So I thought showing a video of, you know, a posterior skin incision was pretty boring. So I've got some cases. I had a patient that cooperated on Monday and came in with almost the right type of fracture. So just a couple words about montasia fractures. About three-quarters of these are type 2 with the apex of the ulna and the radial head posterior. The thing to remember is that you have to reduce the ulna anatomically. You have to identify and stabilize the coronoid and medial wall fragments when necessary. And fix or replace the radial head as well as address the stabilizing ligaments. And to just show an example of this, this is a montasia where definitely there's a lot of posterolateral instability here. This patient wouldn't have done well had that not been recognized and fixed. And here they are about a year out. So this is a case that I want to show you. Normally I would get a CT scan for this to really show me all the fragments. But she came about 10 or 12 days out already. She had fallen in Amsterdam and then flown back to San Francisco because she didn't want surgery there. So you can make out that there's a fracture fragment here. We did some traction fluoroscopy intraoperatively. And you can see that there's a split here, intermedial wall, another piece of coronoid here. This goes down the medial aspect. And then we have olecranon fracture here. So, you know, for me this is kind of ugly. I agree about the supine or sloppy lateral approach, bringing the arm up over MAO stand. Whether you curve your incision or make a straight incision, it probably doesn't matter. But I have a lot of elderly patients in my practice. And so I like to keep the incision off the hardware at least. And the main thing about the approach here is to make sure that you're developing nice, thick flaps and that the flaps aren't too big. With olecranon fractures, unless you've got coronoid and other things that you're going to fix, you really want to just expose the fracture. And we don't want to do a lot of extraneous dissection there that's going to devascularize pieces. So I work a little bit, you know, through the fracture based on what I can do there. Then we may have to add some additional approaches. So here we are after we have exposed the fracture. And we've got a retractor in the fracture. So we've got some medial wall here. We're looking right down inside. You can see the radial head rotating here. And luckily for her, the radial head was intact. There weren't any issues there. When you have a big coronoid piece, you can work right through the fracture here and sometimes put that coronoid together without having to make a separate medial or lateral approach depending on if there's ligamentous instability as well. So we're going to clean out the fracture here and then make some decisions. This was in too many pieces and they were too small to fix that coronoid and anteromedial wall through the fracture. So we decided the first thing we were going to do is actually put the ulna together. And using a long posterior olecranon plate is usually the best option here rather than a straight plate, especially when there's an olecranon fracture involved, not just a montasia. But even with a montasia, sometimes we'll use a wraparound plate if it's getting very proximal. So get your clamp on for these two big fragments and get your ulna out to length. And that's going to help you with the rest of your case in terms of keying in the medial wall and the coronoid. Plate selection is important. There's a lot of companies that manufacture a lot of different plates. Most of them are curved. The longer ones are curved to fit the bow of the ulna. This particular plate only gives us four unicortical screw fixation and this home run screw, so to speak, is going to be coming out right in our coronoid where we don't want it to be. So this is really not the best plate for this particular fracture that I showed you. So we're going to choose a slightly different one that also is probably available by most of our companies now. This happens to be an Acumed plate. But this one wraps around the back. And again, you can see I haven't done a lot of dissection except for around the fracture. These are meant to lay on top of the soft tissues. And we need to split the triceps on this long wraparound plate and kind of sit that down in between. But this gives us three extra holes here, two that are away from the coronoid to get across that shaft for this particular fracture. And I find it pretty handy for this fracture in general. Gives us plenty of holes distal to our fragment as well. And then if you need a separate medial wall plate, there's lots of different mod hand mini frag types of plates to use for that. As Donald said, if we use that supine position we can now bring that arm down over the floriscan. And we have provisional fixation in the plate. So we have some plate tacks here and maybe one or two screws just to help us hold this out to length. And so that shows that we've reduced that medial wall piece. But what we don't have reduced yet is this big coronoid fragment. And we need to prop up the joint there a little bit. So we'll get to that. But this at least gives us the correct length on the ulna. We've seen this approach earlier today. So I'm not going to spend a lot of time or any time really going through that. But here we are looking at these coronoid fragments. There was a separate anterior coronoid and medial wall coronoid piece as well as medial wall coming down. And we came through an extensile flexor pronator approach here which is a nice study that came out in 2015 that talked about between the FCU approach you can get about three centimeters distal to the medial epicondyle. But with an extensile flexor pronator approach you can get about six centimeters down the proximal ulna which gives you pretty good exposure for those large anteromedial fragments that are coming down. So here we are interoperatively. We've got this precontoured coronoid plate that's catching part of our medial wall fracture here as well as buttressing our coronoid. This is showing the plate and flexion extension. So I always visualize this to make sure I'm not getting compression and flexion and I'm not dropping out an extension. And then I confirm that on my fluoroscopy to make sure that we've got the coronoid adequately buttressed here. And we can see that this plate comes down on the medial side to help capture that. Here's another example of a nice comminuted fracture. And yes, she also has osteogenesis imperfecta. Bonus day. So with this particular fracture a lot of this medial wall comminution was much further up the shaft. A lot of this was captured with our posterior plate and with some of our screws coming down the shaft. So we just needed to put this little buttress plate across some of these fragments on the medial wall a little bit more distal. So a lot of these small plates where you're just sort of pushing things in and buttressing it rather than fixing the fracture fragments are very helpful in these cases. This is a case that I borrowed from Scott Edwards, the gentleman with a olecranon fracture and medial wall fragments. And I just want to show you a different way of fixing these. So this is also working through the fracture first, flipping that olecranon piece back. And you're looking down on the coronoid here. So we have several coronoid fragments and medial wall fragments to fix. We've been talking about plating, but there are other ways of fixing these. So first get provisional fixation of the coronoid and then provisional fixation of the medial wall with small plates. And then in this particular case Scott fixed this fracture with an intramedullary nail. And this is not just a nail with one or two locking holes on it. This actually has guided holes that allow you to capture multiple coronoid fragments. It gives you three screws in the coronoid as well as additional screw holes down the shaft and into the olecranon. And this was his result with this was two of these small plates to fix coronoid and medial wall fractures. In terms of how you get to the medial wall, it really depends on where it is and all of those approaches have been shown today. So I'm not going to belabor that point. Dr. Hausman showed several. We saw several before that. So there's basically about three ways of getting there, depending on whether or not you've got some anterior coronoid involved or if it's really strictly medial wall and you don't need to get to the joint. And that would dictate which approach I would use. So in summary of these points, anatomic reduction of the ulna is important. Address the radial head with regard to montages. Address the ligaments. Posterior plates are usually the strongest. And if you're getting pretty proximal, consider using an olecranon plate even if it's not on an olecranon fracture in these montages that are very proximal. And then additional small plates as needed for the medial wall segments. In terms of, you know, the cases we were just showing, we need an anatomic reduction of the joint. That's the olecranon and the coronoid. Work through the fracture if you can to avoid soft tissue stripping in other places. But if you can't, then any one of those three medial approaches we've seen today work really well. And you have to stabilize the coronoid and the medial wall in these cases or you're going to end up with something that looks good in the operating room. And then you could see them in 10 days or two weeks and they're not going to look so good. So things not to do. This is a case that presented to my office. And this is actually the, nobody removed anything secondarily. This was all done at the time of injury. So they fixed and plated the olecranon fracture. There was a radial head fracture. So they decided to excise the radial head and they didn't address the coronoid at all. So she comes in with a very unstable joint. And this was about six months out from the original injury. You know, she required, well, we did one attempt at a radial head implant, a coronoid reconstruction six months out with an allograft, which failed. And she ended up with a total elbow. And this really could have been fixed to begin with. This is another patient that, here's her original injury films, looks like not a big deal fracture here. Something going on in the radial head. Obviously there's some compression of the radial head and neck. She looked okay in the operating room. They elected not to address the radial head. And then she kind of slowly fell out. And this is how she presented when they had gone back in. They took out the plate, but they didn't do anything else. So she's got a comminuted radial head fracture that wasn't addressed. And some posterolateral rotatory instability. So this is her nonunion of her radial head. And this is her after reconstructing those ligaments and replacing her radial head, which helped to stabilize her joint. You have to consider was there a malunion of the ulna. And we thought about that at the time. But they actually fixed the ulna in a pretty good position. It was the radial head and the soft tissues that were a problem. So that's it. Thank you. Thank you. That's great. Thanks.

montasia fractures

ulna fractures

radial head fractures

anatomical reduction

surgical precision