Fractures of the proximal ulna: current concepts in surgical management

Abstract

Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex).In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity.Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first).The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation.For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint.Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability.Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function.The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness. Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.

Keywords: Monteggia fracture; Monteggia-like lesion; coronoid process; elbow stability; olecranon; proximal ulna fracture; radial head.

Fig. 1

Anatomy of the proximal ulna: (a) proximal ulna dorsal angulation (PUDA), (b) varus angulation, (c) olecranon-diaphysis angle (ODA).

Fig. 2

Mayo classification: type-I = undisplaced; type-II = stable/displaced; type-III = unstable/displaced; (a) simple, (b) comminuted.

Fig. 3

(a) incorrect reconstruction: constriction (left) or enlargement (right) of the olecranon width (OW) due to an incorrect dorsal alignment; (b) correct reconstruction.

Fig. 4

Mayo type IIB fracture including comminution of the proximal olecranon fragment and central impression of a 73-year-old lady treated with low-profile double plate osteosynthesis (Olecranon plates 2.8, Medartis, APTUS, Basel, Switzerland).

Fig. 5

Jupiter’s classification of posterior Monteggia fractures (Bado type II).

Fig. 6

Monteggia fracture (type I) combined with a distal humeral fracture of a 39-year-old female resulting from a motorbike accident: (a) and (b) preoperative 3D-CT scans showing the massive comminution of the proximal ulna involving the coronoid process; (c) in a two-step procedure, the distal humerus and an additional second distal ulnar shaft fracture were first restored and the radiohumeral joint was temporarily fixed with a K-wire; (d) and (e) intraoperative situs of the proximal ulna during secondary ulna reconstruction presenting a massive osseous defect; (f) the bone defect was filled with a bony allograft (red circle) while reducing the fracture fragments against the anatomically preshaped proximal ulna plate (Olecranon LCP, DePuy Synthes, Oberdorf, Switzerland); (g) and (h) postoperative controls showing the realignment of the ulnar length with a centred radiocapitellar line (red line) as well as the correct olecranon diaphysis angle (red angle). Note. CT, computerized tomography.

Fig. 7

(a) and (b) Monteggia-like lesion (type IID); (c) CT scans illustrate the radial neck fracture, the comminution of the coronoid base and the additional coronoid tip fragment as well; (d) and (e) postoperative views: the radial head/neck was fixed with free cortical screws and an anatomically preshaped radial head plate and the coronoid and ulna shaft were likewise restored performing double contoured, locked plating (Olecranon plates 2.8 Medartis, APTUS, Basel, Switzerland) with additional free cortical screws. Note. CT, computerized tomography.