A 21-year-old female presented to the emergency department after a motor vehicle collision with left arm pain from striking the steering wheel. Her left upper extremity was swollen and deformed without an open fracture. Reduction was achieved by placing the forearm in supination and flexing the elbow over 90 degrees to relax the biceps, then manually repositioning the radial head anteriorly and reducing the angulated ulnar shaft with pressure. Orthopedics was contacted to discuss urgent operative repair for a Monteggia fracture of the proximal ulna and anterior dislocation of the radial head.

2.  HPI- 21 y/o female presents to the ED post mvc c/o
left arm pain. She was an unrestrained driver and
her arm struck the steering wheel.
 PMX- Herpes type II
 Social- ETOH
 Allergies- Seasonal
 PSX- Elective abortion

3.  P- 120 BP 130/86 RR- 14 T 98.7
 HEENT – NCAT, EOMI
 Cardio- S1 S2
 Lungs- CTAB
 Ext- Left upper extremity is swollen and deformed.
No evidence of open fx. Distal sensation and pulses
intact

6.  Pain Control
 Reduction and Splint
 - Reduction:
- achieved w/ forarm in full supination, & longitudinal traction;
- then elbow is gently flexed to > 90 deg to relax biceps;
- radial head is gently repositioned by direct manual pressure
anteriorly on the bone;
- following reduction, radial head will be stable if left in flexion;
- angulated ulnar shaft is reduced by firm manual pressure;
 Contact Orthopedics to discuss arranging Urgent Operative Repair

7.  Background
 Giovanni Monteggia (1814) first described frx of
proximal 1/3 of ulna in association w/ anterior
dislocation of radial head;
 Mechanism:
 Proposed mechanisms include direct blow & hyper-
pronation injuries as well- as the hyperextension theory

8.  Associated Injuries
 Tear of the annular ligament
 Nerve Damage
 Paralysis of deep branch of the radial nerve is most common.
The posterior interosseous nerve may be wrapped around neck
of radius, preventing reduction;
 Note: that patients whose operative treatment is delayed
may be found to have a progressive PIN palsy from
constant pressure exerted by the dislocated radial head