Updated: 5/25/2021

Monteggia Fractures

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  • Summary
    • A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation.
    • Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture.
    • Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). Adults and unstable injuries generally require ORIF of the ulna.
  • Epidemiology
    • Incidence
      • rare in adults
      • more common in children with peak incidence between 4 and 10 years of age
        • different treatment protocol for children
  • Etiology
    • Associated injuries
      • may be part of complex injury pattern including
        • olecranon fracture-dislocation
        • radial head fx
        • coronoid fx
        • LCL injury
        • terrible triad of elbow
  • Anatomy
    • Ligament
      • annular ligament
  • Classification
    • Bado Classification
      Type I
      60%
      Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (most common in children and young adults)
      Type II
      15%
      Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70 to 80% of adult Monteggia fractures)
      Type III
      20%
      Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head
      Type IV
      5%
      Fracture of the proximal or middle third of the ulna and radius with dislocation of the radial head in any direction
    • Jupiter Classification of Type II Monteggia Fracture-Dislocations
      Type IIA
      Coronoid level
      Type IIB
      Metaphyseal-diaphyseal junction
      Type IIC
      Distal to coronoid
      Type IID
      Fracture extending to distal half of ulna
  • Presentation
    • Symptoms
      • pain and swelling at elbow joint
    • Physical exam
      • inspection
        • may or may not be obvious dislocation at radiocapitellar joint
        • should evaluate skin integrity
      • ROM & instability
        • may be loss of ROM at elbow due to dislocation
      • neurovascular exam
        • PIN neuropathy
          • radial deviation of hand with wrist extension
          • weakness of thumb extension
          • weakness of MCP extension
          • most likely nerve injury
  • Imaging
    • Radiographs
      • recommended view
        • AP and Lateral of elbow, wrist, and forearm
    • CT scan
      • helpful in fractures involving coronoid, olecranon, and radial head
  • Treatment
    • Nonoperative
      • closed reduction
        • indications
          • more common and successful in children
          • must ensure stabilty and anatomic alignment of ulna fracture
        • technique
          • cast in supination for Bado I and III
    • Operative
      • ORIF of ulna shaft fracture
        • indications
          • acute fractures which are open or unstable (long oblique)
          • comminuted fractures
          • most Monteggia fractures in adults are treated surgically
      • ORIF of ulna shaft fracture, open reduction of radial head
        • indications
          • failure to reduce radial head with ORIF of ulnar shaft only
            • ensure ulnar reduction is correct
          • complex injury pattern
          • Monteggia "variants" with associated radial head fracture
      • IM Nailing of ulna
        • indications
          • transverse or short oblique fracture
  • Techniques
    • ORIF of ulnar shaft fracture
      • approach
        • lateral decubitus position with arm over padded support
        • midline posterior incision placed lateral to tip of olecranon
        • develop interval between flexor carpi ulnaris and anconeus along ulnar border proximally, and interval between FCU and ECU distally
      • techniques
        • with proper alignment of ulna radial head usually reduces and open reduction of radial head is rarely needed
        • failure to align ulna will lead to chronic dislocation of radial head
    • ORIF of radial head
      • approach
        • posterolateral (Kocher) approach
      • technique
        • annular ligament often found interposed in radiohumeral joint preventing anatomic reduction after ulnar ORIF
          • treatment based on involved components (radial head, coronoid, LCL)
  • Complications
    • PIN neuropathy
      • up to 10% in acute injuries
      • treatment
        • observation for 2-3 months
          • spontaneously resolves in most cases
          • if no improvement obtain nerve conduction studies
    • Malunion with radial head dislocation
      • usually caused by failure to obtain anatomic alignment of ulna
      • treatment
        • ulnar osteotomy and open reduction of the radial head
  • Prognosis
    • If diagnosis is delayed greater than 2-3 weeks complication rates increase significantly

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Questions (4)
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(OBQ10.240) 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?

QID: 3339
1

Lateral ulnar collateral ligament disruption

9%

(488/5192)

2

Anterior band of the medial collateral disruption

1%

(66/5192)

3

Posterior band of the medial collateral ligament disruption

1%

(53/5192)

4

Annular ligament interposition

85%

(4417/5192)

5

Anconeus muscle interposition

2%

(128/5192)

L 1 C

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(OBQ09.264) 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?

QID: 3077
1

Lateral

2%

(79/3738)

2

Posterior

11%

(395/3738)

3

Posterolateral

11%

(402/3738)

4

Anterior

74%

(2779/3738)

5

Anteromedial

2%

(66/3738)

L 2 C

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