MONTEGGIA
FRACTURE
Gullas College of Medicine
Senior Clerks
TABLE OF CONTENTS
01 Anatomy 04 Treatment Options
Monteggia Fractures Surgical Procedure
02 Epidemiology 05 Post Operative Care
Mechanism of Injury
Clinical Presentation Follow-up & Outcomes
03 Diagnostic Workup 06 Complications
01
ANATOMY
DR. NAYEE
ULNA
- Sigmoid/ semilunar/ trochlear notch
- Anteriorly composed of coronoid process
- Posteriorly composed of olecranon process
- Articulate with trochlea of humerus
RADIAL ANATOMY
-Radial head articulates with capitulum
-Radial neck tapers to radial tuberosity which is insertion for
biceps brachii tendon
Elbow Joint Articulation
- Elbow consists of 3 articulations:
- ulnohumeral ( elbow flexion / extension)
- Radiohumeral ( forearm pronation/ supination)
- Radioulnar ( forearm pronation / supination)
02
MONTEGGIA
FRACTURES
DR. LUXSAMON
Monteggia fracture
● Is a dislocation of the proximal radioulnar joint
(PRUJ) in association with a forearm fracture, most
commonly a fracture of the ulna.
● BADO’s classification - into 4 types
BADO’s classifications
TYPE 1
● Fracture of proximal or middle third of ulna
with anterior dislocation of radial head
● Most common type in children.
● MOI:
○ direct blow to posterior elbow
○ Hyperpronated force on an
outstretched arm
○ Contracted biceps resists forearm
extension
BADO’s classifications
TYPE 1
● Fracture of proximal or middle third of ulna
with anterior dislocation of radial head
● Most common type in children.
● MOI:
○ direct blow to posterior elbow
○ Hyperpronated force on an
outstretched arm
○ Contracted biceps resists forearm
extension
BADO’s classifications
TYPE 2
● Fracture of the proximal or middle third of the
ulna with posterior dislocation of the radial
head
● Most common type in adult.
● MOI: axial load directed up the forearm with a
slightly flex elbow.
BADO’s classifications
TYPE 2
● Fracture of the proximal or middle third of the
ulna with posterior dislocation of the radial
head
● Most common type in adult.
● MOI: axial load directed up the forearm with a
slightly flex elbow.
BADO’s classifications
TYPE 3
● Fracture of the ulna metaphyseal with lateral
dislocation of radial head
● MOI: Varus force on an extended elbow lead
to greenstick fracture of ulna
BADO’s classifications
TYPE 3
● Fracture of the ulna metaphyseal with lateral
dislocation of radial head
● MOI: Varus force on an extended elbow lead
to greenstick fracture of ulna
BADO’s classifications
TYPE 4
Fracture of the proximal or middle third of the ulna
and radius with anterior dislocation of the radial
head
02
EPIDEMIOLOGY
DR. LUXSAMON
Epidemiology
● Uncommon, 1% to 2% of all forearm fractures.
● Distal forearm fractures are far more frequent than midshaft forearm fractures, which occur
in about 1 to 10 per 10,000 people per year.
● Bimodal occurrence
○ highest incidence occurring in young males (10:10,000) and elderly females (5:10,000).
○ risk factors for midshaft forearm fractures:
■ sports (football and wrestling),
■ osteoporosis,
■ post-menopausal phase.
● Bado type I (59%) > type III (26%) > type II (5%) > type IV (1%).
02
MECHANISM
OF
INJURY
DR. LUXSAMON
Mechanism of injury
● Direct blow to the forearm with the elbow
extended and forearm in hyperpronation.
(Fall on an outstretched hand)
● The energy from the ulnar fracture gets
transmitted along the interosseous
membrane leading to rupture of the
proximal quadrate and annular ligaments,
disrupting the radiocapitellar joint.
03
CLINICAL
PRESENTATION
DR. DARLEN
Pain and swelling at elbow joint
Limited range of motion
Radial deviation of hand with wrist extension
Weakness of thumb extension
Weakness of metacarpal extension
03
DIAGNOSTIC
WORK-UP
DR. DARLEN
X-ray
Anteroposterior, lateral, and oblique view of elbow, wrist, and
forearm.
Magnetic resonance imaging (MRI)
Can be done to evaluate any possible interosseous membrane
disruption and TFCC tears.
Figure 1. Monteggia fracture, Anterior dislocation
Figure 2. Monteggia fracture, Lateral dislocation
Monteggia fracture, posterior dislocation
04
TREATMENT
OPTIONS
DR. DHRUV
● Monteggia fracture injury can be treated with operative intervention
and non-operative intervention.
Nonoperative Treatment of Monteggia Fracture–
Indications and Contraindications
Indication Relative contraindication
Patient is unable to tolerate a surgical Any displaced Monteggia fracture or
procedure transolecranon fracture–dislocation
Operative Treatment of Monteggia fracture:
● Operative management of Monteggia fracture injury includes OPEN REDUCTION
AND INTERNAL FIXATION(ORIF).
● The goal of treatment for a Monteggia fracture–dislocation is to have a stable,
reduced elbow and Proximal Radio-Ulnar Joint (PURJ), and the ability to initiate
early range of motion.
● These injuries usually require operative intervention in adults, similar to
femoral neck fractures.
● Should only be treated nonoperatively in a patient who is too frail or has
too many medical comorbidities to be able to tolerate a surgical
procedure.
● The occasional low- demand patient with a minimally displaced fracture
and little or no radial head subluxation may also be treated
nonoperatively.
05
SURGICAL
PROCEDURE
DR. JOSEPH
ORIF
This procedure is normally performed with
the patient in a supine position.
SOFT TISSUE
DISSECTION
Mid ulnar incision in the internervous plane between flexors
and extensors.
FRACTURE
PREPARATION
& REDUCTION
- The ulnar border is subcutaneous at this
site, so the fracture is easily exposed,
with the extensors noted dorsally and the
flexors volarly in this picture.
- Ones the planes are found the fractured
surface is being cleaned to remove
fibrous tissue.
PLATE SCREW
AND FIXATION
PLATE SCREW
AND FIXATION
Proximal fixation has been obtained and
a clamp is used to hold the plate and
distal plane is place
PLATE SCREW
AND FIXATION
CONFIRM
POSITION
AP and lateral images to confirm
position and screw placement
before closure.
CLOSURE
05
POST-OPERATIVE
CARE
DR. JOSEPH
POST-OPERATIVE
CARE
● Immobilization in a long-arm cast for 3 weeks.
● Position the forearm in the determined rotation for
maximal radial head stability (usually supination).
● Elevation of the operated arm.
● Early initiation of active finger mobilization.
● Active wrist, elbow, and gentle forearm rotation
exercises begin after cast removal.
POST-OPERATIVE
CARE
Recommended x-ray controls:
● 2 weeks: Check radial head position.
● 6 weeks: Monitor progress.
● 12 weeks: Assess healing.
● 1 year: Evaluate ulnar union.
Consider load-bearing at around 8 weeks if x-rays
show satisfactory ulnar healing.
06
FOLLOW UP
&
OUTCOMES
06
Management protocol includes RICE, that is
rest, icing, immobilisation and elevation.
Follow up after 2weeks and suggested for
rehab to gain full range of motion
06
COMPLICATIONS
1) Missed diagnosis or delayed treatment of
monteggia fracture.
2) Most common complications include
Nerve injuries, particularly the radial
nerve and the posterior interossous
nerve.
3) Infection- compartment syndrome.
4) Non union
OUR TEAM
NGUSHUAL JOSEPH JOSHUA LUXSAMON WONGLIMKITTIGUL DARLEN UYANGOREN
DHRUV PATEL HRADAY NAYEE MANASHVI GALA
THANK YOU!
