Review Question - QID 219705

The injury noted in Figure B is a Bado type II Monteggia fracture. Compared to the injury noted in Figure A (a Bado type II Monteggia variant with a radial head fracture), surgical management of a simple Bado type II Monteggia fracture is associated with increased post-operative range of motion.

Monteggia fractures are proximal 1/3rd ulna fractures with associated radial head dislocations. The Bado classification is used to classify these injuries with respect to the direction of the radial head dislocation with type I being an anterior radial head dislocation, type II being a posterior dislocation, and type III being a lateral dislocation. The Bado type IV is a combined radial shaft and ulnar shaft fracture with a radial head dislocation (any direction). Monteggia "variants" also exist and are associated with each Bado type when there is a fracture of the radial head/neck in addition to the dislocation. These are important to identify as surgical management of the radial head often requires a separate surgical approach. Furthermore, patients need to be counseled on these injuries since Monteggia variants are associated with increased rates of post-operative osteoarthritis, instability, non-union rates with patients often having decreased range of motion compared to "simple" Monteggia fractures.

Egol et al. retrospectively reviewed the clinical and functional outcomes after operative fixation of Monteggia variant fractures (ipsilateral fractures of the proximal ulna, radial head/neck, and radial head dislocation) in 20 patients with a mean followup of ~3 years. The authors noted radiographic union in 17 of the 20 patients with 3 non-unions. The authors noted elbow osteoarthritis in 14 of the 20 patients at 2 years followup with a mean disability of the arm, shoulder and hand score of 64.1 (worse outcome than the general population). In addition, they noted 8 of 20 patients requiring revision surgery (three for recurrent instability, three for nonunion of the ulna, one for radial head excision and hardware removal, and one for hardware removal alone). The authors conclude that physicians should counsel patients that functional impairment is common after these complex high-energy injuries.

Jupiter et al. describe the Type II Monteggia variant fracture-dislocation in 10 patients (a proximal ulna fracture, a posterior radiocapitellar dislocation, and, a radial head fracture). The patients all underwent ORIF of the ulna fracture with various treatments of the radial head fracture (arthroplasty, ORIF, etc). The post-operative function of the patients were rated excellent/good in 6 (60%), fair in 3 (30%), and poor in 1 patient. Incomplete reduction of the ulnar fracture with residual posterior radiocapitellar subluxation was observed in 40% of cases, all leading to loss of forearm supination. The authors conclude that recognition of the posterior Monteggia fracture-dislocation (Type II Monteggia variant) and its specific anatomic features is essential to achieve a functional outcome.

Konrad et al. performed a retrospective study to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults. The authors reviewed 47 patients who underwent operative management of these injuries with a mean follow-up of ~8 years. They noted that 34 (72%) patients had excellent/good results, 9 (19%) had fair results, and four (8%) had poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The authors noted the following factors to be correlated with a poor clinical outcome: Jupiter type IIa fracture, fracture of the radial head (Monteggia Variant), and coronoid fractures. The authors noted that patients with these types of fractures should be informed about the potential risk of functional deficits and the possible need for further surgery.

Figure A is a lateral radiograph of a Bado type II Monteggia variant with an olecranon fracture and a radial head fracture-posterior dislocation. Figure B is a lateral radiograph of a simple Bado type II Monteggia fracture with an olecranon fracture and a posterior radial head dislocation without fracture.

Incorrect Answers:
Answers 1, 2, 3, and 4: Surgical fixation of simple Bado type II Monteggia fractures is associated with decreased rates of non-union, elbow osteoarthritis, instability, and increased post-operative range of motion compared to Bado type II Monteggia variants (with associated radial head fracture).