Monteggia's Fracture             

- See:
      - Plating Techniques
      - Monteggia Fractures in Children

- Discussion:
    - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/
            anterior dislocation of radial head;
            - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity.
    - Mechanism:
            - proposed mechanisms include direct blow & hyperpronation injuries as well- as the
                      hyperextension theory;

- Type I (or extension type) - 60% of cases:
    - anterior dislocation of radial head (or frx) and fracture of ulnar diaphysis at any level w/
           anterior angulation (usually proximal third);
    - exam:
           - attempt to palpate radial head (ant, post, or lateral);
           - PIN palsy is most common in type I frx and may occur in a delayed fashion if the radial
                    head is not promptly reduced;
    - reduction:
           - achieved w/ forarm in full supination, & longitudinal traction;
           - then elbow is gently flexed to > 90 deg to relax biceps;
           - radial head is gently repositioned by direct manual pressure anteriorly on the bone;
           - following reduction, radial head will be stable if left in flexion;
           - angulated ulnar shaft is reduced by firm manual pressure;


- Type II (flexion type) - 15%
     - posterior or posterolateral dislocation of radial head (or frx);
     - frx of proximal ulnar diaphysis with posterior angulation;
     - posterior Monteggia frx is reduced by applying traction to forearm w/ the forearm in full extension;
           - immobilization is continued until there is union of the ulna;
           - this ordinarily requires 6-10 wks depending on the age of pt;

- Type III - 20%
     - lateral or anterolateral dislocation of the radial head;
     - fracture of ulnar metaphysis;
     - frx of ulna just distal to coronoid process w/ lateral dislocation of radial head;


- Type IV (5%)
     - anterior dislocation of the radial head;
     - frx of proximal 1/3 of radius & frx of ulna at the same level;

- Exam:
     - r/o tear of the annular ligament
     - associated nerve injury:
           - paralysis of deep branch of radial nerve is most common;
                 - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction;
                 - note: that patients whose operative treatment is delayed may be found to have a progressive PIN palsy from
                          constant pressure exerted by the dislocated radial head;
           - spontaneous recovery is usual & exploration is not indicated;

- Radiographs:
    - dislocation of radial head may be missed, eventhough frx of ulna is obvious (need AP, lateral and olbique X-rays of elbow)
    - line drawn thru radial shaft and radial head should align w/ capitellum in any position if the radial head is in normal position
         - this is esp true on the lateral projection;
    - apex of angular deformity of ulna usually indicates direction of radial head dislocation;

- Reduction:
    - immobilize forearm in neutral rotation w/ slight supination, w/ cast carefully molded over lateral side of ulna at level of fracture;
    - keep elbow flexed ( > 90 deg), to relax biceps, so that full supination can be avoided w/o losing reduction;

- Non Operative Treatment:
    - realize that even w/ successful closed reduction of the ulna (and accompanying reduction of the radial head) that subsequently
           there may be slow and progressive shortening and angulation;
           - hence, these patients will require close follow up;

- Treatment:
     - treated by reduction and stabilization of ulna followed by reduction of radial head via supination & direct pressure;
           - ulnar frx is treated w/ compression plate (esp in proximal third)
           - medullary nail in this location may not fill the canal and may thus provide less than rigid fixation;
     - key is to obtain length and alignment, which then allows the radial head to be reduced;
     - type I, III, and IV lesions are held in 110 deg. of flexion;
     - type II lesions with posterior dislocations should be maintained in about 70 deg. of flexion for 6 weeks;


- Delayed Dx:
     - when dx is delayed < 3 months, ORIF is indicated;
     - when > 3 months has elapsed, consider non op treatment because bony ankylosis of the elbow may occur following surgery;
            - bony ankylosis may be more disabling than the joint instability
     - in child, a dislocated radial head should never be resected, since it will cause cubitus valgus, prominence of distal end of ulna,
            and radial deviation of head;

- Complications:
     - PIN or radial nerve palsy from anterior displacement of radial head;
           - spontaneous recovery is usual & exploration is not indicated;
           - see: nerve injuries
     - non union of frx of ulnar shaft
     - radiohumeral ankylosis
     - radioulnar synostosis
     - recurrent radial head dislocation
     - myositis ossificans

The challenge of Monteggia-like lesions of the elbow mid-term results of 46 cases

Giovanni Battista Monteggia (1762-1815).

Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions)

Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment.

Removal of forearm plates. A review of the complications.

The posterior Monteggia lesion.

Monteggia fractures in adults: long-term results and prognostic factors

Loss of alignment after surgical treatment of posterior Monteggia fractures: salvage with dorsal contoured plating.

Monteggia fractures in adults.

Does a Monteggia variant lesion result in a poor functional outcome?: A retrospective study.

Monteggia Fractures in Pediatric and Adult Populations

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Sunday, May 13, 2018 12:19 pm