Combined open bipolar Monteggia and Galeazzi fracture: a case report with a 1-year follow-up

The radial bow and the relationship between the proximal and distal radioulnar joints comprise a complex three-dimensional unit. Hence, the forearm bones are considered a single functional unit. Anatomical restoration is very important to function; therefore, any forearm shaft fracture is considered equivalent to an articular fracture [6].

The Monteggia injury was first described in 1814 by Giovanni Battista Monteggia as “radial head dislocation with ulnar fracture, located between the proximal third and base of the olecranon.” Monteggia based his findings exclusively on clinical examination and injury mechanism, since no X-rays were available at the time [7]. Later, Bado in 1967 used the term “Monteggia lesions” to classify these injuries into four types: type I, fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head; type II, fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head; type III, fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head; and type IV, fracture of the proximal or middle third of the ulna and radius with dislocation of the radial head in any direction [8]. Additionally, Jupiter in 1991 subclassified the type II lesions. According to this subclassification: type IIa, an ulna fracture involving the distal end of the olecranon and the coronoid process; type IIb, a metaphyseal-diaphyseal fracture, distal to the coronoid process; type llc, a diaphyseal fracture of the ulna; and type IId, a fracture of the ulna halfway through the bone [9].

Monteggia fractures are mainly associated with falls on an outstretched hand with forced pronation [10]. The decision on operative or non-operative treatment is based on the injury pattern and the patient’s age. Most pediatric fracture patterns can be managed non-operatively with closed reduction and long-arm casting, as long as reduction in the radial head is confirmed, while most adult fractures call for open reduction and internal fixation [11, 12]. More specifically, in children for Bado types I–III fractures, closed reduction in ulna and radial head dislocation and long-arm casting immobilization in 110° of flexion and full supination is preferred. Indications for operative treatment in those cases are: an open fracture, an acute type IV Bado fracture, instability of the radial head or inability to maintain ulnar length [11, 12].

The Galeazzi fracture describes fractures of the distal radial shaft with distal radioulnar joint disruption [13]. This type of injury was first described in 1842 by Cooper. Richardo Galeazzi, an Italian surgeon, reported, 92 years later, a total of 18 cases of such injuries. Since then, this type of fracture became synonymous to his name. The most common mechanism of the Galeazzi fracture is thought to be a fall that causes an axial load placed on a hyperpronated forearm. However, researchers have been unable to reproduce the mechanism of this injury in a laboratory setting [13].

Campbell, in 1941, used the term “fracture of necessity” for the Galeazzi fracture, since it requires surgical treatment. Those injuries are best treated with open reduction in the radius and the distal radioulnar joint [14]. These injuries have been described as very unstable fracture dislocations and therefore are very difficult to treat non-operatively. Causative factors of this instability include: rupture of the triangular fibrocartilage, the complex mechanical association between radius and ulna and the deforming forces of the brachioradialis, pronator quadratus, thumb extensor and abductors. Closed reduction and cast application (non-operative treatment) have led to unsatisfactory results, since they result in persistent or recurrent dislocations of the distal ulna [13‐15].

Those kind of injuries combined are extremely rare. Only a few cases of a combined injury in the same extremity have been reported in the international literature, none of which included bipolar fractures [2‐5]. In our case, the patient sustained an open bipolar Monteggia, as well as a bipolar Galeazzi injury.

As it was noted in some of the previous similar cases, a fracture involving both forearm bones could be associated with substantial soft tissue injuries, which could disrupt the blood supply [2‐5]. In our case, the patient was diagnosed with pseudarthosis, 6 months after initial surgery. This could be attributed to the open fracture, the soft tissue damage, the high degree of initial displacement, the high energy injury, as well as the pattern of the fractures (bipolar). All of which are well-known nonunion predisposing factors [16]. Our case, when compared to the other published cases, had an additional risk factor for nonunion: the bipolar pattern of the injury.

Although not common, these injuries if not treated correctly may lead to deficits, long-term functional impairment and pain to the patient [2‐5, 13‐15, 17]. The operative treatment in those injuries is essential. In our case, although the patient had to be re-operated, the final functional outcome was satisfactory. The same can be said for most of the other similar cases described, which were also treated operatively.

Forearm fractures often result in occult dislocations in wrist and elbow. Therefore, it is important to keep a keen eye for these injuries and to always examine proximal and distal joints clinically and eventually radiographically for dislocation [17]. A distal radioulnar joint dislocation is not always easy to diagnose. Signs of an occult distal radioulnar joint dislocation that could be looked for in X-ray views are: the loss of radial height and the fracture of the ulnar styloid [14].

Due to the rare occurrence of this combined injury and presence of multiple fractures and dislocations, there is possibility of pitfalls in the management of these cases [14]. Therefore, the treatment of such complex injuries should be performed in the most suitable center, since it depends on the surgeon’s experience and the available resources.