^DEFINITION

^{Fracture of the olecranon process is common, usually displaced, and nearly always treated operatively. Important injury characteristics include displacement, comminution, and subluxation or dislocation of the elbow, and all are accounted for in the Mayo classification (FIG 1).6}

^{Fracture-dislocations of the olecranon can be anterior (transolecranon) or posterior (the most proximal type of posterior Monteggia according to Jupiter and colleagues3) in direction.2, 3, 9, 10}

^{The eponym Monteggia is best applied to metaphyseal or diaphyseal proximal ulnar fracture associated with dislocation of the proximal radioulnar joint.}

^{The Bado classification of Monteggia lesions with Jupiter subclassification of type II fractures is shown in Table 1.}

^{Equivalent injuries in adults}

^{Variable pathology that is felt to be equivalent to injuries classified by the Bado system}

^{Equivalent injuries do not always fall within the traditional definition of a Monteggia fracture in that they do not always have a concomitant radiocapitellar dislocation. Therefore, it can be argued that these injuries are not necessarily equivalent to Monteggia fractures.}

^{Type I and type II injuries are the only ones that have equivalent injury patterns.}

 

^ANATOMY

 

^{The greater sigmoid notch of the ulna is formed by the coronoid and olecranon processes and forms a nearly 180-degree arc capturing the trochlea.}

 

^{The region between the coronoid and olecranon articular facets is the nonarticular transverse groove of the olecranon, a common location of fracture and a place where precise articular reduction is not critical.}

 

^{The triceps has a broad and thick insertion from just superior to the point of the olecranon and the tip of the olecranon process that can be used to enhance fixation of small, osteoporotic, or fragmented fractures and can be split longitudinally, if needed, when applying a plate.}

 

^{The radioulnar articulation is stabilized by the triangular fibrocartilage complex (TFCC) at the distal radioulnar joint, the interosseous ligament in the midforearm, and the annular ligament at the proximal radioulnar joint (PRUJ).}

^{Fracture of the ulna with dislocation of the PRUJ disrupts the annular ligament, but typically, the other structures are spared.}

 

^{In a true Monteggia lesion (fracture-dislocation) of the forearm, the radial head dislocates anterolaterally from the PRUJ.}

^PATHOGENESIS

 

^{Fractures of the olecranon and proximal ulna can result from a direct blow to the point of the elbow or indirect forces during a fall on the outstretched hand.}

 

^{NATURAL HISTORY}

 

^{Stable nondisplaced or minimally displaced olecranon fractures are uncommon. The majority of olecranon fractures are displaced and benefit from operative treatment.}

 

^{The occasional untreated displaced simple olecranon fracture demonstrates a slight flexion contracture, some weakness of extension, no arthrosis, and little, if any, pain.}

 

 

 

 

^{FIG 1 • The Mayo classification of olecranon fractures accounts for the factors that will influence treatment decisions: displacement, comminution, and dislocation or subluxation of the articulations.}

 

 

²⁸³

 

 

^{Table 1 Bado Classification of Monteggia Lesions with Jupiter Subclassification of Type II Fractures}

 

Type

Description

Illustration

 

 

1. ^{Anterior dislocation of the radial head with fracture of the diaphysis of the ulna with anterior angulation of the ulnar fracture (most common type of lesion)}

    

    

    

    

2. ^{Posterior or posterolateral dislocation of the radial head with fracture of the ulnar diaphysis with posterior angulation of the ulnar fracture}

    

    

    

    

    

   ^{IIA Fracture at the level of the trochlear notch (ulnar fracture involves the distal part of the olecranon and coronoid)}

    

    

    

    

   ^{IIB Ulnar fracture is at the metaphyseal-diaphyseal junction, distal to the coronoid.}

    

    

    

    

    

   ^{IIC Ulnar fracture is diaphyseal.}

    

    

    

    

    

   ^{IID Comminuted fractures involving more than one region}

    

    

3. ^{Lateral or anterolateral dislocation of the radial head with fracture of the ulnar metaphysis}

 

 

^IV

^{Anterior dislocation of the radial head with a fracture of the}

^{proximal third of the radius and ulna at the same level}

 

 

 

 

^{Adapted from Bado J. The Monteggia lesion. Clin Orthop Relat Res 1967;50:717; Jupiter JB, Leibovic SJ, Ribbans W, et al. The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.}

 

²⁸⁴

 

^{In contrast, undertreated or poorly treated fracture-dislocations of the olecranon often lead to severe arthrosis and angulation of the arm under the influence of gravity.}

 

^{Even well-treated complex injuries are at risk for stiffness, heterotopic ossification, arthrosis, and occasionally nonunion.}

 

^{PATIENT HISTORY AND PHYSICAL FINDINGS}

 

^{Knowledge of the characteristics of the patient (age, sex, medical health) and the injury (mechanism, energy) will help the surgeon understand the injury and determine optimal treatment.}

 

^{First, the patient is assessed for life-threatening injuries (Advanced Trauma Life Support [ATLS] protocol) and any medical problems that may have contributed to the injury.}

 

 

^{A secondary survey is performed to identify any other fractures, ipsilateral arm injuries in particular. The skin is inspected for any wounds associated with the fracture.}

 

 

^{The pulses are palpated, capillary refill inspected, and an Allen test performed if necessary. Peripheral nerve function is assessed.}

 

^{Patients with high-energy injuries, particularly those with ipsilateral wrist or forearm injuries, are at risk for compartment syndrome. If the clinical examination is suggestive or unreliable (owing to problems with mental status), compartment pressure monitoring should be performed.}

 

^{IMAGING AND OTHER DIAGNOSTIC STUDIES}

 

 

^{Anteroposterior (AP) and lateral radiographs are used for initial characterization of the injury. Radiographs after reduction or splinting or oblique views can be useful.}

 

^{Computed tomography (CT) is useful for characterization of fracture-dislocations. In particular, three-dimensional (3-D)}

^{CT reconstructions can be useful for assessment of the coronoid and radial head.}

^{DIFFERENTIAL DIAGNOSIS}

^{Elbow dislocation}

^{Essex-Lopresti fracture-dislocation of the forearm (disruption of the interosseous ligament and or TFCC usually with fracture of the radial head)}

^{Fracture-dislocations of the elbow (“terrible triad” injury) Distal humerus fracture}

 

 

^{NONOPERATIVE MANAGEMENT}

 

^{Nonoperative management is appropriate for the rare fracture of the olecranon that is less than 2 mm displaced with the elbow flexed 90 degrees.}

 

^{Four weeks of splint immobilization followed by activeassisted mobilization of the elbow will usually result in a healed fracture and good elbow function.}

 

^{SURGICAL MANAGEMENT}

 

^{The vast majority of olecranon fractures are displaced and merit operative treatment.}

 

^{Transverse, noncomminuted fractures not associated with fracture-dislocation are treated with tension band wiring.4, 8}

 

^{Comminuted fractures and fracture-dislocations are treated with dorsal contoured plate and screw fixation.1, 2, 3}

 

 

^{The treatment of fracture-dislocations requires attention to the coronoid, radial head, and lateral collateral ligament.2, 9, 10, 11}

 

^{Fracture-dislocations of the forearm (anterolateral Monteggia injuries) is treated with anatomic realignment of}

^{the ulna and plate and screw fixation.10 Inadequate radiocapitellar alignment suggests residual ulnar angulation.}

 

^{Preoperative Planning}

 

^{The fracture characteristics that determine treatment are defined on radiographs and CT.}

 

^{Templating the surgery with tracings of the radiographs is a useful way of running through the surgery in detail before}

 

²⁸⁵

^{performing it, familiarizing oneself with the anatomy, anticipating problems, and ensuring that all of the implants and equipment that might be necessary are available.}

 

^Positioning

 

^{In most patients, a lateral decubitus position with the arm over a bolster or support is best.}

 

^{Some patients with fracture-dislocations that require both medial and lateral access may be positioned supine with the arm supported on a hand table.}

 

^{A sterile pneumatic tourniquet is used.}

^Approach

 

^{A dorsal longitudinal skin incision is used.}

 

^TECHNIQUES

• ^{Tension Band Wiring}

^{Reduction and Kirschner Wire Fixation}

 

 

^{Blood clot and periosteum are cleared from the fracture site to facilitate reduction. Limited periosteal elevation is performed at the fracture site to monitor reduction.}

 

^{A large tenaculum clamp is used to secure the fracture in a reduced position (TECH FIG 1A,B). A drill hole can be made in the dorsal cortex of the distal fragment to facilitate clamp application.}

 

^{Two 1.0-mm smooth Kirschner wires are drilled across the fracture site (TECH FIG 1C).}

 

^{If these are drilled obliquely from dorsal-proximal to volar-distal, they will exit the anterior ulnar cortex distal to the coronoid process, providing an anchoring point of cortical bone to limit the potential for pin migration.}

 

^{In anticipation of later impaction of the proximal ends of the wires, the Kirschner wires should be retracted 5 to 10 mm after drilling through the anterior ulnar cortex.}

 

 

 

^{TECH FIG 1 • A. A lateral radiograph with the arm in plaster shows a transverse, noncomminuted fracture of the olecranon. B. An open reduction is held with a fracture reduction forceps. C. Two 1-mm Kirschner wires are drilled obliquely across the fracture site so that they exit the anterior ulnar cortex distal to the coronoid process. (A,B: Copyright David Ring, MD.)}

^Wiring

 

^{The apex of the ulnar diaphysis just distal to the flat portion of the proximal ulna is drilled with a 2.0-mm drill, with or without prior subperiosteal dissection.}

 

^{When two wires are used, a second drill hole is made a centimeter more distal.}

 

^{If one wire is used, it should be 18 gauge. My preference is to use two 22-gauge stainless steel wires to limit the size of the knots, which may diminish implant prominence. The wires are passed through the drill holes. A large-bore needle can be used to facilitate passage of the wire through the drill hole (TECH FIG 2A).}

 

^{The two tension wires are each passed over the dorsal ulna in a figure-of-eight fashion, then around the Kirschner wires, and underneath the insertion of the triceps tendon using a largebore needle (TECH FIG 2B).}

 

²⁸⁶

 

 

 

^{TECH FIG 2 • A. Two 22-gauge stainless steel tension wires are passed in a figure-of-eight fashion through drill holes in the ulnar shaft. B. They engage the triceps insertion proximally. C,D. The wires are tensioned on both sides. These do not need to be tight but simply snug, with all slack taken u Attempts to tighten these smaller 22-gauge wires will break them. E. The proximal ends of the Kirschner wires are bent 180 degrees and impacted into the olecranon process, beneath the triceps insertion. F. The resulting fixation has a relatively low profile and is unlikely to migrate. G,H. Even these small wires are strong enough for active exercises to regain elbow motion. (A,B,D,F-H: Copyright David Ring, MD.)}

 

 

²⁸⁷

 

^{Each wire is tensioned both medially and laterally by twisting the wire with a needle holder (TECH FIG 2C,D).}

 

^{This should be done to take up slack only. These small wires will break if they are firmly tightened, which is not necessary.}

 

 

^{The tightening should be done in a place that will make the wire knots less prominent. After tightening, the knots are trimmed and bent into the soft tissues to either side.}

 

^{The Kirschner wires are then bent 180 degrees and trimmed.}

 

^{These bent ends are then impacted into the proximal olecranon, beneath the triceps insertion, using a bone tamp (TECH FIG 2E-H).}

• ^{Plate and Screw Fixation of Olecranon Fractures}

   

  ^{Contour the plate to wrap around the proximal aspect of the olecranon or use a precontoured plate (TECH FIG 3A-C).}

   

  ^{A straight plate will have only two or three screws in metaphyseal bone proximal to the fracture.}

   

  ^{Bending the plate around the proximal aspect of the olecranon provides additional screws in the proximal fragment. The most proximal screws can be very long, crossing the fracture line into the distal fragment. In some cases, these screws can be directed to engage one of the cortices of the distal fragment, such as the anterior ulnar cortex.}

   

  ^{A plate contoured to wrap around the proximal ulna can be placed on top of the triceps insertion. Alternatively, the triceps insertion can be incised longitudinally and partially elevated medially and laterally sufficiently to allow direct plate contact with bone.}

   

   

   

  ^{TECH FIG 3 • A. A lateral radiograph illustrates a comminuted olecranon fracture with a small proximal olecranon fragment. B. An oblique view shows the fragmentation. C. A 3.5-mm limitedcontact dynamic compression plate and screws contoured to wrap around the dorsal surface of the olecranon is used for fixation. D. A 22-gauge stainless steel wire engages the triceps insertion— this is useful when the olecranon fragment is small, fragmented, or osteopenic. (Copyright David Ring, MD.)}

   

   

  ^{Distally, a dorsal plate will lie directly on the apex of the ulnar diaphysis. The muscle need only be split sufficiently to gain access to this apex—there is no need to elevate the muscle or periosteum off either the medial or lateral flat aspect of the ulna.}

   

  ^{No attempt is made to precisely realign intervening fragmentation— once the relationship of the coronoid and olecranon facets is restored and the overall alignment is restored, the remaining fragments are bridged, leaving their soft tissue attachments intact.}

   

  ^{Bone grafts are rarely necessary if the soft tissue attachments are preserved.}

   

  ^{If the olecranon fragment is small, osteoporotic, or fragmented, a wire engaging the triceps insertion should be used to reinforce the fixation (TECH FIG 3D).}

   

  ^{The plate and screws will serve to hold the coronoid and olecranon facets in proper alignment and bridge fragmentation, and the wire will help ensure fixation even if screw purchase is lost.}

   

  ²⁸⁸

• ^{Plate and Screw Fixation of the Fracture-Dislocations of the Olecranon}

  ^Exposure

   

  ^{In the setting of a fracture-dislocation of the olecranon (TECH FIG 4A), fractures of the radial head and coronoid process can be evaluated and often definitively treated through the exposure provided by the fracture of the olecranon process.}

   

  ^{With little additional dissection, the olecranon fragment can be mobilized proximally as one would do with an olecranon osteotomy, providing exposure of the coronoid through the ulnohumeral joint.}

   

  ^{If the exposure of the radial head through the posterior injury is inadequate, a separate muscle interval (eg, Kocher or Kaplan intervals) accessed by the elevation of a broad lateral skin flap can be used.}

   

  ^{If the exposure of the coronoid is inadequate through posterior injury and olecranon fracture, a separate medial or lateral exposure can be developed.}

   

  ^{A medial exposure—between the two heads of the flexor carpi ulnaris, or by splitting the flexor-pronator mass more anteriorly, or by elevating the entire flexor-pronator mass from dorsal to volar—may be needed to address a complex fracture of the coronoid, particularly one that involves the anteromedial}

  ^{facet of the coronoid process.7}

   

  ^{When the lateral collateral ligament is injured, it is usually avulsed from the lateral epicondyle. This facilitates repair that can be performed using suture anchors or suture placed through drill holes in the bone.}

   

  ^{The fracture of the coronoid can often be reduced directly through the elbow joint using the limited access provided by the olecranon fracture (TECH FIG 4B,C).}

   

   

   

  ^{TECH FIG 4 • A. A complex anterior fracture-dislocation of the elbow. A lateral radiograph shows extensive comminution of the trochlear notch of the ulna, including the coronoid, and anterior displacement of the forearm. B,C. The coronoid fragments are connected to the dorsal metaphyseal fragments in this patient, which facilitates reduction and fixation. (A,C: Copyright David Ring, MD.)}

  ^Fixation

   

  ^{Provisional fixation can be obtained using Kirschner wires to attach the fragments either to the metaphyseal or diaphyseal fragments of the ulna or to the trochlea of the distal humerus when there is extensive fragmentation of the proximal ulna.}

   

  ^{An alternative to keep in mind when there is extensive fragmentation of the proximal ulna is the use of a skeletal distractor (a temporary external fixator; TECH FIG 5A).}

   

  ^{External fixation applied between a wire driven through the olecranon fragment and up into the trochlea and a second wire in the distal ulnar diaphysis can often obtain reduction indirectly when distraction is applied between the pins.}

   

   

   

  ^{Definitive fixation can usually be obtained with screws applied under image intensifier guidance. The screws are placed through the plate when there is extensive fragmentation of the proximal ulna. A second, medial plate may be useful when the coronoid is fragmented.}

   

  ^{If the coronoid fracture is very comminuted and cannot be securely repaired, the ulnohumeral joint should be protected with temporary hinged or static external fixation or temporary pin fixation of the ulnohumeral joint, depending on the equipment and expertise available.}

   

  ^{A long plate is contoured to wrap around the proximal olecranon (TECH FIG 5B).}

   

  ^{Avery long plate should be considered (between 12 and 16 holes), particularly when there is extensive fragmentation or the bone quality is poor.}

   

  ^{When the olecranon is fragmented or osteoporotic, a plate and screws alone may not provide reliable fixation.}

   

  ^{In this situation, it can be useful to use ancillary tension wire fixation to control the olecranon fragments}

  ^{through the triceps insertion (TECH FIG 5C).}

   

   

  ²⁸⁹

   

   

   

   

  ^{TECH FIG 5 • A. When there is diaphyseal comminution, a temporary external fixator may be useful. B. A long, 3.5-mm limited contact dynamic compression plate is used for fixation. A 22-gauge stainless steel wire is used to enhance fixation of the comminuted olecranon fragments. C. The comminution extending into the diaphysis heals with the bridging plate. The trochlear notch is restored with good elbow function. (B,C: Copyright David Ring, MD.)}

• ^{Anterolateral Monteggia Fractures}

^Exposure

 

^{The ulna is exposed through a dorsal incision elevating the muscle from one side of the ulnar diaphysis, leaving the periosteum intact and disrupting the muscle on the opposite side as little as possible (TECH FIG 6).}

 

^{Exposure of the radiocapitellar and PRUJs should rarely be necessary. Inadequate radiocapitellar/PRUJ alignment is nearly always due to residual malunion of the ulna. If necessary, expose the joint as for a radial head fracture.}

^Fixation

 

^{Reduce the radiocapitellar joint or PRUJ.}

 

^{Realign the ulnar fracture and provisionally apply a 3.5-mm limited contact dynamic compression plate or equivalent.}

 

^{If there is fragmentation at the ulnar fracture site, it might be helpful to provisionally hold the reduction with a temporary external fixator (which the author has done) or temporary stabilization of the radiocapitellar articulation (which the author has not done) while getting provisional fixation of the ulna.}

 

^{Place two screws in each side of the plate proximal and distal to the fracture side and then check radiocapitellar/PRUJ alignment in several positions of elbow and forearm rotation and from several different radiographic angles under the image intensifier.}

 

 

 

^{TECH FIG 6 • A. Posterior midline incision positioned just off the lateral aspect of the olecranon. B. Deep surgical interval uses the internervous plane between the anconeus and flexor carpi ulnaris.}

 

 

²⁹⁰

 

^{If the alignment is inadequate, revise your fixation of the ulna accordingly.}

 

^{Failure to obtain adequate length of the ulna can lead to persistent dislocation of the radial head (TECH FIG 7).}

 

^{Only enter the radiocapitellar joint if you can be 100% certain that the ulna is aligned properly. Interposition of the annular ligament is very uncommon.}

 

 

 

^{TECH FIG 7 • Malunion of the ulna with resulting apex dorsal angulation results in dislocation of the radial head.}

 

 

^{PEARLS AND PITFALLS}

^{Prominence ▪ The use of two small (22-gauge) wires rather than one large one will result in}

^{of olecranon smaller knots. Care taken to place the Kirschner wires below the triceps insertion hardware and impacting them into bone will limit prominence and the potential for}

^{migration.5,8}

^Narrowing

^{of trochlear notch}

• ^{The surgeon should not use a tension wire alone on a comminuted fracture. An}

^{intact articular surface to absorb compressive forces with active motion is mandatory for tension band wiring to be effective.}

^Plate

^loosening

• ^{The surgeon should use a dorsal plate contoured to wrap around the olecranon,}

^{providing a greater number of screws and screws at different, nearly orthogonal}

^{angles. Use of a medial or lateral plate should be avoided.10,11}

^{Loss of}

^{fixation of the proximal (olecranon) fragment}

• ^{Screw fixation alone should not be trusted if the fragment is small, fragmented, or}

^{osteoporotic. A tension wire engaging the triceps insertion should be added.}

^{Failure to}

^{recognize a complex injury}

• ^{The surgeon should be vigilant for subluxation or dislocation of the elbow,}

^{fracture of the coronoid or radial head, and injury to the lateral collateral ligament. When identified, each injury is treated accordingly. The olecranon and proximal ulna are always secured with a plate and screws.}

 

 

^{POSTOPERATIVE CARE}

 

^{When good fixation is obtained (which occurs in most patients), active-assisted and gravity-assisted elbow and forearm exercises can be initiated immediately after surgery.}

^{A delay of several days for comfort is reasonable.}

 

^{If the lateral collateral ligament was repaired, the patient must be instructed not to abduct the shoulder for the first month, as this imparts a varus moment across the elbow and stresses the ligament repair.}

 

^{If the fixation is tenuous, it is reasonable to immobilize the arm in a splint for a month or so before beginning exercises.}

 

^OUTCOMES

^{Nonunion is nearly unheard of after simple olecranon fractures, and early implant failure is usually due to noncompliance.6}

 

 

^{The appeal of tension band wiring has been limited by prominence of the implants; however, if the techniques described herein are followed, few patients will request a second surgery specifically for}

^{implant removal.8}

^{Macko and Szabo5 pointed out that it was initial implant prominence and not migration that led to implant-related problems after tension band wiring of olecranon fractures.}

^{In any case, a second surgery for implant removal is not unreasonable and it may not be appropriate to consider this a complication.}

^{Some surgeons have considered plate-and-screw fixation of simple, noncomminuted olecranon}

^{fractures.1 However, plates can also cause symptoms, and if only a few screws can be placed in the olecranon fragment, particularly in the setting of fragmentation or osteoporosis, it may be preferable to use the soft tissue attachments to enhance fixation rather than relying on implant-bone purchase alone.}

^{Medial and lateral plates have been associated with early failure, malunion, and nonunion in the treatment of complex proximal ulnar fractures.10, 11}

^{Dorsal plates perform better, but the elbow is often compromised in the setting of such complex injuries.}

 

^{COMPLICATIONS}

^{Implant loosening Implant breakage Nonunion Malunion Instability Arthrosis}

 

 

^REFERENCES

1. ^{Bailey CS, MacDermid J, Patterson SD, et al. Outcome of plate fixation of olecranon fractures. J Orthop Trauma 2001;15:542-548.}

    

    

2. ^{Doornberg J, Ring D, Jupiter JB. Effective treatment of fracturedislocations of the olecranon requires a stable trochlear notch. Clin Orthop Relat Res 2004;(429):292-300.}

    

    

3. ^{Jupiter JB, Leibovic SJ, Ribbans W, et al. The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.}

    

    

4. ^{Karlsson M, Hasserius R, Besjakov J, et al. Comparison of tensionband and figure-of-eight wiring techniques for treatment of olecranon fractures. J Shoulder Elbow Surg 2002;11:377-382.}

    

    

5. ^{Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am 1985;67(9):1396-1401.}

    

    

6. ^{Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. J Bone Joint Surg Am 1995;77A:316-327.}

    

    

7. ^{O'Driscoll SW, Jupiter JB, Cohen M, et al. Difficult elbow fractures: pearls and pitfalls. Instruct Course Lect 2003;52:113-134.}

    

    

8. ^{Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma 2004;18:446-449.}

    

    

9. ^{Ring D, Jupiter JB, Sanders RW, et al. Transolecranon fracturedislocation of the elbow. J Orthop Trauma 1997;11:545-550.}

    

    

10. ^{Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am 1998;80(12):1733-1744.}

     

     

11. ^{Ring D, Tavakolian J, Kloen P, et al. Loss of alignment after surgical treatment of posterior Monteggia fractures: salvage with dorsal contoured plating. J Hand Surg Am 2004;29(4):694-702.}