CLINTON F. PICKETT D.O. Orthopaedic Resident

KIRK DABNEY M.D. Attending Orthopaedic Surgeon

April 15, 1996






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.

Monteggia Fractures


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.

  1. 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.
  2. 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.
  3. 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.
  4. Type IV monteggia lesions Anterior dislocation of the radial head with a fracture of the proximal radius. The ulna has a apex anterior angulated fracture.
Monteggia Equivalents.
  1. 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.
  2. II With less severe injuries there may be a minimally angulated greenstick fracture and a dislocation may be missed.
  1. 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.
  2. 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.
  3. 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.
  4. Radial collateral ligament attaches to the annular ligament.
  1. Letts M. , Locht R., Wiens J.;Monteggia Fracture Dislocations in Children JBJS 67B Nov 1985
  2. Wiley J.J. ,Galey J.P. Monteggia Injuries In Children JBJS vol. 67B Nov 1985
  3. Armstrong P.F., Joughin V.E., Clarke H.M. Pediatric fractures of the forearm, wrist, and hand Skeletal Trauma 1994 W.B. Saunders
  4. King R. E. Fractures of the shafts of the radius and ulna Rockwood and Green Volume 3 1991 Lippincott
  5. Bado, J.L., Monteggia Lesion, CORR 50, Jan-Feb, 1967.