22 A1.3(Monteggia fractures) IndicationsyMonteggia fractures (adults) ContraindicationsySoft-tissue conditions yNoncompliant patient (the radial head needs to be reduced in any case) AdvantagesyS pontaneous and lasting reduction of radial head Ring D, Jupiter JB, Simpson NS (1998) Monteggia fractures in adults. J Bone Joint Surg Am; 80 (12):1733-44. yLess risk of secondary radial head dislocation Note The restoration of ulnar length is the goal of any treatment of this fracture, allowing spontaneous reduction of radial head. Open reduction of th e radial head and repair of the annular l igament are seldom required. Reduction and retention of the radial head is mandatory with any treatment. CREFIndicationsyOpen fracture of a higher degree (eg, Gustil o 2 & 3) ySoft-tissue condition (eg, burn) Ostermann PA, Henry SL, Seligson D (1987) Treatment of ulna fracture with external fixation a useful alternative Unfallchirurg; 90 (3):122-127. German. AdvantagesyRapid procedure yInexpensive yModest risk of infection DisadvantagesyPin-track infection yLess comfortable yDoes mostly not qualify as definitive treatment: Relative stability and risk of prolonged healing with need for conversion to ORIFORIFIndicationsyStandard procedure for Monteggia fractures ySecondary procedure after CREFContraindicationsyCritical soft-tissue condition AdvantagesyAnatomical reduction and early functional treatment yPatient¶s comfort Note For Monteggia fractures we favor ORIF providing absolute stability and adequate radial head reduction. For the management of radial head dislocation and / or fracture we refer to the Bado classification. In almost all cases the radial head reduces spontaneously with the fixation of the ulna and doesn¶t need further surgical treatment. Ring D, Jupiter JB, Simpson NS (1998) Monteggia fractures in adults. J Bone Joint Surg Am; 80 (12):1733-44. In the event of inadequate reduction and / or persistent instability of radial head open revision is preferred. In the event of an additional radial head fracture treatment depends on fracture type ( Mason classification). Radial head fractures are treated according to the guidelines for isolated radial head fractures. Prognosis is worst with comminuted radial head fracture. Plates and Screws One-third tubular plates are adequate only for very distal fractures (Dimension: 3.5mm). DCPAdvantageyInexpensive DisadvantageyVascular / periosteal compromise LC-DCPAdvantageyLess vascular / periosteal compromise and improved axial compression compared to DCPLCPAdvantageyGood anchorage in osteoporotic bone with less screw loosening DisadvantageyNew implant with no l ong-term follow-up yet yBulky implant in small forearms Note Cerclage wire and screws alone are not adequate for this fracture type. Locking compression plates follow a new concept in fracture treatment. Surgical Technique Supine positioning Place arm abducted in supine position on the operating table Approach to the ulna enlarge Skin incision The Skin incision is along the subcutaneous border of the ulna, between the olecranon process and the ulnar styloid process. enlarge Dissection The dissection should be carried out between the flexor carpi ulnaris and the extensor carpi ulnaris muscles. The internervous plane is between t he ulnarand posterior interosseous nerves. enlarge enlarge Incision of ulnar periosteum According to the position and length of the plate, a delicate detachment ofmuscles from the periosteum i s performed.
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y Noncompliant patient (the radial head needs to be reduced in anycase)
Advantages
y S pontaneous and lasting reduction of radial headRing D, Jupiter JB, Simpson NS (1998) Monteggia fractures inadults. J Bone Joint Surg Am; 80 (12):1733-44.
y Less risk of secondary radial head dislocation
NoteThe restoration of ulnar length is the goal of any treatment of this fracture,allowing spontaneous reduction of radial head. Open reduction of the radial
head and repair of the annular l igament are seldom required.
Reduction and retention of the radial head is mandatory with any treatment.
CREF
Indications
y Open fracture of a higher degree (eg, Gustilo 2 & 3)
y Soft-tissue condition (eg, burn)Ostermann PA, Henry SL, Seligson D (1987) Treatment of ulna
fracture with external fixation a useful alternative Unfallchirurg;
90 (3):122-127. German.
Advantages
y Rapid procedure
y Inexpensive
y Modest risk of infection
Disadvantages
y Pin-track infection
y Less comfortable
y Does mostly not qualify as definitive treatment: Relative stabilityand risk of prolonged healing with need for conversion to OR IF
ORIF
Indications
y Standard procedure for Monteggia fractures
y Secondary procedure after CREF
Contraindications
y Critical soft-tissue condition
Advantages
y Anatomical reduction and early functional treatment
y Patient¶s comfort
Note
For Monteggia fractures we favor OR IF providing absolute stability andadequate radial head reduction.For the management of radial head dislocation and / or fracture we refer to the
Bado classification. In almost all cases the radial head reduces spontaneouslywith the fixation of the ulna and doesn¶t need further surgical treatment.R ing D, Jupiter JB, Simpson NS (1998) Monteggia fractures in adults. J
Bone Joint Surg Am; 80 (12):1733-44.
In the event of inadequate reduction and / or persistent instability of radialhead open revision is preferred. In the event of an additional radial head
fracture treatment depends on fracture type (Mason classification). Radialhead fractures are treated according to the guidelines for isolated radial headfractures.Prognosis is worst with comminuted radial head fracture.
Plates and Screws
One-third tubular plates are adequate only for very distal fractures(Dimension: 3.5mm).
DCP Advantage
y Inexpensive Disadvantage
y Vascular / periosteal compromise
LC-DCP
Advantage
y Less vascular / periosteal compromise and improved axialcompression compared to DCP
LCP Advantage
y Good anchorage in osteoporotic bone with less screw loosening
Disadvantage
y New implant with no long-term follow-up yet
y Bulky implant in small forearmsNoteCerclage wire and screws alone are not adequate for this fracture type.
Locking compression plates follow a new concept in fracture treatment.
Surgical Technique
Supine positioning
Place arm abducted in supine position on the operating table
Approach to the ulna
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Skin incision
The Skin incision is along the subcutaneous border of the ulna, between the
olecranon process and the ulnar styloid process.
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Dissection
The dissection should be carried out between the flexor carpi ulnaris and the
extensor carpi ulnaris muscles. The internervous plane is between the ulnar and posterior interosseous nerves.
enlarge
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I ncision of ulnar periosteum
According to the position and length of the plate, a delicate detachment of
A second screw is inserted eccentrically (yellow drill sleeve) in the oppositefragment.
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T ighten screw
By tightening the eccentrically inserted screw, unilateral axial compression is
achieved.
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Add additional screws
To increase axial compression, a second screw can be placed eccentrically in
either fragment.
When the second screw is tightened, the first screw needs to be loosened toallow the plate to slide on the bone.
All other screws are inserted centrically (green drill sleeve) and do not serve
to increase compression.
Functional aftercare
Because of the dislocation of the radial head, aftertreatment in Monteggia
fractures might differ a little from the usual functional aftercare.
Following stable fixation of the ulna, postoperative treatment might consist inimmobilization in a long cast for 3 weeks (allowing the disrupted ligaments to
heal) with intermittent elbow-mobilization assisted by physiotherapy. The
operated arm is elevated and active mobilization of fingers and wrist is startedwithin the first week.
X-ray control
Postoperatively, after 6 weeks, after 12 weeks and after 1 year.
ÄWeight-bearing³ (in accordance with radiographic assessment after 6 weeks)at approximately 8 weeks after surgery.
Removal of implant
Removal of a plate on the lateral aspect of the ulna by stab incisions
On the forearm the issue of implant removal is controversial. As radius andulna are not weightbearing bones and as removal of plates can be a demanding
procedure, implant removal is not mandatory. Furthermore, there is a risk of
refracture not to be neglected (1/2).
The general guidelines (3) today are:
y removal only in symptomatic patients, possibly only on the ulna as
the ulna is the more exposed boney removal not earlier than 2 years after osteosynthesis
y minimally invasive removal by stab incisions for screws and plate
is to be preferred to complete open approach to the plates, if plate position does allow such a manoeuvre
NEUTRALIZATION WITH LAG SCREW
1 Principle top
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N eutralization plate
As a lag screw osteosynthesis on its own is not able to bear weight andshearing forces, a protection or neutralization plate has to be added to allow
early mobilization.
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Lag screw
Observe the optimal inclination of the screw in relation to a simple fracture
plane.
a) shows a lag screw oriented perpendicular to the fracture plane. This is an
ideal inclination in the absence of forces along the bone axis.
b) shows an inclination half way between the perpendicular axis to the
fracture plane and to the long axis of the bone. This inclination is better suitedto resist compressive load along the bone long axis.
2 Insertion of Lag screw top
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Drill gliding hole
To insert a 3.5 mm lag screw, a gliding hole is drilled with the 3.5 drill bit a s