Review Question - QID 216883

The radiocapitellar joint is dislocated following fixation of the ulnar fracture. In this situation, the surgeon should revise and re-reduce the ulna fracture.

Monteggia fractures consist of a proximal ulna fracture with a concomitant radial head dislocation. The direction of radial head dislocation classically follows the apex of the ulna fracture, which is the premise of the Bado Classification. These injuries require open reduction internal fixation (ORIF) to provide a stable elbow. Following fixation of the ulna, the elbow should be flexed and the stability of the radial head evaluated. If the radial head is not found to be stable the ulna is malreduced and requires revision ORIF.

Ring et al review Monteggia fractures in children and adults. They report that stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. They conclude that the key to a good outcome after a Monteggia-type fracture-dislocation of the forearm remains early recognition of proximal radioulnar dissociation.

Patel et al review Monteggia injuries in adults. They report that in adults, this injury is managed with open reduction and internal fixation of the ulna fracture. They highlight that care should be taken to ensure anatomic reduction of the proximal ulna. They conclude that if radial head dislocation or subluxation persists following ulna ORIF, the reduction of the ulna should be reassessed.

Figure A is the injury film demonstrating a Bado I Monteggia fracture. Figure B is the immediate postoperative image showing persistent dislocation of the radiocapitellar joint. Illustration A is a radiograph following revision ORIF of the ulna and subsequent reduction of the radial head.

Incorrect Answers:
Answer 1: Radial neck osteotomy, may be required if reduction of the radial head cannot be achieved following anatomic reduction of the ulna. However, revision ulnar ORIF should be attempted first.
Answer 2: Radial head arthroplasty would not result in reduction of the radial head.
Answer 3: The radial head is not reduced secondary to malediction of the ulna. Positional changes will not result in radial head reduction.
Answer 4: The ulna is malreduced and should be revised. Shortening osteotomy would not result in reduction of the radial head.