summary Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. Diagnosis can be made with plain radiographs of the elbow. Treatment may be closed reduction and casting for length stable ulna fractures with a stable radiocapitellar joint. Surgical management is indicated for radial heads that are not stable following closed reduction. Epidemiology Demographics 4 to 10 years of age is peak incidence Etiology Definition radial head dislocation plus proximal ulna fracture or plastic deformation of the ulna without obvious fracture Classification Bado Classification Type I Apex anterior proximal ulna fracture with anterior dislocation of the radial head Type II Apex posterior proximal ulna fracture with posterior dislocation of the radial head Type III Apex lateral proximal ulna fracture with lateral dislocation of the radial head Type IV Fractures of both the radius and ulna at the same level with ananterior dislocation of the radial head (1-11% of cases) Presentation Symptoms pain, swelling, and deformity about the forearm and elbow Physical exam must palpate over radial head with all ulna fractures because spontaneous relocation of radial head is common must examine for plastic deformation of the ulna if there is a presumed isolated radial head dislocation isolated radial head dislocations almost never occur in pediatric patients Imaging Radiographs obtain elbow radiographs for all forearm fractures to evaluate for radial head dislocation assess radiocapitellar line on every lateral radiograph of the elbow a line down the axis of the radial neck should pass through the center of the capitellar ossification center obtain forearm radiographs for all radial head dislocations Treatment Nonoperative closed reduction of ulna and radial head dislocation and long arm casting indications Bado Types I-III with radial head is stable following reduction length stable ulnar fracture pattern reduction technique reduction technique uses traction radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length for Type I, elbow flexion is the main reduction maneuver if reduction of radiocapitellar joint is unsuccessful, annular ligament is most common block to reduction immobilization Type I 110° of flexion and full supination to tighten interosseous membrane and relax biceps tendon Type II fulll extension. Type III full extension and valgus mold Operative pinning/nailing of ulna + reduction of radial head ± annular ligament repair/reconstruction indications Bado Types I-III with radial head is not stable following reduction ulnar length is not stable (unable to maintain ulnar length) acute Bado Type IV open fractures older patients ≥ 10y if closed reduction is not stable symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity) who had delayed treatment or missed diagnosis technique open reduction of radial head through a lateral approach if needed in chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave structure annular ligament reconstruction almost never required for acute fractures ORIF similar to adult treatment indications closed physes