Jack, a four-year old Hound Mix, was admitted to the Veterinary Referral Center of Northern Virginia’s Emergency Division after an unknown trauma to his left front leg. The owners were out of town and their brother was watching the dog. Jack evidently escaped from the fenced-in yard and came back holding up the left forelimb.
He was stable on presentation with no signs of shock. Jack did have some abrasions on his muzzle and rear legs. The left elbow was swollen and painful. A full blood panel was run and found to be within normal limits. A lateral thoracic radiograph showed no lung or diaphragm injury. Radiographs of the left elbow showed a combination injury which included luxation of the head of the radius and fracture of the ulna. This fracture fits the description of a Monteggia fracture (see Image 1).
The Monteggia (pronounced mon-tej’e-a) fracture was first described by an Italian surgeon named Giovanni Battista Monteggia in 1803 when he diagnosed the injury in a ballet dancer. It consists of a dislocation of the radial head and a fracture of the proximal ulna. In people, it is also known as a Parry fracture as it frequently occurs when a person attempts to deflect a blow with his forearm. In small animals, this fracture occurs with trauma to the forelimb like getting caught in bicycle spokes.
The Monteggia fracture requires a common technique called open reduction and internal fixation (ORIF) to successfully reestablish function to the leg. In general, the repair consists of three steps: open reduction of the radius back into its joint; internal fixation of the ulnar fracture; and securing the proximal radius to the ulna.
Jack’s Monteggia fracture was repaired by reducing the radial head and placing a 2.7 mm seven-hole plate on the ulna. Stabilization of the radius to the ulna was not possible (see Images 2 and 3).
Postoperative care consisted of very limited “bathroom only” breaks outside and keeping Jack on one floor of the house eliminating all stairs. Also, it was imperative to maintain elbow flexibility by doing passive range of motion exercises of the elbow three times per day with ten repetitions of each exercise. This was critical to prevent stiffening of the elbow. Light weight bearing was encouraged and no bandage or splint was applied to the leg so stiffness of the joint did not occur.
In his classic 1943 Orthopedic Surgical text, Watson-Jones stated the following regarding the Monteggia fracture: “no fracture presents with so many problems; no injury is beset with greater difficulty; no treatment is characterized by more general failure.”
Given those not-so-encouraging words, the surgical outcome on Jack has gone very well. At Jack’s recheck appointment five months after surgery he was fully weight bearing with excellent range of motion and has returned to normal function (see Image 4). His last radiograph still shows some slow ulnar bone healing but it should close over time (see Image 5).