the radial head is present.
VOL. LXXIII.
Curry---IMonteggia
No. 5
to residua1 myositis ossificans is reduced. Excision of the radiaI head in the oId cases reduces the tendency to ffexion bIock.g, lo In the flexion type, presenting posterior anguIation at the uInar fracture site and where the radia1 head is disIocated backreduction is reIativeIy easy by wards, manipulation and traction, foIIowed by pIaster of paris fixation in fuI1 extension. Operation in this type of case is infrequent. The fixation must be maintained unti1 there is soIid uInar union.lO In the great majority of cases, a11 authors agree that some type of reconstruction surgery shouId be done, directed toward internal fixation of the fractured uInar fragments and repair of the ruptured orbicular Iigament, or repIacement thereof by the use of fascia Iata or the deep fascia on the IateraI surface of the forearm. The Iatter technic has the advantage of being able to handIe both conditions at the same time through the same incision.8 FVith rupture of the orbicuIar Iigament, there is nothing to maintain reduction at the head of the radius. InternaI fixation of the ulnar fragments and maintenance of reduction of the radial head are imperative to obtain the maximum function.’ CASE
REPORT
Mr. L. Ii;., a white maJe, t\venty-five years of age, was admitted to HurJey HospitaJ, Flint, Michigan, November 26, 1940, tJle victim of an automobile collision. There were muJtiple injuries invoJving the Jeft elbow region, the left femur and the left foot. There were many face and scaJp Jacerations, and the patient n-as in shock. An immediate examination disclosed fractures of the fourth and fifth toes and an obvious fracture of the left femur. The left eJbow showed marked deformity. The Jaccrations were sutured and intensive antishock measures were carried out. The fractures were splinted and the patient’s genera1 condition did not warrant any further definitive investigation or management. Within a few hours, however, the;e was a satisfactory response to the preJiminary anti-shock meas-
Fracture
Arn<~icon Jw,rr,;rl 01 Surgery
6lj
FIG. .+. Photograph
Ib/e years I~““topcrati\~ely, sfmwing feft upper estrcmity hanging in cstension. The forearm is in :I neutral position mith dight fksion.
ures and x-ray examinations were made of the left elho~~, Jeft femur and left foot. The cIbow films showed a fracture at the junction of the upper and second quarter of the ulna witfl marked overriding and angulation, and a severe upward displacement of the radial head. The Ieft femur showed a long spiral obJique fracture with fragmentation, and marked dispJacemcnt in the middle third. The fractures in the fourth and fifth toes \vere insignificant. The left Jower extremity was placed in traction, and evaIuation of the multiple injuries resulted in a decision to take care of the left eJbow J>ony pathologica condition first. The patient’s genera1 condition was considered good enough on No\emher 2&h, two days folIowing injury, and he was prepared for an open reconstruction operation on the Jeft elbow. Identification of the ulnar fracture and the disJocated radial head was accompJished through a curved posterior Jateral incision over the elbow joint and extending down tile forearm for a distance of six inches.8 The ulnar fracture showed some comminution and the smaJ1 fragments were removed, inasmuch as they had no muscIe periostea1 attachments. Reduction was easiIy accompJished and main-
tainetl
by the insertion
of a four-screw
Vitd-
lium plate on the Iatcral surface of the ulna. This automatically improved the position of the dislocated radial head, and with the aid of digital pressure a complete reduction nas accomplishecl. HoLyever, the slightest movement in any direction produced a redislocation. The orbicuIar ligament was completely cvulsed. A strip of the deep fascia from the lateral surface of the forearm three to four inches in length and one-quarter inch in \vidth was liberated, leaving its base intact at approximately the Ieve of the radial neck. The free end was then threaded around the radial neck and attached to the fised flasilar portion, thus producing a sling, so to speak, as IveIl as a fixation agent against the tendency to recurrent disIocation.x A satisfactory retention leas secured 1,~ this means. The \vound was irrigated with saline solution and closed in Iawrs with chromic catgut for the subcutaneous tissue, and cotton for the skin. The left upper extremity was immobilized in a plaster of paris dressing extending from the asilla to the knuckle line, with the forearm at right angles and in supination.
FIG. 7. Photograph showing minimal restriction of pronation of the Idt forearm.
A postoperative film showecl satisfactor,3 position at the ulnar fracture site and a complete reduction of the radial head dislocation. Progress films taken weekly showed a maintenance of these findings. The plaster dressing leas removed at eight weeks and a check fiIm showed osteogenesis in progress at the ulnar fracture site and a maintenance of the radial head reduction. Clinical examination showed a norma contour at the eIbow with a minimal degree of active and passive supination and pronation, and a flesion arc of about thirty-five degrees. (It is to be noted that in the meantime, and shortly after the elbow reconstruction, open reduction, fracture assembly and internal fixation was clone for the femoral fracture.) A lighter plaster of paris dressing was again applied to the left upper extremity as a precautionary measure, and this remained in place for a month. Following removal physiotherapy measures were instituted under a competent physiotherapist. There was progressive improvement in all movements. The wound had healed by first intention. Further management of this patient then was concentrated upon the femoral fracture, and
FIG. 8. Photograph showing minimal restriction of supination of the left f “IXU,ll .
coincidently the Ieft elbow disabilities gradually improved. At five months there was almost complete supination and pronation, and flexion within ten to fifteen degrees of normal, with about the same for extension. Clinical examination of the patient made March, 1946, showed aImost complete ffexion minimal restriction of of the left forearm, supination and pronation, and an extension linlit~ltion of about ten degrees. The patient kvas conducting his occupation as a skilled mechanic. COMMENTS
in this case the radia1 head disiocation was severe and the destroyed orbicular Iigament was repIaced by the use of a segment of the pronator fascia, of seIected length and width. This folIowed interna fixation of the ulnar fragments. The satisfactory resuIt obtained indicates the proper selection of early operative management. Two identical cases in ad&s have since been handIed the same way with comparatively good results. Two cases in children, one aged six and one aged eight, have been satisfactorily handIed by manipulation, radial head reduction, and plaster of paris fixation with the forearm supinated and in fifty degrees of flexion. Both cases gave satisfactory resuIts. In a11 five cases there was a failure to restore fuI1 compIete function. In a recent case of Iong standing, ten years, the radia1 head was excised. The indications for excision were localized pain and motor disturbances associated with the radial nerve. The anteriorly displaced radial head exhibited a prominent tumor mass and there was some restriction of supination and pronation. Forearm flexion and extension were off about IO degrees. Removal was done through an anterior incision and an excellent result followed.
Osteogenesis at an ulnar fracture site is notoriousIy s[ow, and indicates protection for a Iong time. In young chiIdren the orbicuiar Iigament seems to slip back over the radia1 head with greater ease. The impression obtained is that following a Monteggia fracture compIete restoration of normal function is a rarity. Satisfactory\ function, however, may be obtained when early management is possible, carefully seIected and painstakingly done. This injury presents a major surgical problem to the fracture surgeon. KEFEKENCES
I. CA~~P~ELL,WILLIS. 2.
1.
4.
5.
6. 7. 8.
g.
IO.
I I.
12.
Textbook of Operative Orthopedics. Pp. 564-56g, St. Louis, rg3g. The C. V. htosby Company. C~NNINGIIAM, S. R. Fracture of the ulna with disIocation of the head of the radius. J. Bone ++Join! SW&, 16: 351-354. 1934. 1IuNT. G. II. Fracture of the shaft of the ulna vith d&cation of the head of the radius. J. A. hf. A., 112: 1241-1244, 1939. KEY and CONWEL.L.Textbook Fractures, Dislocations, and Sprains. 3rd ed., St. Louis rg)_t2.The C. V. Mosby Company. KIXI, izI. G. Dislocation of the head of the radius associated with fracture of the upper third of ulna. Antiseptic, 37: ~05y 1067, 1g4o. i\l~~_c:tt,IIENKY. Dislocation of the inferior end 01 the ulna. Am. J. Surp., I: 141-146, I@. NAYLOK, A. WIonteggiu fractures. hit. J. Surg., 29: 323~326, I g42. SIWZD, J. S. and B~YD, ~!AKOLLX Treatment of fractwes of ulna with dislocation of the head of the radius (Ylontcggia fracture). J. A. M. A., I 15: 6gg-17o4, 1940. SPEED, I*;ELLOGG S. Textbook of Fractures and Dislocations. 3rd cd., p. 462. PhifadeIphia, 1935. Lea S; Febigcr. \V.%TSO\;JONES. Twtbook Fractures and Joint Injuries. 3rd cd., voi. 2. Baltimore, 1g44. The \T’ilIiams cli \C’ilkins Company. \C’ILSOU,P. D. and COCHRAY, \v. A. Fractures and DisIocations. p. 222, Phifadelphia, 1925. J. B. Lippmcott Company. \vISE, R. A. Lateral dislocation of the head of the radius with fracture of the ulna (hlontcggin fractures. J. I3one <* Joint Surp., 23: 3-9-385, 1941.
of Traunw,
FLINT,
MICHIGAN
T
HE combination of a fracture of the upper end of the ulna with radial head dislocation was first described by Monteggia in 1814. Two cases were reported and the terminology of “ hlonteggia fracture” has been used quite universally since. J. S. Speeds stated in 1940, that during the prexrious tweIve years thirty-four articles on this subject appeared in the literature, and onIy two of them were in EngIish. His series of sixty-two is 64 far the Iargest on record. In another series of 257 consecutive fractures of the ulna the condition occurred fourteen times, representing about 5 per cent.” The Monteggia fracture may be produced by indirect or direct violence, the basic reason being that the radius and ulna form mutual splints, each bound to the other at the top and bottom b;\ strong ligaments and attached almost throughout by the strong interosseous membrane. The ulna fractures and shortens thereby putting stress and strain on the radial head which dislocates. A dislocated radial head should, therefore, be suspetted when there is a fracture of the ulnar shaft four to five inches from the elbow. Neglect of this observation resuIts in a severe disability.” The dislocation f,‘ir out-shadows the fractured ulna in importance.” Dislocation of the radial head anteriorly is present in the large percentage of cases (84 per cent). The injury is more often produced by a direct blow on the forearm, and the head of the radius pulls out of the annular ligament, which also ruptures. The condition occurs in childhood in which better resuIts have been obtained, compared with frequent failures in adults. * I’ro~nthe Fracture
Scrvicc,
M.D.
for Surgcq
Section
for Surgery 613
I lurlcy
I Iw+itaI
Two types of dispkcement are described: (I) The flexion type, rare, and occurring in IO to 13 per cent of cases, in which the radial heatI is disIocated backwards and the ulnar fracture angulation is in the same direction. (2) Extension type, presenting anterior angulation of the ulnar fracture site and a radia1 head dispIacement upwards and outwards. This is the common type. Many compIications have resulted, i.e., non-union of the fracture, maI-reduction of the radial head, myositis ossificans, ankylosis of the radiaI-uInar joint, and cross union between the radia1 and ulnar shafts.‘” The angIe of the uInar fracture is usualI?- toward the radius, probabIy due to pull of the supinator muscle. DisIocation of the radia1 head may occur in fractures of both bones of the forearm in the upper third.” The management of the Monteggia fracture, extension type, is a difficuIt mechanical problem. EarIy operation is recommended, consisting of uInar plating, radia1 head reduction and orbicular Iigament reconstruction. lj8 Open reduction is done more often in North American than in the British clinics. The Iatter claim that repair of the orbicular ligament is unnecessary when accurate reduction of the radia1 head is done.’ ManipuIation of the forearm with fixation at a 44 degree in supination, is recomflexion angle, mended when considering the non-operative management.” This maneuver is more successfu1 in children and aImost never in adults. Fixation in pIaster of paris should extend over a six to eight weeks’ period. Operative management is indicated in the non-reducible radial head cases, and excision in the old cases has produced of Trauma,
IIurIey
IIospitnl,
Flint,
AIichigan.
614
American
Jcn~rnnl 01 Surgery
Curry-Monteggia
the radial fairly good results, However, head shouId be saved if possible.” There is a strong tendencyto the recurrence of the deformity and dislocation of the radial head, and it seems Iogical to advise primary internal fixation for the fractured ulna with reduction
Fracture
of the radial head dislocation, and an of associated reconstruction or repair the orbicular Iigament.8 Some authors”’ oppose earIy reconstruction of the orbicuIar ligament, stating this can be done two to three months later, after the essential hematoma has absorbed and the tendency
FIG. 2. lateral view taken three ycnrs after reduction, internal fixation of the fr:ictured ulna and replacement of disIocated radial head. Thcrc has been some calcificntion 01 the reconstructed orbicular Iigamcnt. Union is firm nt the ulnar fracture site. FIG. 3. Same as Figure 2; anterior posterior view. RlinimnI I:rtcraI displnccmrnt of the radial head is present.
VOL. LXXIII.
Curry---IMonteggia
No. 5
to residua1 myositis ossificans is reduced. Excision of the radiaI head in the oId cases reduces the tendency to ffexion bIock.g, lo In the flexion type, presenting posterior anguIation at the uInar fracture site and where the radia1 head is disIocated backreduction is reIativeIy easy by wards, manipulation and traction, foIIowed by pIaster of paris fixation in fuI1 extension. Operation in this type of case is infrequent. The fixation must be maintained unti1 there is soIid uInar union.lO In the great majority of cases, a11 authors agree that some type of reconstruction surgery shouId be done, directed toward internal fixation of the fractured uInar fragments and repair of the ruptured orbicular Iigament, or repIacement thereof by the use of fascia Iata or the deep fascia on the IateraI surface of the forearm. The Iatter technic has the advantage of being able to handIe both conditions at the same time through the same incision.8 FVith rupture of the orbicuIar Iigament, there is nothing to maintain reduction at the head of the radius. InternaI fixation of the ulnar fragments and maintenance of reduction of the radial head are imperative to obtain the maximum function.’ CASE
REPORT
Mr. L. Ii;., a white maJe, t\venty-five years of age, was admitted to HurJey HospitaJ, Flint, Michigan, November 26, 1940, tJle victim of an automobile collision. There were muJtiple injuries invoJving the Jeft elbow region, the left femur and the left foot. There were many face and scaJp Jacerations, and the patient n-as in shock. An immediate examination disclosed fractures of the fourth and fifth toes and an obvious fracture of the left femur. The left eJbow showed marked deformity. The Jaccrations were sutured and intensive antishock measures were carried out. The fractures were splinted and the patient’s genera1 condition did not warrant any further definitive investigation or management. Within a few hours, however, the;e was a satisfactory response to the preJiminary anti-shock meas-
Fracture
Arn<~icon Jw,rr,;rl 01 Surgery
6lj
FIG. .+. Photograph
Ib/e years I~““topcrati\~ely, sfmwing feft upper estrcmity hanging in cstension. The forearm is in :I neutral position mith dight fksion.
ures and x-ray examinations were made of the left elho~~, Jeft femur and left foot. The cIbow films showed a fracture at the junction of the upper and second quarter of the ulna witfl marked overriding and angulation, and a severe upward displacement of the radial head. The Ieft femur showed a long spiral obJique fracture with fragmentation, and marked dispJacemcnt in the middle third. The fractures in the fourth and fifth toes \vere insignificant. The left Jower extremity was placed in traction, and evaIuation of the multiple injuries resulted in a decision to take care of the left eJbow J>ony pathologica condition first. The patient’s genera1 condition was considered good enough on No\emher 2&h, two days folIowing injury, and he was prepared for an open reconstruction operation on the Jeft elbow. Identification of the ulnar fracture and the disJocated radial head was accompJished through a curved posterior Jateral incision over the elbow joint and extending down tile forearm for a distance of six inches.8 The ulnar fracture showed some comminution and the smaJ1 fragments were removed, inasmuch as they had no muscIe periostea1 attachments. Reduction was easiIy accompJished and main-
tainetl
by the insertion
of a four-screw
Vitd-
lium plate on the Iatcral surface of the ulna. This automatically improved the position of the dislocated radial head, and with the aid of digital pressure a complete reduction nas accomplishecl. HoLyever, the slightest movement in any direction produced a redislocation. The orbicuIar ligament was completely cvulsed. A strip of the deep fascia from the lateral surface of the forearm three to four inches in length and one-quarter inch in \vidth was liberated, leaving its base intact at approximately the Ieve of the radial neck. The free end was then threaded around the radial neck and attached to the fised flasilar portion, thus producing a sling, so to speak, as IveIl as a fixation agent against the tendency to recurrent disIocation.x A satisfactory retention leas secured 1,~ this means. The \vound was irrigated with saline solution and closed in Iawrs with chromic catgut for the subcutaneous tissue, and cotton for the skin. The left upper extremity was immobilized in a plaster of paris dressing extending from the asilla to the knuckle line, with the forearm at right angles and in supination.
FIG. 7. Photograph showing minimal restriction of pronation of the Idt forearm.
A postoperative film showecl satisfactor,3 position at the ulnar fracture site and a complete reduction of the radial head dislocation. Progress films taken weekly showed a maintenance of these findings. The plaster dressing leas removed at eight weeks and a check fiIm showed osteogenesis in progress at the ulnar fracture site and a maintenance of the radial head reduction. Clinical examination showed a norma contour at the eIbow with a minimal degree of active and passive supination and pronation, and a flesion arc of about thirty-five degrees. (It is to be noted that in the meantime, and shortly after the elbow reconstruction, open reduction, fracture assembly and internal fixation was clone for the femoral fracture.) A lighter plaster of paris dressing was again applied to the left upper extremity as a precautionary measure, and this remained in place for a month. Following removal physiotherapy measures were instituted under a competent physiotherapist. There was progressive improvement in all movements. The wound had healed by first intention. Further management of this patient then was concentrated upon the femoral fracture, and
FIG. 8. Photograph showing minimal restriction of supination of the left f “IXU,ll .
coincidently the Ieft elbow disabilities gradually improved. At five months there was almost complete supination and pronation, and flexion within ten to fifteen degrees of normal, with about the same for extension. Clinical examination of the patient made March, 1946, showed aImost complete ffexion minimal restriction of of the left forearm, supination and pronation, and an extension linlit~ltion of about ten degrees. The patient kvas conducting his occupation as a skilled mechanic. COMMENTS
in this case the radia1 head disiocation was severe and the destroyed orbicular Iigament was repIaced by the use of a segment of the pronator fascia, of seIected length and width. This folIowed interna fixation of the ulnar fragments. The satisfactory resuIt obtained indicates the proper selection of early operative management. Two identical cases in ad&s have since been handIed the same way with comparatively good results. Two cases in children, one aged six and one aged eight, have been satisfactorily handIed by manipulation, radial head reduction, and plaster of paris fixation with the forearm supinated and in fifty degrees of flexion. Both cases gave satisfactory resuIts. In a11 five cases there was a failure to restore fuI1 compIete function. In a recent case of Iong standing, ten years, the radia1 head was excised. The indications for excision were localized pain and motor disturbances associated with the radial nerve. The anteriorly displaced radial head exhibited a prominent tumor mass and there was some restriction of supination and pronation. Forearm flexion and extension were off about IO degrees. Removal was done through an anterior incision and an excellent result followed.
Osteogenesis at an ulnar fracture site is notoriousIy s[ow, and indicates protection for a Iong time. In young chiIdren the orbicuiar Iigament seems to slip back over the radia1 head with greater ease. The impression obtained is that following a Monteggia fracture compIete restoration of normal function is a rarity. Satisfactory\ function, however, may be obtained when early management is possible, carefully seIected and painstakingly done. This injury presents a major surgical problem to the fracture surgeon. KEFEKENCES
I. CA~~P~ELL,WILLIS. 2.
1.
4.
5.
6. 7. 8.
g.
IO.
I I.
12.
Textbook of Operative Orthopedics. Pp. 564-56g, St. Louis, rg3g. The C. V. htosby Company. C~NNINGIIAM, S. R. Fracture of the ulna with disIocation of the head of the radius. J. Bone ++Join! SW&, 16: 351-354. 1934. 1IuNT. G. II. Fracture of the shaft of the ulna vith d&cation of the head of the radius. J. A. hf. A., 112: 1241-1244, 1939. KEY and CONWEL.L.Textbook Fractures, Dislocations, and Sprains. 3rd ed., St. Louis rg)_t2.The C. V. Mosby Company. KIXI, izI. G. Dislocation of the head of the radius associated with fracture of the upper third of ulna. Antiseptic, 37: ~05y 1067, 1g4o. i\l~~_c:tt,IIENKY. Dislocation of the inferior end 01 the ulna. Am. J. Surp., I: 141-146, I@. NAYLOK, A. WIonteggiu fractures. hit. J. Surg., 29: 323~326, I g42. SIWZD, J. S. and B~YD, ~!AKOLLX Treatment of fractwes of ulna with dislocation of the head of the radius (Ylontcggia fracture). J. A. M. A., I 15: 6gg-17o4, 1940. SPEED, I*;ELLOGG S. Textbook of Fractures and Dislocations. 3rd cd., p. 462. PhifadeIphia, 1935. Lea S; Febigcr. \V.%TSO\;JONES. Twtbook Fractures and Joint Injuries. 3rd cd., voi. 2. Baltimore, 1g44. The \T’ilIiams cli \C’ilkins Company. \C’ILSOU,P. D. and COCHRAY, \v. A. Fractures and DisIocations. p. 222, Phifadelphia, 1925. J. B. Lippmcott Company. \vISE, R. A. Lateral dislocation of the head of the radius with fracture of the ulna (hlontcggin fractures. J. I3one <* Joint Surp., 23: 3-9-385, 1941.