Monteggia fracture is a fracture of the proximal ulna and
radial head subluxation. It is imperative that you restore the length and the
proper alignment of the ulna so that the radial head can be reduced. If we
malalign the ulna, then the radial head will remain subluxed. There are some
cases where the fracture of the ulna is so comminuted that we will be unable to
restore the length of the ulna. We will not even know if we restored the length
of the ulna.
There is a technique that I use in the reconstruction of the ulna
in cases where the ulna is too comminuted. I will open the fracture ulna, and I
will approach the radial head. I will reduce the radial head to the capitellum
and reduce the ulna to the radius and make sure that the proximal radioulnar
joint is anatomic. Once that joint is anatomic, I will pin it with either one
or two K wires. I transfix the ulna to the radial head. We know that the radial
head is reduced, now the ulna will be reduced because the radioulnar joint is
reduced. We are temporarily transfixing the ulna to the radial head, and that
will help to restore the proper length of the ulna. Once the proper length of
the ulna is defined, then reconstruction of the ulna is simplified utilizing a
dorsal ulnar plate. Next, the K wires are removed and the radioulnar joint is
tested for stability. Occasionally, the K wires may be left in place for a few
weeks if needed to provide additional stability, then removed later on.
Monteggia fracture is not a simple fracture. It is a
fracture of the proximal ulna with dislocation of the radial head. Monteggia
fracture can happen in children and in adults. It is one of the most common
injuries that is missed in the emergency room in children. The radial head may
be dislocated or subluxed, and this problem may not be clear on x-rays. If this
injury is missed, then the child will probably need a big surgery to deal with
this big problem. Treatment of this fracture depends on the age of the patient.
In general, in pediatric patients, you will do closed reduction of the ulna and
closed reduction of the radial head. In adult patients, you will do open
reduction with internal fixation of the ulna with dorsal plate and closed
reduction of the radial head. A line drawn from the proximal radius should
bisect the capitellum in all x-ray views. If you are in doubt and not sure, get
x-rays of the other side and compare. Always examine the patient for posterior
interosseous nerve injury.
The most common type is anterior Monteggia. That
means that the apex of the fracture is anteriorly and the radial head goes
anteriorly. Just make it a practice, when you have a fracture of the proximal
ulna, look at the radius and the radial head, and see the position of the
radial head in relationship to the capitellum. Anterior Monteggia is more
common in children. Posterior Monteggia constitutes 70-80% of Monteggia
fractures in adults. There are four types of Monteggia: Type I, Type II, Type
III, and Type IV. Monteggia fracture is classified according to the direction
of displacement of the radial head. The radial head has two relations: relation
with the capitellum and relation with the proximal radioulnar joint. When the
radial head subluxes or dislocates, it subluxes or dislocates from these two
joints. The radial head becomes free. This means that the radius is not
connected to the capitellum or to the superior radioulnar joint. A Type I
fracture is of the middle or the proximal third of the ulna with anterior
dislocation of the radial head, and it has the characteristic that the apex of
the ulnar fracture is anteriorly. Type I fracture is the most common of all
types (especially in children). Type I occurs in about 60% of fractures. In
children, reduce the fractured ulna and reduce the dislocation of the radial
head and immobilize the elbow in flexion and supination. When you flex the
elbow, especially more than 90 degrees, you will relax the biceps (watch the
circulation). A Type II fracture is a posterior type fracture. Posterior
Monteggia is the most common type in adults. It is associated with a higher
complication rate and carries the worst prognosis. 15% of Monteggia fractures
are Type II. It is a fracture of the middle or proximal third of the ulna with
posterior dislocation of the radial head. You should immobilize the elbow in
extension. Type III is a lateral Monteggia. About 20% of Monteggia fractures
are Type III. It is a fracture of the proximal ulna with lateral dislocation of
the radial head. 5% of Monteggia fractures are Type IV; it is very rare. It is
a fracture of the proximal ulna with anterior dislocation of the radial head
and fracture of the proximal third of the radius below the bicipital
tuberosity. The patient will need surgery, even in children. In this case, the
radial head is dislocated, and you also have fractures of the radius and the
ulna. The posterior interosseous nerve is adjacent to the radial neck, placing it
at risk for a traction injury with dislocation of the proximal radius.
You
should do a neurovascular examination. A nerve injury which involves the
posterior interosseous nerve is not uncommon. Ask the patient to “hitchhike”
and extend their fingers. Make sure the wrist is in dorsiflexion when you ask
the patient to extend the fingers. In posterior interosseous nerve injury, the
finger extensors will not be working. If the posterior interosseous nerve is
injured, observe the patient. In case of posterior interosseous nerve injury in
Monteggia fracture, you will reduce and stabilize the fracture and reduce the
radial head dislocation. Observe the nerve; do not explore the nerve. Typically
the nerve injury is a neuropraxia. It can be expected to resolve itself with
observation in 6-12 weeks. If it does not resolve, you will do EMG and nerve
studies after that period of observation. Any time that you have an ulnar shaft
fracture or any fracture of the proximal ulna, check the radial head position.
Make sure that the radial head is reduced to the capitellum (be aware that the
subluxation may be subtle). Recognition of Monteggia fracture in children is
important. Early appropriate treatment is much easier than treating a missed
radial head dislocation. To treat a Monteggia fracture in adult patients, do
open reduction internal fixation (ORIF) of the ulna. When the ulna is properly
aligned and fixed, the radial head will reduce by itself. After fixation of the
ulnar fracture, if the radial head is still not reduced, then assess the ulnar
reduction. Check for malalignment or malreduction of the ulna. It is imperative
that you restore the length and the proper alignment of the ulna, so that the
radial head can be reduced. If we malalign the ulna, then the radial head will
remain subluxed. Radial head instability may be caused by nonanatomic reduction
of the ulna or by interposition of the annular ligament. Fracture of the ulna
may be too comminuted, and it may not be reduced properly. The fracture may
also need bone graft later on for healing. A Monteggia variant associated with
radial head fracture, in addition to dislocation of the radial head fracture,
in addition to dislocation of the radial head and fracture of the ulna can be a
problem. The radial head fracture is usually fixed or replaced, a prosthesis is
used to replace the radial head in the elderly, especially if the fracture is
comminuted. The subluxation of the radial head is reduced, and the fractured
ulna is fixed as usual. Treatment is different in pediatric patients. The
radial head ossifies around four years of age. In Type I, Type II, and in Type
III Monteggia fractures, you will do closed reduction of the ulna to restore
the length of the ulna, and you will do closed reduction of the radial head.
Closed reduction is much more successful in young children. In anterior
Monteggia, you will immobilize the elbow in flexion and supination. In
posterior Monteggia, you will immobilize the elbow in extension. Ulnar fixation
with a rod or a plate is needed in older patients with unstable fractures. Type
IV fractures require surgery. Surgery is also done in cases where we are unable
to restore the proper length of the ulna, we are unable to reduce the ulna, and
we are unable to reduce the radial head. In this situation, we can use IM rod
or a plate. Dislocation of the radial head with fracture of both the radius and
ulnar shaft. Do closed reduction of the radial head with intramedullary pin
fixation of the radius and the ulnar shaft fractures. The radius and ulnar
shaft fractures are stabilized surgically to give a lever arm for reduction of
the radial head. In this type of fracture, the radial head subluxation may be
missed or unappreciated, because the focus is usually on the forearm fractures.
To treat a missed or neglected Monteggia fracture in children, do osteotomy of the
ulna and lengthening with correction of the angulation, and reduction of the
radial head in addition to plating of the ulna. The patient may need open
reduction of the radial head.
With elbow dislocations, recognize the terrible triad: elbow
dislocation, radial head fracture, and coronoid fracture. The terrible triad is
not a simple elbow dislocation; it is a complex elbow dislocation. In addition
to these three injuries of the elbow, there is always a tear of the lateral
ulnar collateral ligament. The treatment usually is reduction and splinting of
the elbow.
This cannot be the definitive treatment; it is the initial
treatment. If no surgery is done, you will have recurrent dislocation of the
elbow. You need to do surgery for reduction and fixation of the fractures and
also to restore the elbow stability. This injury is unstable. Simple reduction
and splinting is not going to work for this injury. You have to recognize the terrible
triad which means surgery. There are multiple types of elbow dislocation based
on the position of the olecranon relative to the humerus. The most common type
of elbow dislocation is the posterolateral type. There are two basic types of
elbow dislocations: simple and complex. Simple elbow dislocations have no
fracture seen, and are usually a ligamentous injury. Complex elbow dislocations
have associated fractures in addition to the ligamentous injury. With any elbow
dislocation, you need to check the shoulder and the wrist for injuries and
fractures because it can occur in up to 15%. When you have a simple dislocation
of the elbow, you need to reduce it and then check the range of stability of
the elbow. If you find that the elbow is stable with range of motion, then you
will do a short period of immobilization with a posterior splint for
approximately one week with the elbow in about 90 degrees of flexion. Then start
active range of motion of the elbow. Recurrence of the dislocation is rare
(less than 1%). If you keep the elbow immobilized more than 3 weeks, there will
be severe stiffness of the elbow. Surgery should be done if the dislocation is
irreducible, if there is associated fracture, or if you are unable to maintain
stability of the elbow. After immobilization and early range of motion of the
elbow, you will see the patient and do follow up x-rays to check joint
congruity and to make sure that the elbow reduction is maintained. To treat the
terrible triad, you should initially do a closed reduction. Open reduction and
internal fixation of the coronoid (if possible), of the radial head or excise
the radial head with radial head arthroplasty if the radial head is
unreconstructable. In addition, you will do lateral ulnar collateral ligament (LUCL)
repair. Never excise the radial head alone in this situation. For an elbow
dislocation with olecranon fracture, do open reduction and plate fixation.
K-wires and tension band is not strong enough to hold the fracture and
stabilize the elbow at the same time. For an elbow dislocation with a radial
head fracture, do fixation or replacement of the radial head (never do excision
of the radial head alone in this situation). The LUCL is the most important
lesion in recurrence or persistence of instability of the elbow following
simple elbow dislocation.
The injury progresses from lateral to medial. The lateral
collateral ligament fails first, and it avulses proximally at the lateral
epicondyle. The medial collateral ligament (MCL) fails last. In varus
posteromedial rotary instability, there is an elbow injury plus LUCL tear, plus
coronoid fracture which involves the medial facet of the coronoid. Treatment for
chronic dislocation is open reduction capsular releases with hinge external
fixation and early range of motion. Loss of terminal extension is a
complication of elbow dislocation. Usually for decreased range of motion of the
elbow, you will do static progressive splinting between 6-10 weeks. No manipulation
of the elbow is done, which is different from the knee after total knee
replacement, where you can do manipulation up to three months. With heterotopic
ossification, do excision. Remove the myositis and excise the posterior part of
the MCL to allow more flexion. To be functional, the range of motion of the
elbow should be between 30-130 degrees. Some physicians suggest that if the
flexion is less than 100, you will do release of the posterior bundle of the
MCL in addition to release of the ulnar nerve. If you want more flexion of the elbow,
excise the posterior part of the MCL.
This cannot be the definitive treatment; it is the initial
treatment. If no surgery is done, you will have recurrent dislocation of the
elbow. You need to do surgery for reduction and fixation of the fractures and
also to restore the elbow stability. This injury is unstable. Simple reduction
and splinting is not going to work for this injury. You have to recognize the terrible
triad which means surgery. There are multiple types of elbow dislocation based
on the position of the olecranon relative to the humerus. The most common type
of elbow dislocation is the posterolateral type. There are two basic types of
elbow dislocations: simple and complex. Simple elbow dislocations have no
fracture seen, and are usually a ligamentous injury. Complex elbow dislocations
have associated fractures in addition to the ligamentous injury. With any elbow
dislocation, you need to check the shoulder and the wrist for injuries and
fractures because it can occur in up to 15%. When you have a simple dislocation
of the elbow, you need to reduce it and then check the range of stability of
the elbow. If you find that the elbow is stable with range of motion, then you
will do a short period of immobilization with a posterior splint for
approximately one week with the elbow in about 90 degrees of flexion. Then start
active range of motion of the elbow. Recurrence of the dislocation is rare
(less than 1%). If you keep the elbow immobilized more than 3 weeks, there will
be severe stiffness of the elbow. Surgery should be done if the dislocation is
irreducible, if there is associated fracture, or if you are unable to maintain
stability of the elbow. After immobilization and early range of motion of the
elbow, you will see the patient and do follow up x-rays to check joint
congruity and to make sure that the elbow reduction is maintained. To treat the
terrible triad, you should initially do a closed reduction. Open reduction and
internal fixation of the coronoid (if possible), of the radial head or excise
the radial head with radial head arthroplasty if the radial head is
unreconstructable. In addition, you will do lateral ulnar collateral ligament (LUCL)
repair. Never excise the radial head alone in this situation. For an elbow
dislocation with olecranon fracture, do open reduction and plate fixation.
K-wires and tension band is not strong enough to hold the fracture and
stabilize the elbow at the same time. For an elbow dislocation with a radial
head fracture, do fixation or replacement of the radial head (never do excision
of the radial head alone in this situation). The LUCL is the most important
lesion in recurrence or persistence of instability of the elbow following
simple elbow dislocation. 