Monteggia Fracture Treatment & Management

Updated: Nov 13, 2018
  • Author: Floriano Putigna, DO, FAAEM; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
  • Print
Treatment

Approach Considerations

Pain should be managed as needed in the immediate period. If the fracture is open, the status of the patient's tetanus immunization should be determined and addressed as indicated. Intravenous (IV) antibiotics should be administered to patients with open fractures. Open wounds should be irrigated with sterile saline solution and dressed with sterile, moist gauze. The radial head should be reduced in the emergency department (ED) if possible.

Pediatric patients should undergo emergency closed reduction and splint application. Closed reduction in children is easiest when performed with procedural sedation or general anesthesia. Ketamine 1-2 mg/kg IV or 3-4 mg/kg intramuscularly (IM) is a very useful drug for sedation. An image intensifier should be available with real-time and static images to verify anatomic reduction of the fracture and congruent relationship of the radiohumeroulnar joint. The position of the elbow when immobilized depends on the fracture pattern, as described earlier.

Nonoperative treatment is successful for most Monteggia injuries in children, for the following reasons [16] :

  • The majority of the fractures are inherently stable
  • Children require a shorter time for both the osseous and the ligamentous injuries to heal
  • Children have little trouble regaining motion lost through stiffness, despite immobilization of the fractures for the duration of the initial healing period (3-6 weeks)
  • The potential may exist for remodeling of mild residual angular deformities (< 10°)

Indications for treatment of Monteggia fractures are based on the specific fracture pattern and the age of the patient (ie, pediatric or adult). [17, 18]  Although most pediatric fracture patterns can be managed conservatively with closed reduction and long arm casting, most adult fractures require open reduction and internal fixation (ORIF). Few contraindications for surgery exist. Once the radial head is reduced in closed injuries, surgical treatment may be delayed until the patient is stable and the surgery may be performed in a more elective fashion.

Closed reduction of the radial head dislocation under sedation should be performed on an emergency basis within 6-8 hours of the injury. This is usually achieved with supination of the forearm, but it may require traction and direct pressure on the radial head. If closed reduction is unsuccessful, the patient should be taken to the operating room (OR) within this same time frame for open reduction. Delay in reduction of the radius may lead to permanent articular damage, further nerve injury, or both.

The stability of the reduction depends on the fracture pattern. Greenstick fractures have plastic deformation that may resist maintenance of reduction and necessitate completion of the fracture to keep the radial head reduced. However, completing the fracture may make it more difficult to maintain rotational alignment of the ulna. This difficulty can be alleviated with appropriate reduction techniques. Greenstick proximal ulna fractures require appropriate reduction using supination in addition to flexion and extension maneuvers. [19]   

An open fracture requires immediate operative intervention. In closed injuries, once the radial head is reduced, the forearm is splinted, and operative fixation of the ulna fracture may then be carried out electively. Whereas adults usually require operative internal fixation to stabilize the ulna and prevent further displacement forces on the radiocapitellar joint, children with closed Monteggia fractures are generally treated in a closed fashion. A posterior long arm splint with the elbow in 90° of flexion and full supination is the immobilization method of choice for types I, III, and IV. Type II injuries (posterior lesions) are best splinted in 70° elbow flexion with supination.

If the wound is open and heavily contaminated, serial debridement may be indicated before plate fixation. In medically unstable patients, emergency treatment of the open wound is still necessary. The procedure can be limited to irrigation and debridement of the open wound and closed reduction at the bedside, performed with regional anesthesia or, if absolutely necessary, with local anesthesia and sedation. If the patient is unable to tolerate operative treatment, the fracture-dislocation may be treated with cast immobilization after reduction of the radius and irrigation and debridement if the fracture is open.

Future research will help identify appropriate treatment protocols for achieving optimum long-term outcomes. The most important step is to educate the specialist, emergency physician, and primary care physician regarding correct diagnosis and treatment of these injuries.

Next:

Surgical Therapy

Open fractures require emergency surgical consultation. The initial treating physician may reduce the radial head dislocation and splint this fracture. Otherwise, an orthopedic surgeon should be consulted immediately to reduce the radial head. Anatomic reduction of the ulna is usually required before radial head reduction. Unless the fracture is open, surgical treatment is performed on an elective basis. Whereas most adults require operative treatment, most pediatric fractures are treated with closed reduction.

Operative fixation of complete fractures of the ulna with proximal radioulnar joint (PRUJ) dislocation is recommended in children. The complete disruption of bone continuity is likely to be associated with substantial soft-tissue trauma in these injuries. Shortening and angulation of complete fractures after cast immobilization is not uncommon. Anatomic reduction of the ulnar fracture and radial head often requires operative treatment.

In the past, transverse and short oblique fractures were adequately treated with intramedullary wire fixation. Intramedullary wires, however, cannot be relied on to maintain reduction of complete fractures that are either long oblique in pattern or comminuted; the wires therefore are not used anymore. These fractures are likely to displace or even shorten; consequently, they should be fixed with a plate and screws.

As a result of the rapidity of osseous repair and the tolerance of cast immobilization in children, the use of plate-and-screw constructs that are smaller (typically a one-third tubular or semitubular plate) and shorter (two or three holes [four or six cortices] proximal and distal to the fracture) than those recommended for adults are usually adequate.

Operative details

Patients with fracture-dislocations of the forearm should initially be stabilized if more serious injuries are present. Adequate pain control should be provided in the preoperative period, and the affected arm should be placed in a long arm splint to reduce further injury and pain.

After adequate analgesia and sedation, a closed reduction of the radial head can be performed with distal traction and direct pressure over the radial head. This can be done in the ED or in the OR. An open technique should be considered if the radius is fractured or irreducible.

Once the radius has been reduced, the ulnar fracture is addressed with rigid internal fixation. In adult Monteggia fracture, fixation with a 3.5-mm dynamic compression (DC) plate or a limited contact–dynamic compression (LC-DC) plate is recommended. If the fracture is comminuted, purchase should be obtained, if possible, with three or four screws (six or eight cortices) proximal and distal to the fracture.

Once the ulna is stabilized, the stability of the radial head is assessed by means of intraoperative fluoroscopy. Permanent radiographs should be taken, and a posterior long arm splint should be placed with the elbow immobilized in 90° of flexion and full supination for types I, III, and IV. Type II is best splinted in the same manner, but in 70° flexion at the elbow to prevent radial head subluxation.

If the radial head cannot be reduced, the reduction and alignment of the ulna should be checked. If the radial head is unstable after ulnar fixation, then the elbow should be splinted in supination, which is the position of stability.

If the radial head remains unstable despite confirming anatomic reduction of the ulna surgical repair of the annular ligament and lateral ligaments should be considered.  Chronic radial head dislocation may require surgical reconstruction of the annular ligament. [20]

Previous
Next:

Postoperative Care

Follow-up appointments are scheduled for wound checks and suture removal according to the nature of the soft-tissue injury and operative treatment. If rigid fixation is achieved and the radiocapitellar joint remains stable, the patient is referred to begin range-of-motion (ROM) exercises under the close supervision of a qualified physical therapist.

Patients with stable injuries may be placed in ROM braces for 6-8 weeks. Unstable injuries should remain in cast immobilization until stability is achieved at 4-6 weeks.

Significant concern exists regarding loss of elbow motion with prolonged immobilization. Chronic radiocapitellar instability is unusual and may be addressed surgically.

Previous
Next:

Complications

Complications can be divided into two broad categories: acute and chronic. Acute complications include the following:

  • Bleeding
  • Nerve damage
  • Swelling
  • Compartment syndrome
  • Loss of initial reduction
  • Failure to diagnose the correct pathology

Chronic complications include the following:

  • Malunion
  • Nonunion
  • Radioulnar synostosis
  • Elbow stiffness
  • Myositis ossificans
  • Infection
  • Chronic pain

Many of the complications listed are significantly reduced with timely diagnosis, adequate reduction, stable surgical fixation, and appropriate postoperative care.

Most nerve injuries are neurapraxias of the radial and median nerves, and function usually returns within 1-6 months. Baseline electrodiagnostic studies are obtained early. If nerve function does not return within 2-3 months, surgical exploration may be indicated. If the nerve injury results from reduction or operative treatment, it should be addressed immediately. Prolonged or complete nerve dysfunction requires early splinting and therapy and may result in the need for tendon transfers.

Li et al conducted a study of the pathology of posterior interosseous nerve injury associated with Monteggia fracture-dislocation in children. [21] For all eight patients, closed reduction was attempted before exploration of the posterior interosseous nerve. The nerve was found to be trapped acutely posterior to the radiocapitellar joint in four of five patients with Bado type III Monteggia fractures. In the remaining patients, chronic compressive changes and epineural fibrosis of radial nerve were observed, related to the time between injury and operation.

After microsurgical neurolysis, complete recovery of nerve function was obtained for all eight patients. [21] The authors concluded that immediate surgical exploration of the posterior interosseous nerve should be performed for all children with Bado type III Monteggia fracture-dislocation in whom there is decreased or absent function of muscles innervated by the posterior interosseous nerve in the presence of an irreducible radial head.

If the radial head dislocates after surgery, improper ulnar reduction must be considered. If this is the case, the hardware should be removed and a proper reduction of the ulna should take place. If dislocation of the radial head is recognized more than 6 weeks after the surgery, a radial head excision should be performed. Treatment of chronic radial head dislocation in children with Monteggia fracture has been controversial, but some suggest that surgical treatment may be warranted. [22, 23]

In the case of nonunion or malunion, bone grafting and revision internal fixation may be considered.

Chronic pain may be the result of hardware or improper reduction. If all mechanical causes have been excluded, consulting a pain management specialist should be considered.

Previous
Next:

Long-Term Monitoring

The patient should be evaluated at 5-7 days. If nonsurgical management has been employed, consideration should be given to leaving the splint or cast on and overwrapping to avoid loss of reduction by removing the immobilization. Follow-up radiography at 2, 4, and 6 weeks and then every 3 months thereafter is recommended to monitor healing and union of the fracture.

The average duration of casting is 6 weeks for pediatric patients and 8-12 weeks for adults. A posterior long arm cast in 90-110° flexion and supination should be used to maintain reduction based on fracture type. If surgery was performed, a wound check is necessary, with suture removal 5-7 days after the operative procedure. Surgical repair should allow for a shorter period of cast immobilization and early ROM in a brace, beginning 2-4 weeks after the procedure.

In pediatric patients, hardware removal commonly takes place 6-12 months after healing to prevent growth disturbance. In adults, hardware removal is optional; it may be considered in cases of pain, infection, or malunion/nonunion. For this reason, these patients should be followed for at least 1 year. [24]

Previous