A 39-year-old man with a chronic Monteggia fracture-dislocation malunion, new wrist pain
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A 39-year-old left-hand dominant man with a history of left Monteggia fracture-dislocation that was treated abroad about 10 years ago presented to clinic.
The patient had 1 week of severe, atraumatic left wrist pain, dorsal deformity and decreased range of motion (ROM). He had woken up from sleep with severe pain and was evaluated at an ED. There, radiographs of the left wrist and elbow were obtained demonstrating dorsal distal radioulnar joint (DRUJ) dislocation with significant ulnar impaction, ulnocarpal and radiocarpal arthritis, radiocapitellar subluxation with radial head deformity, and proximal ulnar fracture malunion with intact hardware (Figures 1 and 2). The patient currently denied elbow pain.
Source: Hisham Awan, MD
On exam, the patient had obvious deformity of the wrist with dorsal prominence of the ulnar head and associated tenderness at the ulnar wrist. There was a well-healed incision over the dorsal, proximal ulna. He was able to make a composite fist. However, he had only a 10° flexion-extension arc of wrist ROM with mechanical block, as well as a mechanical block to pronosupination. He had a 30° to 100° flexion-extension arc at the elbow. Significant DRUJ instability was also appreciated. Radial, median and ulnar sensorimotor nerves were intact with normal ulnar and radial pulses at the wrist. Mild volar and dorsal muscle atrophy were present, which the patient stated were chronic at his baseline.
What are the treatment options?
See answer below.
Chronic proximal ulna malunion with chronic posterior subluxation, deformity of radiocapitellar joint
There are multiple pathologies present in this patient and numerous potential treatment options. The patient has a chronic proximal ulna malunion from a Monteggia fracture-dislocation. Additionally, the chronic posterior subluxation and deformity of the radiocapitellar joint is a sequela from the Monteggia fracture-dislocation. However, the patient has a relatively functional flexion-extension arc of the elbow and no elbow pain. Thus, this may not need to be addressed. The patient’s complaint is isolated wrist pain, deformity and decreased function. This is presumed to be the result of chronic stress and eventual attenuation of the DRUJ or a missed, concomitant DRUJ injury at the time of the trauma. The treating surgeon should consider why this occurred. Was this a ramification of malreduced proximal ulnar fixation resulting in significant ulnar positivity causing ulnocarpal impaction and stress on the DRUJ or was this a result of chronic longitudinal instability from malreduction of the radiocapitellar joint? Likely, all of these factors played a role in the patient’s presentation. The DRUJ, ulnocarpal joint and longitudinal stability all likely need to be addressed in the treatment of this patient’s problem.
Possible options for treatment include 1) intraosseous membrane (IOM) reconstruction with an ulnar head resection (Darrach procedure); 2) radial head arthroplasty with a Darrach procedure; or 3) DRUJ arthroplasty. Options 1 and 2 both address chronic longitudinal instability and ulnocarpal/DRUJ pathologies, but have their downsides. With option 1, the radiocapitellar joint is not addressed, which can result in continued longitudinal stress on the forearm, potentially causing stress on the IOM reconstruction and recurrent instability. However, if we address the radiocapitellar joint with a radial head arthroplasty (option 2), there is no guarantee that the radiocapitellar joint will be stable or pain-free postoperatively because the capitellum is likely pathologic, as well. Additionally, radiocapitellar arthroplasty has been recalled and is not an option in this case. Option 3 addresses all the issues with which this patient presents, but not without potential complication. Like all arthroplasties, there is a risk for wear and/or fatigue failure, particularly in a younger man, as the longitudinal stress of the forearm will be seen at the ultra-high-molecular-weight polyethylene ball and radial plate cover.
Operative technique
The decision was made to proceed with DRUJ arthroplasty under regional block and monitored anesthesia care. The patient was placed on the table in supine position with the left upper extremity extended over a hand table. The extremity was exsanguinated, and an upper arm tourniquet was inflated. A longitudinal incision was made over the ulnar shaft and extended distally toward the center of the wrist. Blunt dissection was utilized to protect the cutaneous nerves. An ulnarly based flap of extensor retinaculum was made. The ulnar head was exposed and a provisional cut in the ulnar head was made. The ulna was retracted volarly to expose the ulnar side of the radius. A burr was used to remove the volar lip of the radius to allow us to appropriate positioning of the plate. The trial plate was held in place with guidewires. Fluoroscopic imaging confirmed excellent placement of the plate. Next, a hole was drilled through the slot for the peg on the actual plate. The trial implant was removed and the locking plate was placed and impacted. The screw in the slotted hole was replaced. Three locking screws were placed proximally. The cutting guide was used, and the ulna was cut for the appropriate length from the ulnar stem. A guide pin was placed in the center in the medullary canal of the ulna and was reamed. A size 5 ulnar stem was placed and the UHMWPE ball was inserted, the locking cap was placed and the set screw was inserted into the implant (Figure 3). Excellent stability was achieved. Intraoperative fluoroscopy confirmed adequate placement of all implants (Figure 4). The wound was irrigated. The capsule and retinaculum were closed over the top of the implant. The incision was closed and a sterile dressing and a short-arm splint were applied.
The patient was kept non-weight-bearing for the first 2 weeks postoperatively. At 2 weeks postoperatively, the sutures were removed, wrist radiographs were obtained (Figure 5), the patient was placed in a custom thermoplastic short-arm splint, and occupational therapy for finger, hand and wrist range of motion was initiated. He continued to have a 5-pound weightlifting restriction for 1 month postoperatively. At the time of the 3-month follow-up conducted via a virtual visit secondary to the COVID-19 pandemic, the patient demonstrated pain-free wrist ROM in flexion/extension and pronation/supination.
Discussion
Monteggia fracture-dislocations are defined as proximal-third ulna fractures with an associated radial head dislocation or instability. This injury is more often seen in the pediatric population; however, when seen in the adult population, it is considered more difficult to treat. In adults, these injuries can result from ostensibly innocent mechanical falls to high-energy mechanisms. For diaphyseal and metaphyseal Monteggia fracture-dislocations, emphasis must be placed on the restoration of ulnar length and alignment. This will commonly result in reduction of the proximal radioulnar and radiocapitellar joints. If these joints do not reduce anatomically after ulnar fixation, the ulnar reduction should be evaluated for malalignment. Chronic or late presenting malreduction of the radiocapitellar or ulnohumeral joint is commonly due to insufficient fixation of the ulna. More worrisome, however, in children this injury can be missed up to 33% of the time resulting in chronic Monteggia fracture-dislocation and its sequelae. More common sequelae include elbow pain or deformity, loss of elbow flexion and supination, late neuropathy and elbow arthritis. If found early, an ulnar osteotomy, radiocapitellar reduction and revision fixation can be performed with good results.
DRUJ instability reports
DRUJ instability after proximal ulnar malreduction is a rare phenomenon. Emilie V. Cheung, MD, and colleagues wrote a case report of a patient with a missed DRUJ dislocation in the setting of a Monteggia fracture-dislocation. This patient presented to them 6 months after ulnar fixation with residual radiocapitellar and DRUJ dislocations. This was successfully treated with closed reduction and pinning of the DRUJ for 6 weeks. This may have been the first report of ipsilateral longitudinal instability of the forearm in the setting of a Monteggia fracture-dislocation. Yanchao Zhang and colleagues published a second case report of a patient who did not have DRUJ instability until after fixation of the proximal ulna where both the radiocapitellar and distal radio-ulnar joints were found to be unstable. This was successfully treated with revision ulnar fixation and pinning of the DRUJ for 4 weeks. Both of these examples were in patients whose misdiagnoses were discovered within 1 year of injury. Our patient presented to our clinic 10 years after his injury and fixation. However, the common thread remains that one must restore the longitudinal stability of the forearm when residual elbow or distal forearm instability is noted. In our case, we felt this was best attained with a DRUJ arthroplasty, mechanically linking the distal radius and ulna without the need to address the proximal ulnar malunion. Jesse B. Jupiter, MD, MA, and colleagues followed up 11 patients for a median of 60 months after DRUJ arthroplasty and found no patient required removal of hardware with improvements in DASH, pain rated wrist evaluation, VAS, satisfaction scores, and range of motion. In a study by Antonio Rampazzo, MD, PhD, and colleagues, 46 arthroplasties were reviewed in patients younger than 40 years of age showing similar improvements in functional outcome scores as Jupiter’s study as well as a 96% implant survival rate at 5 years. The patient is now currently pain free with functional elbow, forearm and wrist range of motion.
To conclude, Monteggia fracture-dislocations in adults are a rare entity. As in pediatric Monteggia fracture-dislocations, restoration of ulnar length, alignment and rotation is paramount and will commonly result in the reduction of the radiocapitellar joint. If continued subluxation is noted, it should be addressed without delay. The most common complications of chronic Monteggia fracture-dislocations are elbow pain, loss of elbow flexion and supination, elbow deformity, late neuropathy and elbow arthritis. We present here a rare case of late DRUJ instability necessitating DRUJ arthroplasty with an excellent early result. This case demonstrates that when treating Monteggia fracture-dislocations acutely, one must be vigilant in anatomic reduction and alignment of the ulna fracture and not miss residual proximal or distal joint instability of the forearm.
- References:
- Bae DS. J Pediatr Orthop. 2016;doi:10.1097/BPO.0000000000000765.
- Cheung EV, et al. J Bone Joint Surg Am. 2009;doi:10.2106/JBJS.H.00269.
- Delpont M, et al. Orthop Traumatol Surg Res. 2018;doi:10.1016/j.otsr.2017.04.014.
- Jupiter JB, et al. J Orthop Trauma. 1991;doi:10.1097/00005131-199112000-00003.
- Kachooei AR, et al. Arch Bone Jt Surg. 2014;2180-2184.
- Rampazzo A, et al. J Hand Surg Am. 2015;doi:10.1016/j.jhsa.2015.04.028.
- Ramski DE, et al. J Pediatr Orthop. 2015;doi:10.1097/BPO.0000000000000213.
- Ring D, et al. J Bone Joint Surg Am. 1998;80:1733-1744.
- Wong JC, et al. Hand Clin. 2015;doi:10.1016/j.hcl.2015.06.006.
- Zhang Y, et al. Medicine (Baltimore). 2019;doi:10.1097/MD.0000000000015310.
- For more information:
- Hisham Awan, MD, is associate professor and director of The Ohio State University Hand and Upper Extremity Center. He can be reached at 915 Olentangy River Road, Columbus, OH 43212; email: hisham.awan@osumc.edu.
- Travis L. Frantz, MD, is a fellow, sports medicine and shoulder at TRIA Orthopaedic Surgery. He can be reached at 8100 Northland Drive, Bloomington, MN 55431; email: travis.frantz@tria.com.
- Steven R. Niedermeier, MD, is a hand and upper extremity surgery fellow at OrthoCarolina Hand Center. He can be reached at 4212 Craig Ave., Charlotte, NC 28211; email: steven.niedermeier@orthocarolina.com.
- Edited by Travis Frantz, MD, and Ian Savage-Elliott, MD. Frantz is a sports medicine and shoulder fellow at TRIA Orthopaedic Center in Minneapolis. He completed his orthopedic surgery residency at The Ohio State University Wexner Medical Center in Columbus, Ohio. Savage-Elliott is a chief resident in the department of orthopedic surgery at Tulane University Medical Center in New Orleans. He will pursue fellowship training in foot and ankle and sports medicine following residency completion. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com
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Bae DS. J Pediatr Orthop. 2016;doi:10.1097/BPO.0000000000000765.
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