Monteggia fracture-dislocations consist of a fracture of the ulnar shaft with concomitant dislocation of the radial head. The ulnar fracture is usually obvious, whereas the radial head dislocation can be overlooked, with potentially serious functional and medico-legal ramifications.
Typically, Monteggia fracture-dislocations occur as the result of a fall onto an outstretched hand (FOOSH) 4.
The Bado classification is used to subdivide the fracture-dislocation into four types which all have different treatment options and prognoses and is based on the principle that the direction in which the apex of the ulnar fracture points is the same direction as the radial head dislocation 3. The direction of radial head dislocation depends on whether abduction or adduction forces were applied during the fall 1.
As is usually the case, in everyday practice, describing the fracture-dislocation is far more important than remembering the grade.
Monteggia fractures occur mostly in children (peak incidence at ages 4-10 years) and rarely in adults.
When a forearm fracture is identified, it is important to image both the elbow and the wrist, and good quality AP and lateral views are required. Provided that films of adequate quality are obtained, the ulnar fracture is usually obvious and the radial head dislocation should be readily identifiable.
Regarding paediatric patients, one should take into account
- the age-dependent normal appearance of the elbow centres of ossification, which could mimic a fracture to the inexperienced eye
- that up to 24% of cases are associated with a distal radial fracture
- that an apparently isolated ulnar plastic/greenstick fracture may actually represent a Monteggia-equivalent lesion with spontaneous radial head reduction
Treatment and prognosis
All four types of Monteggia fracture-dislocations (see Bado classification) are treated with open reduction and internal fixation. Types I, III, IV are cast at 110 degrees of flexion, whereas type II is cast at 70 degrees of flexion 4,6.
In the paediatric population, treatment depends on the type of ulnar fracture: 7,8
- bowing/greenstick fracture: closed reduction of the ulnar bow and casting
- complete transverse/short oblique fracture: closed reduction and intramedullary fixation
- long oblique/comminuted fracture: open reduction and internal fixation
History and etymology
It is named after Giovanni Battista Monteggia, Italian surgeon (1762-1815), who first described what is now known as the Bado type I fracture in 1814 5-6.
- 1. Rahij Anwar, Kenneth W. R. Tuson, Shah Alam Khan. Classification and Diagnosis in Orthopaedic Trauma. ISBN: 9781139469418
- 2. Konrad GG, Kundel K, Kreuz PC et-al. Monteggia fractures in adults: long-term results and prognostic factors. J Bone Joint Surg Br. 2007;89 (3): 354-60. doi:10.1302/0301-620X.89B3.18199 - Pubmed citation
- 3. Iyer RS, Thapa MM, Khanna PC et-al. Pediatric bone imaging: imaging elbow trauma in children--a review of acute and chronic injuries. AJR Am J Roentgenol. 2012;198 (5): 1053-68. doi:10.2214/AJR.10.7314 - Pubmed citation
- 4. Cooper G. Blueprints Orthopedics. Blackwell Publishers. (2005) ISBN:1405104015. Read it at Google Books - Find it at Amazon
- 5. Bado JL. The Monteggia lesion. Clin. Orthop. Relat. Res. 50 : 71-86. - Pubmed citation
- 6. Williams GR, Ramsey ML, Wiesel SW. Operative Techniques in Shoulder and Elbow Surgery. Lippincott Williams & Wilkins. (2010) ISBN:145110264X. Read it at Google Books - Find it at Amazon
- 7. Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. The Journal of the American Academy of Orthopaedic Surgeons. 6 (4): 215-24. Pubmed
- 8. Beutel BG. Monteggia fractures in pediatric and adult populations. Orthopedics. 35 (2): 138-44. doi:10.3928/01477447-20120123-32 - Pubmed
Wrist and hand fractures
- wrist and hand fractures (Amsterdam wrist rules)
- distal radial fracture (Frykman classification)
- distal ulna fractures
- fracture dislocations of the radius and ulna
- carpal fractures
- metacarpal fractures
- phalanx fractures