Open reduction and internal fixation of Monteggia fractures

Ulnar fractures are common. Due to the cause of violence and the posture of the injured limb and the state of muscle contraction, a double fracture or a single fracture of the radius and ulna can occur. Among them, it can occur in different planes. Upper 1/3 of the ulnar shaft fracture combined with humeral head dislocation (Montaggia fracture). The lower third of the humerus fracture combined with the lower ankle joint dislocation (Galeazzi fracture). Among them, the double fracture of the ulnar and radial bone accounted for 5.41% of the total fracture, which was the third. The fracture of the tibia was 4.23%, which was the fifth. The ulnar fracture accounted for 1.05% and was the 17th. The Monteggia fracture accounted for 0.63% and was the 38th. Gai's fracture accounted for 0.35% and was the 50th. Due to the rotational function of the forearm, in the event of a fracture, there is a severe rotational shift in addition to overlap and lateral displacement. Therefore, the requirements for resetting are higher. If the manual reset is not satisfactory, it is difficult to achieve the recovery of the expected function, that is, the indication of surgical reduction. Treatment of diseases: ulnar and radial fractures Indication 1. Adult fresh Monteggia fractures, especially those with failed manual reduction, should be treated with open reduction at an early stage. 2. Children's Monteggia fracture, after repeated maneuver reduction, the humeral head can not be reset, the annular ligament may be clipped in the upper ankle joint, need to open the reduction to repair or reconstruct the annular ligament. 3. Adult old Monteggia fracture with ulnar fracture non-union, feasible ulnar incision and reduction bone graft, radial head resection. Preoperative preparation Internal fixation equipment should be prepared before surgery. Usually, the upper 1/3 of the ulna is fixed with a triangular intramedullary needle. It is advisable to prepare several intramedullary needles of different outer diameters, and the length should reach the distal end of the ulna. Surgical procedure Incision Surgery is performed under the balloon tourniquet. The skin incision originates from the lower outer side of the olecranon, along the lateral edge of the ulna, and ends at the middle 1/3 junction of the ulna and is about 8 cm long. 2. Reveal the fracture Cut the skin, subcutaneous tissue and deep fascia, and then cut the periosteum along the outer edge of the ulna, and remove the subperiosteum. The elbow muscle, the ulnar wrist extensor muscle and the supinator muscle were pulled to the lateral side, and the deep flexor muscle was pulled to the medial side to reveal the posterior lateral joint capsule and fracture end of the elbow joint. 3. Fracture internal fixation Remove blood from the fracture end. Usually the internal fixation of the fracture can be fixed by steel plate or intramedullary nail. The intramedullary needle is fixed by bending the elbow joint to 90°. A triangular intramedullary needle is retrogradely inserted from the proximal medullary cavity of the fracture, and a small opening is made at the olecranon to allow the intramedullary needle to pass through the skin. Then the bone fracture is used to reduce the ulnar fracture, and then the intramedullary needle is inserted into the distal medullary cavity, and the needle tail is shortly bent and placed outside the skin. For patients with nonunion, it is necessary to remove the hardened bone end and open the medullary cavity and bone graft. Check the humeral head for a reset. When the ulnar fracture is repositioned and fixed, some patients with humeral head can be reset by themselves. If it is not reset, the humeral head can be pressed backwards (stretched) to reset it. Then bend the elbow joint to 60 ° ~ 70 °, the humeral head can be more stable. If the humeral head is still not stable, an annular ligament repair is required. 4. Repair or reconstruct the annular ligament The anterior and posterior joint capsules of the elbow joint are cut longitudinally and retracted outward to reveal the humeral head and neck. Check the injury of the annular ligament. If the injury is not serious, the annular ligament should be sutured with the non-absorbent line or the absorbable line after the reduction of the humeral head. If the tear is severe or has been torn off, the entire annular ligament is removed, the humeral head is reset, and 1/3 aponeurosis of the triceps tendon is cut or a 10 cm × 1 cm deep fascia strip is cut on the dorsal side of the forearm. Distal, but not cut off the proximal end, so that it becomes a sacral aponeurosis or fascia strip, the fascia strip is wound around the posterior medial aspect of the humerus neck, and then wound to the posterolateral side in front of the neck, the fascia is smooth Face the humeral neck to reconstruct the annular ligament. 5. Suture incision The wound was flushed with isotonic saline, and the ulnar periosteum, the elbow muscle, the ulnar wrist extensor and the supinator muscle were sutured. The subcutaneous tissue and skin are then sutured. complication The main complication of the upper 1/3 of the ulnar fracture is nonunion. Therefore, it has been suggested that even for fresh fractures, bone grafting can be performed at the same time to prevent the occurrence of nonunion. For patients with existing nonunion, the principle of nonunion should be strictly followed. In addition, external fixation of gypsum should be strictly performed until the fracture or bone graft is healed.