Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70 to 80% of adult Monteggia fractures)
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A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding?
Lateral ulnar collateral ligament disruption
Anterior band of the medial collateral disruption
Posterior band of the medial collateral ligament disruption
Annular ligament interposition
Anconeus muscle interposition
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In pediatric Monteggia fractures the annular ligament is commonly interposed in the radiocapitellar joint.
Bado initially described and classified Monteggia fractures. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable. Type III is the one most commonly associated with irreducibility of the radial head because of interposition of the annular ligament. The incidence of posterior interosseous nerve injury is high with this lesion. The nerve deficit usually completely resolves rapidly and spontaneously.
Tan et al reviewed their treatment of 35 children with Type I and Type III Monteggia fractures. All radial heads were explored and the interposed annular ligament was stretched out of the joint space. They noted that none of the patients had any recurrent dislocation or subluxation.
Ring et al in their review stress the importance of an anatomic reduction of the ulna to restore the reduction of the radial head.
Ring D, Jupiter JB, Waters PM
J Am Acad Orthop Surg. 6(4):215-24. PMID: 9682084 (Link to Abstract)
Ring, JAAOS 1998
Tan JW, Mu MZ, Liao GJ, Li JM
Injury. 2008 Apr;39(4):451-5. PMID: 18005963 (Link to Abstract)
Tan, INJURY 2008
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A 45-year-old male falls off his motorcycle and injures his arm. AP and lateral radiographs reveal a proximal ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated?
A Monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation (See Illustration A).
Bado initially described and classified these injuries. The most common injury pattern in children is an extension (type 1) with anterior radial head dislocation and apex anterior ulnar shaft fracture, whereas the type II variety is most common in adults. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna.
These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable as illustrated by Fowles' case series, but may also require pinning if the fracture is oblique and unstable.
Clin Orthop Relat Res. 1967 Jan-Feb;50:71-86. PMID: 6029027 (Link to Abstract)
Bado, CORR 1967
Fowles JV, Sliman N, Kassab MT.
J Bone Joint Surg Am. 1983 Dec;65(9):1276-82. PMID: 6654941 (Link to Abstract)
Fowles, JBJS 1983
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Title: Chonic Monteggia Fx / Ulnar Nonunion Faculty:Melvin P. Rosenwasser, MD Du...
Title: Monteggia Author: Alfred W. Hess, MD Duration: 13:29
Educational video describing the classification of monteggia fractures
HPI - At age 26, patient endured a motorcycle crash in October of 2010. He was treated by an outside surgeon with revision ORIF & bone grafting from distal radius. Went on to a nonunion of the ulnar shaft, chronic radiocapitellar dislocation, and heterotopic ossification about the elbow.
Would you offer surgery?
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HPI - History of fall on left outstretched hand while playing football on 08-01-2015.
HPI - h/o fall at basketball.injured non dominant limb
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