Flying kayaks cause a very uncommon fracture type: first report of an "atypical monteggia like" fracture

J. Nelson, R. Jenni, P. Stillhard, C. Sommer

Objective

Traumas which are retrospectively seen as obvious can initially be overlooked, especially if the fracture combinations are rare and unexpected. The combination of a two part ulnar fracture of the shaft and a lateral condylar fracture of the humerus is very rare. No reports of this combination could be found in literature.

Methods

October 2013, a 46 year old man was delivered by ambulance to our emergency department after he had been hit by a load of kayaks while riding his motorcycle. When 2 kayaks and their rooftop attachment system came flying off a car driving in front of him, the patient had tried to protect himself by shielding his face with his left arm. Due to the impact he fell from his motorcycle at high speed. However, he could not report the exact details of his fall. He had immediate pain in his left arm.

At arrival the patient was cardiopulmonary stable and conscious with a GCS-Score of 15. On physical examination the left arm was very painful and there were some abrasions of the hands.

The x-ray showed a severely displaced segmental fracture of the ulna shaft like a monteggia type however without dislocation of the radial head (Fig. 1).

Focused on the ulna, the fracture was fixed with a long LCP (Fig. 2).

Fig.1: x-rays after the accident
Fig. 2: intraoperative x-rays

Results

After surgery the patient complained of pain in the left elbow. Postoperative x-rays showed an initially overlooked fracture of the radial condyle of the humerus mimiking a radial head dislocation (Fig. 3).

Fig. 3: Postop x-rays

In a second operation this humerus fracture was reduced and fixed with a small antiglide-plate and lag. The further healing was uneventful (Fig. 4).

Fig. 4: radiological follow-up after 6 months

Conclusion

In this case an extremely rare mechanism caused a very uncommon fracture type. Based upon the first x-ray we expected a monteggia fracture but could not find the dislocated radial head next to the ulna fracture. Never be blinded by the obvious fracture on x-rays even if there is an uncommon combination. Look at the x-rays in detail and expect rare combinations of fractures. Retrospectively our case is a clear monteggia mechanism where the energy went through the lateral humeral condyle instead of the radiohumeral joint. We call it an "atypical monteggia like" fracture.