You are in: eMedicine Specialties > Orthopedic Surgery > ELBOW Monteggia FractureArticle Last Updated: May 24, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Floriano Putigna, DO, FAAEM, Staff Physician, Department of Emergency Medicine, Dwight D Eisenhower Army Medical Center, Fort Gordon, Georgia Floriano Putigna is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Osteopathic Association Coauthor(s): Kevin Strohmeyer, MD, Consulting Surgeon, Department of Orthopedic Surgery, Darnall Army Community Hospital; Richard L Ursone, MD, Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, Brooke Army Medical Center Editors: Steven I Rabin, MD, Clinical Associate Professor, Loyola University Medical Center; Chair, Department of Orthopedic Surgery, Dreyer Medical Clinic; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert J Nowinski, DO, Clinical Assistant Professor of Orthopaedic Surgery, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic Specialists and Sports Medicine, Newark, Ohio; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: fracture-dislocation involving the proximal ulna and radius, ulna fracture, Monteggia lesion, radial head dislocation, forearm fracture, broken arm INTRODUCTIONSection 2 of 12
  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 less 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. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Arm, Broken Elbow, and Elbow Dislocation. 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.1 Interestingly, he described this injury pattern in the pre-Roentgen era based solely on the history of injury and on 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 4 types (see Images 1-7)2:
The Bado classification is based on the recognition that the apex of the fracture is in the same direction as the radial head dislocation. ProblemThe 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."3 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. FrequencyMonteggia fractures constitute less than 5% of forearm fractures, with published literature supporting 1-2%.4, 5 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. EtiologyMonteggia 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.6, 7 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. PathophysiologyThe 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. ClinicalFollowing 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:
INDICATIONSSection 3 of 12
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. RELEVANT ANATOMYSection 4 of 12
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. CONTRAINDICATIONSSection 5 of 12
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. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
StagingSee Bado classification of Monteggia fracture-dislocations. TREATMENTSection 7 of 12
Medical TherapyPain should be managed as needed in the immediate period. If the fracture is open, the status of the patient's tetanus immunization should be determined and addressed as indicated. Intravenous antibiotics should be administered to patients with open fractures. Open wounds should be irrigated with sterile saline solution and dressed with sterile, moist gauze. The radial head should be reduced in the emergency department if possible. Pediatric patients should undergo closed reduction and splint application emergently. Closed reduction in children is easiest when performed under procedural sedation or general anesthesia. Ketamine 1-2 mg/kg IV or 3-4 mg/kg IM is a very useful drug for sedation. An image intensifier should be available with real-time and static images to verify anatomic reduction of the fracture and congruent relationship of the radiohumeroulnar joint. The position of the elbow when immobilized depends on the fracture pattern as described earlier. Nonoperative treatment is successful for most Monteggia injuries in children because (1) the majority of the fractures are inherently stable, (2) they require a shorter time for both the osseous and the ligamentous injuries to heal, (3) children have little trouble regaining motion lost through stiffness, despite immobilization of the fractures for the duration of the initial healing period (3-6 wk), and (4) the potential may exist for remodeling of mild, residual angular deformities (<10°). Surgical TherapyOpen fractures require emergent surgical consultation. The initial treating physician may reduce the radial head dislocation and splint this fracture. Otherwise, an orthopedic surgeon should be consulted immediately to reduce the radial head. Anatomic reduction of the ulna is usually required prior to radial head reduction. Unless the fracture is open, surgical treatment is performed on an elective basis. While most adults require operative treatment, most pediatric fractures are treated closed. Operative fixation of complete fractures of the ulna with proximal radioulnar joint dislocation is recommended in children. The complete disruption of bone continuity is likely to be associated with substantial soft-tissue trauma in these injuries. Shortening and angulation of complete fractures after cast immobilization is not uncommon. Anatomic reduction of the ulnar fracture and radial head often requires operative treatment. In the past, transverse and short oblique fractures were adequately treated with intramedullary wire fixation. Intramedullary wires, however, cannot be relied on to maintain reduction of complete fractures that are either long oblique in pattern or comminuted; the wires therefore are not used anymore. These fractures are likely to displace or even shorten and, consequently, should be fixed with a plate and screws. As a result of the rapidity of osseous repair and the tolerance of cast immobilization in children, the use of plate-and-screw constructs that are smaller (typically a one-third tubular or semitubular plate) and shorter (2 or 3 holes [4 or 6 cortices] proximal and distal to the fracture) than those recommended for adults are usually adequate. Preoperative DetailsPatients with fracture-dislocations of the forearm should initially be stabilized if more serious injuries are present. Adequate pain control should be provided in the preoperative period, and the affected arm should be placed in a long arm splint to reduce further injury and pain. Intraoperative DetailsAfter adequate analgesia and sedation, a closed reduction of the radial head can be performed with distal traction and direct pressure over the radial head. This can be done in the emergency department or in the operating room. An open technique should be considered if the radius is fractured or irreducible. Once the radius has been reduced, the ulnar fracture is addressed with rigid internal fixation. In adult Monteggia fracture, fixation with a 3.5-mm dynamic compression (DC) plate or a limited contact–dynamic compression (LC-DC) plate is recommended. If the fracture is comminuted, purchase should be obtained, if possible, with 3-4 screws or 6-8 cortices proximal and distal to the fracture. Once the ulna is stabilized, the stability of the radial head is assessed using intraoperative fluoroscopy. Permanent radiographs should be taken, and a posterior long arm splint should be placed with the elbow immobilized in 90° of flexion and full supination for types I, III, and IV. Type II is best splinted in the same manner, but in 70° flexion at the elbow to prevent radial head subluxation. If the radial head is unable to reduce, the reduction and alignment of the ulna should be checked. If the radial head is unstable after ulnar fixation, then the elbow should be splinted in supination, which is the position of stability. Postoperative DetailsFollow-up appointments are scheduled for wound checks and suture removal based on the nature of the soft-tissue injury and operative treatment. If rigid fixation is achieved and the radiocapitellar joint remains stable, the patient is referred to begin range-of-motion exercises under the close supervision of a qualified physical therapist. Patients with stable injuries may be placed in range-of-motion braces for 6-8 weeks. Unstable injuries should remain in cast immobilization until stability is achieved at 4-6 weeks. Significant concern exists regarding loss of elbow motion with prolonged immobilization. Chronic radiocapitellar instability is unusual and may be addressed surgically. Follow-upThe patient should be evaluated with the dressing and splint changed at 5-7 days. A posterior long arm cast in 90° flexion should be placed at that time. Follow-up radiography at 2, 4, and 6 weeks is recommended to monitor healing and union of the fracture. After this point, if the patient is reliable and stability is present, the above-described therapy can be continued. If the hardware is causing significant problems, the provider may consider removing it. However, unless infection is present, waiting at least 1 year is recommended. COMPLICATIONSSection 8 of 12
Complications include infection, bleeding, malunion, nonunion, nerve injury, redislocation of the radial head, radioulnar synostosis, and chronic pain. Many of the complications listed are significantly reduced with timely diagnosis, adequate reduction, stable surgical fixation, and appropriate postoperative care. Most nerve injuries are neurapraxias, and function usually returns within 1 to 6 months. Baseline electrodiagnostic studies are obtained early. If nerve function does not return within 2 to 3 months, surgical exploration may be indicated. If the nerve injury results from reduction or operative treatment, it should be addressed immediately. Prolonged or complete nerve dysfunction requires early splinting and therapy and may result in the need for tendon transfers. If the radial head dislocates after surgery, improper ulnar reduction must be considered. If this is the case, the hardware should be removed and a proper reduction of the ulna should take place. If dislocation of the radial head is recognized more than 6 weeks after the surgery, a radial head excision should be performed. A nonunion or malunion complication can be considered for bone grafting. Chronic pain may be the result of hardware or improper reduction. If all mechanical causes have been excluded, consulting a pain management specialist should be considered. OUTCOME AND PROGNOSISSection 9 of 12
In 1991, Anderson and Meyer used criteria to evaluate forearm fractures and their prognosis, as follows8:
Pain, nerve dysfunction, and cosmetic deformity are other factors to consider when evaluating the outcome of treatment in Monteggia fracture-dislocations. Type II lesions that are associated with ulnohumeral dislocation have been noted to have outcome scores with greater disability than those without ulnohumeral dislocation. FUTURE AND CONTROVERSIESSection 10 of 12
Future research will help to identify appropriate treatment protocols to achieve optimum long-term outcome. The most important step is to educate the specialist, emergency physician, and primary care physician to correctly diagnose and treat these injuries. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: May 24, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||
