Monteggia fracture treatment
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Monteggia Fracture: Treatment
A Monteggia fracture is a proximal ulna fracture combined with dislocation of the proximal radioulnar joint (PRUJ) and radial head. Treatment is guided by the Bado classification, the patient's age, and whether the injury is acute vs. chronic.
Classification (Bado)
| Type | Ulnar Fracture | Radial Head | Frequency |
|---|---|---|---|
| I | Anterior angulation | Anterior dislocation | Most common in children |
| II | Posterior angulation | Posterior/posterolateral dislocation | ~80% in adults |
| III | Metaphyseal fracture | Lateral/anterolateral dislocation | Almost exclusively in children |
| IV | Any level | Anterior + radius fracture at same level | Adults only |
Jupiter's subclassification of type II (adults):
- IIA - Fracture through the coronoid
- IIB - Proximal metaphysis-diaphysis junction
- IIC - Diaphyseal
- IID - Complex olecranon-to-diaphysis
Core Principle
The ulnar reduction is the key to everything. Restoring ulnar length, alignment, and the proximal ulnar dorsal angulation (PUDA, ~5-6 degrees) typically allows the radial head to reduce spontaneously. Persistent radial head subluxation after anatomic ulnar reduction almost always means inadequate ulnar reduction, or soft tissue interposition (annular ligament, ECU, brachialis, osteochondral fragment).
"In most instances, reduction of the ulnar fracture leads to reduction of the radial head." - Rockwood and Green's Fractures in Adults, 10th ed. 2025
Treatment by Age
Children (Pediatric)
Treatment is dictated by the pattern of the ulnar fracture (Campbell's Operative Orthopaedics, 15th Ed. 2026):
| Ulnar Injury Pattern | Treatment |
|---|---|
| Plastic deformation | Closed reduction of the ulnar bow + long-arm cast |
| Incomplete (greenstick/buckle) fracture | Closed reduction + cast immobilization |
| Complete transverse or short oblique | Closed reduction +/- intramedullary K-wire fixation |
| Long oblique or comminuted | ORIF with plate and screws |
- Cast immobilization: long-arm cast at 90-100 degrees of elbow flexion and supination
- Follow-up radiographs weekly for 2-3 weeks to confirm maintenance of radial head reduction
- Avoid pinning the radiocapitellar joint if possible - the need for pinning suggests inadequate ulnar reduction or entrapped soft tissue
- ~90% of children achieve good to excellent results with prompt treatment
Adults
Adults almost universally require operative fixation. Closed reduction is not reliable because the periosteum is thick enough to hold the fracture reduced in children but not in adults.
Adult ORIF: Step-by-Step
Goal: Stable, reduced elbow and PRUJ with the ability to initiate early range of motion.
Position: Lateral decubitus (preferred); can also be supine with arm across the chest
Approach: Posterior midline incision; interval between ECU and FCU for ulnar shaft access
Surgical Steps (Rockwood & Green, 10th Ed. 2025)
- Reduce and fix the ulna first - Anatomic reduction with restoration of PUDA is the priority
- Implant choice:
- 3.5 mm LCDC plate or precontoured proximal ulna locking plate (preferred over tension band or 1/3 tubular plates, which have high failure rates)
- Minimum 3-4 screws (6-8 cortices) both proximal and distal to the fracture
- Address the coronoid if fractured - use mini-fragment plates, screws, or retrograde screws through the plate
- Assess the radial head - if fractured:
- Repair with 1.5-2 mm countersunk screws if salvageable
- Radial head arthroplasty if not salvageable (do NOT simply excise - rapid proximal radial migration will occur)
- Evaluate the LCL and repair with suture anchors if avulsed
- Confirm radial head reduction fluoroscopically
Type II Monteggia (Fragment-Specific Protocol - Campbell's BOX 62.8):
- Repair/replace radial head → 2. Reduce ulnar shaft → 3. Stabilize coronoid → 4. Fix olecranon to shaft → 5. Repair MCL/LCL osseous insertions → 6. Repair lateral collateral ligament origin
Nonoperative Treatment (Adults)
Reserved only for very rare cases - essentially nonfunctional patients or those unfit for surgery. Closed reduction has extremely high failure rates in adults and is not recommended as definitive treatment.
Chronic (Missed/Neglected) Monteggia Fracture
Typically defined as diagnosis >4 weeks after injury. More common in children when the ulnar injury is subtle (plastic deformation).
Surgical principles (Campbell's Operative Orthopaedics, 15th Ed. 2026):
- Ulnar osteotomy to correct the deformity (overcorrection osteotomy)
- Annular ligament reconstruction - using native ligament, triceps tendon strip, or fascia (Boyd, Lloyd-Roberts, Bell-Tawse technique)
- Stabilize the osteotomy in the position of maximal radiocapitellar stability
- Avoid radial head resection in children/young adults - salvage procedure only
- Complications are high: compartment syndrome, residual subluxation, ulnar nerve palsy, limited motion, osteotomy nonunion
Complications
| Complication | Notes |
|---|---|
| Radial head re-dislocation | Most common; usually due to ulnar malreduction |
| Posterior interosseous nerve (PIN) palsy | PIN passes close to the radial neck; usually neurapraxia, resolves spontaneously |
| Elbow stiffness / heterotopic ossification (HO) | Encourage early ROM; routine radiation prophylaxis not recommended (risk of nonunion) |
| Nonunion | Especially with inadequate fixation (1/3 tubular plates, tension bands) |
| Radial migration | If radial head is excised in context of PRUJ injury |
| Radiocapitellar arthritis | Long-term, especially with missed/chronic injuries |
Outcomes
- Type I and III Monteggia fractures generally have good to excellent outcomes.
- Type II and IV fractures (especially with associated radial head or coronoid fractures) have significantly worse outcomes - up to 45-46% fair/poor results have been reported even with operative treatment.
- Radial head fracture is the single biggest prognostic indicator for a poor outcome (Rockwood & Green, Ring et al., Konrad et al.).
- With modern precontoured locking plates and systematic injury management, outcomes have markedly improved.
Sources: Rockwood and Green's Fractures in Adults, 10th Ed. 2025 | Campbell's Operative Orthopaedics, 15th Ed. 2026 | Tintinalli's Emergency Medicine | POSNA Study Guide
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