- Author: Floriano Putigna, DO, FAAEM; Chief Editor: Harris Gellman, MD more...
The eponym Monteggia fracture is most precisely used to refer to a dislocation of the proximal radioulnar joint in association with a forearm fracture. These injuries are relatively uncommon, accounting for fewer than 5% of all forearm fractures.
The ulna fracture is usually clinically and radiographically apparent. Findings associated with the concomitant radial head dislocation are often subtle and can be overlooked. The keys to successful diagnosis of a Monteggia fracture are clinical suspicion and radiographs of the entire forearm and elbow. Properly assessing the nature of this injury in a timely fashion is imperative in order to prevent permanent disability or limb dysfunction.
History of the injury
In 1814, Giovanni Battista Monteggia of Milan first described this injury as a fracture to the proximal third of the ulna with associated anterior dislocation of the radial head. Interestingly, he described this injury pattern in the pre-Roentgen era based solely on the basis of the history of injury and the physical examination findings. However, this particular fracture pattern only accounts for about 60% of these types of injuries.
More than 150 years later, in 1967, Bado coined the term Monteggia lesion and classified the injury into the following four types :
Type I - Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (see the first and second images below)
Type II - Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (see the third and fourth images below)
Type III - Fracture of the ulnar metaphysis with lateral dislocation of the radial head (see the fifth and sixth images below)
Type IV - Fracture of the proximal or middle third of the ulna and radius with anterior dislocation of the radial head (see the seventh image below)
The Bado classification is based on the recognition that the apex of the fracture is in the same direction as the radial head dislocation.
The first challenge is correctly assessing the extent and nature of the injury. The ulna fracture is usually noted, commonly in the proximal third of the ulna. The olecranon, midshaft, and distal shaft may be involved. In his classic 1943 text, Watson-Jones stated that "no fracture presents so many problems; no injury is beset with greater difficulty; no treatment is characterized by more general failure." Some injuries associated with radiocapitellar dislocation (such as the transolecranon fracture-dislocation of the elbow) are mislabeled as Monteggia lesions, when in fact the proximal radioulnar joint remains intact. The Monteggia lesion is most precisely characterized as a forearm fracture in association with dislocation of the proximal radioulnar joint.
The radial head dislocation may not be apparent and will possibly be missed if the elbow is not included in the radiograph. Whenever a fracture of a long bone is noted, the joints above and below should be evaluated using radiographs in orthogonal planes (planes at 90° angles to each other). If one of the forearm bones is injured, injury should be looked for in the other bone and in associated joints of the forearm, elbow, and wrist. This principle also applies to a Galeazzi fracture, which is a fracture of the distal radius with concomitant dislocation of the distal radioulnar joint.
Separate radiographs should be taken of the elbow. The radial head should point towards the capitellum on all radiographs of the elbow.
Unrecognized dislocations may result from reduction of the dislocated radius prior to presentation. This may occur in the field spontaneously or as a result of manipulation by emergency responders. The treating physician may reduce an unrecognized dislocation while reducing or immobilizing the ulna fracture.
Problems relating to treatment are discussed in Complications.
Monteggia fractures constitute less than 5% of forearm fractures, with published literature supporting 1-2%.[6, 7] Of the Monteggia fractures, Bado type I is the most common (59%), followed by type III (26%), type II (5%), and type IV (1%). Monteggia fractures are one third as common as the more familiar Galeazzi fractures.
Monteggia fractures are primarily associated with falls on an outstretched hand with forced pronation. If the elbow is flexed, the chance of a type II or III lesion is greater. In some cases, a direct blow to the forearm can produce similar injuries. Evans in 1949 and Penrose in 1951 studied the etiology of Monteggia fractures on cadavers by stabilizing the humerus in a vise and subjecting different forces to the forearm.[8, 9] Penrose considered type II lesions a variation of posterior elbow dislocation. Bado believed that the type III lesion, the result of a direct lateral force on the elbow, was primarily observed in children. In essence, high-energy trauma (eg, a motor vehicle collision) and low-energy trauma (eg, a fall from a standing position) can result in the described injuries. A high index of suspicion, therefore, should be maintained with any ulna fracture.
The forearm structures are intricately related, and any disruption to one of the bones affects the other. The ulna and radius are in direct contact with each other only at the proximal and distal radioulnar joints; however, they are unified along their entire length by the interosseous membrane. This allows the radius to rotate around the ulna. When the ulna is fractured, energy is transmitted along the interosseous membrane, displacing the proximal radius. The end result is a disrupted interosseous membrane proximal to the fracture, a dislocated proximal radioulnar joint, and a dislocated radiocapitellar joint.
Radial head dislocation may lead to an injury of the radial nerve. The posterior interosseous branch of the radial nerve, which courses around the neck of the radius, is especially at risk, particularly in Bado type II injuries. Injuries to the anterior interosseous branch of the median nerve and the ulnar nerve also have been reported. Most nerve injuries are neurapraxias and typically resolve over a period of 4-6 months. Splinting of the wrist in extension and finger range-of-motion exercises help to prevent contractures from developing while the patient awaits resolution of the nerve injury.
Following the above mechanism, patients present with elbow pain. Depending on the type of fracture and severity, they may experience elbow swelling, deformity, crepitus, and paresthesia or numbness. Some patients may not have severe pain at rest, but elbow flexion and forearm rotation are limited and painful.
The dislocated radial head may be palpable in the anterior, posterior, or anterolateral position. In type I and IV lesions, the radial head can be palpated in the antecubital fossa. The radial head can be palpated posteriorly in type II lesions and laterally in type III lesions.
The skin should be closely inspected to ensure an open fracture is not present. Pulses and capillary refill should be documented. A negligible hematoma may be present at the site if no direct trauma is associated.
Motor function must be thoroughly tested because the branches of the radial nerve can become entrapped, causing weakness or paralysis of finger or thumb extension. The sensory branch is not usually involved but also should be checked. Bado indicated that spontaneous recovery is the usual course, and exploration is appropriate if function does not begin to return within 2 to 3 months.
Monteggia fractures in the pediatric population typically manifest with unique features that have led to a decreased emphasis on the direction of the radial head dislocation and an increased focus on the character of the fracture of the ulna. When the various fracture types occur in the immature bone of children, distinct patterns result and influence treatment considerations. Plastic deformation of the ulna in association with anterior radial head dislocation represents up to 31% of anterior Monteggia lesions. Poor recognition of this injury pattern can lead to recurrent or persistent dislocation because the radial head reduction remains unstable until the plastic deformity is corrected. Incomplete fractures of the ulna and greenstick fractures represent other variants that must be corrected along with the radial head dislocation.
Monteggia fractures in children based on type of ulnar injury are as follows:
Incomplete (greenstick or buckle) fracture
Complete transverse or short oblique fracture
Comminuted or long oblique fracture
Indications for treatment of Monteggia fractures are based on the specific fracture pattern and the age of the patient (ie, pediatric or adult). Most pediatric fracture patterns can be managed conservatively with closed reduction and long arm casting. However, most adult fractures require open reduction and internal fixation techniques.
The radial head dislocation should be reduced emergently. Closed reduction under sedation should be performed within 6-8 hours of the injury. This is usually achieved with supination of the forearm, but it may require traction and direct pressure on the radial head. If closed reduction is unsuccessful, the patient should be taken to the operating room within this same time frame for open reduction. Delay in reduction of the radius may lead to permanent articular damage, further nerve injury, or both.
An open fracture requires emergent operative intervention. In closed injuries, once the radial head is reduced, the forearm is splinted and operative fixation of the ulna fracture may be carried out in an elective fashion. Adults usually require operative internal fixation to stabilize the ulna and prevent further displacement forces on the radiocapitellar joint. Closed Monteggia fractures in pediatric patients are generally treated in a closed fashion. A posterior long arm splint with the elbow in 90° of flexion and full supination is the immobilization method of choice for types I, III, and IV. Type II injuries (posterior lesions) are best splinted in 70° elbow flexion with supination.
The annular and radial collateral ligaments stabilize the radial head. These ligaments stretch or rupture during radial head dislocation. The radial head articulates with the humeral capitellum and the radial notch of the proximal ulna. The radius and ulna are closely invested by the interosseous membrane, which accounts for the increased risk of displacement or injury to the radius when the ulna fractures.
The distal ulna and radius also articulate at the distal radioulnar joint. The ulna provides a stable platform for rotation of the radius and forearm. The ulna and interosseous membrane also may provide stable platforms for dislocation of the proximal radius, leading to the Monteggia fracture.
The posterior interosseous nerve travels around the neck of the radius and dives under the supinator as it courses into the forearm. The median and ulnar nerves enter the antecubital fossa just distal to the elbow. The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. Neural injuries are generally traction injuries and result from stretching around the displaced bone or from energy dispersed during the initial injury.
Few contraindications to surgery exist. Once the radial head is reduced in closed injuries, surgical treatment may be delayed until the patient is stable and the surgery may be performed in a more elective fashion.
Open fractures require emergent operative attention. If the wound is open and heavily contaminated, serial debridement may be indicated prior to plate fixation. In medically unstable patients, emergent treatment of the open wound is still necessary. The procedure can be limited to irrigation and debridement of the open wound and closed reduction at the bedside. This can be performed under regional anesthesia or local anesthesia with sedation if absolutely necessary. If the patient is unable to tolerate operative treatment, the fracture dislocation may be treated with cast immobilization after reduction of the radius and irrigation and debridement if the fracture is open.
Beutel BG. Monteggia fractures in pediatric and adult populations. Orthopedics. 2012 Feb. 35(2):138-44. [Medline].
Monteggia GB. Instituzioni Chirrugiche. Milan: Maspero; 1814. vol 5:
Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967 Jan-Feb. 50:71-86. [Medline].
Watson-Jones R. Fracture and Joint injuries. 3rd edition. Baltimore: Williams and Wilkins; 1943. Vol. 2: P. 520.
Stitgen A, McCarthy JJ, Nemeth BA, Garrels K, Noonan KJ. Ulnar fracture with late radial head dislocation: delayed Monteggia fracture. Orthopedics. 2012 Mar 7. 35(3):e434-7. [Medline].
Bruce H.E., Harvey J.P., Wilson J.C. Monteggia Fractures. J Bone Joint Surg Am. 1974. 56:1563.
Reckling F.W. Unstable fracture-dislocation of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am. 1982. 64:857.
Evans EM. Pronation injuries of the forearm with special reference to anterior Monteggia fractures. J Bone Joint Surg. 1949. 31B:578-588.
Penrose JH. The Monteggia fracture with posterior dislocation of the radial head. J Bone Joint Surg. 1951. 33B:65-73.
Ruchelsman DE, Pasqualetto M, Price AE, Grossman JA. Persistent posterior interosseous nerve palsy associated with a chronic type I monteggia fracture-dislocation in a child: a case report and review of the literature. Hand (N Y). 2009 Jun. 4(2):167-72. [Medline]. [Full Text].
Tan JW, Mu MZ, Liao GJ, Li JM. Pathology of the annular ligament in paediatric Monteggia fractures. Injury. 2008 Apr. 39(4):451-5. [Medline].
Guitton TG, Ring D, Kloen P. Long-term evaluation of surgically treated anterior monteggia fractures in skeletally mature patients. J Hand Surg Am. 2009 Nov. 34(9):1618-24. [Medline].
Leonidou A, Pagkalos J, Lepetsos P, Antonis K, Flieger I, Tsiridis E, et al. Pediatric Monteggia fractures: a single-center study of the management of 40 patients. J Pediatr Orthop. 2012 Jun. 32(4):352-6. [Medline].
Li H, Cai QX, Shen PQ, Chen T, Zhang ZM, Zhao L. Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children. Chin J Traumatol. 2013. 16(3):131-5. [Medline].
Anderson LE, Meyer FN. Fractures of the shafts of the radius and ulna. Rockwood CA, Green DP, and Bucholz R, eds. Fractures in Adults. 3rd ed. Philadelphia, Pa: JB Lippincott; 1991. vol 1:
Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone Joint Surg Am. 2009 Jun. 91(6):1394-404. [Medline].
Datta T, Chatterjee N, Pal AK, Das SK. Evaluation of outcome of corrective ulnar osteotomy with bone grafting and annular ligament reconstruction in neglected monteggia fracture dislocation in children. J Clin Diagn Res. 2014 Jun. 8(6):LC01-4. [Medline]. [Full Text].
Anderson LD, Sisk D, Tooms RE, et al. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am. 1975 Apr. 57(3):287. [Medline].
Boyd HB, Boals JC. The Monteggia lesion. A review of 159 cases. Clin Orthop Relat Res. 1969 Sep-Oct. 66:94-100. [Medline].
Huang E, Grimes P. Fractures, forearm. Medscape Reference. [Full Text].
Jessing P. Monteggia lesions and their complicating nerve damage. Acta Orthop Scand. 1975 Sep. 46(4):601-9. [Medline].
Jupiter JB, Leibovic SJ, Ribbans W, et al. The posterior Monteggia lesion. J Orthop Trauma. 1991. 5(4):395-402. [Medline].
LD Anderson, D Sisk, RE Tooms and WI Park. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J of Bone Joint Surgery. 1975. 57:292. [Full Text].
McLaughlin HL. Trauma. Philadelphia, Pa: WB Saunders; 1959.
Mullick S. The lateral Monteggia fracture. J Bone Joint Surg Am. 1977 Jun. 59(4):543-5. [Medline].
Overly F, Steele D. Common pediatric fractures and dislocations. Clinical Pediatric Emergency Medicine. 2002. 3(2):106-117.
Perron AD, Hersh RE, Brady WJ, et al. Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation. Am J Emerg Med. 2001 May. 19(3):225-8. [Medline].
Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am. 1998 Dec. 80(12):1733-44. [Medline].
Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J Am Acad Orthop Surg. 1998 Jul-Aug. 6(4):215-24. [Medline].
Speed JS, Boyd HB. Treatment of fractures of the ulna with dislocation of the head of the radius. JAMA. 1940. 115:1699-1704.
Strauss EJ, Tejwani NC, Preston CF, Egol KA. The posterior Monteggia lesion with associated ulnohumeral instability. J Bone Joint Surg Br. 2006 Jan. 88(1):84-9. [Medline].