1 Principles top
Anatomical reduction and stable fixation of both fractures are desirable for 21-A3 fractures. Begin by exposing both fractures.
Usually, the ulnar fracture will be fixed first. Malreduction of the first of the fractures will usually impede reduction of the other. The specific fracture fixation is determined by the character of each fracture and is discussed below.
Rare type IV Monteggia fractures (complete dislocation of the radial head relative to capitellum) must be recognized, because both dislocation and fracture must be reduced.
Lag screw principles
Lag screws must be inserted as perpendicularly as possible to the fracture plane, to produce compression without displacement of the fracture. Lag screw osteosynthesis alone is not able to resist functional loading. Therefore, a protection plate must be added to allow early mobilization.
Whenever possible (considering soft-tissue condition, fracture configuration, associated radial head fracture etc.), position the plate so an appropriate lag screw can be inserted through it. This offers improved stability.
The plate can be applied either on the lateral, the medial, or the posterior aspect of the ulna. The optimal position depends on the fracture configuration and associated injuries.
When placing the plate in the posterior aspect, make sure that the proximal screws do not protrude into the joint.
In a medial or lateral plate position all screws can be inserted bicortically, thus having better purchase.
To improve proximal stability (short fragment and/or osteoporosis) a posterior plate can be curved around the olecranon and anchored with an axial screw.
2 Reduction and preliminary fixation top
Cleaning of the fracture site
Expose the fracture ends with minimal soft tissue dissection off the bone.
Remove hematoma and irrigate.
Check elbow stability.
Reduce the fracture with the help of small pointed reduction forceps and provisionally fix with forceps or K-wires.
3 Plate preparation topenlarge
Choosing the right plate
Use a six or seven hole plate, depending on the fracture configuration. Usually, three screws in each fragment provide sufficient stability.
The plate may be a small fragment dynamic compression plate (3.5 DCP), or limited contact dynamic compression plate (LC-DCP), or a specific proximal ulna prebent plate.
In osteoporotic bone, a locking plate (LCP) plate may be used.
Prebending and contouring
Prebend the plate according to the surface anatomy of the ulna.
Contouring of the plate is achieved with bending irons or a bending press.
4 Lag screw insertion topenlarge
Drill a 3.5 mm gliding hole for the lag screw into the posterior cortical bone of the distal fragment.
Insert the 2.5 mm drill sleeve into the gliding hole until it reaches the far cortical bone.
Now drill the far cortex with the 2.5 mm drill bit.
Countersink the cortex of the distal fragment in order to have more surface area to distribute the force caused by the head of the lag screw.
Measure the depth of the hole with the hook of the depth gauge pointing proximally.
Tap the far cortex with the 3.5 mm cortical tap and protection sleeve.
Always measure before tapping so as not to disturb the tapped thread.
Lag screw insertion
Closely observe the compression effect on the fracture line while tightening the lag screw.
The reduction forceps should be removed just before the final tightening of the screw.
5 Protection plate topenlarge
Apply the contoured plate and fix it to the bone with three screws proximal and three screws distal to the fracture in neutral position to protect the lag screw.
An interim assessment of alignment, stability and range of motion is advisable after fixation of the ulna. Check results with image intensifier or x-ray.
6 Final assessment topenlarge
Final assessment, after fixing both radius and ulna, includes range of motion in pronation, supination, flexion and extension. Fixation should be stable and crepitus or restricted motion should be absent. Radiocapitellar and ulnohumeral joints should remain located through a full range of motion.
Check results with image intensifier or x-ray.