A fifty-three-year-old right-hand-dominant civil engineer sustained a fall from a curb onto his outstretched left hand six months prior to presentation to us (Figs. 1-A and 1-B). At that time, the patient was diagnosed as having a Bado type-I Monteggia fracture and he was treated acutely with open reduction and internal fixation of the ulnar fracture and closed reduction of the radial head dislocation. To our knowledge, the wrist had not been examined. Following surgery, the patient continued to have forearm, elbow, and wrist pain as well as limitation in forearm rotation. Three months after the initial surgery, the initial treating surgeon recommended excision of the radial head as treatment for the rotation contracture of the forearm.
The patient presented to us for a second opinion six months after injury. He had persistent elbow pain that was laterally based, limitation of forearm rotation, and wrist pain. On physical examination, elbow range of motion was from 0° of extension to 90° of flexion. The forearm could be rotated to 80° of pronation and 0° of supination. The wrist range of motion was from 60° of extension to 45° of flexion. There was mild soft-tissue swelling at the distal radioulnar joint and mild tenderness to palpation. There was some laxity of the distal radioulnar joint, but this was believed to be symmetrical with that measured in the contralateral wrist. In addition, the patient exhibited weakness on resisted extension of the thumb and all digits. Sensibility to light touch was normal throughout the forearm, wrist, and hand. Electromyography revealed fibrillation potentials in the muscles that were innervated by the posterior interosseous nerve. Radiographs of the forearm revealed an anterior dislocation of the radial head and delayed union of the ulnar shaft fracture. Radiographs of the wrist were not made.
The patient underwent revision open reduction and internal fixation of the ulnar fracture with iliac crest bone-grafting and open reduction of the radial head dislocation. Within the radiocapitellar joint, there were no interposed structures blocking reduction. Intraoperative fluoroscopy in multiple planes revealed that the radiocapitellar joint was reduced.
Two weeks following surgery, the patient continued to experience pain in the lateral part of the elbow, and there was crepitus with forearm rotation, limitation of forearm rotation, and minimal but persistent wrist pain. He had the sensation that the radial head was dislocating at the elbow during active elbow and forearm motion. There was tenderness to palpation over the interosseous membrane. Radiographs revealed anterior dislocation of the radial head (Fig. 2-A) and dorsal dislocation of the ulnar head (Fig. 2-B). Magnetic resonance imaging of the forearm was acquired, which revealed rupture of the interosseous membrane proximal and distal to the ulnar fixation plate and dorsal dislocation of the distal radioulnar joint (Fig. 2-C).
Three weeks following the revision surgery, the elbow and wrist were examined with the patient under general anesthesia. With the forearm held in supination, the radiocapitellar and distal radioulnar joints were stable during flexion and extension of the elbow. However, with the forearm held in pronation, the radial head dislocated anteriorly at the proximal radioulnar joint. At the distal radioulnar joint, the distal aspect of the ulna was reduced with supination but underwent dorsal dislocation with pronation. Therefore, with the forearm in full supination, the distal radioulnar joint was reduced and pinned with use of two 2-mm Steinmann pins, with each pin engaging four cortices (Figs. 3-A and 3-B). Distal radioulnar joint reconstruction was not performed. The radiocapitellar joint remained stable during flexion and extension of the elbow. Postoperatively, active range-of-motion exercises were permitted with the elbow in flexion and extension and with the wrist fixed in supination.
Six weeks later, the Steinmann pins were removed and the elbow and wrist were examined with the patient under general anesthesia. Intraoperative fluoroscopy revealed that both the radiocapitellar joint and the distal radioulnar joint remained stable and reduced during full flexion and extension of the elbow and during forearm rotation.
One year following the last operation, elbow range of motion was from 0° of extension to 135° of flexion. The forearm could be rotated to 90° of pronation and 80° of supination. The wrist range of motion was from 80° of extension to 70° of flexion. The patient had no functional limitations or pain. Subjectively, he had full recovery of strength in the muscles that were innervated by the posterior interosseous nerve. Radiographs revealed a healing ulnar shaft fracture, a reduced radiocapitellar joint, and a reduced distal radioulnar joint (Figs. 4-A through 4-D).