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Adult Both Bone Forearm Fracture

A Monteggia fracture-dislocation is a fracture of the proximal one third of the ulna and an associated dislocation of the radial head and is named after Giovanni Battista Monteggia who described it in 1814. Monteggia fractures are thought to occur from a fall on to a hyper-pronated forearm / hand. They are relatively uncommon with an incidence of between 1% to 2% of all forearm fractures. They are more frequently seen in children compared to adults however, the literature and treatment options must be interpreted with caution as the groups are often mixed together.

The forearm comprises two bones (radius & ulna) that are held together at different levels by different soft tissue structures. Distally the forearm is connected at the Distal Radio-Ulna Joint (DRUJ) by the Triangular FibroCartilage Complex (TFCC). In the mid-portion the bones are connected by the interosseous membrane and proximally the radius is held by the annular and quadrate ligaments. The annular ligament arises from the anterior and posterior aspects of the radial notch in the proximal ulna. The annular ligament is a strong band of fibres that encircle the proximal radius, maintaining its position in the radial notch but also allowing it to freely rotate during supination and pronation. The quadrate ligament arises from the inferior border of the radial notch on the ulna and connects directly to the radial neck. Its’ function is to increase the stability of the Proximal Radio-Ulnar Joint (PRUJ) and restrict excessive supination / pronation.

The Synthes Locking Compression Plate (LCP) has uniformly spaced combination (combi) holes. The plate can be applied in any of the following modes:

Compression Bridging Neutralisation Buttress Tension band

The combi holes can accommodate standard cortical / cancellous screws and locking screws. The combi holes are a mirror image relative to the middle of the plate. This places the threaded hole section (for locking screws) closer to the fracture and the dynamic compression unit (DCU) side of the hole is furthest away from the fracture. This means that with eccentric cortical / cancellous screw placement, then compression is achieved at the fracture site.

As the plates allow the insertion of locking screws, this converts the construct into a fixed angle device and you do not need to rely on plate/bone compression to maintain the stability of the construct.

The small fragment LCP plates will accept the following screw sizes:

3.5mm cortical screws 4.0mm cancellous screws 3.5mm locking screws

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- See
- Pediatric Both Bone Frx
- Deforming Forces
- Discussion of Blount Fractures
- Implants for Fractures of the Radius and Ulna
- Plating Techniques

- Indications for Operative Treatment:
- all displaced, unstable fractures of the radius and ulna in adults;
- radial shaft fractures: all displaced fractures of the radius with greater than 10 deg of angulation or w/ subluxation of proximal
or distal R-U joint
- ulnar shaft fracture: isolated frxs of the ulna with angulation greater than 10 deg;

- Exam Considerations:
    - forearm compartment syndrome
- references:
- Acute compartment syndrome of the forearm

- Pre Op Planning:
- tourniquet:
- open fractures: (see Gustillo Classification)
- open fractures should be treated as an emergency, but fixation may be delayed upto 24 hrs;
- immediate ORIF in grade I, II, and IIIa fractures can have good results (low infection rate);
- autogenous bone grafting can be carried out early for grade I and II fractures (if needed);
- grade IIIb and IIIc fractures had poor results;
- these fractures were serially debrided until judged clean, only at which time was bone grafting performed;
- despite these measures, infections may occur in upto 3/4 of these patients;
- wound closure:
- some surgeons will close surgical incisions, where as, traumatic wounds are left open and are closed by delayed suture at a
second or third look debridement;
- 2 days of antibiotics should follow each wound debridement;
- consider antibiotic bead pouch between debridements;
- references:
- Immediate internal fixation of open fractures of the diaphysis of the forearm.
- The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review.

- Surgical Approach:
- Approach to the Ulna
- Anterior Approach: (Henry);
- main disadvantage is postoperative finger stiffness due to stripping of FDS/FPL origin;
- Dorsal Approach (Thompson):
- main disadvantage is possible injury to the posterior interosseous nerve;

- Surgical Reduction:
- both frx are exposed and provisionally reduced before either fixation is completed;
- the frx that has the least comminution (usually the ulna) is fixed first;
- if reduction is impossible the plate on the other bone is loosened and second bone reduced;
- after reduction and provisional fixation of both bones, pronation and supination are examined (if OK, all the screws are inserted);
- comminution and segmental bone loss:
- comminution makes it difficult to restore bone to length;
- interosseous membrane is identified, proximally & distally, & used guide in restoring bones to adequate length;
- bone grafting:
- it is generally recommended that bone grafting be applied to both bone forearm fractures w/ more than 50% comminution;
- indications for bone grafting have recently been challenged by Wright et al 1997, who were unable to find any
advantages to bone grafting in a retrospective review of 198 both bone fractures;
- if bone graft is used, it should be away from interosseous membrane to decrease risk of synostosis (this complication is
more common in head injured patients);
- refs:
- The management of segmental bone loss associated with forearm fractures.
- Comminuted fractures of the proximal radius and ulna.
- Cross-union complicating fracture of the forearm. Part I: Adults.
- The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review.
- Fracture-related and implant-specific factors influencing treatment results of comminuted diaphyseal forearm fractures without bone grafting.

- Surgical Fixation:  

- Wound Closure:
- closure of both incisions without tension may be difficult;
- ulnar would should preferably be closed first, since it is located close to the subcutaneous border;
- radial wound, however, can be left open over a portion of its length, if the metal implant is safely placed under the muscle;

- Post Operative Care, Complications, and Evaluation

Forearm fractures: treatment by rigid fixation with early motion.

Long-term follow-up of forearm bone diaphyseal plating.

Operative treatment of malunited fractures of the forearm.

Immediate internal fixation of open fractures of the diaphysis of the forearm.

Comminuted fractures of the proximal radius and ulna.