Monteggia fractures in adults

The records concerning ten consecutive years of experience with Monteggia f ractures in adult patients at a level-one trauma center were retrospectivel y 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 c lassification of Bado, there were seven type-I, thirty-eight type-II, one t ype-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 scr ews in three patients (all of whom had a Bado type-II fracture). An ulnar d iaphyseal fracture was fixed with an intramedullary Steinmann pin in one pa tient. The remaining patients had fixation with a plate and screws. The fra cture of the radial head was treated with either complete or partial excisi on of the fragments in twelve patients (with replacement with a silicone pr osthesis 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 reoperatio n within three months after the initial operation; five had revision of a l oose 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 elbo w articulation. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotat ory instability of the ulnohumeral joint in one, and instability of the dis tal 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 s core 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 t wenty-two, fair for two, and poor for six. Six of the eight patients who ha d an unsatisfactory (fair or poor) result had had a Bado type-II fracture w ith a concomitant fracture of the radial head. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patien ts, a proximal radioulnar synostosis in one, a malunited fracture of the co ronoid process and a proximal radioulnar synostosis in one, a malunion of t he ulna in one, and painfully restricted rotation of the forearm after oper ative fixation of a comminuted fracture of the radial head in one. The othe r two unsatisfactory results were in a patient who had had a Bado type-I fr acture and in one who had had a Bado type-IV fracture. The results of the present series are much better than those reported in mo st 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 fixatio n leads to a satisfactory result in most adults who have a Monteggia fractu re. The posterior (Bado type-II) fracture is the most common type of Monteg gia 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 M onteggia fractures, remain the most challenging elements in the treatment o f these injuries.