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 Table of Contents  
CASE REPORTS
Year : 2022  |  Volume : 37  |  Issue : 2  |  Page : 95-99

A rare case of comminuted fracture shaft humerus with intercondylar extension with monteggia dislocation and its management: A case report


Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission17-May-2022
Date of Acceptance06-Sep-2022
Date of Web Publication19-Oct-2022

Correspondence Address:
Arulkumar Nallakumarasamy
Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_9_22

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  Abstract 

Background: Monteggia fracture-dislocation is a rare entity in adults with an incidence of less than 1%. However, a combination of fracture shaft humerus with distal intraarticular extension along with monteggia fracture-dislocation in an ipsilateral upper limb is very hard to find and manage, owing to its rare presentation. Materials and Methods: In this report, we detailed the surgical management of comminuted fracture(splinter) of shaft humerus with intercondylar extension AO C2 with typeII monteggia fracture-dislocation with the usage of proper implants in a 25year old male with a 3 year follow-up. Result: It shows that the fracture united well at the appropriate period and the elbow range of movements was satisfactorily ranging from 20° to 130° with no limitation in supination and pronation. Conclusion: Such complex elbow injuries are difficult to find in the literature. This study addresses the proper surgical management in terms of approach and usage of appropriate implants to improve the long-term functional outcome when dealing with such injuries.

Keywords: Anatomical plates, complex humerus fracture, rare monteggia variant, triceps-split approach


How to cite this article:
Nallakumarasamy A, Manjhi B, Sinha S, Arya R, Singh LP. A rare case of comminuted fracture shaft humerus with intercondylar extension with monteggia dislocation and its management: A case report. J Bone Joint Dis 2022;37:95-9

How to cite this URL:
Nallakumarasamy A, Manjhi B, Sinha S, Arya R, Singh LP. A rare case of comminuted fracture shaft humerus with intercondylar extension with monteggia dislocation and its management: A case report. J Bone Joint Dis [serial online] 2022 [cited 2022 Nov 29];37:95-9. Available from: http://www.jbjd.in/text.asp?2022/37/2/95/358804




  Introduction Top


Monteggia fracture was first described by Giovanni Battista Monteggia in 1814 as a fracture of the proximal third of the shaft of the ulna with subluxation or dislocation of the radial head.[1] Elbow injuries are common in children and young adults forming around 10–40% of total injuries. Intraarticular fractures of the distal humerus comprise 0.5%-7% of all fractures and about 30% of elbow fractures. Simultaneous occurrence of these injuries is extremely rare in the literature.


  Case Description Top


A 25year old male fell on his outstretched left hand from his bike. He was presented to the emergency room after 3 hours of injury complaining of severe pain, gross swelling and deformity in his left elbow and lower arm with restricted range of motion. On examination, there was no open wound, no distal neurovascular deficit and no features of compartment syndrome. There was no other systemic injury and the patient’s vitals were stable.

Radiographs showed a comminuted fracture(splinter) of shaft humerus with intercondylar extension with fracture of the shaft of the ulna at the proximal and middle third junction with posterior angulation along with a posteriorly dislocated radial head as shown in [Figure 1].
Figure 1: X-ray left elbow with arm AP and Lateral

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The limb was splinted with posterior slab support and a CT scan was done as shown in [Figure 2]. After 3 days the swelling subsided and the patient was posted for surgical intervention after pre-anaesthetic fitness.
Figure 2: CT image left elbow

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Open reduction and internal fixation under general anaesthesia were done. An extensile posterior approach in the lateral decubitus position was used to address both fractures simultaneously. The radial and ulnar nerves were explored and protected. Internal fixation of a long butterfly fragment of the humerus shaft with 3 lag screws and supracondylar fragment with 1 lag screw was done. Intercondylar compression was achieved with one (4 mm) cannulated cancellous screw. The lateral column and shaft humerus were fixed with a 10hole 3.5 mm lateral metaphyseal plate (neutralizing plate) and orthogonal plating with a medial plate (3.5 mm anatomical locking plate) spanning the medial column fracture was done. Elbow was exposed posteromedially and ulnar length was restored with compression plating with a 6 hole 3.5 mm limited contact dynamic compression plate. The radial head got reduced spontaneously and was found to be stable as shown in [Figure 3]. An above elbow long posterior slab support is given postoperatively for soft tissue healing.
Figure 3: Immediate post operative xray

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The post-operative period was uneventful with no sign of wound infection, and radial and ulnar nerve injury. After 7 days of elbow immobilization active range of motion was started.

At 6 weeks follow-up patient had improved range of motion and radiographs demonstrated callus formation with radial head in anatomical reduced position as in [Figure 4].
Figure 4: At 6 weeks follow-up

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At 36 months follow-up, radiographs revealed a union of fractures of humerus and ulna and reduced radial head as in [Figure 5]. Clinically patient had flexion contracture of 20° with further flexion to 130°, supination to 90°and pronation to 85° with minimal restrictions of daily activities as in [Figure 6].
Figure 5: At 36 months follow-up

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Figure 6: Clinical images at 36 months follow-up

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  Discussion Top


Concomitant occurrence of Monteggia fracture-dislocation and fracture of the distal humerus fracture is an extremely rare injury in adults.[2] Our review of the literature revealed only four articles reporting six cases of ipsilateral intercondylar humerus fractures and Monteggia fracture-dislocations in adults,[3],[4],[5],[6] in these cases, they have managed the fracture using DCP/LCDCP for ulna and reconstruction plates for the distal humerus.

We report that our patient had Bado type 2 Monteggia variant with concomitant ipsilateral comminuted(splinter) fracture of the shaft humerus with intercondylar extension AO type C1 which represents a complex and intrinsically unstable fracture pattern. This high energy complex injury represents an uncommon Monteggia variant which was not previously described in the literature. The injury most probably resulted from elbow hyperextension with axial loading with the abducted arm in an attempt to break the fall.

The exact mechanism of this kind of injury is very difficult to determine, one of the most widely accepted theories is that isolated Monteggia fracture-dislocation is caused by hyper-pronation as described by Evans.[7] However, Tompkins described that this kind of injury is caused mostly by hyperextension of the elbow.[8]

Anatomical reduction of the distal humerus articular surface and rigid fixation of the diaphysis is the prerequisite for early rehabilitation. Previously reported cases used 3.5 mm reconstruction plates for medial and lateral column fixation of the distal humerus while in our case we used a 3.5 mm (10 holes) lateral metaphyseal locking plate for the reconstruction of the lateral column and spanning the shaft humerus fracture whereas medial column was fixed with 3.5 mm medial anatomical locking plate which added more stability and rigidity for early physiotherapy. We used a lag screw for the intercondylar extension of distal humeral fracture to achieve compression of the two intraarticular fragments rather than a positional cortical screw. The radial head was able to be get reduced after those fracture fixations.

We employed the extensile posterior approach to address both the fractures simultaneously. Olecranon osteotomy was not performed for the distal humeral fracture because of the proximal one-third ulnar fracture. The triceps splitting approach allows excellent exposure for shaft humerus and radial nerve exploration with limited access to the lower end of the humerus but adequate for simple intraarticular fracture without having to osteotomized the olecranon process, thus avoiding the complications related to the olecranon osteotomy.[9] The functional outcome was very good with acceptable flexion contracture.


  Conclusion Top


Monteggia fracture-dislocations associated with an ipsilateral distal humeral fracture are extremely rare injuries in adults. Our case report is unique as we have not identified similar injuries reported in the literature. The mechanism of injury probably involves a combination of hyperextension, hyper pronation and axial loading.

A long-term favourable outcome was achieved due to the early detection, full understanding of the injury, proper surgical intervention with strong internal fixation, as well as early functional exercise.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be g uaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Peltier LF Eponymic fractures: Giovanni battista monteggia and monteggia’s fracture. Surgery 1957;42:585-91.  Back to cited text no. 1
    
2.
Arora S, Sabat D, Verma A, Sural S, Dhal A An unusual monteggia equivalent: A case report with literature review. J Hand Microsurg 2011;3:82-5.  Back to cited text no. 2
    
3.
Beredjiklian PK, Bozentka DJ, Ramsey ML Ipsilateral intercondylar distal humerus fracture and monteggia fracture-dislocation in adults. J Orthop Trauma 2002;16:438-40.  Back to cited text no. 3
    
4.
Pankaj A, Malhotra R, Bhan SMonteggia fracture-dislocation with intercondylar fracture of the ipsilateral humerus: An unusual Monteggia variant. Injury 2005;36:51-4.  Back to cited text no. 4
    
5.
Wang YH, Han QL, Tao R, Sun FR Ipsilateral intercondylar distal humeral fracture and bado type Ii monteggia lesion in an adult: A case report. Orthop Surg 2010;2:161-4.  Back to cited text no. 5
    
6.
Byanjankar S, Sharma JR, Shrestha R, Panthi S, Dwivedi R, et al. Ipsilateral distal humerus intercondylar fracture with radial nerve palsy and monteggia fracture dislocation in adult. MOJ Orthop Rheumatol 2017;9:00368.  Back to cited text no. 6
    
7.
Evans EM Pronation injuries of the forearm, with special reference to the anterior monteggia fracture. J Bone Joint Surg Br 1949;31B:578-88, illust.  Back to cited text no. 7
    
8.
Tompkins DG The anterior monteggia fracture: Observations on etiology and treatment. J Bone Joint Surg Am 1971;53:1109-14.  Back to cited text no. 8
    
9.
Ziran BH, Smith WR, Balk ML, Manning CM, Agudelo JF A true triceps-splitting approach for treatment of distal humerus fractures: A preliminary report. J Trauma 2005;58:70-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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