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Monteggia Fracture: Causes, Symptoms & Treatment

A Monteggia fracture is a combined injury of the forearm involving a fracture of the ulna and a dislocation of the radial head. Prompt medical treatment is essential.

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Things worth knowing about "Monteggia fracture"

A Monteggia fracture is a combined injury of the forearm involving a fracture of the ulna and a dislocation of the radial head. Prompt medical treatment is essential.

What Is a Monteggia Fracture?

A Monteggia fracture is a specific injury of the forearm characterized by two simultaneous lesions: a fracture of the ulna (the inner forearm bone) in its proximal third, combined with a dislocation of the radial head at the elbow joint. This combination makes it a particularly serious injury that requires prompt and accurate treatment. The condition is named after the Italian surgeon Giovanni Battista Monteggia, who first described it in the 18th century.

Causes

A Monteggia fracture is typically caused by a direct blow to the forearm or an indirect force mechanism. Common causes include:

Falling onto an outstretched arm
A direct impact to the ulna, such as during a defensive arm movement (also known as a "nightstick injury")
Forceful rotation (torsion) of the forearm combined with axial loading
High-energy trauma such as road traffic accidents or sports injuries

In children, the injury can occur with relatively minor forces due to the greater flexibility of developing bone.

Classification According to Bado

Monteggia fractures are commonly classified using the Bado classification, which distinguishes four types:

Type I: Anterior angulation of the ulna fracture with anterior dislocation of the radial head (most common type)
Type II: Posterior angulation of the ulna fracture with posterior dislocation of the radial head
Type III: Ulna fracture with lateral dislocation of the radial head (most common in children)
Type IV: Fractures of both the ulna and radius with anterior dislocation of the radial head (rarest type)

Symptoms

The typical signs and symptoms of a Monteggia fracture include:

Severe pain in the elbow and forearm
Swelling and bruising around the affected area
Visible or palpable deformity of the elbow
Significantly reduced range of motion of the elbow joint
In some cases, numbness or weakness due to injury of the posterior interosseous nerve (a branch of the radial nerve)

Diagnosis

Diagnosis is primarily established through imaging:

X-rays of the forearm and elbow in two planes are the key diagnostic tool. It is essential to include both the wrist and elbow joint in the images to avoid missing associated injuries.
Computed tomography (CT) may be used for complex fractures or pre-operative planning.
Magnetic resonance imaging (MRI) can be helpful when ligament injury or nerve damage is suspected.

A common diagnostic pitfall is failing to identify the radial head dislocation when attention is focused solely on the ulnar fracture.

Treatment

Conservative Treatment

In children, non-operative management may be appropriate in selected cases. Under brief anesthesia, the fracture is reduced by closed manipulation and immobilized in an above-elbow cast for several weeks. This approach is only suitable for stable fracture patterns and specific types.

Surgical Treatment

In adults, surgery (open reduction and internal fixation, ORIF) is usually required. The surgical approach involves:

Stabilization of the ulna using a metal plate and screws (plate osteosynthesis)
Reduction of the radial head back into its correct position, which typically occurs automatically once the ulna is stably fixed
If the radial head remains unstable: additional stabilization or reconstruction of the annular ligament (ligamentum anulare radii)

Recovery and Prognosis

With early and appropriate treatment, the prognosis for a Monteggia fracture is generally good. Children tend to heal faster and more completely than adults. Post-treatment care includes:

Immobilization for several weeks
Follow-up X-rays to monitor healing progress
Physiotherapy to restore elbow mobility, strength and function

Untreated or incorrectly managed Monteggia fractures can lead to permanent functional impairment, chronic pain, and joint damage. Potential complications include nerve injury, non-union (failure of the bone to heal), or recurrent dislocation of the radial head.

References

Bado, J. L. - The Monteggia Lesion. Clinical Orthopaedics and Related Research, 1967.
Ring, D., Jupiter, J. B. & Waters, P. M. - Monteggia Fractures in Children and Adults. Journal of the American Academy of Orthopaedic Surgeons, 1998.
Rockwood and Green's Fractures in Adults, 8th Edition - Wolters Kluwer Health, 2015.

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