This document provides information on Monteggia fracture-dislocations, including: - Classification into 4 main types based on the direction of the ulnar fracture and radial dislocation. Type 1 is the most common. - Description of injury mechanisms, radiographic evaluation, treatment approaches including closed or open reduction of fractures and dislocations, and casting. - Complications like neglected fractures and nerve injuries. Variations like Monteggia equivalents and revisions to the classification system are also discussed. Surgical techniques for addressing chronic cases, like annular ligament reconstruction and ulnar osteotomies, are covered.

1. MONTEGGIA FRACTURE-
DISLOCATION
MOHAMMED FAWAS, jr, calicut medical college

2. intro
• Monteggia fracture-dislocations (or lesions) 1 to 2% of
forearm fractures
• consist of a proximal radial dislocation and a fracture of the
ulna
• Described in 1814 by Giovanni Batista Monteggia, a surgical
pathologist and public health official in Milan, Italy

3. classification
• based on the direction of the apex of the ulnar fracture and
the direction of the proximal radial dislocation
• In 1967 by Jose Luis Bado, director of the Orthopedic and
Traumatology Institute in Montevideo, Uruguay

4. • Type 1: Anterior dislocation of the radial
head, fracture of the ulnar diaphysis at
any level with anterior angulation.
• Type 2: Posterior or posterolateral
dislocation of the radial head, fracture of
the ulnar diaphysis with apex posterior
angulation.

5. • Type 3: Lateral or anterolateral dislocation of
the radial head, fracture of the ulnar
metaphysis
• Type 4: Anterior dislocation of the radial
head with a fracture of the proximal third of
the ulna and fracture of the radius at the
same level

6. Type 1
• DEFINITION: A type I lesion is an anterior dislocation of the radial head
associated with an ulnar diaphyseal fracture at any level. This is the
most common Monteggia lesion in children.
• ULNAR FRACTURE SITE: metaphysis or diaphysis
• INJURY MECHNISMS: direct trauma, hyperpronation, and
hyperextension

7. • The fracture dislocation is
sustained by direct contact on
the posterior aspect of the
forearm, either by falling onto
an object or by the object
striking the forearm. The
continued motion of the
object forward dislocates the
radial head after fracturing the
ulna

10. • RADIOGRAPHIC EVALUATION: maybe
normal on AP despite obvious disruption on
lateral view. Line drawn through the center
of the radial neck and head should extend
directly through the center of the capitulum,
and remain intact regardless of the degree of
flexion or extension of the elbow

11. • TREATMENT:
• An anatomic, stable reduction of the ulnar fracture
• Percutaneous intramedullary fixation of complete transverse and
short oblique ulna fractures is standard.
• Open reduction and internal fixation with plate and screws of the rarer
long oblique and comminuted fracture is also standard
• stable reduction of the radial head dislocation Irreducible or unstable
radial head approached surgically usually involves repairing entrapped
soft tissues.
• This aggressive approach avoids late complications.

12. • A long-arm cast 4 to 6 weeks forearm in slight supination
and the elbow flexed 90 to 110 degrees depending on the
degree of swelling.
• Radiographs are obtained every 1 to 2 weeks until fracture
healing.

13. • Reduction of a type I
Monteggia fracture
dislocation

14. Type 2
• DEFINITION: A type II lesion is a posterior dislocation of the
radial head associated with an ulnar diaphyseal or
metaphyseal fracture.
• MC lesion in adults but very rare in children
• ULNAR FRACTURE SITE: metaphysis or diaphysis
• INJURY MECHNISMS: direct force and sudden rotation and
supination

16. • RADIOGRAPHIC EVALUATION:
• typical- proximal metaphyseal fracture of the ulna with
possible extension into the olecranon.
• Midshaft fractures also occur, with an oblique fracture
pattern.
• The radial head is dislocated posteriorly or posterolaterally
and should be carefully examined for other injuries.
• +/- fractures of the anterior margin of the radial head

17. • TREATMENT:
• Ulnar reduction with longitudinal traction.
• Radial head reduction spontaneously or with gentle,
anteriorly directed force over the radial head.
• If the ulnar fracture is stable cast immobilization with the
elbow in extension.
• If the ulnar fracture is unstable percutaneous
intramedullary K-wire
• Comminuted or very proximal fractures open reduction and
internal fixation with plate and screws or tension band
fixation.

18. • The Boyd approach can be used to obtain reduction of the
radial head if it cannot be obtained through closed
manipulation.
• Associated compression fractures of the radial head require
early detection to avoid late loss of alignment.
• Open reduction and internal fixation may be required to
maintain radiocapitellar joint stability.
• Cast immobilization usually 6 weeks

19. • Longitudinal traction and
pronation of the forearm and
immobilization in 60 degrees
flexion or complete extension

20. • Type 2 Monteggia fractures were further subclassified into four
different patterns as follows
• 2A: Very proximal ulna fracture through the coronoid
• 2B: Fracture at the junction of the proximal metaphysis and diaphysis
of the ulna
• 2C: Diaphyseal ulnar fracture
• 2D: Complex fracture involving the ulna from the olecranon into the
diaphysis

21. Type 3
• DEFINITION: A type III lesion is a lateral dislocation of the
radial head associated with an ulnar metaphyseal fracture.
• This is the second most common pediatric Monteggia
lesion.
• ULNAR FRACTURE SITE: metaphysis
• INJURY MECHNISMS: varus stress at the level of the elbow

23. • RADIOGRAPHIC EVALUATION:
Radiographs of the entire forearm
should be obtained because of the
association of distal radial and ulnar
fractures with this complex elbow
injury.

24. • TREATMENT:
• aimed at obtaining and maintaining reduction of the radial
head, either by open or closed technique.
• usually performed by anatomic, stable reduction of the
ulnar fracture that in turn leads to a stable reduction of the
proximal radioulnar and radiocapitellar joints.

26. • Immobilization:
• If radial head dislocated in straight lateral or anterolateral
100 to 110 degree
• If there is posterolateral component for dislocation 70 to 80
degree

27. Type 4
• DEFINITION:
• anterior dislocation of the radial head associated with
fractures of both the ulna and the radius.
• The original description was of a radial fracture at the same
level or distal to the ulna fracture.
• ULNAR FRACTURE SITE: diaphysis
• INJURY MECHNISMS: hyperpronation and direct blow

28. • increased risk for a compartment syndrome.
• Failure to recognize the radial head dislocation is the major
complication of this fracture.
• RADIOGRAPHIC EVALUATION: The radial and ulnar fractures
usually are in the middle third, with the radial fracture
usually distal to the ulnar injury.

29. • TREATMENT: Stabilization of the radial fracture converts a
type IV lesion to a type I lesion
• Closed reduction ,intramedullary or plate fixation, follow
type I protocol.
• Immobilized in a long-arm cast for 4 to 6 weeks in 110 to 120
degrees of flexion with the forearm in neutral rotation.
• A short-arm cast is used thereafter if additional fracture
protection is necessary.

31. Monteggia equivalent lesions
• Type I Equivalents
• Isolated dislocation of radial head
• Radial neck fracture (isolated)
• Radial neck fracture in combination with a fracture of the ulnar diaphysis
• Radial and ulnar fractures with the radial fracture above the junction of
the middle and proximal thirds
• Fracture of ulnar diaphysis with anterior dislocation of radial head and an
olecranon fracture

33. • Type II Equivalents
• Fractures of the proximal radial epiphysis or
radial neck.
• Type III and Type IV Equivalents
• Fractures of the distal humerus
(supracondylar, lateral condylar) in
association with proximal forearm fractures.

34. • BOYD APPROACH

35. • Incision - lateral border of the triceps posteriorly to the lateral condyle
and extending it along the radial side of the ulna.
• The incision is carried under the anconeus and extensor carpi ulnaris in
an extraperiosteal manner, elevating the fibers of the supinator from
the ulna.
• This carries the approach down to the interosseous membrane, allowing
exposure of the radiocapitellar joint, excellent visualization of the
orbicular ligament, access to the proximal fourth of the entire radius,
and approach to the ulnar fracture.

36. • Kochers Approach:
• Incision : begin skin incision over the lateral epicondyle &
continue it distally and obliquely directly over lateral
epicondyle to end at proximal ulna.
• Interneural plane – Between Anconeus and ECU.
• Safer as it affords protection to the PIN.

37. • Dormans and Rang:
• In 1990
• Extended Bado's classification by adding a type V,
• intermittent and habitual dislocation of the radiocapitellar
joint and proximal radioulnar joint.

38. complications
• 1. Neglected Monteggia Fracture.
• 2. Nerve Injuries.
• 3. Periarticular Ossification.
• 4. Compartment Syndrome.

39. Chronic, Missed, or Neglected
Monteggia Fracture
• Recognition of a dislocated radial head at the time of injury
can prevent the difficult problem of persistent radial head
dislocation.
• restricted motion, deformity, functional impairment
(weakness, instability), pain, degenerative arthritis, and late
neuropathy.

40. ANNULAR LIGAMENT RECONSTRUCTION
• Bell-Tawse used the central portion of the triceps tendon
passed through a drill hole and around the radial neck to
stabilize the reduction and immobilized the elbow in a
longarm cast in extension.
• Bucknill and Lloyd-Roberts modified the Bell-Tawse
procedure by using the lateral portion of the triceps tendon,
with a transcapitellar pin for stability. The elbow was
immobilized in flexion.

41. • Hurst and Dubrow used the central portion of the triceps
tendon, but carried the dissection of the periosteum distally
along the ulna to the level of the radial neck, which provided
more stable fixation than stopping dissection at the
olecranon as described by Bell-Tawse.
• They also used a periosteal tunnel rather than a drill hole for
fixation of the tendinous strip to the ulna.
• Thompson and Lipscomb used a fascia lata graft passed
through a hole drilled in the ulna.

42. Osteotomy
• Various types of osteotomies have been used to facilitate
reduction of the radial head and prevent recurrent subluxation
after annular ligament reconstruction.
• Kalamchi reported using a drill hole ulnar osteotomy to obtain
reduction of the radial head in two patients. Minimal periosteal
stripping with this technique allowed the osteotomy to heal
rapidly.
• Mehta used an osteotomy of the proximal ulna stabilized with
bone graft.

43. • Freedman et al reported a delayed open reduction of a type
I Monteggia lesion without annular ligament reconstruction
but with ulnar osteotomy, radial shortening, and deepening
of the radial notch of the ulna.
• Oner and Diepstraten suggested that ulnar osteotomy is
not necessary in type I lesions (anterior dislocation), but in
type III lesions (anterolateral dislocation) recurrent
subluxation is likely without osteotomy.

44. • Left. Floating open osteotomy without fixation or bone graft.
• Center. Hirayama distraction osteotomy, grafted and fixed with a plate and
screws.
• Mehta osteotomy is similar but is held with a bone graft only.
• Right. Valgus osteotomy for a type III lesion: floating osteotomy with bone
graft. This osteotomy can be stabilized with an intramedullary pin.