Wednesday, November 2, 2011

Complex Monteggia Fracture Dislocation

A 25 year old male was involved in a severe motor vehicle collision in which his car collided with a transport truck.  He sustained an isolated open fracture dislocation of his dominant elbow.  On physical examination he had multiple small open wounds over the posterior aspect of his elbow and forearm.  He had a normal neurologic and vascular examination.

Radiographs were performed which demonstrated an extremely comminuted fracture dislocation of his elbow.  He had complete disruption of his proximal radioulnar joint with anterior dislocation of the radial head representing a Type I Monteggia injury variant.

The patient was brought emergently to the operating room for irrigation and debridement of his open wounds as well as open reduction and internal fixation of his fracture. He had massive disruption of the deep soft tissues and musculature around the elbow.

The joint was meticulously reduced and repaired and the ulnar shaft component was held with clamps. However, the radial head was not reduced indicating that length had not been completely restored to the comminuted ulnar shaft. Length was then added and held with a minifragment plate on the shaft of the ulna and the radial head was then reduced. A plate spanning the joint and ulnar shaft components was then placed to hold the reduction. The plate was a 3.5 mm LCDC thickness plate.

The elbow was then brought through a full range of motion and the radial head remained reduced and stable throughout the full arc of flexion and extension in full pronation and supination.

Postoperatively, the patient was started on a rehabilitation program of elbow range of motion exercises 48 hours after surgery. He was able to regain excellent motion and return to his full time manual job within six months of injury. Final radiographs demonstrated a healed ulna with a concentrically reduced joint.

Type I (anterior) Monteggia injuries are fracture dislocations of the elbow in which the ulna is fractured and the proximal radioulnar joint is disrupted. The radial head dislocates anteriorly in this type of injury. In adults, these injuries typically result from high energy mechanisms and can have a high incidence of nerve or vascular injury. The key to restoring elbow stability is anatomic reduction and length restoration of the ulnar shaft.

Most cases do not involve such an extensive fracture of the joint as was seen in this patient. However, like other Monteggia injuries, anatomic ulnar alignment was the key to restoration of elbow joint stability in this case. This patient had an excellent result which was only possible by accurately restoring his anatomy and placing sufficient sized implants to ensure a rigid and stable construct that allowed for early range of motion and elbow rehabilitation.

Authored By: Daphne Beingessner, M.D.