How to approach Monteggia-like lesions in adults: A review

Abstract

Monteggia-like lesions encompass a wide spectrum of fractures of the forearm and elbow associated with dislocations, subluxations and ligamentous lesions. Many attempts have been made to classify these injuries, not only to understand their pathology but also to develop optimal treatments. Unfortunately, although some of these classifications are complete, they are either complex, not immediately usable, or not exhaustive. An orthopedic surgeon who aims to rapidly treat this kind of injury needs a visual classification, and knowledge of the best surgical approach. Monteggia like lesions do not allow for mistakes during surgery, as even a minor error could be prove detrimental to performing and completing all surgical steps. In this paper, based on our extensive experience in treating these rare lesions, we suggest a practical guide to the best surgical approach for various types of Monteggia like lesions. Some technical tips and pitfalls are also described.

Keywords: Monteggia like lesions; Surgical approach; Tips.

Fig. 1

Draft of the Taylor-Sham approach (Courtesy of Istituti Ortopedici Rizzoli - Bologna, Italy).

Fig. 2

a) Pre-operative radiography and CT scan: simple fracture of the proximal ulna and comminuted fracture of the radial head in osteoporotic bone in a 74- year-old woman. b) Post-operative radiography: global posterior approach and subcutaneous Kocher approach– Pre-contoured locking plate and cemented radial head prosthesis.

Fig. 3

a) Pre-operative radiography and CT scan: fracture of the proximal ulna and coronoid fracture (large fragment); comminuted fracture of radial head in a 66-year old woman. b) Post-operative radiography: global posterior approach and subcutaneous Kocher approach – Free lag screws for coronoid fracture. Pre-contoured locking compression plate and radial head prosthesis.

Fig. 4

a) 3D-CT scan: comminuted fracture of the proximal ulna and of the radial head in a 58-year old man. b) Post-operative radiography: global posterior approach and subcutaneous Kocher approach – Pre-contoured locking compression plate, cemented radial head prosthesis and suture anchor fixation of lateral ulnar collateral ligament.

Fig. 5

a) Radiographs and 3D-CT scan: fracture-dislocation of ulno-humeral joint, comminuted fracture of proximal ulna and sigmoid notch; large fragment of coronoid process. Fracture of the radial head with a small fragment. Osteoporosis. The patient was an 86-year-old woman. b) Intraoperative fluoroscopy: Taylor-Scham approach - temporary fixation of the fragments with clamps and K-wires. c) Post-operative radiography: Pre-contoured locking compression plate and 2.4 T buttress plate for coronoid fracture. Removal of the small fragment of the radial head.

Fig. 6

a) 3D-CT scan: high comminution of proximal ulna, sigmoid notch; large fragment of coronoid process. Comminuted fracture of the radial head. The patient was a 58-year-old woman. b) Intraoperative fluoroscopy and surgical field: The Taylor-Sham approach and standard Kocher approach - filling of cancellous gap with autograft obtained from the excision of radial head fragments and morselized homologous bone. c) Post-operative radiograph: Pre-contoured locking compression plate, free screws, headless 18-mm screw and 2.0 buttress plate for coronoid fracture; Radial head prosthesis.

Fig. 7

a) Radiographs and CT scan: comminuted fracture of the proximal ulna and coronoid process. Simple fracture of the radial head in a 26-year-old man. b) Radiographs at 9 months after surgery: global posterior approach and subcutaneous Kocher approach – Pre-contoured locking compression plate, two lag 2.7 mm screws and two loose K. wires for synthesis of comminuted coronoid process. Synthesis of the radial head with 2 small fragments screws (2.4 mm). Fracture healing; presence of heterotopic ossifications.

Fig. 8

a) 3D-CT scan: comminution of the proximal ulna, coronoid and of the radial head in osteoporotic bone in a 72-years old woman. b) Post-operative radiographs: global posterior approach - initial attempt to perform anatomical synthesis of comminuted osteoporotic fragments with consequent biological damage – Weak final bridging plate fixation (No locked screws). - cemented radial head prosthesis. c) Radiographs at 3 months after surgery: Breakage of one screw, implant loosening. d) Post-operative radiographs after revision surgery: Pre-contoured bridging plate, iliac crest graft.