Intramedullary ulnar fixation for the treatment of monteggia fracture

Background: Although many pediatric Monteggia fractures can be treated nonoperatively, the presence of any residual radiocapitellar subluxation following ulnar reduction mandates a more aggressive approach to restore and maintain ulnar length. In younger children, restoration and maintenance of ulna length may be achieved through intramedullary fixation of the ulnar shaft. Description: A Steinmann pin or flexible intramedullary nail is introduced percutaneously through the olecranon apophysis and advanced within the medullary canal to the ulnar fracture site. If necessary, the ulnar length and alignment are then restored by either a closed reduction or open reduction. The pin or nail is advanced across the fracture site into the distal fracture fragment and then advanced to a point just proximal to the distal ulnar physis. Once restoration of normal radiocapitellar alignment is verified fluoroscopically, the pin is bent and cut outside of the skin and a cast or splint is applied. Alternatives: Closed reduction and cast immobilization is a well-accepted form of treatment for a Monteggia fracture. If ulnar length and alignment along with an anatomic reduction of the radiocapitellar joint can be achieved in this fashion, surgery can be avoided, but close radiographic follow-up is recommended to assess for loss of alignment with subsequent radial-head subluxation. Open reduction and internal fixation with use of a plate-and-screw construct can achieve similar results to intramedullary fixation and should be considered for length-unstable fractures and those in which an appropriately sized intramedullary implant fails to maintain adequate ulnar alignment. If plastic deformation of the ulna is present with residual radiocapitellar subluxation following reduction of the ulnar diaphysis, consideration should be given to elongating the ulna through the fracture site with use of plate fixation in order to allow reduction of the radial head. Rationale: Intramedullary fixation provides several benefits over open reduction and plate fixation for these injuries. In general, treatment can be rendered with a shorter anesthetic time, less scarring, and without the concern for symptomatic retained hardware associated with plating along the subcutaneous boarder of the ulna shaft.