CLINTON F. PICKETT D.O. Orthopaedic
KIRK DABNEY M.D. Attending Orthopaedic
April 15, 1996
CLINICAL CASE PRESENTATION
THE ALFRED I. DUPONT INSTITUTE
L.S. , a 12 year-old right-
hand dominant female presented to this institution complaining of right
forearm pain. The patient stated that while playing basketball she fell
down and another player subsequently fell onto her right arm. The patient
was brought to the emergency department for evaluation.
Physical exam revealed an alert
white female . The right upper extremity was neuro-vascular intact. The
volar surface of the proximal forearm had two small puncture wounds . Radiographs
revealed a comminuted fracture of the proximal one-third of the ulna with
over-riding of the fragments. The radial head was dislocated anteriorly
The patient was taken to the
operating room where the wounds were extended with an incision and irrigated
with approximately six liters of fluid .After irrigation and debridement,
open reduction and fixation of the ulna with a four -hole plate was performed.
The radial head was reduced closed .
The upper extremity was then splinted with eighty degrees of flexion and
full supination. The patient was admitted for dressing changes ,observation
,and IV antibiotics. Three days later she was discharged to home after
application of a long-arm cast.
0.4% of all forearm fractures.
In 1814 Giovanni Battista Monteggia
published a report of two cases of traumatic lesions characterized by a
fracture of the proximal one-third of the shaft of the ulna associated
with an anterior dislocation of the radial-humeral joint.
Malgaigne described the injury
as a dislocation of the radius which accompanied a fracture of the ulna
at any level. He noted that
When there is a fracture of
only one bone of the forearm with angulation or overlap there must be a
subluxation of one or the other radial-ulnar joint.
When taking radiographs of the
fracture , the nearest joint must also be included.
When a fracture is unstable
in this area it is an indication for internal fixation.
Bado classified four types of
monteggia lesions and stated that the radial head would dislocate in the
direction of the apex of angulation of the ulna.
- Type I monteggia lesion -anterior dislocation of the radial head .
The ulna shaft is fractured with apex angulation anteriorly. Mechanism
of injury is described as direct trauma to posterior ulna, or fall onto
an outstretched arm with the momentum of the body causing forced pronation
of the forearm. Another mechanism described is falling on an outstretched
arm with the elbow hyperextended. This pattern is most common type.
- Type II. monteggia lesion -posterior or posterior-lateral dislocation
of the radial head. The ulna shaft is fractured with apex posterior. This
lesion is thought to be due to a rotational force in supination or direct
trauma of the forearm in the supinated position. This pattern is rare in
children and is frequently an open fracture.
- Type III monteggia lesion Lateral or anterior-lateral dislocation of
the radial head with fracture of the ulnar metaphysis. This pattern is
unusual and all reported cases have been in children. The mechanism of
injury may be direct trauma over the inner aspect of the elbow with or
without a rotational force. This causes an adduction force displacing the
radial head anteriorly. Supination or pronation forces added will cause
posterior-lateral or anterior-lateral dislocation.
- Type IV monteggia lesions Anterior dislocation of the radial head with
a fracture of the proximal radius. The ulna has a apex anterior angulated
- Anterior dislocation of the radial head with plastic deformation of
- Fracture of the ulnar diaphysis with a fracture of the neck of the
- Fracture of the ulnar diaphysis with a fracture of the proximal third
of the radius proximal to the ulnar fracture
- Fracture of the ulnar metaphysis with anterior dislocation of the radius.
- Fracture of the ulnar diaphysis with anterior dislocation of the radial
head and fracture of the olecranon
- Fracture of the ulnar metaphysis with fracture of the neck of the radius
- Posterior dislocation of the elbow and fracture of the ulnar diaphysis
, with or without a fracture of the proximal radius.
- I It is essential to insist on a true lateral to evaluate the radial-humeral
joint. A line drawn through the center of the radial head should pass through
the center of the capitellum in lateral flexion or extension views.
- II With less severe injuries there may be a minimally angulated greenstick
fracture and a dislocation may be missed.
- The capsule of the elbow joint blends with the annular ligament. The
annular ligament is attached to the anterior and posterior margins of the
ulnar notch. The annular ligament is the most important structure in maintaining
the radial head in alignment.In children the radial head may pull out of
the annular ligament, whereas in adults the annular ligament usually tears.
- The quadrate ligament extends between the neck of the radius and the
inferior border of the radial notch of the ulna. This structure may be
disrupted when excessive rotation of the forearm occurs.
- The interosseous membrane fibers course from the radius to the ulna
in an oblique fashion . The fibers are taut in supination and lax in pronation.
- Radial collateral ligament attaches to the annular ligament.
- Approximately 90% of these injuries in children have good results with
- Open reduction is required if adequate closed reduction cannot be achieved.
This occurs more frequently in older children or when there has been a
delay in diagnosis.
- Type I fractures. -Apply traction with the forearm extended and supinated
. If the radial head does not spontaneously reduce with this motion then
the elbow is gently flexed while pressure is applied anteriorly over the
head of the radius. After reduction is attained the elbow is immobilized
in full supination and 100degrees of flexion if possible.
- Type II fractures are reduced with the forearm in extension and supination,
and pushing with the thumb over the posterior aspect of the radial head.
Bado suggests placing the elbow in 90 degrees of flexion and applying gentle
traction and pronation . The arm is then immobilized in extension for four
weeks then placed in a long arm cast with the elbow flexed for an additional
- Type III fractures. Closed reduction is performed by applying traction
and putting abduction strain on the extended elbow. Supinating the forearm
while applying pressure on the lateral side of the radial head. The arm
is then placed in a long-arm cast in flexion and supination for 6 weeks.
- Type IV fractures are more difficult to reduce by closed means. If
the ulna fracture is unstable plate fixation should be used instead of
intramedullary pinning. Plating of the radial fracture may be needed to
maintain the reduction. Some authors have used pins and plaster to maintain
a closed reduction.
- If fracture is unstable intramedullary fixation of the ulna with a
K-wire or a Rush rod inserted percutaneously in the younger child. Older
children may require plating .
- If the radial head will not reduce, there may be interposition of the
annular ligament or osteocartilaginous fragments. Using a posterior approach
to the elbow, both components of the monteggia lesion can be approached.
If the annular ligament cannot be repaired it can be reconstructed using
triceps fascia .
- Many authors condemn transcapitellar pinning of the radial head. Cross
pinning of the radius to the ulna increases risk of a cross-union.
- Leaving the radial head dislocated will result in progressive valgus
deformity and collateral ligament instability of the elbow with restricted
- Decreased range of motion -Usually closed treatment results less loss
- Overlooked wrist trauma -Forearm fractures should increase suspicion
of additional wrist or elbow pathology.
- Redislocation of radial head -- may occur after reconstruction . May
also be due to interposition of the annular ligament or the radial nerve.
- Heterotopic ossification -if it does not affect function do not remove
- Persistent dislocation of the radial head and healed angular deformity
of the ulna. May need to osteotomize the ulna and reconstruct the annular
- Nerve impingement -posterior interosseous nerve most common. Nerve
is tethered as it passes under the fibrous arch of the supinator and arcade
of Frohse. Radial nerve palsy with anterior dislocation of the radial head
has been reported. Function usually recovers in 8-12 weeks . Initially
conservative treatment is indicated. If no return of function is seen in
3 months surgical exploration is indicated.
- Letts M. , Locht R., Wiens J.;Monteggia Fracture Dislocations in Children
JBJS 67B Nov 1985
- Wiley J.J. ,Galey J.P. Monteggia Injuries In Children JBJS vol. 67B
- Armstrong P.F., Joughin V.E., Clarke H.M. Pediatric fractures of the
forearm, wrist, and hand Skeletal Trauma 1994 W.B. Saunders
- King R. E. Fractures of the shafts of the radius and ulna Rockwood
and Green Volume 3 1991 Lippincott
- Bado, J.L., Monteggia Lesion, CORR 50, Jan-Feb, 1967.