22 A1.

3(Monteggia fractures)  Less vascular / periosteal compromise and improved axial

compression compared to DCP
Indications
 Monteggia fractures (adults) LCP
Advantage
Contraindications  Good anchorage in osteoporotic bone with less screw loosening
 Soft-tissue conditions Disadvantage
 Noncompliant patient (the radial head needs to be reduced in any  New implant with no long-term follow-up yet
case)  Bulky implant in small forearms
Note
Advantages Cerclage wire and screws alone are not adequate for this fracture type.
 Spontaneous and lasting reduction of radial head Locking compression plates follow a new concept in fracture treatment.
Ring D, Jupiter JB, Simpson NS (1998) Monteggia fractures in Surgical Technique
adults. J Bone Joint Surg Am; 80 (12):1733-44.
 Less risk of secondary radial head dislocation Supine positioning
Note
The restoration of ulnar length is the goal of any treatment of this fracture,
allowing spontaneous reduction of radial head. Open reduction of the radial Place arm abducted in supine position on the operating table
head and repair of the annular ligament are seldom required.
Reduction and retention of the radial head is mandatory with any treatment.
Approach to the ulna
CREF
Indications
 Open fracture of a higher degree (eg, Gustilo 2 & 3)
 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 enlarge
 Rapid procedure
 Inexpensive Skin incision
 Modest risk of infection

Disadvantages The Skin incision is along the subcutaneous border of the ulna, between the
 Pin-track infection olecranon process and the ulnar styloid process.
 Less comfortable
 Does mostly not qualify as definitive treatment: Relative stability
and risk of prolonged healing with need for conversion to ORIF
ORIF
Indications enlarge
 Standard procedure for Monteggia fractures
 Secondary procedure after CREF Dissection

Contraindications
 Critical soft-tissue condition The dissection should be carried out between the flexor carpi ulnaris and the
extensor carpi ulnaris muscles. The internervous plane is between the ulnar
Advantages and posterior interosseous nerves.
 Anatomical reduction and early functional treatment
 Patient’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. enlarge
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).

DCP enlarge
Advantage
 Inexpensive Incision of ulnar periosteum
Disadvantage
 Vascular / periosteal compromise
According to the position and length of the plate, a delicate detachment of
LC-DCP muscles from the periosteum is performed.
Advantage
1 Principles top
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Axial compression is achieved by eccentric drilling. enlarge

Eccentric drilling 3 Reduction of the radial head top

In transverse and short oblique fractures of the diaphysis, placement of a lag
screw is not always possible. However, axial compression with help of the
plate can be achieved. Spontaneous reduction

Usually reduction of the radial head spontaneously follows anatomical

reduction of the ulna (>90%).

Open reduction

In the case of incomplete reduction or persistent luxation (<10%), soft tissue

interposition (joint capsule, annular ligament) has to be suspected and further
investigated.
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Approach to the radial head

Dynamic compression principle

Boyd approach or separate incision by lateral approach to the radial head.

The holes of the plate are shaped like an inclined and transverse cylinder. Like
a ball, the screw head slides down the inclinated cylinder. Since the screw
head is fixed to the bone via the shaft, it can only move vertically relative to
the bone.

The horizontal movement of the head, as it impacts against the angled side of
the hole, results in movement of the bone fragment relative to the plate, and
leads to compression of the fracture.

2 Monteggia lesions: General considerations top enlarge

Stabilization of radial head

The interposed soft tissue structure is reduced and sutured if possible. In cases
of late reconstructions a strip of forearm fascia can be used as a new annular
ligament.
enlarge

In the adult displaced Monteggia lesion, anatomical reduction and stable

fixation are mandatory.

The ulna fracture must be anatomically reduced in order to ensure accurate

reposition of the radial head.

Once operative fixation is achieved, the surgeon must ensure the stability of enlarge
the radial head, preferably under image intensification.

4 Definitive fixation top

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enlarge Insert 1st screw

Instability of the radial head or incomplete reduction usually suggests a The prebent plate is fixed with one screw to one of the main fragments. A
malreduction of the ulna fracture. reduction clamp is placed on the opposite fragment.

enlarge
 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 and

ulna 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
enlarge refracture not to be neglected (1/2).

Insert 2nd screw eccentrically The general guidelines (3) today are:

A second screw is inserted eccentrically (yellow drill sleeve) in the opposite  removal only in symptomatic patients, possibly only on the ulna as
fragment. the ulna is the more exposed bone

 removal not earlier than 2 years after osteosynthesis

 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

enlarge NEUTRALIZATION WITH LAG SCREW

Tighten screw 1 Principle top

By tightening the eccentrically inserted screw, unilateral axial compression is

achieved.

enlarge

Neutralization plate

As a lag screw osteosynthesis on its own is not able to bear weight and
enlarge shearing forces, a protection or neutralization plate has to be added to allow
early mobilization.
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 to
allow the plate to slide on the bone.

All other screws are inserted centrically (green drill sleeve) and do not serve enlarge
to increase compression.
Lag screw
Functional aftercare
Observe the optimal inclination of the screw in relation to a simple fracture
plane.
Because of the dislocation of the radial head, aftertreatment in Monteggia
fractures might differ a little from the usual functional aftercare.
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.
Following stable fixation of the ulna, postoperative treatment might consist in
immobilization in a long cast for 3 weeks (allowing the disrupted ligaments to
heal) with intermittent elbow-mobilization assisted by physiotherapy. The b) shows an inclination half way between the perpendicular axis to the
operated arm is elevated and active mobilization of fingers and wrist is started fracture plane and to the long axis of the bone. This inclination is better suited
within the first week. to resist compressive load along the bone long axis.

X-ray control 2 Insertion of Lag screw top

Postoperatively, after 6 weeks, after 12 weeks and after 1 year.

„Weight-bearing“ (in accordance with radiographic assessment after 6 weeks)

at approximately 8 weeks after surgery.
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Removal of implant
Drill gliding hole If necessary, use bending pliers to contour the plate to fit the anatomy of the
bone (radius).
To insert a 3.5 mm lag screw, a gliding hole is drilled with the 3.5 drill bit as
perpendicular to the fracture line as possible.

enlarge

enlarge

Drill thread
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Insert a drill sleeve and drill the thread in the far cortex with the 2.5 drill bit.
Application of the plate

The plate is applied to the bone with centrically drilled 3.5 cortex screws.

Note that the plate screws do not interact with the previously placed lag
screws.

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Tap the hole

Tap the hole in the cortex with the 3.5 tap (exception: self-drilling screws).

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Insert lag screw

Insert and tighten the first lag screw.

Insert a 2nd lag screw to secure a large wedge fragment in the same manner as
the first screw.

3 Application of 3.5 plate top

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Determining length and contouring of plate

Plate length is determined by the fracture pattern and location. If possible 3

holes proximal and 3 holes distal to the fracture should be used.