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Proximal Ulna Fractures
Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington
Hospital
Visiting Professor, Manchester University
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Overview
Olecranon fractures
Monteggia fracture dislocations
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Undisplaced
Comminuted
Simple
Displaced Unstable
Mayo Classification
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Minimising complication / re-operation
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Anatomical reduction
Bicortical penetration
Subchondral placement
Patient selection
Fracture personality
Bone quality
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Alternatives
Dorsal plating (30% re-operation v 50% with TBW)
Parallel plating
Intramedullary device
Suture repair
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Indications
Simple transverse or stable oblique fractures
Osteotomy
Very proximal fractures
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Isolated Olecranon Fracture
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Super elderly / Low demand? Dementia? Unfit?
Non-operative
Is ulnohumeral joint stable?
Simple transverse/ stable oblique
Suture repair
Comminuted
YES NO
Plate Fixation(+/- suture repair)
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Transolecranon Monteggia Fracture Dislocations
Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint
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Bado Classification
Anterior
Posterior
Lateral
Radial diaphyseal fracture
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Jupiter Classification of Type II Fractures
IIa Coronoid level
IIb Metaphyseal/Diaphyseal junction
IIc Distal to coronoid
IId Fracture extending to distal 1/2 ulna
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Ring Classification
Type I Apex anterior diaphyseal ulna fracture with anterolateral dislocation of radiocapitellar and PRUJ
Type II Metaphyseal buckle fractures with anterolateral radiocapitellar dislocation (paediatric only)
Type III Apex posterior ulna fractures with posterior dislocation radiocapitellar joint
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Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttress radial head lateral ligament complex
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Bado I, Ring I
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Jupiter IIb, Ring III
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Jupiter IIa, Ring III
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Complication
Fixation failure - osteoporosis common
Ulna non-union
Ulno-humeral instability
Radio-ulna synostosis
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Outcome Monteggia Fractures
Anterior (Bado I, Ring I) good outcomes less likely to involve radial head or coronoid
Posterior (Bado II, Ring III) poor worse if unstable coronoid fracture present (Jupiter IIa)
coronoid / radial head fractures and re-operation associated with poorer outcome.
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Summary
Tension band wiring > 50% re-operation
Newer techniques reduce secondary surgery
Ulna alignment and coronoid key to success in Monteggia fractures
Recommended