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Monteggia fractures classically involve a proximal ulna fracture with an associated radial head dislocation. The presence of radial head/neck fracture and comminution of the proximal ulna with coronoid involvement elevates the complexity of surgical reconstruction considerably. The Jupiter classification captures this injury pattern as a subgroup of Bado posterior Monteggia lesions. Access to the critical coronoid fragment can be problematic from the posterior approach and may result in tenuous reduction and fixation, directly affecting the functional outcome. Multiple operative techniques have been described to address the broad spectrum of injuries seen in Monteggia fractures. This article will cover commonly used fixation techniques for Monteggia fractures with a comprehensive literature review, including technical tips, outcomes, and complications.
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Disclosures for this Article
Editors
Dawn M. LaPorte, MD, has no relevant conflicts of interest to disclose.
Authors
All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.
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Dawn M. LaPorte, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.
Learning Objectives
Upon completion of this CME activity, the learner will:
•
Understand the anatomy of and classification systems for Monteggia fractures.
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Appreciate the complex variations of Monteggia fractures and associated potential operative challenges.
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Understand the management options and considerations for Monteggia fractures and associated outcomes.
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The eponymous Monteggia fracture, first identified by Dr Giovanni Battista Monteggia and later classified by Dr Jose Luis Bado, was originally described as a fracture at the proximal ulna associated with a dislocation of the radiocapitellar joint.
Monteggia fractures, comprising an estimated 1% to 2% of all forearm and elbow fractures, present in a bimodal distribution, with low-energy mechanisms common in elderly patients and high-energy mechanisms common in young adults.
As such, 3 main complex variations of Monteggia fractures include proximal radius fractures, coronoid comminution with metaphyseal extension, and ulnohumeral joint instability. Recognizing the spectrum of injury and anticipating potential operative challenges facilitate planning for technical aspects of surgery and instrumentation. Broadening the surgical armamentarium to address these challenges can improve opportunities to restore the anatomic alignment of the elbow for severe variants of Monteggia fractures.
The forearm can be visualized as a ring encompassing the ulna and radius as well as the proximal and distal radioulnar joints. As such, an injury to the proximal ulna should be met with suspicion as the energy imparted must exit at another point.
Evolution of the ring concept for the forearm and its implication on treatment: from Galeazzi, Monteggia, Essex-Lopresti, and Darrach to the current era.
The primary osseous injury in Monteggia lesions involves a fracture of the proximal or, less frequently, the middle-third ulna. The most common adult Monteggia fracture pattern demonstrates an apex posterior deformity. Jupiter et al
further subdivided this injury to recognize specific fractures at the coronoid, metaphyseal-diaphyseal junction, and distal half of the ulna. Failure to adequately recreate ulnar length and proximal anteromedial varus angulation prevents reduction of the radiocapitellar joint and impedes forearm pronosupination. Important anatomic considerations of the proximal radius include slightly oval concave radial head articulation with the capitellum and the lesser sigmoid notch and the approximately 10° varus neck-shaft angle.
The nonarticulating portion of the radial head encircles approximately 110° of the circumference and consistently includes the 90° arc estimated by palpating the Lister tubercle and radial styloid.
Monteggia fractures often involve soft tissue pathology, including the annular and quadrate ligaments, the interosseous membrane, and the lateral collateral ligamentous complex.
The annular ligament stabilizes the radial head within the proximal radioulnar joint, originating and inserting into the anterior and posterior aspects of the lesser sigmoid notch. The quadrate ligament, a thickening of the inferior elbow capsule, prevents excessive pronosupination. Although the proximal interosseous membrane is often disrupted, the distal portion usually remains intact, highlighting the importance of anatomic ulnar reduction in restoring forearm alignment.
Injuries of the lateral ulnar collateral ligament typically occur as avulsions from the origin at the lateral epicondyle or at the supinator crest, but may occur as intrasubstance tears or bony avulsions. The medial ligamentous complex is not typically injured unless dislocation or considerable valgus stress to the ulnohumeral joint occurs.
classified the Monteggia lesions into 4 types based on the direction of the radial head displacement: anterior (type 1), posterior (type 2), lateral (type 3), and any deformity associated radial shaft fracture (type 4). At the time of the original publication, the direction of radiocapitellar joint dislocation was critical to facilitate the reduction by maneuvers in the opposite direction of the injury mechanism.
There was no distinction between pediatric and adult Monteggia fractures, heavily favoring closed reduction and immobilization as the treatment of choice.
subdivided the most common Bado type 2 lesion into 4 types based on the fracture’s location and involvement of the coronoid process. Fractures of the proximal ulna can occur at the level of the coronoid (type 2A), at the metaphyseal-diaphyseal junction distal to the coronoid (type 2B), at the ulna diaphysis (type 2C), or at the trochlear notch with extension to the metaphysis often with a separate coronoid fragment (type 2D). This classification also included radial head comminution as a subdivision to the scheme. In our experience, the Jupiter classification, which incorporates the coronoid and radial head fracture, more accurately anticipates the surgical complexity, implant needs, and functional outcome.
Although less recognized, ulnohumeral instability is also a critical component of preoperative evaluation, especially in the setting of coronoid fracture, which may require specialized implants and joint stabilizers. Based on the report by Strauss et al,
the Monteggia fracture with ulnohumeral instability results from a high-energy mechanism in all cases. All injuries were Bado type 2, but not all dislocations involved the coronoid, indicating more extensive ligamentous disruption.
Clinical Evaluation
Multiple reduction attempts of the elbow should be avoided since it is difficult to maintain alignment in complex fracture patterns, and they increase the patient’s discomfort and worsen the soft tissue swelling. The soft tissues should be closely examined for skin tenting and open fractures, which can occur in up to 10% of injuries and necessitate more urgent operative intervention.
Associated nerve injuries have been previously reported, and the posterior interosseous nerve, in particular, has a higher propensity for injury because of its proximity to the radial head and neck.
Anteroposterior and lateral radiographs of the elbow, forearm, and wrist should be obtained and scrutinized for joint incongruity. The radiocapitellar line should bisect the capitellum in each view, the absence of which raises the suspicion of radial head subluxation or dislocation. Double densities or the inability to visualize the ulnohumeral joint line can suggest fractures of the radial head or the coronoid. While subluxation at the ulnohumeral joint can occur with coronoid fractures, ulnohumeral disruption may indicate a transolecranon fracture-dislocation rather than a Monteggia fracture.
Additional imaging with computed tomography and 3-dimensional reconstruction with humeral subtraction can better characterize fracture patterns of the coronoid, metaphyseal fragment, and proximal radius. The intact humerus and olecranon can obscure the assessment of these associated injuries in radiographs, which are frequently taken with the elbow partially flexed leading to suboptimal lateral views. Once the posterior cortex is reduced, we found that the anterior coronoid or metaphyseal fragment may not be readily visible intraoperatively. The degree of displacement and the location of the fragments based on the computed tomography scan can direct the surgeons to assess their reduction and screw trajectory more critically. Furthermore, the coronoid fixation devices and radial head arthroplasty are commonly a separate instrumentation set, and we strongly recommend multiple options be available in case of an intraoperative change in fixation strategy.
Management
Most Monteggia fractures are inherently unstable, and satisfactory reduction is difficult to maintain with closed treatment alone. Gentle traction improves the ulnar length, which indirectly reduces the radiocapitellar joint, and orthosis immobilization serves as a temporizing measure until definitive treatment can be rendered. If the pain is well controlled and elbow joint reduced, compliant patients can be discharged and treated electively within 1 to 2 weeks. A study by Foruria et al
showed that delayed definitive treatment might be associated with heterotopic ossification (HO). The decision to treat Monteggia fractures nonoperatively is rare and primarily compelled by substantial medical comorbidities. Elderly patients, even with a sedentary lifestyle, benefit from surgery due to an expedited return to daily function and reliable outcomes.
Inadequate reduction of the ulna creates persistent subluxation of the radial head and subsequent limitation of elbow motion and forearm rotation.
Surgical exposure
An extended posterior incision permits access to the proximal ulna, radial head, and coronoid. The skin flap at the level of the fascial plane is raised laterally to access a separate intermuscular interval using either a Kocher (posterolateral) or Kaplan (lateral) approach. Although we prefer the Kaplan approach (between extensor carpi radialis brevis and extensor carpi ulnaris) to access the radiocapitellar joint directly, the Kocher approach (between anconeus and extensor carpi ulnaris) is a slightly more posterior and popular approach to expose the radial head. The forearm should be pronated during the deep dissection into the muscle interval to avoid posterior interosseous nerve injury.
For larger and comminuted fragments requiring screw or plate fixation, exposure through the cubital tunnel floor and elevating the flexor-pronator muscle off the medial cortex of the proximal ulna allows adequate access to the coronoid. The ulnar nerve can be exposed and protected in both in situ or anteriorly transposed positions. The coronoid fragment often extends to the posterior metaphysis, allowing fracture reduction through the posterior approach to the metaphyseal cortical read.
The first critical step in the surgical strategy is to reconstruct the anatomic alignment of the ulna. The restoration of congruent radiocapitellar and ulnohumeral joints depends on the restoration of ulnar length and coronoid anatomy, respectively. The posterior approach provides direct exposure for ulnar fixation. Although time consuming, meticulous reduction of each fragment based on cortical read can assist in the restoration of anatomic alignment of the ulna. Malreduction of the ulna results in malreduction of the radiocapitellar joint.
Dorsal contour plating is the preferred construct, which provides a mechanical advantage to resist the deformity of the ulna during elbow flexion.
The contour of the plate around the olecranon allows additional fixation proximally, which can have limited working length. The modern plate design also permits variable locking constructs at the metaphyseal region, which can span a considerable length of the ulna (Fig. 1).
For severely comminuted cases, additional plates can be applied to the medial or lateral cortex. Further dissection through the ulnar periosteum, especially in the presence of proximal radial fracture, can increase the risk of synostosis.
Figure 1Surgical fixation of the coronoid fracture using variable angle screws from posterior-to-anterior through the dorsal plate. Bicortical purchase with multiple screws increases the strength of the construct (arrows) and provides a rigid buttress to restrict ulnohumeral subluxation.
correlated unsatisfactory results with malunion of the coronoid process and ulnohumeral instability. Figure 2 demonstrates 3 common patterns of coronoid fractures. The anteromedial sagittal split (Fig. 2A) may require common flexor muscle elevation posterior-to-anterior for adequate exposure.
For a large en bloc segment (Fig. 2B), reduction through posterior cortical read will indirectly restore coronoid buttress.
Figure 2Common patterns of coronoid fractures. A The sagittal split of the coronoid fragment (arrow). BEn bloc segmental fragment at the metaphysis, which includes the coronoid (arrow). C Metaphyseal comminution with a triangular coronoid fragment (arrow).
In severely comminuted patterns (Fig. 2C), the coronoid can be accessed by elevating the flexor-pronator muscle off medially. We first stabilize the posterior cortex of the ulna, and the triangular or quadrangular coronoid fragments can be reduced to the solid posterior foundation.
Medium-sized reduction forceps or K-wires can maintain the reduction while the implant is applied. With an appropriate trajectory, the posterior-to-anterior screws can capture the coronoid in addition to the metaphyseal fragments (Fig. 1). In our experience, this fixation strategy and reduction technique addressed the most complex Monteggia fractures. A separate coronoid plate augmentation through the same approach is feasible but challenging due to the presence of screws in this region from the posterior plate. Multiple fixation attempts with a coronoid plate can lead to considerable fragmentation of the bone. For Regan and Morrey type 1 and 2 coronoid fractures, the suture lasso technique demonstrates favorable outcomes for smaller fragments insufficient for screw fixation.
The same approach to address the radial head can be used without the need for medial exposure. Inadequate reduction of the coronoid fracture, especially with a sizable quadrangular fragment (Fig. 3), leads to a poor clinical outcome with limited motion and pain.
Intraoperative range of motion and stability should be assessed to determine the management of radial head fractures. Mason 1 nondisplaced radial head fractures may be managed nonoperatively with fixation of the ulna alone. Displaced radial head fractures with mechanical block can be reduced and secured with countersunk-headed screws or headless compression screws (1.5 to 2.5 mm diameter) in a conical or tripod fashion.
Modern advances with low-profile, fixed-angle locking plates have improved the viability and use of such implants to treat complex radial head and neck fractures.
As a secondary stabilizer to valgus stress in the elbow, modern plating can provide a biomechanical advantage over headless compression screws or nonlocking plates, especially in the setting of a notable head or neck comminution.
Recent studies have reported good clinical outcomes at the short- and mid-term follow-up and a reduction in the historically high hardware removal rates, with placement on the nonarticulating safe zone of the radial head.
Clinical results after different operative treatment methods of radial head and neck fractures: a systematic review and meta-analysis of clinical outcome.
For small fragments (less than 25%), excision of the radial head fracture may also provide acceptable outcomes, especially in elderly cohorts with an intact lateral collateral ligamentous and coronoid.
Fractures of the radial head. A review of eighty-eight cases and analysis of the indications for excision of the radial head and non-operative treatment.
Furthermore, the radial head can displace a considerable distance from its native position, including posterior to capitellum, adjacent to the interosseous membrane distal to the proximal radioulnar joint, and in some cases, medial to the proximal ulna (Figure 4, Figure 5). It is desirable to retrieve these fragments to avoid motion impingement and prevent a nidus for HO.
Figure 4Radial head fracture (arrow) with displacement to the posterior side of the capitellum.
Figure 5Monteggia fracture with ulnohumeral dislocation. A, B Similar to prior report, this variant of Monteggia fractures is associated with severe comminution of metaphysis and coronoid. The patient’s clinical course was complicated by loss of reduction of coronoid and recurrent dislocation. C, D The ulnohumeral stabilization required revision ulna fixation and IJS, with gradual initiation of motion despite the joint stabilizer, due to the concern for subtle instability.
Radial head fractures that cannot be reconstructed secondary to comminution can be addressed with radial head arthroplasty. We found that the comminution of the radial neck, which can be underappreciated, can be a frequent source of nonunion and loss of fixation. When a stable construct is difficult to achieve, arthroplasty provides a reliable option and possibly has a lower reoperation rate in the setting of elbow fracture-dislocation.
Reoperation rates and costs of radial head arthroplasty versus open reduction and internal fixation of radial head and neck fractures: a retrospective database study.
With varus gapping of the joint, there is an inherent tendency to overstuff the radial head prostheses. Although radial head resection has led to satisfactory functional results in some patients, clinical and biomechanical studies demonstrated increased elbow stability and improved kinematics with restoring the proximal radius compared with resection.
The lateral collateral ligament complex, if disrupted, can be repaired to the lateral epicondyle using suture anchors or through a bone tunnel. The tendinous segment of the extensor-supinator mass, confluent with the lateral ulnar collateral ligament, is robust and secured to the bone with number 2 or equivalent-sized nonabsorbable braided suture. Reconstruction with free auto- or allograft is rarely needed, and satisfactory “docking” to the proximal ulna may be challenging in the setting of fracture.
Ulnohumeral instability
Monteggia fractures with ulnohumeral dislocation are generally associated with highly comminuted fracture patterns (Fig. 5).
The restoration of ulnohumeral joint congruency must be rigorously examined after fixation of the proximal ulna and coronoid. In our experience, the lateral collateral ligamentous complex and common extensor tendons can be secured while addressing radial head and neck injuries. If the medial instability persists, a static external fixator can be used to provide stability using the technique described by Rao and Cohen,
with separate lateral incisions for pin placement in the mid-diaphysis of the humerus and ulna. We generally favor a more direct implant stabilization with an internal joint stabilizer (IJS) or transarticular pins rather than an attempt at medial collateral ligament repair.
The discrete medial collateral ligament is difficult to identify in the setting of severe trauma, and there may not be enough osseous integrity of the proximal ulna to allow for robust repair or reconstruction.
The IJS is a recent addition to the surgeon’s armamentarium for addressing ulnohumeral instability. An axial pin is first established through the distal humerus isocentric rotational axis and subsequently connected through a boom and connecting rods to the base plate on the ulna.
In the setting of Monteggia fractures treated with dorsal plates, the placement of the IJS can be challenging with the need for plate overlap. Inadequate soft tissue availability over the olecranon limits robust closure, and the wound should be frequently monitored for possible dehiscence. The plate orientation can be modified with medial or lateral plating along the proximal ulna with the IJS along the dorsal cortex for instability. The plate may be required to be longer to increase the stiffness, given the mechanical disadvantage compared to the dorsal plate.
Revision for persistent ulnohumeral instability and proximal ulna nonunion is particularly problematic. In a small case series of 6 patients reported by Strauss et al,
1 patient with residual instability required a hinged elbow fixator, and 3 patients developed proximal ulna nonunion requiring revision fixation with bone grafting. As a result, a considerable deviation of the treatment strategy and revision surgery are likely, and this unpredictability must be accurately conveyed to the patient.
Historically, the literature routinely combined adult and pediatric injuries with widely varying treatments, including casting, intramedullary rod, and plating. Inadequate reduction and fracture instability of the ulna were common sequelae and resulted in a failure of bone healing, recurrent radiocapitellar dislocation, and subsequent upper extremity disability with poor outcome in greater than 50% of adult patients.
The modern surgical treatment involves restoration of ulnar alignment with indirect reduction of the radial head. Although outcomes vary based on injury severity and the presence of concomitant fractures, prior case series have demonstrated that 60% to 90% of patients should expect to achieve a functional ulnohumeral range of motion after the restoration of normal anatomy.
With the appreciation for the heterogeneity of Monteggia fractures, the literature suggests that injuries with associated radial head or coronoid fractures present challenging fixations and demonstrate poorer clinical outcomes.
examined the correlation between Bado and Jupiter classifications on outcomes in 47 patients at an average follow-up of 8.4 years after open reduction internal fixation. Jupiter type 2A, directly involving the coronoid, had less motion and a poorer outcome. The coronoid and radial head fracture fractures were independently associated with diminished function using the Broberg and Morrey elbow scale.
followed 48 patients at an average follow-up of 6.5 years and described good-to-excellent functional results in 83% of patients. Of the 8 patients with unsatisfactory results, 6 had associated fractures of the radial head, and 4 of those also had fractures of the coronoid. In their experience, the fracture of the coronoid was difficult to reduce in the majority of the patients, and despite the bone healing, the ulnohumeral joint was thought to be unstable with the development of arthrosis.
Subtle incongruity may be present, leading to symptomatic degenerative changes in one-third of the patients, and some of those with advanced osteoarthritis required additional procedures.
The risk of proximal ulna nonunion is increased with comminution and inadequate reduction of the ulna. The incidence of proximal ulnar nonunion reported in the literature ranges from 10% to 18%.
Based on the review of the literature, malreduction of the ulna, fracture comminution, and inadvertent distraction with an external fixator are some of the suspected causes of the nonunion.
The Monteggia fractures with ulnohumeral dislocation are generally associated with extensive comminution of the ulnar metaphysis. Open fracture and extensive soft tissue injury are frequently observed. The nonunion rate in these severe variants of Monteggia fractures can approach 50%.
The treatment of nonunion with bone graft and revision fixation results in reliable healing but should be addressed before progressive deformity develops.
We have encountered extensive devascularization of the metadiaphyseal junction of the proximal ulna, which required the use of the native bone to restore normal anatomy with expected nonunion. Later, a staged reconstruction of the nonunion segment was performed using a free vascularized fibula.
While recurrent radial head dislocation does not comprise the majority of complications, it is consistently reported in the literature.
Most authors directly addressed the source of the radial head dislocation, which includes revision fixation of the ulna, open retrieval of the annular ligament, and fascial loop reconstruction of the annular ligament.
The majority of recurrent radiocapitellar subluxation and dislocation is associated with the loss of bony fixation of the ulna. If a large segmental instability is suspected due to metaphyseal comminution, additional distal fixation (>6 cortical purchase) may be necessary. In chronic posttraumatic dislocations, the correction of ulna deformity alone may not provide a satisfactory reduction of the radiocapitellar joint due to extensive interposed fibrosis. Radial head arthroplasty with shorter radial neck osteotomy may be effective, and in some situations, a simple radial head excision may provide a highly functional elbow.
The biologic cascade of HO or synostosis development commences at the onset of injury and is partly influenced by the surgeon’s decisions. Prior studies have determined independent association with fracture comminution, joint dislocation, burns, and brain injuries.
Furthermore, the traumatic disruption of radial and ulnar periosteum, which results from severe variants of Monteggia fractures, is a known risk factor for synostosis.
The risk of synostosis can be mitigated by avoiding extensive soft tissue dissection and use of separate muscular intervals to address the radius and ulna.
The value of prophylactic treatments, including radiation and nonsteroidal anti-inflammatory drugs, were inconclusive based on level I evidence and meta-analysis.
In summary, the spectrum of injury of Monteggia fractures can vary widely, from a simple proximal ulna fracture with radial head dislocation to a complex fracture pattern with comminution of proximal radius and ulna. The anatomic restoration of the proximal ulna is the primary and most critical portion of surgical reconstruction using a contoured dorsal plating system. The stable ulna construct provides a solid foundation to secure the anterior cortical fragments, including the coronoid. The complexity of Monteggia fractures is influenced by 3 main variables: (1) coronoid fracture, (2) radial head comminution, and (3) ulnohumeral instability. While the collective outcome of Monteggia fractures is favorable, these poor prognostic factors substantially affect the functional outcome and increase the reoperation rate.
Evolution of the ring concept for the forearm and its implication on treatment: from Galeazzi, Monteggia, Essex-Lopresti, and Darrach to the current era.
Clinical results after different operative treatment methods of radial head and neck fractures: a systematic review and meta-analysis of clinical outcome.
Fractures of the radial head. A review of eighty-eight cases and analysis of the indications for excision of the radial head and non-operative treatment.
Reoperation rates and costs of radial head arthroplasty versus open reduction and internal fixation of radial head and neck fractures: a retrospective database study.
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