• It is a fracture of the proximal 3rd of
the ulna with dislocation of the radial
• 1814- Giovanni Batista MONTEGGIA described
the fracture--# of the ulna between the
proximal 3rd and the base of olecranon with an
ant. Dislocation of the radial head.
• Bado defined –radial head # or dislocation
with # of the middle or proximal ulna.
ANATOMY AND BIOMECHANICS
• Structures related to fracture..
Ligaments: annular ligament
bones: radial head
• for stability primary lig.
• Failure of this leads to failure of others
• It maintains the position of the radial head within the notch
through entire rom.
• Tighter in supination.
• Reinforced by radial collateral lig.
QUADRATE LIG.: Lig.of Denuce
• Between the radius and ulna distal to annular lig.
• Dense ant. Boarder-tightens in supination.
• Limits the rotation
• Excessive pronation-instability of radial head.
OBLIQUE LIG.:Lig of Weitbrecht
• Ulna proximally to radius distally
• Begins bellow the radial notch ends just bellow
the biceps tuberosity on the radius.
• Bow of the radius tightens the lig. In supination
INTEROSSEOUS MEM.: distal to oblique lig.
• Fibres in opposite direction.
• Tightens in supination.
Radial head :
• In supination long axis of the ellipse is perpendicular to
ulna.-annular lig and ant boarder of quadrate lig stabilize
• Contact between Radial head and notch max. in supination
Bow of the Radius:
• Apex of the radial bow is lateral
• Curvature allows increased range of pronation-as the radius
rotates along the axis between PRUJ and DRUJ
• Bow tightens the oblique and interrosseous mem. In
• Plays an active role in # mechanism
• inserting into the biceps tuberosity—major deforming force.
• Violently pulling the proximal radius away from the
capitellum as the elbow goes into extension.
• During treatment effect of biceps regulated by elbow flexion-
prevents the recurrence of dislocation.
Anconeus and forearm flexors:
• Acts to create a radially angulated bow in the ulna
• Helps in stabilize the elbow in extension, creating a valgus
• In Pronation couteracts the varus moment produced by
pronator teres against an intact ulna.
• Fore arm flexors create a bowstring effect on ulna.
PIN: ant/ant.lat to the radial head and neck
path through supinator.
Ulnar nerve : at risk in type 2 #
MONTEGGIA FRACTURE IN CHILDREN
CLASSIFFICATION AND MECHANISM OF INJURY
• EXTENSION INJURY
• FLEXION INJURY
• ADDUCTION INJURY
• TYPE 1: ant dislocation of radial head + ulna
diaphyseal # with ant.angulation.70%
• Type 2: post/post.lat dislocation of head +
ulna# with post.angulation. Uncommon in
• Type 3: lat/ant.lat dislocation of head + ulna
metaphyseal # with lat angulation.23%
• Type 4: type1+ radius #
Letts peadiatric classification
• Type A: ant. dislocation of radial head + plastic
deformation of ulna.
• Type B: ant.dislocation + greenstick #
• TYPE C: ant.dislocation + complete #
• Type D:post.dislocation + ulna #
• Type E:lat. dislocation + ulna greenstick #
MECHANISM OF INJURY
• Direct blow theory: blow on post aspect
Hyper pronation theory :
during fall out stretched
hand-initially pronation is
forced into further pronation
Hyper extension theory: on out stretched hand with forward
momentum elbow in hyper ext.-radius dislocates ant. By violent
contracture of biceps- after wt transferred to ulna-resulting #
Type 2: occurs when forearm is
suddenly loaded in a longitudinal
direction with elbow bent to 60*
flexion provided the ant cortex is
weakened otherwise post
dislocation may occur.
Clinical presentation radiography
• Fusiform swelling at elbow
• Painful movements
• Angular change… apex at ant.
• Tenting of the skin or ecchymosis.
• Child may not be extend the digits at mcp joints or ip joint
of the thumb-paresis of PIN
RADIOLOGY:x ray- AP, LAT
• Radiocapitellar relation-lat view-line draw though the
center of the radial neck and head should extend directly
through the center of capitellum…in any degree.
• Post angulation
• Associated fractures
• Radiology: radial head dislocation
Proximal metaphyseal # of ulna
with possible extension into olecranon
• Type 3: lat.swelling
limitation of supination
Radiology: lat displacement of radial head
Ulna metaphyseal #
• Type 4: same as type 1
Risk of compartmental syndrome
rare in children
radiocapitellar joint should be examined.
failure to recognise the dislocation is major
radiology: ant radial dislocation
# bb at middle 3rd with radial # distal to ulna
Management of monteggia fractures
o Conservative: MRD
• Reduction of ulnar #: longitudinal traction and correction of angulation-
upto 10* angulation is acceptable.
• Reduction of radial head:accomplished by flexing the elbow 90* or above –
spontaneous reduction or post.directed pressure
Flexion 110-120* stabilizes the reduction.
• Check x ray
• Alleviation of deforming forces: flexion to alleviate the force of the biceps
• Immobilization and aftercare: a/e cast 3-4wks, serial x rays.
b/e cast after 4 wks-mobilization.
Full activity after 6-8 wks
Failure of ulnar reduction
Failure of radial head reduction: due to interposition of materials , or
o Surgical approach: BOYD approach
• Extensive nature
• incision : following the lat. boarder of triceps posteriorly to the
lateral condyle and extending along the radial side of ulna.
• Incision carried under the anconeus and ECU in extra periosteal
• Elevating the fibers of supinator from ulna.
• Down to the interosseous mem. Exposing the radiocapitellar
oblique lig.; .proximal radius and ulna
TRETMENT OF ANNULAR LIG.
• Head of the radius is repositioned anatomically after
removing any portion of the annular lig.
• A strip of fascia 1.3cm wide 11.5cm long is made free from
the muscles of the forearm , leaving its attached to prox .
• Strip is passed btwn the radial notch of the ulna and the
tuberosity of the radius and around the neck.
• Fastened itself with interrupted non absorbable sutures.
• If still unstable fixed with a large smooth trans articular pin,
through capitellum across the joint and into head and neck of
radius, proximal end bent outside.wound closed.
• Forearm kept in slight supination &a/e cast
• Pin breakage,infection
• Cast and pin removed at 3-6 wks
Structures used for reconstruction:
Bell-tawse: Strip of triceps tendon
watson-jones : Palmaris longus tendon
may and mauk Chromic ligature
thompson and lipscom: Fascialata graft
Radial head resection done in:
• Chronic persistent dislocations
• un treated isolated dislocations or
• ignored until skeletal maturity
If the ligament is intact it is incised and retracted to
Surgical Treatment of ulna fracture
• If closed reduction is not satisfactory or child
is older than 12yrs-internal fixation with IM
• Minimally invasive
• Single pin or multiple or plating
• After care: A/E cast-90-110* flxn.
Treatment in type 2 fractures
• longitudinal traction along the axis of
With elbow 60* of flxn.
• Radius dislocation reduce spontaneously.
• anteriorly directed pressure over post, aspect.
• Elbow extended and immobilized in this
position- 4 wks.
• Byods approach can be used..
• Reduction and lig repair is same as type 1.
• Ulna # exposed subcutaneously fixed with
plating or pinning.
• After care: cast either in extension or flexion
to 80* ,if im pinning is used …for 3-4 wks.
Treatment in type 3
• Longitudinal traction in extension.
• Valgus stress placed on ulna-reduction.
• Radial head reduce spontaneously.
• Or pressure over lat.side.
• Check x ray- A/e cast in flxn.
• Radial head reduced through byods approach.
• Repair of lig.
• Ulna plating or pinning.
• After care:A/E cast in 110* flxn.-3-4wks.
• Removable splint for additional 3-4wks
• Early rom
Treatment in type 4
Non operative: MRD
• if # is unstable-reduced and fixed percutaneously
• 12yrs or older plating of radius through HENRY’S
• radial head is reduced by closed
• Ulna plating or pinning.
• After care: A/E cast at 100 to 120* of flxn-4wks
B/E cast for additional 4 wks with early rom.
Old Monteggia in children
• Present with-pain
Valgus deformity and
prominence at ant. Aspect
marked limitation of flexion
Progressive cubitus valgus
<12yrs- radial should be replaced in its position by ORIF.
Radial head can be reduced as late as 6 months or
more.requires osteotomy of angulated ulna.
Reconstruction of lig.
SPEED AND BOYD;
• Through the boyds approach # ulna and radial
• If ulna has united in malposition osteotomy done.
• Fixation done with compression plate or
• Reconstruction of annular lig done.
Dangers of early excision of head
• Traumatic ossification
• Proximal migration and dislocation of DRUJ.
• Impaction on capitellum.
• Isolated dislocation of radial head
• Radial neck #
• Radial neck # with # ulna diaphysis.
• # ulnar diaphysis + radial head dislocation+
• Post.dislocation of ulnohumeral joint with or
without proximal radius #.
Monteggia fracture dislocation in
• Classification; Bado –same as in children.
• Jupiter discribed sub groups in type 2.
Type 2a:ulna # involves the distal olecranon and
Type2b: ulna # is at M/D JN.distal to coronoid.
Type2d:# extends to proximal 3rd to half of the ulna.
Bado type 2 and jupiter type2a has worst prognosis.
Good results in-
• Early accurate diagnosis
• Rigid fixation of ulna
• Accurate reduction of radial head
• Post-op immobilization to allow ligaments to heal.
Treatment plans: acute;
• closed reduction of head + rigid fixation of proximal ulna
• In interposition of lig/capsule-open reduction and repair or
reconstruction of lig.+ ulna plating.
• OLD:6wks or older dislocation never reduced .excision of
head+ ulna plating +graft
Various methods of ulna fixation
• Intramedullary fixation; with rush nails or square nails.
failed plating; and
in multiple injuries.
Non union due to;
u/3rd wide cavity
insufficient apposition of frag.
side to side,rotatory motion
Open reduction with plate and screws
• 3.5 DCP or LCDCP used
• Incision along the subcutaneous boarder after
reduction plating done.
• Post. Splint in 120* to prevent redislocation of
radial head. 4-6 wks after cuff and collar.
• Extension is not permitted until 6 wks.
Treatment of old fracture
• For injuries 6wks or old-excision of head.
• Ulna plating with graft
• PIN palsy
• Malunion or non union
• Radiohumeral fibrous ankylosis
• Radioulnar synostosis
• Recurrence of dislocation
• Myositis ossificans
• nerve passes beneath the fibrous arch of
• Sensory Br. Separates before passing beneath the
arch ..motor br. Below the arch
• Pure motor deficit with intact sensation by
• Combined due to stretching.
• Function usually returns in 2-3 months..
Exploration not required.
• Mal union : if few degrees of malunion or subluxation-
resection of head.
Moderate to severe –osteotomy + plating + resection of
• Non union : resection of head + ulna plating + graft
• Radiohumeral fibrous ankylosis: due to repeated closed
attempts. Treatment is continuous passive motion.
• Radioulnar synostosis:fibrous/bony:even after
resection results are poor, best to leave and allow
shoulder compensatory motions.
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