Delayed Bone Union in Monteggia Fracture

[Riarug]

I broke my right ulna and dislocated my right radius on January 22 2012.  I was kicked by a horse.

I had surgery later the same day which resulted in a plate (6 screws).  The plaster cast was removed 2 weeks post surgery replaced by a fiberglass cast.  At 6 weeks post surgery more x-rays were taken and the arm was recasted for an additional 3 weeks.  At the time the orthopedic surgeon indicated no signs of soft callus.  After 3 weeks, the cast was removed even though no callus was observed in order to start physiotherapy.

4-5 weeks post cast removal I began to experience jolting pain radiating from my elbow to the inside of my forearm.  As well, if I held my arm in the air and bent my elbow, I had severe pain in what felt like the bone in the plate area.  I returned to the surgeon who x-rayed and then re-casted my arm.  At the time he indicated that he could not see a source for my pain.  There was still no evidence of bone callus forming.  I was in the cast for 3 weeks and attended my scheduled appointment with the surgeon where the cast was removed and my arm x-rayed.  The x-ray showed that the plate had failed.  It was cracked straight through one side of a screw hole.  I went into surgery the next evening and had the plate removed, my bones were trimmed and an allograft was completed.  A plate 3 times thicker than the original was installed.  Tissue samples were taken to see if there was any underlying conditions/infection which could explain the delay.  They were negative.  This was 8 weeks ago today.

After the first surgery/accident I had numbness in my pinky and ring fingers and after the second surgery I had numbness in my middle finger as well.  2 weeks ago the numbess turned to pins and needles and tingling.  I went to the emergency department and they x-rayed my arm in-cast and decided to remove the cast.  2 weeks out of cast (which did not solve the numbness and tingling issues) and I attended my scheduled surgeon's apointment.  He x-rayed my arm and indicated no callus development and re-casted my arm.

My question is: I have now been in a cast in excess of 4 months since January.  I know saving the bone is the first priority, however I am unsure if casting is the best option.  I have been told that I will have permanent loss of function, the extent of which can't be answered right now.  Is there something I should be doing to encourage bone growth??  Is there something I should be looking into in terms of reasons for delayed union??  I am deeply concerned about this situation.  This is my dominant arm and I want to ensure I am making the best decisions for the best outcome in this situation.

Any advice would be appreciated. I am a 42 year old femail with no other known health issues.

Cynthia

[Riarug]

Thanks for your reply.

I do not smoke, I do not drink alcohol in any great quantities.  I started taking multi-vitamins after my second surgery.

With regards to the plate failure it was very strange.  I had xrays taken when I experienced the pain (after the first surgery) and at that time I was not in a cast.  Thh\e x-ray did not show any signs of plate failure at that point.  The surgeon recast my arm and 3 weeks later when my arm was re-xrayed the crack straight through one side of one of the screw holes was plainly visibl.  I did not fall, or lift heavy objects.  I did write an exam though.  Which was very painful and caused a lot of arm soreness for a few days.  The crack looked to have happened while my arm was casted.  The surgeon had no explanation.

The surgeon has not mentioned a bone stimulator.  Is there evidence that such a device promotes bone growth??

Cynthia

[karmazrevenge]

Delayed union can be caused by many things.  Do you smoke?  Do you drink alcohol?  Do you take too many vitamins or not enough?  Do you have osteoporosis or osteopoenia?  All of these are factors.  As far as casting goes, what your surgeon has done seems appropriate to me.  In my office we cast similarly, especially if a patient has pain.    Why did your plate fail?  Did you fall on it?  Has your surgeon mentioned a bone stimulator?  

There are lots of things I still need to know, but don't be concerned about the length of time you've been casted.  I have patients that are in and out of them for more than a year and they recover their mobility and use of limb beautifully.