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Adult Monteggia lesion with ipsilateral wrist injuries
Injury,12,413-416
413
PrintedinGreatBritain
Adult Monteggia injuries
lesion with ipsilateral
wrist
George B. Mullan, Alfred Franklin and Neil P. Thomas Orthopaedic Department,
University College Hospital, London
INTRODUCTION THE
case is presented of a patient who sustained a lateral Monteggia lesion with fractures occurring in the ipsilateral wrist. A review of the literature on Monteggia lesions does not mention associated fractures of the wrist in adults. However, associated wrist injuries have been described occurring in children. The mechanism of injury giving rise to this rare combination of fractures is discussed. CASE
REPORT
A 44-year-old woman fell off her bicycle whilst on holiday, injuring her left forearm and wrist. She was taken to the local hospital and X-rayed. The complexity of the injury was recognized and her immediate management consisted of suture of a V-shaped wound over the olecranon, the application of a below-elbow plaster and a collar and cuff sling. The patient was then referred to University College Hospital for further management, where she was seen 13 days later. Radiographs of the ieft upper limb (Fig. 1) showed a lateral Monteggia lesion, a Smith’s fracture of the wrist with minimal displacement and a fracture of the waist of the scaphoid. The wound over the olecranon was found to be healed and the sutures were removed. At operation, the proximal fracture of the ulna in the region of the coronoid process was reduced and fixed with an inter-fragmental compression screw and a 5-hole A0 semitubular plate. The distal fracture of the ulna was similarly reduced and fixation was maintained with a 6-hole semitubular plate. The latter fixation was supplemented with a bone graft taken from the right iliac crest (Fig. 2). Suction drainage was used and the limb immobilized in an above-elbow plaster after remanipulation ofthe Smith’s fracture. The postoperative course was uneventful and the patient was discharged from hospital after 8 days. The plaster was removed at 8 weeks. An X-ray film showed
that the fractures of the proximal ulna were united. The fracture of the scaphoid remained ununited although there was no tenderness on palpation. The patient began a course of physiotherapy. At 5 months, her range of elbow flexion was lo’-95’. She had IO’ of dorsiflexion and 15” of palmar flexion at the wrist. Pronation was 90”, supination was nil and her grip was power 4. The patient stated that she was not inconvenienced by the residual loss of movement of her elbow and wrist, and that she had returned to her former employment. DISCUSSION
In 18 14 Monteggia described a traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius, henceforth known as the Monteggia fracture. Bado (1967) classified under the term Monteggia lesion ‘a group of injuries having in common a dislocation of the radio-humeral-ulnar joint, associated with a fracture ofthe ulna at various levels’ with, in a few cases, lesions of the wrist. Bado’s classification has been generally accepted in discussions of the Monteggia lesion, although some authors prefer the original definition given by Monteggia. Bado’s classiftcation is as follows: Type 1: Anterior dislocation of the radial head with fracture of the ulnar diaphysis at any level, with anterior angulation. Type 2: Posterior or posterolateral dislocation of the radial head with fractures of the ulnar diaphysis with posterior angulation. Type 3: Anterolateral or lateral dislocation of the radial head with fracture of the ulnar metaphysis. Type 4: Anterior dislocation of the radial
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
414
a
c
b
Fig. 1. a, Radiograph of the elbow showing the lateral displacement of the radial head and a fracture of the olecranon at the level of the coronoid process. b,
Radiograph of forearm and wrist, illustrating the fractures of the proximal ulna, and the slightly displaced Smith’s fracture. c, Radiograph ofthe wrist, showing the fracture of the waist of the scaphoid and a lateral view of the elbow fracture.
a
b
Fig. 2. a, Post-reduction lateral radiograph ofthe injured elbow. b, Post-reduction
anteroposterior radiograph ofthe injured elbow, showing the reduced radial head. head with fracture of the proximal third of the radius with a fracture of the ulna at the same level. Boyd (1940), Evans (1949), Boyd and Boals (1969) and Bado (1967) are in agreement as to the mechanism of this injury. When an adult or
child falls on the outstretched hand, the hand becomes locked in relation to the ground and, at the same time, a rotational force may be applied by the weight of the falling body. This force produces an external rotation of the arm, thereby pronating the forearm. This can lead to
Mullan et al.: Adult Monteggia Lesion
hyperpronation of the forearm causing either a transverse or oblique fracture with or without a butterfly fragment at the upper third of the ulna. Bado (1967) referred to associated wrist injuries occurring in type 1 lesions. These appear to be epiphyseal injuries of the radius. Furthermore, he stated that type 3 lesions, which account for 5-20 per cent of cases in the series reviewed occurred ‘exclusively in children’ (Boyd, 1940; Boyd and Boals, 1969; Bruce et al., 1974; Evans, 1949). Smith described the fracture of the wrist which bears his name in 1847. Nine years earlier Barton had described anterior and posterior dislocations of the wrist (the posterior fracture dislocation he described was probably a Colles fracture). Neither of these authors had the benefit of X-rays in describing the injuries and hence an element of confusion arose as to the exact nature ofthe fractures (Ellis, 1965). These eponymous wrist fractures which are reverses of the Colles fracture were classified on a radiological basis by Thomas (1957). He divided Smith’s fracture into three adult types with a separate group for epiphyseal injuries in children. Type 1 is a cornminuted fracture ofthe distal radius accompanied by an avulsion fracture of the ulna styloid. This is the commonest type and is most often seen in older patients, especially women. The case presented here is of this type. Type 2, which is the next most common presentation, is an anterior marginal fracture of the distal radius with ventral subluxation of the carpus. It is seen in younger patients, particularly men, and corresponds to the anterior fracture-dislocation described by Barton; hence the Barton fracture is a type of Smith’s fracture. Type 3 is an oblique fracture of the distal radius on the lateral view, with anterior displacement of the distal fragment but no comminution. This is the rarest type and, according to Thomas, is often accompanied by fractures of the metacarpals, but this observation is not borne out by other authors (Woodyard, 1969). Furthermore, there does not appear to be any mention in the literature of associated carpal bone fractures such as occurred in this case. The mechanism of fracture originally described by Smith was a fall onto the back of the hand (Ellis, 1965). A different mechanism was suggested for types 1 and 2 fractures by Thomas on the basis of several patients’ claim to have fallen backwards onto the palm of the outstretched hand. In such cases, the forearm is locked in full supination and the weight of the
Fig. 3. Lateral radiograph ofthe injured wrist, showing mal-union ofthe Smith fracture 3 months after injury.
falling body pronates the upper limb whilst the hand is held fixed on the ground. Evans (1951) stated that a twisting force combined with a heavy compressional force provides the ideal theoretical mechanism for the production of such a fracture. A backward fall onto the outstretched supinated hand would also provide the mechanism for the scaphoid fracture. Weber et al. (1974) have shown biomechanically that scaphoid waist fractures are produced by a force applied to the radial portion of the dorsiflexed wrist. Forced dorsiflexion would therefore occur where the hand is fixed palm downwards on the ground with the motion of the body compressing and rotating the wrist. It became evident in reviewing the literature that the association of a Monteggia lesion with wrist fractures occurring in adults is very rare. The incidence of metacarpal fractures occurring with Smith’s fracture is mentioned, but there have been no reports of associated carpal fractures. The mechanism causing this combination of fractures is complex. It is postulated that when the patient fell off her bicycle, she fell backwards onto the palm of her outstretched hand. The forearm then locked in full spination
416
Injury: the British Journal of Accident Surgery Vol. 1 Z/No.
and the weight of the falling body pronated the upper limb as the hand was held firmly on the ground. As has already been pointed out, this is the initial mechanism required for a Monteggia fracture. It also explains the mechanism for the other fractures: a twisting force combined with a heavy compressional force could produce both a Smith and a scaphoid fracture. The outcome of the treatment of this ‘pot pourri’ of injuries is not entirely satisfactory. The movements of flexion and extension at the elbow are relatively good in that she has a 90’ arc of movement. However, movements at the wrist joint are poor, as the original position of the Smith fracture was not maintained (Fig. 3). Subjectively the patient is delighted with the result as she has no pain and her range of movements are compatible with her normal working routine. The fact that she is unable to supinate her forearm and hand does not appear to trouble her.
her secretarial assistance, and Mr L. D. Ellis, Photographic Department, University College Hospital, for the preparation ofthe illustrations.
Acknowledgements
The authors wish to thank Mr A. 0. Ransford for permission to report this case. The authors would also like to thank Miss Carol Bishop for Requestsforreprintsshouldbe addressedto:Mr George B.
5
REFERENCES
Bado J. L. (1967) The Monteggia lesion. Clin. Orthop. Rel. Res. SO, 7 1.
Boyd H. B. (1940) Treatment of fractures of the ulna with dislocation of head ofradius. JAMA 115, 1699. Boyd H. B. and Boals J. C. (1969) The Monteggia lesion-a review of 159 cases. Clin. Orthoo. 66.94. Bruce H. E., Harvey J. P. and Wilson J: E. (1974) Monte&a fractures. J. Bone Joint Surg. 56A, 1563. Ellis J. (1965) Smith’s and Barton’s fractures. J. Bone Joint Surg. 47B, 724. Evans E. M. (1949) Pronation injuries of the forearm, with special reference to the- anterior Monteggia fracture. J. Bone Joint Sum. 31B. 578. Evans E. M. (1951) Fractuks of radius and ulna. J. Bone Joint Surg. 33B, 548. Monteggia G. B. (18 14) Instituzioni Chirurgische. Milan, G. Maspan. Thomas F. B. (1957) Reduction of Smith’s fractures. J. Bone Joint Surg. 39B, 463. Weber J. R., Chao E. Y. and Lincheid R. L. (1974) Biomechanical analysis of the dorsiflexed wrist with emphasis on scaphoid waist fracture. J. Bone Joint S&g. 56A, 855. Woodyard J. E. (1969) A review of Smith’s fractures. J. Bone Joint Surg. SlB, 324.
Mullan, Orthopaedic Department, Cork Regional Hospital, Wilton,
Cork, Eire.
ERRATUM
In the article by D. Campbell and G. E. Kempson ‘The comparative stiffness of external fixation frames’ (Injury 12,297), there was an error in Tables II and IV. The figures under the Torsion (N. m degree-r) and Compression (N/mm) sections should be reversed in each table. The authors regret this error.
413
PrintedinGreatBritain
Adult Monteggia injuries
lesion with ipsilateral
wrist
George B. Mullan, Alfred Franklin and Neil P. Thomas Orthopaedic Department,
University College Hospital, London
INTRODUCTION THE
case is presented of a patient who sustained a lateral Monteggia lesion with fractures occurring in the ipsilateral wrist. A review of the literature on Monteggia lesions does not mention associated fractures of the wrist in adults. However, associated wrist injuries have been described occurring in children. The mechanism of injury giving rise to this rare combination of fractures is discussed. CASE
REPORT
A 44-year-old woman fell off her bicycle whilst on holiday, injuring her left forearm and wrist. She was taken to the local hospital and X-rayed. The complexity of the injury was recognized and her immediate management consisted of suture of a V-shaped wound over the olecranon, the application of a below-elbow plaster and a collar and cuff sling. The patient was then referred to University College Hospital for further management, where she was seen 13 days later. Radiographs of the ieft upper limb (Fig. 1) showed a lateral Monteggia lesion, a Smith’s fracture of the wrist with minimal displacement and a fracture of the waist of the scaphoid. The wound over the olecranon was found to be healed and the sutures were removed. At operation, the proximal fracture of the ulna in the region of the coronoid process was reduced and fixed with an inter-fragmental compression screw and a 5-hole A0 semitubular plate. The distal fracture of the ulna was similarly reduced and fixation was maintained with a 6-hole semitubular plate. The latter fixation was supplemented with a bone graft taken from the right iliac crest (Fig. 2). Suction drainage was used and the limb immobilized in an above-elbow plaster after remanipulation ofthe Smith’s fracture. The postoperative course was uneventful and the patient was discharged from hospital after 8 days. The plaster was removed at 8 weeks. An X-ray film showed
that the fractures of the proximal ulna were united. The fracture of the scaphoid remained ununited although there was no tenderness on palpation. The patient began a course of physiotherapy. At 5 months, her range of elbow flexion was lo’-95’. She had IO’ of dorsiflexion and 15” of palmar flexion at the wrist. Pronation was 90”, supination was nil and her grip was power 4. The patient stated that she was not inconvenienced by the residual loss of movement of her elbow and wrist, and that she had returned to her former employment. DISCUSSION
In 18 14 Monteggia described a traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius, henceforth known as the Monteggia fracture. Bado (1967) classified under the term Monteggia lesion ‘a group of injuries having in common a dislocation of the radio-humeral-ulnar joint, associated with a fracture ofthe ulna at various levels’ with, in a few cases, lesions of the wrist. Bado’s classification has been generally accepted in discussions of the Monteggia lesion, although some authors prefer the original definition given by Monteggia. Bado’s classiftcation is as follows: Type 1: Anterior dislocation of the radial head with fracture of the ulnar diaphysis at any level, with anterior angulation. Type 2: Posterior or posterolateral dislocation of the radial head with fractures of the ulnar diaphysis with posterior angulation. Type 3: Anterolateral or lateral dislocation of the radial head with fracture of the ulnar metaphysis. Type 4: Anterior dislocation of the radial
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
414
a
c
b
Fig. 1. a, Radiograph of the elbow showing the lateral displacement of the radial head and a fracture of the olecranon at the level of the coronoid process. b,
Radiograph of forearm and wrist, illustrating the fractures of the proximal ulna, and the slightly displaced Smith’s fracture. c, Radiograph ofthe wrist, showing the fracture of the waist of the scaphoid and a lateral view of the elbow fracture.
a
b
Fig. 2. a, Post-reduction lateral radiograph ofthe injured elbow. b, Post-reduction
anteroposterior radiograph ofthe injured elbow, showing the reduced radial head. head with fracture of the proximal third of the radius with a fracture of the ulna at the same level. Boyd (1940), Evans (1949), Boyd and Boals (1969) and Bado (1967) are in agreement as to the mechanism of this injury. When an adult or
child falls on the outstretched hand, the hand becomes locked in relation to the ground and, at the same time, a rotational force may be applied by the weight of the falling body. This force produces an external rotation of the arm, thereby pronating the forearm. This can lead to
Mullan et al.: Adult Monteggia Lesion
hyperpronation of the forearm causing either a transverse or oblique fracture with or without a butterfly fragment at the upper third of the ulna. Bado (1967) referred to associated wrist injuries occurring in type 1 lesions. These appear to be epiphyseal injuries of the radius. Furthermore, he stated that type 3 lesions, which account for 5-20 per cent of cases in the series reviewed occurred ‘exclusively in children’ (Boyd, 1940; Boyd and Boals, 1969; Bruce et al., 1974; Evans, 1949). Smith described the fracture of the wrist which bears his name in 1847. Nine years earlier Barton had described anterior and posterior dislocations of the wrist (the posterior fracture dislocation he described was probably a Colles fracture). Neither of these authors had the benefit of X-rays in describing the injuries and hence an element of confusion arose as to the exact nature ofthe fractures (Ellis, 1965). These eponymous wrist fractures which are reverses of the Colles fracture were classified on a radiological basis by Thomas (1957). He divided Smith’s fracture into three adult types with a separate group for epiphyseal injuries in children. Type 1 is a cornminuted fracture ofthe distal radius accompanied by an avulsion fracture of the ulna styloid. This is the commonest type and is most often seen in older patients, especially women. The case presented here is of this type. Type 2, which is the next most common presentation, is an anterior marginal fracture of the distal radius with ventral subluxation of the carpus. It is seen in younger patients, particularly men, and corresponds to the anterior fracture-dislocation described by Barton; hence the Barton fracture is a type of Smith’s fracture. Type 3 is an oblique fracture of the distal radius on the lateral view, with anterior displacement of the distal fragment but no comminution. This is the rarest type and, according to Thomas, is often accompanied by fractures of the metacarpals, but this observation is not borne out by other authors (Woodyard, 1969). Furthermore, there does not appear to be any mention in the literature of associated carpal bone fractures such as occurred in this case. The mechanism of fracture originally described by Smith was a fall onto the back of the hand (Ellis, 1965). A different mechanism was suggested for types 1 and 2 fractures by Thomas on the basis of several patients’ claim to have fallen backwards onto the palm of the outstretched hand. In such cases, the forearm is locked in full supination and the weight of the
Fig. 3. Lateral radiograph ofthe injured wrist, showing mal-union ofthe Smith fracture 3 months after injury.
falling body pronates the upper limb whilst the hand is held fixed on the ground. Evans (1951) stated that a twisting force combined with a heavy compressional force provides the ideal theoretical mechanism for the production of such a fracture. A backward fall onto the outstretched supinated hand would also provide the mechanism for the scaphoid fracture. Weber et al. (1974) have shown biomechanically that scaphoid waist fractures are produced by a force applied to the radial portion of the dorsiflexed wrist. Forced dorsiflexion would therefore occur where the hand is fixed palm downwards on the ground with the motion of the body compressing and rotating the wrist. It became evident in reviewing the literature that the association of a Monteggia lesion with wrist fractures occurring in adults is very rare. The incidence of metacarpal fractures occurring with Smith’s fracture is mentioned, but there have been no reports of associated carpal fractures. The mechanism causing this combination of fractures is complex. It is postulated that when the patient fell off her bicycle, she fell backwards onto the palm of her outstretched hand. The forearm then locked in full spination
416
Injury: the British Journal of Accident Surgery Vol. 1 Z/No.
and the weight of the falling body pronated the upper limb as the hand was held firmly on the ground. As has already been pointed out, this is the initial mechanism required for a Monteggia fracture. It also explains the mechanism for the other fractures: a twisting force combined with a heavy compressional force could produce both a Smith and a scaphoid fracture. The outcome of the treatment of this ‘pot pourri’ of injuries is not entirely satisfactory. The movements of flexion and extension at the elbow are relatively good in that she has a 90’ arc of movement. However, movements at the wrist joint are poor, as the original position of the Smith fracture was not maintained (Fig. 3). Subjectively the patient is delighted with the result as she has no pain and her range of movements are compatible with her normal working routine. The fact that she is unable to supinate her forearm and hand does not appear to trouble her.
her secretarial assistance, and Mr L. D. Ellis, Photographic Department, University College Hospital, for the preparation ofthe illustrations.
Acknowledgements
The authors wish to thank Mr A. 0. Ransford for permission to report this case. The authors would also like to thank Miss Carol Bishop for Requestsforreprintsshouldbe addressedto:Mr George B.
5
REFERENCES
Bado J. L. (1967) The Monteggia lesion. Clin. Orthop. Rel. Res. SO, 7 1.
Boyd H. B. (1940) Treatment of fractures of the ulna with dislocation of head ofradius. JAMA 115, 1699. Boyd H. B. and Boals J. C. (1969) The Monteggia lesion-a review of 159 cases. Clin. Orthoo. 66.94. Bruce H. E., Harvey J. P. and Wilson J: E. (1974) Monte&a fractures. J. Bone Joint Surg. 56A, 1563. Ellis J. (1965) Smith’s and Barton’s fractures. J. Bone Joint Surg. 47B, 724. Evans E. M. (1949) Pronation injuries of the forearm, with special reference to the- anterior Monteggia fracture. J. Bone Joint Sum. 31B. 578. Evans E. M. (1951) Fractuks of radius and ulna. J. Bone Joint Surg. 33B, 548. Monteggia G. B. (18 14) Instituzioni Chirurgische. Milan, G. Maspan. Thomas F. B. (1957) Reduction of Smith’s fractures. J. Bone Joint Surg. 39B, 463. Weber J. R., Chao E. Y. and Lincheid R. L. (1974) Biomechanical analysis of the dorsiflexed wrist with emphasis on scaphoid waist fracture. J. Bone Joint S&g. 56A, 855. Woodyard J. E. (1969) A review of Smith’s fractures. J. Bone Joint Surg. SlB, 324.
Mullan, Orthopaedic Department, Cork Regional Hospital, Wilton,
Cork, Eire.
ERRATUM
In the article by D. Campbell and G. E. Kempson ‘The comparative stiffness of external fixation frames’ (Injury 12,297), there was an error in Tables II and IV. The figures under the Torsion (N. m degree-r) and Compression (N/mm) sections should be reversed in each table. The authors regret this error.