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The Journal of Bone and Joint Surgery 80:1733-44 (1998)
© 1998 The Journal of Bone and Joint Surgery, Inc.

Monteggia Fractures in Adults*

DAVID RING, M.D.{dagger}, JESSE B. JUPITER, M.D.{dagger} and N. SHAUN SIMPSON, M.D., F.R.C.S.(I){ddagger}, BOSTON, MASSACHUSETTS

Investigation performed at the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. There were twenty-five women and twenty-three men, and the average age was fifty-two years (range, eighteen to eighty-eight years). According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. The ulna was fixed with a tension band-wire construct supplemented with screws in three patients (all of whom had a Bado type-II fracture). An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. The remaining patients had fixation with a plate and screws. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. At the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done, the average score according to the system of Broberg and Morrey was 86 points (range, 15 to 100 points). The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. Six of the eight patients who had an unsatisfactory (fair or poor) result had had a Bado type-II fracture with a concomitant fracture of the radial head. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patients, a proximal radioulnar synostosis in one, a malunited fracture of the coronoid process and a proximal radioulnar synostosis in one, a malunion of the ulna in one, and painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head in one. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture in one who had had a Bado type-IV fracture. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Fractures of the forearm with dislocation of the proximal radioulnar joint are known as Monteggia fractures2,6,8,47. This eponym is among the most widely recognized by orthopaedic surgeons, largely because of the notoriously poor results associated with the treatment of these injuries, particularly in adults8,39,48. The most recent comprehensive studies of Monteggia fractures in the English-language literature8,39 documented the results of treatment before the routine use of standard compression plates, as developed by the Association for the Study of Internal Fixation (AO/ASIF)32 and others. Furthermore, in most reports, the results of the treatment of Monteggia fractures in children and adults have been presented together2,6,8,45,47. Monteggia fractures in adults are distinct from those in children with regard to the mechanism and patterns of injury, the prognosis, and the preferred method of treatment; therefore, they should be considered separately12,23,34,37,38,41.

We performed this retrospective review of ten consecutive years of experience with Monteggia fractures in adults in order to define better the circumstances and patterns of injury as well as to document the results of treatment with current fixation techniques.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Fifty-one adults who had a fracture of the forearm and dislocation of the proximal radioulnar joint (a Monteggia fracture) were managed at Massachusetts General Hospital between January 1985 and December 1994. No patient who had an anterior (transolecranon) fracture-dislocation of the elbow was included in the present study4,42. The patients were managed by a number of surgeons, and no standard treatment or rehabilitation protocols were used. The results for six patients were presented in an earlier investigation of ulnar fracture patterns in posterior Monteggia fractures23. Three patients, including one who had a posterior dislocation of the radial head (a Bado type-II Monteggia fracture2), one who had a Bado type-II fracture with a concomitant fracture of the radial head, and one who had an anterior dislocation of the radial head (a Bado type-I Monteggia fracture), had been followed for less than twenty-four months and were excluded from the study. The study protocol was reviewed and approved by the Human Subjects Committee.

The medical records and radiographs of all forty-eight patients who had been followed for at least twenty-four months were reviewed. The data for eleven patients, five of whom had died and six of whom could not be contacted, were obtained solely from these records. Additional data were gathered for the other thirty-seven patients. Twenty-two of them returned for an interview, an examination, and radiographs. Eleven were unable to come in for an examination but were contacted by telephone, and eight of the telephone interviews were supplemented by a discussion with the patient's local orthopaedic surgeon. The four remaining patients had died before the time of the most recent follow-up, but additional data on these patients were available from local surgeons who had examined them.

The average age of the twenty-five women and twenty-three men was fifty-two years (range, eighteen to eighty-eight years). Twenty-two right limbs, eighteen of which were dominant, and twenty-six left limbs, one of which was dominant, and twenty-six left limbs, one of which was dominant, were involved. The fractures were classified according to the system of Bado2, which is based on the direction of the dislocation of the radial head; it was anterior (type I) in seven patients, posterior (type II) in thirty-eight, lateral (type III) in one, and associated with a concomitant fracture of the proximal end of the radial shaft (type IV) in two.

Twenty-nine fractures were caused by a fall from a standing height and were considered relatively low-energy injuries. The remaining nineteen fractures were high-energy injuries and were caused by a fall from a height of at least fifteen feet (4.6 meters) (eight fractures); a motor-vehicle accident (four); a crush injury (three); or an explosion, an assault with a baseball bat, a low-velocity gunshot wound, or a motorcycle accident (one each).

Bado Type-I Fractures
The average age of five men and two women who had a Bado type-I fracture was twenty-six years (range, eighteen to forty-one years) (Table I). All of the fractures were high-energy injuries; four patients had associated polytrauma. According to the classification system of Gustilo and Anderson17, four fractures were open type-III injuries; specifically, two were type-IIIA degloving injuries and two were type-IIIC injuries (disruption of the brachial artery). Three of the open injuries were treated with fasciotomy of the forearm because of compartment syndrome. Reconstruction of the soft-tissue envelope was accomplished with split-thickness skin grafts in each patient. One patient had an associated ulnohumeral dislocation, and three patients (including both who had a type-IIIC injury) had an ipsilateral diaphyseal fracture of the humerus representing a so-called floating elbow injury44 (Figs. 1-A and 1-B). Three patients had a nerve palsy; it was radial in one, ulnar in one, and both median and ulnar in one. One patient had a nondisplaced fracture of the radial head, which was treated nonoperatively.


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  		TABLE I COMPARISON OF THE BADO TYPE-I AND TYPE-II MONTEGGIA FRACTURES

 


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  		Figs. 1-A and 1-B: An eighteen-year-old man who sustained a Bado type-I (anterior) Monteggia fracture of the left, nondominant upper extremity in a fall from a scaffolding that was three stories high. Fig. 1-A: Radiograph, made in the trauma room, demonstrating a proximal fracture of the ulnar diaphysis and anterior dislocation of the radial head from the proximal radioulnar joint. The distal end of the humeral diaphysis was also fractured, which makes this a so-called floating elbow injury. Remarkably, there was no wound and no major injury to nerves or blood vessels.

 


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  		Fig. 1-B Radiograph made nine months after both diaphyseal fractures were rigidly fixed with dynamic compression plates; the fractures had healed within three months after the operation. Nine years after the injury, the patient had no pain or instability, normal strength, ulnohumeral motion from 5 degrees short of full extension to 140 degrees of flexion, and 160 degrees of rotation of the forearm evenly distributed between pronation and supination. The score according to the system of Broberg and Morrey7 was 100 points, which is considered an excellent result.

 
The ulnar fracture in all seven patients was fixed with a 3.5-millimeter dynamic compression plate with an average of seven holes (range, six to ten holes). Manipulative reduction and stable restoration of the length and alignment of the ulna were sufficient to achieve reduction in six patients. The remaining patient needed an open reduction of the radial head. The dislocation of the proximal radioulnar joint in this patient was not recognized until eight weeks after the injury. Therefore, open reduction of the radial head with fascial loop reconstruction of the annular ligament3 was performed in addition to the plate fixation of the ulna.

Bado Type-II Fractures
The average age of the twenty-three women and fifteen men who had a Bado type-II fracture was fifty-eight years (range, twenty-seven to eighty-eight years) (Table I). Twenty-nine fractures were the result of a fall from a standing height, and nine were high-energy injuries. The average age of the nine patients who had a high-energy injury was twenty-nine years, and all but one were men. In marked contrast, the twenty-nine patients in whom the fracture was the result of a low-energy mechanism were an average of sixty-seven years old and were predominantly women (twenty-two patients; 76 percent). Four of the patients who had a high-energy injury had associated polytrauma. Six patients had an injury of the ipsilateral upper extremity: there were three distal radial fractures (one was diaphyseal with disruption of the distal radioulnar joint [a so-called Galeazzi fracture39]), one glenohumeral dislocation, one proximal humeral fracture, and one fracture of the humeral diaphysis. Two fractures were open type-I injuries and one was an open type-IIIA injury according to the classification system of Gustilo and Anderson17. Two patients (including the one who had a type-IIIA injury) had a compartment syndrome in the forearm that necessitated fascial release, but none had neural dysfunction or vascular injury.

The Bado type-II fractures were subclassified on the basis of the location of the ulnar fracture according to the system of one of us (J.B.J.) and colleagues23. Ten fractures were at the level of the coronoid process (type A), with most of the coronoid process separated from the proximal aspect of the ulna as a single large fragment (a type-III fracture according to the system of Regan and Morrey40). Twenty-five fractures were through the proximal ulnar metaphysis just distal to the coronoid process (type B), and three were through the diaphysis (type C). All ten of the patients who had a type-A injury had a concomitant fracture of the radial head.

Three ulnar fractures were fixed with a tension bandwire construct combined with interfragmentary screws. An intramedullary Steinmann pin was used for one. The remaining thirty-four fractures were fixed with a plate and screws. Twenty-seven fractures were fixed with a 3.5-millimeter dynamic compression plate (seventeen) or a limited-contact dynamic compression plate (ten); two, a reconstruction plate; four, a semitubular plate; and one, a one-third tubular plate. The plates had an average of eight holes (range, five to eleven holes). Of the three type-C injuries, two were treated with a plate applied to the lateral surface of the ulna and one was fixed with a Steinmann pin. Twenty-eight of the type-A and B fractures, which were more proximal, were treated with a plate applied to the posterior surface of the ulna and the olecranon, and seven were treated with a plate applied to either the medial or the lateral surface of the ulna (Figs. 2-A and 2-B). Nine of the ten type-A fractures were fixed with screws inserted through the posterior plate, and others were used independently.



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  		Figs. 2-A and 2-B: A forty-six-year-old man who sustained a Bado type-II (posterior) Monteggia fracture of the left, nondominant upper extremity when he tripped and fell while working as a contractor. Fig. 2-A: Lateral radiograph, made at the time of presentation in the emergency room, demonstrating a fracture of the proximal ulnar metaphysis distal to the coronoid process with apex posterior angulation and posterior dislocation of the radial head from the proximal radioulnar joint. Note the triangular anterior cortical butterfly fragment of the ulnar fracture and the comminuted fracture of the radial head.

 


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  		Fig. 2-B Lateral radiograph made eight years after fixation of the ulnar fracture with an interfragmentary lag screw and a seven-hole dynamic compression plate applied to the medial surface of the ulna. The fracture of the radial head was fixed with a combination of minifragment screws and small Kirschner wires. The patient had a reoperation three weeks after the index operation to remove a smooth wire that had migrated from the radial head into the elbow articulation. When this radiograph was made, the patient had mild pain with vigorous activities, no instability, normal strength, and full motion of the elbow and forearm. The score according to the system of Broberg and Morrey7 was 93 points, which is considered a good result.

 
Twenty-six patients (68 percent) had an associated fracture of the radial head, which was classified according to the system of Mason29 as type II in seven patients and type III (comminuted) in nineteen. Five of the seven Mason type-II fractures were small marginal fragments; these were not treated in three patients and were excised in two. The remaining two Mason type-II fractures were repaired with screws. Ten of the Mason type-III fractures were treated with excision of the radial head; two heads were replaced with a silicone prosthesis. Eight of the Mason type-III fractures were treated with open reduction and internal fixation with a plate, screws, wires, or a combination of these devices, and the remaining Mason type-III fracture was not addressed during the initial operation.

Bado Type-III and IV Fractures
The patient who had a Bado type-III fracture was a thirty-four-year-old man. The fracture, which was the result of a low-velocity gunshot wound, was treated with irrigation, débridement, and fixation with a dynamic compression plate.

The two men who had a Bado type-IV fracture were twenty and forty-three years old. The cause of the fracture was a fall from a height and a motor-vehicle accident, respectively. Both patients had associated polytrauma, and one also had a radial nerve palsy. The fractures were treated with stable anatomical fixation of both bones of the forearm with 3.5-millimeter dynamic compression plates.

Postoperative Treatment
The postoperative regimen varied. Only two patients were managed with immobilization of the limb for more than four weeks. One had had fixation with a Steinmann pin, and the other had had a Bado type-II fracture that displaced after the plate, which had been applied to the lateral surface of the ulna, loosened. The former patient wore the cast for six weeks, and the latter patient, for ten weeks. Most of the patients had initiated gentle active mobilization of the ulnohumeral and radioulnar joints either before or immediately after removal of the sutures (usually within fourteen days after the operation).

Subsequent Treatment
Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the index operation. The ulnar fixation device loosened and the fracture became malaligned in six patients; in five of these patients the original plate had been applied to the medial or lateral surface of the proximal aspect of the ulna and the olecranon, and the remaining patient had loosening of a tension band-wire and lag-screw construct. The fixation devise loosened in both the proximal and the distal fragment in two patients and in only the proximal fragment in four. One limb healed in malalignment during immobilization in a cast. The fixation was revised in five patients; four had a posterior plate applied, and one had the medial plate reapplied so that it wrapped around the olecranon process proximally. In this latter patient, a residual apex posterior deformity of the ulna was accepted. In three patients who had a Mason type-III fracture of the radial head, a secondary resection of the radial head was performed. This was done in order to address combined loosening of the fixation device and restricted rotation of the forearm due to prominence of the implant in two patients and in order to address a fracture of the radial head in a patient in whom it had not been treated at the time of the index operation. One patient needed a reoperation three weeks after the index procedure to remove a wire that had migrated out of the radial head and into the elbow articulation (Figs. 2-A and 2-B).

Assessment
The overall result at the most recent follow-up examination was graded according to the system of Broberg and Morrey7. With this system, a score of 95 to 100 points is considered excellent; a score of 80 to 95 points, good; a score of 60 to 80 points, fair; and a score of less than 60 points, poor. A good or excellent result is considered satisfactory and a fair or poor result, unsatisfactory. The most recent radiographs were analyzed to assess healing, problems related to the hardware, and osteoarthrosis.

Statistical Analysis
Statistical comparison of dichotomous variables was performed with the Fisher exact test (Number Cruncher Statistical System, version 5.3; Dr. Jerry L. Hintze, Kaysville, Utah). Multiple logistic regression analysis was performed with BMDP Statistical Software (Los Angeles, California) in an attempt to account for confounding among factors important in the outcome of Bado type-II fractures. The independent variables were age, gender, the energy of the injury, associated fracture of the coronoid process, and associated fracture of the radial head.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The average duration of follow-up was 6.5 years (range, two to fourteen years). There were several complications in addition to the early reoperations in nine patients. One patient had persistent instability of the ulnohumeral joint, which was believed in retrospect to be due to a combination of posterolateral rotatory instability resulting from the damage to the lateral collateral ligament complex that may occur as the radial head dislocates posteriorly9,22,23,35 and residual malalignment of the coronoid process. This patient was managed with immobilization in a cast for four weeks followed by gradual, restricted mobilization in a brace.

A proximal radioulnar synostosis developed in three patients, one of whom had a Bado type-IV fracture and two of whom had a Bado type-II fracture with an associated fracture of both the coronoid process and the radial head. All three of these patients had sustained a high-energy injury and had polytrauma; one had a closed head injury (Figs. 3-A, 3-B, and 3-C). The patient who had the Bado type-IV fracture had successful operative resection of the synostosis eleven months after the injury. The result for this patient improved from poor to good. The other two patients declined additional operative treatment.



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  		Figs. 3-A, 3-B, and 3-C: A forty-six-year-old man who sustained a Bado type-II fracture of the right, dominant upper extremity in a fall from the roof of a two-story house. Fig. 3-A: Lateral radiograph, made at the time of presentation in the emergency room, demonstrating a fracture of the proximal end of the ulna at the level of the coronoid with apex posterior angulation. The coronoid process fractured as a single large fragment. There is also a comminuted fracture of the radial head. In addition to these injuries, the patient had an ipsilateral glenohumeral dislocation with an associated injury of the brachial plexus, a fracture of the contralateral radial head, and a closed head injury.

 


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  		Fig. 3-B Lateral radiograph made immediately after the index operation, which consisted of excision of the fragments of the radial head and fixation of the ulnar fracture with a plate applied to the posterior surface. The fracture of the coronoid process was fixed with interfragmentary screws that passed through the plate. This radiograph demonstrates residual malalignment of the coronoid process and ulnohumeral instability. In retrospect, it was believed that the ulnohumeral instability was related to a combination of the posterolateral ligamentous injury that occurred when the radial head dislocated posteriorly (posterolateral rotatory instability) and the residual malalignment of the coronoid process. The upper extremity was immobilized in a cast for four weeks after the ulnohumeral reduction, and a hinged brace was worn for four additional weeks after the cast was removed.

 


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  		Fig. 3-C Lateral radiograph, made seven years after the injury, demonstrating a proximal radioulnar synostosis and osteoarthrosis of the ulnohumeral joint. In addition, the radiocapitellar joint is malaligned, indicating residual deformity of the ulna. The patient had severe disabling pain, severe weakness, moderate instability, no rotation of the forearm, and ulnohumeral motion from 25 to 90 degrees. The score according to the system of Broberg and Morrey7 was 15 points, which is considered a poor result.

 
The patient who had a Bado type-II fracture proximally and a Galeazzi fracture distally had persistent instability of the distal radioulnar joint, which was treated with open reduction and internal fixation of a nonunion of the ulnar styloid process.

The patient who had fixation of a Bado type-II ulnar diaphyseal fracture with an intramedullary Steinmann pin had a delayed union. When the pin was removed six months postoperatively, the fracture had not healed and the apex posterior deformity recurred. The fracture subsequently healed with immobilization in a cast. This patient had substantially restricted rotation of the forearm and a poor result at the latest follow-up examination.

One patient had a transient incomplete ulnar neuropathy postoperatively. The fracture of the radial neck associated with a Bado type-I fracture took more than eight months to heal. In another patient, the most proximal portion of a semitubular plate, which had been somewhat prominent, was noted to have broken on radiographs made twelve years postoperatively; this was asymptomatic and inconsequential. Six patients had elective removal of the ulnar plate, but no late problems related to the hardware were encountered. None of the neural injuries that occurred at the time of the fracture resolved, and all of the involved patients had a subsequent reconstructive tendon transfer.

The average score overall according to the scale of Broberg and Morrey7 was 86 points (range, 15 to 100 points) at the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done. Eighteen patients had an excellent result, twenty-two had a good result, two had a fair result, and six had a poor result. Twenty-six patients had no pain, fifteen had mild pain, six had moderate pain, and one had severe pain. Only one patient had symptoms referable to persistent instability. Strength was diminished in seven patients. Flexion averaged 128 degrees (range, 90 to 150 degrees); extension, -16 degrees (range, -45 to 0 degrees); pronation, 65 degrees (range, 0 to 80 degrees); and supination, 63 degrees (range, 0 to 80 degrees). Only ten patients had less than 100 degrees of ulnohumeral motion. All eight of the patients who had a fair or poor result had restricted ulnohumeral motion. Only seven patients, all but one of whom had had a fracture of the radial head, had less than 100 degrees of rotation of the forearm. The restriction was due to a proximal radioulnar synostosis in two patients, an enlarged and misshapen radial head after operative repair in three patients (Figs. 4-A and 4-B), an ulnar malunion in one patient, and scarring from extensive soft-tissue injury in the patient who did not have a fracture of the radial head.



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  		Figs. 4-A and 4-B: A sixty-two-year-old man who sustained a Bado type-II fracture of the left, nondominant upper extremity in a fall while he was walking. The initial radiographs (not shown) resembled Fig. 3-A. The ulnar fracture was fixed with a posteriorly applied limited-contact dynamic compression plate with an interfragmentary screw to secure the coronoid process. The fracture of the radial head was reduced and was fixed with two screws. Lateral (Fig. 4-A) and anteroposterior (Fig. 4-B) radiographs, made four years after the injury, demonstrating anatomical reduction of the ulnar fracture, with restoration of the normal contour and dimensions of the trochlear notch. There is no evidence of osteoarthrosis. However, the radial head is enlarged and misshapen. The patient had no pain, instability, or weakness and was very pleased with the function of the upper extremity despite the fact that he had only 20 degrees of pronation and 30 degrees of supination. Ulnohumeral motion was from 15 to 125 degrees, and the score according to the system of Broberg and Morrey7 was 85 points, which is considered a good result. The patient was not interested in additional operative intervention to address the limited rotation of the forearm.

 

Bado Type-I, III, and IV Fractures
Only one patient who had a Bado type-I fracture had an unsatisfactory result, which was related to severe soft-tissue injury (including disruption of the brachial artery) and permanent neural damage. Of the six remaining patients, three had an excellent result and three had a good result. The seven patients who had a Bado type-I injury had an average of 115 degrees (range, 80 to 140 degrees) to ulnohumeral motion and 135 degrees (range, 40 to 160 degrees) of rotation of the forearm. The average score according to the system of Broberg and Morrey7 was 90 points (range, 53 to 100 points).

The patient who had a Bado type-III fracture had 120 degrees of ulnohumeral motion, 120 degrees of rotation of the forearm, and a score of 100 points.

The two patients who had a Bado type-IV fracture both initially had an unsatisfactory result. The result for one of these patients improved to good following successful resection of a proximal radioulnar synostosis. This patient had 125 degrees of ulnohumeral motion, 140 degrees of rotation of the forearm, and a score of 93 points at the latest follow-up examination. The patient who had a fair result had 90 degrees of ulnohumeral motion, 80 degrees of rotation of the forearm, and a score 79 points.

Bado Type-II Fractures
Fourteen of the patients who had a Bado type-II fracture had an excellent result, eighteen had a good result, one had a fair result, and five had a poor result. They had an average of 112 degrees (range, 65 to 140 degrees) of ulnohumeral motion and 126 degrees (range, 0 to 160 degrees) of rotation of the forearm. The average score was 85 points (range, 15 to 100 points).

All of the patients who had an unsatisfactory result had had a fracture of the radial head. Four of these patients also had a fracture of the coronoid process. A proximal radioulnar synostosis developed in two of the patients who had a fracture of the coronoid process. In one of these patients and in two others, the fracture of the coronoid process was not anatomically reduced. Although the coronoid process healed in all three patients, the elbow remained somewhat unstable and painful osteoarthrosis developed (Figs. 3-A, 3-B, and 3-C). Of the two unsatisfactory results that were not associated with a fracture of the coronoid process, one was due to residual ulnar malunion after fixation with a Steinmann pin and the other was due to painfully restricted rotation of the forearm after open reduction and internal fixation of a comminuted fracture of the radial head. In the latter patient, prominence of the implant used to fix the radial head was thought to be at least partially responsible for the painful restriction.

Among the patients who had a Bado type-II fracture, those who had a fracture of the radial head were more likely to have an unsatisfactory result than those who did not have a fracture of the radial head (six [23 percent] of the twenty-six patients who had a fracture of the radial head had an unsatisfactory result compared with zero of the twelve who did not); however, with the number of patients available, we could not detect a significant difference between the two groups according to the Fisher exact test (p = 0.15). In contrast, the prevalence of unsatisfactory results for the patients who had a fracture of the coronoid process was significantly higher than the prevalence for those who did not have a fracture of the coronoid process (four of ten compared with two [7 percent] of twenty-eight; p = 0.03). Multiple logistic regression analysis was unable to account for the confounding between fractures of the radial head and those of the coronoid process because of the limited number of patients who had a fracture of the coronoid process as well as the fact that every patient who had a fracture of the coronoid process also had a fracture of the radial head.

Ulnohumeral Osteoarthrosis
Radiographs of the elbow, made five years or more after the injury, were available for twenty-three patients: four who had had a Bado type-I fracture and nineteen who had had a Bado type-II fracture (six of whom also had a fracture of the radial head). The average interval between the injury and the most recent radiographic examination was nine years (range, five to fourteen years). The radiographs were evaluated for the presence of osteoarthrosis according to the rating system of Broberg and Morrey7. Only one patient had evidence of osteoarthrosis. This patient, who had had a Bado type-II fracture as well as a fracture of the radial head, had grade-II changes related to a malunion of the coronoid process (Figs. 3-A, 3-B, and 3-C). Two patients who had been followed radiographically for less than five years had grade-I changes; these were also related to a malunion of the coronoid process, as documented four years postoperatively.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Effective treatment of Monteggia fractures in adults is notoriously challenging. Near the middle of this century, Watson-Jones noted serious permanent disability in thirty-two of thirty-four consecutive adult patients who had been managed for a Monteggia fracture48. Bruce et al., in 1974, noted a fair or poor result in sixteen (76 percent) of twenty-one adults who had had treatment of a Monteggia fracture 8. In one of the most recent studies published in the English-language literature, in 1982, Reckling documented a fair or poor result in thirteen of nineteen adults who had had a Bado type-I fracture and a fair result in all five adults who had had a Bado type-II fracture39. However, all of these series were evaluated before the wide application of the stable plate-fixation techniques that were developed by the Association for the Study of Internal Fixation (AO/ASIF)32 and others.

In our series of Monteggia fractures in adults, Bado type-II fractures (posterior dislocation of the radial head) were more common than Bado type-I fractures (anterior dislocation of the radial head) by a ratio of 5.4 to one. Near the middle of this century, Penrose38 as well as Pavel et al.37 noted the predominance of what are now classified as Bado type-II fractures in adult patients; however, this distribution of injury patterns has not been observed in all studies. In some series, this may have been the result of the inclusion of fractures in both children and adults8,45,47 as Bado type-I injuries are more common, and type-II fractures are rare, in children41. In other studies, there may have been a failure to recognize many proximal Bado type-II injuries (for example, those that involved the coronoid process) as Monteggia fractures23,37,38.

While the 83 percent rate of satisfactory results in the present study illustrates the benefits of anatomical reduction and stable fixation with a plate in that it allows early active mobilization, it should be noted that these results were obtained after a number of reoperations or, in some patients, after reconstructive procedures. There is room for improvement, particularly with regard to the treatment of Bado type-II fractures. If the results of the index operations before any reconstructive procedures are considered, and if a reoperation within three or four months postoperatively is regarded as an unsatisfactory result, then sixteen (33 percent) of the forty-eight patients overall and thirteen (50 percent) of the twenty-six patients who had a Bado type-II fracture with a concomitant fracture of the radial head had an unsatisfactory result. Most of the difficulties encountered were related to operative fixation of a very proximal ulnar fracture, a comminuted fracture of the radial head, or a fracture of the coronoid process.

Only three of the Bado type-II fractures were diaphyseal. In most Bado type-II Monteggia fractures, which are most common among elderly women, the proximal fragment is small, metaphyseal, and osteopenic. The challenge is to obtain stable fixation without violating the trochlear notch with screws of excessive length. Six patients in the present study had early failure of the ulnar fixation; this group included five of the seven patients who had a plate applied to the medial or lateral (rather than the posterior) surface of the ulna and one of the three patients who had fixation with a tension band-wire construct. Since posterior tensile forces are encountered at the apex of the proximal end of the ulna with active motion, a plate applied to the lateral or medial surface of the ulna is less mechanically effective than a plate applied to the posterior surface of the ulna, which functions as a tension band32. We recommend fixation of the ulnar fracture with a stout plate, such as a 3.5-millimeter limited-contact dynamic compression plate (Synthes, Paoli, Pennsylvania), applied to the posterior surface of the ulna and contoured proximally to reach the tip of the olecranon; semitubular and one-third tubular plates and tension band-wire constructs may not be rigid or strong enough. The proximal contour makes it possible to put more screws in the proximal fragment, and the most proximal screws will be oriented at 90 degrees to the more distal screws, creating a more stable construct (Figs. 4-A and 4-B).

Nineteen (73 percent) of the twenty-six fractures of the radial head associated with a Bado type-II fracture were comminuted (Mason29 type III). Good results have been reported following open reduction and internal fixation of fractures of the radial head, but most of these fractures were simple (Mason type II)11,16,25. The results after repair of Mason type-III fractures have been less predictable11,16,25. Hotchkiss recently modified Mason's classification to reflect the difficulties associated with repair of comminuted fractures of the radial head20,21. Hotchkiss type-II fractures include two-part and more comminuted fractures that are amenable to operative fixation. Hotchkiss type-III fractures are those that, because of excessive comminution, cannot be repaired easily; excision with or without prosthetic replacement should be considered for such fractures20,21. Three of the eight patients in the present study who had had operative repair of a Mason type-III fracture had restricted rotation of the forearm postoperatively because the radial head was enlarged and misshapen. In one patient, prominence of the implant may have contributed to the painfully restricted motion. Two other patients had early secondary resection of the radial head to address a combination of loosening of the fixation and restricted rotation of the forearm due to prominence of the implant. Finally, one patient needed an early reoperation to remove a wire that had migrated from the radial head into the proximal radioulnar joint. Overall, six of the eight patients who had operative repair of a Mason type-III fracture had a complication. If a fracture of the radial head is fixed operatively, it is imperative that no prominent implant be placed on the articular surface of the radial head46.

The question remains as to whether it is better to treat a severely comminuted fracture of the radial head associated with a Bado type-II fracture with simple excision or with prosthetic replacement. Ten of our twelve patients who had resection of the radial head without prosthetic replacement had a satisfactory result. The data in our series are insufficient to determine if use of a prosthetic radial head is indicated for injuries associated with ulnohumeral instability as a result of either a fracture of the coronoid process or posterolateral rotatory instability due to injury of the lateral collateral ligament complex. Preservation of radiocapitellar contact with a prosthesis might increase the stability of the ulnohumeral articulation in this setting1,18,27,31,43. The only patients in the present study who had pain in the wrist were those who had had a concomitant injury of the wrist. With regard to persistent ulnohumeral instability after operative fixation of the ulna, which occurred in one patient in the present study, if malalignment of the coronoid process and residual flexion deformity through the ulnar fracture have been addressed and if pronation of the forearm does not restore stability28, repair of the lateral collateral ligament complex should be considered33,35,43.

The findings of the present investigation reemphasize the fact that, regardless of the pattern of injury, large fractures of the coronoid process must be anatomically reduced40,42. Stable anatomical reduction was obtained in seven of ten patients in our study who had such a fracture. Osteoarthrosis developed in three patients who had a malunion of the coronoid process, and all three had an unsatisfactory result. One of the patients who had an anatomical reduction had a poor result because of a proximal radioulnar synostosis. All six of the remaining patients who had a stable anatomical reduction of the coronoid process had a satisfactory result. Anatomical reduction and stable fixation of a fracture of the coronoid process can be difficult to achieve. In the setting of a Bado type-II fracture, it may be possible to manipulate the coronoid process and to visualize its reduction directly by hinging the ulnar fracture open19. Alternatively, reduction is often facilitated indirectly with the use of distractor30,42. Another option is to carry the dissection anteriorly to expose the coronoid process. This can be done through the posterior skin incision either laterally, through the interval used to expose a fracture of the radial head, or medially, by elevating a broad, full-thickness medial skin flap and mobilizing the ulnar nerve anteriorly into the subcutaneous tissues10,36. The coronoid process is then exposed by elevating the ulnar origin of the flexor carpi ulnaris anteriorly36. Stable fixation of the coronoid process is achieved with interfragmentary compression screws inserted through the posterior surface of the ulna either through or adjacent to the plate23,30,32,41.

A posttraumatic proximal radioulnar synostosis developed in three patients in the present study. This disabling complication led to a poor result in all three patients, although the result was upgraded to good in one patient after successful resection of the synostosis24. All three of these patients had fractures of the proximal aspects of the radius and ulna and a high-energy mechanism of injury; one also had a closed head injury. Recommendations for limiting the risk of synostosis include the avoidance of simultaneous exposure of both bones (such as with the Boyd exposure5) and the encouragement of early active mobilization. Each bone should be approached through a separate muscular interval. For instance, the ulna can be approached directly subcutaneously between the anconeus and the extensor carpi ulnaris laterally and the flexor carpi ulnaris medially, and the radial head can be exposed between the anconeus and the extensor carpi ulnaris. A single midline longitudinal skin incision can be used, and access to each interval can be achieved through the elevation of skin flaps10,36. Because of the increased risk of heterotopic ossification after a head injury13-15, prophylaxis with indomethacin or another nonsteroidal anti-inflammatory medication may be considered for patients who have such an injury if it can be safely initiated within a week after the injury26.

Bado type-I, III, and IV fractures in adults tend to be the result of high-energy trauma, unlike those in children, which tend to be the result of a fall from playground equipment41. In particular, five of the seven Bado type-I fractures in the present study were associated with either a so-called floating elbow injury44 or a massive soft-tissue injury; two of the five were associated with disruption of the brachial artery. Despite the severity of these injuries, the results are usually good provided that stable anatomical fixation of both bones of the forearm is achieved.

With the use of current plate-fixation techniques, complications due to axial malalignment of the ulna are uncommon; most problems occur near the elbow. Only three patients in the present study had substantial residual malalignment of the ulna, and only one of them had an unsatisfactory result. In contrast, problems near the elbow led to an unsatisfactory result in five patients, all of whom had had a Bado type-II fracture; two patients had malunion of the coronoid process that led to osteoarthrosis of the ulnohumeral joint, one had a proximal radioulnar synostosis and malunion of the coronoid process that led to osteoarthrosis, one had a proximal radioulnar synostosis, and one had painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head. This finding emphasizes the transitional nature of the Bado type-II fracture, which often represents a combined injury of the elbow and the forearm.

The key to a good result of the treatment of a Monteggia fracture is prompt recognition of the injury pattern as well as anatomical reduction of the ulna, including restoration of the normal contour and dimensions of the trochlear notch. Current plate-fixation techniques have improved the ability to achieve these goals. Attention must be paid to appropriate treatment of associated injuries at the level of the elbow, including fractures of the coronoid process and the radial head as well as posterolateral rotatory instability of the ulnohumeral articulation.


   Footnotes
 
*Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was AO North America, Paoli, Pennsylvania.

{dagger}Department of Orthopaedic Surgery, Massachusetts General Hospital, ACC 527, 15 Parkman Street, Boston, Massachusetts 02114.

{ddagger}72 Highlands Road, Derry, Northern Ireland, United Kingdom.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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