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Monteggia Fracture; Causes, Diagnosis, Treatment

Monteggia Fracture/Ulnar styloid fracture is common and may be associated with a distal radial fracture (DRF) or occurs as an isolated injury [rx]. In spite of acting as a unique strut on the ulnar end to stabilize the ulnar soft tissue and maintain the congruency of the distal radioulnar joint (DRUJ), the majority of these connected tissues including the triangular fibrocartilage complex (TFCC) are at the base of the ulnar styloid or fovea [rx–rx].

An ulna fracture is a break of the ulna bone in the forearm. They are often associated with radius fractures.^[rx] When the middle portion of the ulna is broken without other associated fractures, it may be called a nightstick fracture.

The ulnar styloid plays a crucial role in wrist biomechanics. The ulnar styloid base and the fovea are the insertion points for the primary stabilizers of the DRUJ, the superficial and deep portions of the palmar and dorsal radioulnar ligaments.^[rx,rx,rx] In addition, the ulnar styloid functions as a strut, helping to stabilize the extensor carpi ulnaris (ECU), its sub-sheath, and the ulnocarpal ligaments.^[rx] Because of its anatomic importance, the potential exists for ulnar styloid fractures to cause ulnar-sided wrist symptoms.

Monteggia Fracture

Anatomy of Monteggia Fracture

The management of acute ulnar styloid fractures is based on the long-term effect that they may have on the stability of the distal radioulnar (DRU) joint. The relationship of the ulnar styloid to the stabilizing ligaments determines whether a specific fracture type is likely to result in DRU joint instability.

The static stability of the DRU-joint is achieved by the bony congruity between the sigmoid notch of the radius and the ulnar head and the ligaments which hold the joint together [rx–rx]. The ulno-radial ligament represents the transverse, peripheral part of the Triangular Fibro-Cartilage Complex (TFCC) [rx–rx]. The ligaments run from the fovea of the ulnar head and the base of the ulnar styloid to the dorsal and palmar edges of the sigmoid notch on the distal radius [rx–rx, rx]. The ulno-radial ligament is the major stabilizer of DRU-joint in the dorsal/palmar direction [rx, rx].

Types of Monteggia Fracture

Nightstick fracture – is a fracture of the middle portion of the ulna without other fractures.^[rx]
Distal ulna fractures – typically occur along with distal radius fractures.^[rx]
Monteggia fracture – a fracture of the proximal third of the ulna with the dislocation of the head of the radius
Hume fracture – a fracture of the olecranon with associated anterior dislocation of the radial head

Causes of Monteggia Fracture

Monteggia Fracture

Sudden forceful fall down
Road traffic accident
Falls – Falling onto an outstretched hand is one of the most common causes of a broken ulnar styloid fracture.
Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
Have osteoporosis – a disease that weakens your bones
Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
Wave an inadequate intake of calcium or vitamin D
Football or soccer, especially on artificial turf
Rugby
Horseback riding
Hockey
Skiing
Snowboarding
In-line skating
Jumping on a trampoline

Symptoms of Monteggia Fracture

Common symptoms of a Colles fracture include:

Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
Swelling
Tenderness
Bruising
Obvious deformity, such as a bent wrist
Pain
Bruising
Tenderness
The wrist hanging in a deformed way
Pain, especially when flexing the ulnar styloid fracture
Deformity of the wrist, causing it to look crooked and bent.
Your wrist is in great pain.
Your wrist, arm, or hand is numb.
Your fingers are pale.

Diagnosis of Monteggia Fracture

Diagnosis can be made upon the interpretation of anteroposterior and lateral views alone.^[rx]

The classic ulnar styloid fracture has the following characteristics:^[rx]

Transverse fracture of the ulnar styloid fracture
dorsal displacement and dorsal angulation, together with radial tilt^[rx]

Other characteristics^[rx]^[rx]

Radial-ulnar styloid fracture shortening
Loss of ulnar inclination≤
Radial angulation of the wrist
Comminution at the fracture site
Associated fracture of the ulnar styloid process in more than 60% of cases.

Differential Diagnosis/ Associated Injuries

Scapholunate ligament tear
Median nerve injury
TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
Compartment syndrome
Ulnar styloid fracture
DRUJ (Distal Radial Ulnar Joint) Instability
Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for ulnar styloid fracture must include two views-a postero-anterior (PA) view and lateral view.[rx]
The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Monteggia Fracture

Treatment available can be broadly

Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your shoulder area, then get medical care immediately. Ulnar styloid fracture causes significant pain in the front part of your shoulder, closer to the base of your neck. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness and tingling in the arm/hand.
Apply ice to your fractured clavicle – After you get home from the hospital (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured clavicle in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your clavicle for 15 minutes three to five times daily until the soreness and inflammation eventually fades away

Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your arm and shoulder in all different directions. Don’t aggravate the ulnar styloid so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light calisthenics and then progress to holding light weights (five-pound weights to start). Your ulnar styloid needs to move a little bit during the later phases of the injury to stimulate complete recovery.
Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
Get a supportive arm sling – Due to their anatomical position, an ulnar styloid fracture can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. A figure-eight splint wraps around both shoulders and the base of your neck in order to support the injured shoulder and keep it positioned up and back. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body. You’ll need to wear the sling constantly until there is no pain with arm movements, which takes between two to four weeks for children or four to eight weeks for adults.
Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder and upper chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and shoulder movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements and flexibility
Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a distal radius locking plate, coracoclavicular screws, Knowles pin fixation.
Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vicryl tape, dacron arterial graft for coracoclavicular ligament reconstruction.

Rest your shoulder

Once you’re discharged from the hospital in an arm sling, your top priority is to rest your shoulder and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the fractured clavicle.
Athletes in good health are typically able to resume their sporting activities within two months of breaking they’re ulnar styloid depending on the severity of the break and the specific sport.
Sleeping on your back (with the sling on) is necessary to keep the pressure off your shoulder and prevent stressing the clavicle injury.

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Eat nutritiously during your recovery

All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including ulnar styloid. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your clavicle. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.

Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

Physical therapy

Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury. After an ulnar styloid, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-up care

You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

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Breathing Exercise

To elevate breathing problem or remove the lung congestion.

Medications

Medication can be prescribed to ease the pain.

Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
Muscle Relaxants – These medications provide relief from associated muscle spasms.
Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, naproxen
Calcium & vitamin D3 – to improve bones health and healing fracture.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
Dietary supplement -to remove general weakness & improved health.
Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion in sever case.

Surgery

The evidence for different types of surgery for breaks of the middle part of the clavicle is poor as of 2015.^[10]

Surgery is considered when one or more of the following conditions present.

Comminution with separation (bone is broken into multiple pieces)
Significant foreshortening of the clavicle (indicated by shoulder forward)
Skin penetration (open fracture)
Associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
Nonunion after several months (3–6 months, typically)
Displaced distal third fractures (high risk of nonunion)

Open reduction and internal fixation. This is the procedure most often used to treat ulnar styloid fracture fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

Plates and screws – After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone. After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.
Pins or screws – Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
Precontoured locking plates
Hook plate
Distal radius plates
Ulnar styloid fracture screws
Flexible coracoclavicular fixation
Arthroscopic treatment
Intra-medullary fixation
Tension band fixation

Closed Reduction and Casting

All fractures characterized by minor comminution, without or with minimal displacements can be considered for closed reduction and cast immobilization. Mainly type I and type IIA Melone’s fracture can be managed conservatively. The fracture should be kept under closed observation to look for any re-displacement.
Despite the widespread acceptance of immobilization in a plaster cast, questions remain regarding the optimum position, the duration of immobilization and the need to extend the cast proximal to the ulna. No clear consensus exists as to the best position for immobilizing the wrist in plaster. Sarmiento et al.[rx] advocated immobilization in a position of supination to decrease the deforming force of the brachioradialis, which may cause loss of reduction.

Pins and Plaster Technique

Placement of pins in the metacarpals and forearm was initially advocated by Bohler in 1923, but it gained popularity after the report by Green, who showed good or excellent results in 86% of his patients.[rx]
However, he noted a high incidence of minor or major complications, one-third of which were related to pin site only. Other researchers also noted that one-third of the complications were related to pins and 16% of the patients needed reoperation for complications.[rx]

Percutaneous Pinning

Extra-articular fractures of the distal end of the ulna with extensive comminution or the fractures that have no more than two articular fragments, in which anatomical reduction is obtainable, are amenable to percutaneous pinning of the fracture fragments and application of a plaster cast. A single pin placed through the radial styloid as a means of stabilizing the displaced fracture fragment was first suggested by Lambotte in 1908.[rx,rx]

External Fixation

External fixation is generally accepted as superior to plaster immobilization in the young patients with an intra-articular comminuted fracture of the distal radius. Other indications for external fixation include some unstable extra-articular fractures with significant comminution and failure to maintain reduction after an initial attempt at closed management in a cast, certain situations of multiple trauma, the presence of dysfunctional contralateral limb, severe open fractures with significant soft tissue injury and neurovascular compromise, and bilateral injuries.[rx]

Limited Open Reduction

In intra-articular fractures that have more than 2 mm of displacement, the radio-carpal joint may be incongruent despite adequate attempts at reduction. The incongruency usually involves the lunate part of the distal end of the radius.
The ulna styloid process and scaphoid facet are more amenable to reduction through ligamentotaxis or by manipulation and reduction.
A new technique of combining external fixation with open reduction of the displaced lunate fossa through a small, longitudinal incision and elevation of the impacted fragment without direct visualization of the surface of the joint has been described.[rx]

Open Reduction and Internal Fixation

One of the recent advances in the treatment of distal ulna fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.

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Arthroscopic-Assisted Fracture Reduction

Intra-articular fractures of the radius can be arthroscopically assessed, and reduction of the particular components and assessment and repair of ligamentous injury can then be undertaken.[rx,rx,rx] The ideal timing for arthroscopically assisted distal radius surgery is 3 to 7 days after injury.

Rehabilitation Guideline for Non-Operative/Conservative rehabilitation ^[rx]

Acute Stage (0-8 weeks)

Goals

Protection with short-arm cast
Control pain and edema
Maintain range in digits, elbows, shoulder

Interventions

AROM and PROM of digits, elbow, shoulder
Elevation of hand and digits to control edema
Cast removal between 6-8 weeks

Sub Acute Stage

Goal

Control pain and edema (TENS, ice)
Increase ROM
Increase activities of daily living (ADLs)

Interventions

AROM and PROM of digits, elbow, shoulder
AROM wrist flexion/ extension, forearm supination/ pronation
PROM of low load and prolonged stretch

Settled Stage

Goals

Regain full ROM
Begin strengthening
Return to activity

Interventions

Continue all ROM exercises
Progress to the strengthening of all joints^[rx]

Rehabilitation Guideline for External Fixation by Pho et al

Acute Stage (1-6 weeks)

Goals

Control pain and edema (TENS, ice)
Protect surgical site
Maintain ROM of digits, elbow, shoulder

Interventions

Elevation
AROM of digits, elbow, shoulder
AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

Goal

Protect fracture site
Control pain and edema (TENS, ice)
ROM of involved and uninvolved joints

Interventions

AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

Goal

Regain full ROM
Begin strengthening
Increase tolerance to ADLs

Interventions

ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
PROM of low load and prolonged stretching of wrist motions
Grip strengthening
ADL training within tolerance^[rx]

Cryotherapy

Cryotherapy is an effective modality for controlling edema in the acute phase after trauma and during rehab due to its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid^[rx]. Cryotherapy can also be combined with compression and elevation in the treatment of edema.^[rx]
To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post application.^[rx]Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.^[rx] Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobulinemia, Cold urticaria.^[rx]

Electrical Stimulation

The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.^[rx]
Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.^[rx]
The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.

Supervised Active rehabilitation program used in Study

ISOMETRIC EXERCISE

Wrist flexors and extensors

ACTIVE RANGE OF MOTION EXERCISE

Assisted stretch to forearm flexors and extensor musculature and radial/ulnar deviation
Weight-bearing wrist extension exercise(hand on the table with the patient leaning forward on them) to patient tolerance
Active stretch to shoulder girdle and rotator cuff musculature
Active stretch to elbow flexor and extensor musculature

INTRINSIC HAND MUSCLE EXERCISE

Thumb/digit opposition
Repetitive squeezing of therapy
repetitive towel wringing exercise

STRENGTHENING ROUTINE

Biceps curl with 1,5-2 pound weights bilaterally
Shoulder abduction, flexion and extension reps with 2-pound weights bilaterally
Repetitive squeezing of a rubber ball in affected wrist
Flexion and extension of wrist using 1,5-pound weights increasing as tolerated

FUNCTIONAL ACTIVITIES

Patient is encouraged to resume pre-accident activities that involve the affected extremity (eg. writing, typing, cooking, etc.)

Complications of Monteggia Fracture

There were no major complications such as neurovascular injury, infection, or impaired wound healing. Surgery-related complication at 2-year follow-up included nonunion in 3 patients (11%),

DRUJ subluxation in 3 patients (11%),
implant migration in 4 patients (14%),
Radiographic resorption of the ulnar styloid in 4 patients (14%).
Radiographic nonunion was noted in 1 patient in group A (8%) and 2 in group B (13%). Residual DRUJ subluxation was noted in 3 patients; all were in group B (20%).
Partial or complete radiographic resorption of the ulnar styloid was found in 1 patient in group A (8%) and 3 in group B (20%).
Implant migration was noted in 1 patient in group A (8%), and 2 in group B (13%).
Subsequent removal surgery due to implant irritation occurred in 13 patients (46%), with 4 in group A (31%) and 8 in group B (53%).
A total of 11 patients (39%) with surgery-related complications included 5 (38%) in group A and 12 (80%) in group B, with a significant difference

There are risks associated with any type of surgery. These include

Nonunion (1-5%)
Infection (~4.8%)
4% in the surgical group develop adhesive capsulitis requiring surgical intervention
Bleeding
Problems with wound healing
Blood clots
Damage to blood vessels or nerves
Reaction to anesthesia
Hardware prominence
Malunion with cosmetic deformity
Restriction of ROM
Difficulty with bone healing
Hardware irritation
Fracture comminution (Z deformity)
Fracture displacement
Increased fatigue with overhead activities
Dissatisfaction with appearance
The difficulty with shoulder straps, backpacks and the like
~30% of patient request plate removal
Superior plates associated with increased irritation
Superior plates associated with increased risk of subclavian artery or vein penetration