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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 19-25

Monteggia Fracture-Dislocation


1 Department of Paediatric Orthopaedics, Jupiter Gait Lab, Jupiter Hospital, SRCC Children Hospital, Mumbai, Maharashtra, India
2 Department of Paediatric Orthopaedics, Jupiter Hospital, SRCC Children Hospital, Mumbai, Maharashtra, India

Date of Submission29-Mar-2022
Date of Acceptance04-Apr-2022
Date of Web Publication25-May-2022

Correspondence Address:
Taral V Nagda
Department of Paediatric Orthopaedics, Jupiter Gait Lab, Jupiter Hospital, SRCC Children Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2667-3665.346021

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  Abstract 


Monteggia fracture dislocation in children is not so common, interesting and often missed injury pattern in children. The article reviews the historical aspects, classifications and their importance, clinical and radiological aspects and principles of management of this injury. It also deals with management of late presenting Monteggia lesions and has some case examples to illustrate practical management of fresh injury and delayed cases.

Keywords: Monteggia Fracture dislocation, Monteggia Lesion, Children, Delayed presentation


How to cite this article:
Nagda TV, Dhamele J. Monteggia Fracture-Dislocation. J Orthop Assoc South Indian States 2022;19, Suppl S1:19-25

How to cite this URL:
Nagda TV, Dhamele J. Monteggia Fracture-Dislocation. J Orthop Assoc South Indian States [serial online] 2022 [cited 2022 Jul 6];19, Suppl S1:19-25. Available from: https://www.joasis.org/text.asp?2022/19/3/19/346021



“No fracture presents so many problems; no injury is beset with greater difficulty; No treatment characterized by more general failure”.


  Introduction Top


Monteggia fracture-dislocations represent not so common but interesting injury pattern in children. The management of this eponymous fracture is no longer an enigma because of better understanding of mechanism of injury, better clarity of techniques of reduction techniques of different types, clearer knowledge of indications and means of internal fixation, and better insights into management of missed Monteggia and late presenting cases. [Table 1] presents some interesting trivia about this interesting fracture.
Table 1: Monteggia fracture-dislocation in numbers

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  From the Past Top


In 1814, Monteggia et al.,[1] a surgical pathologist and public health official from Milan, described an injury complex that included a fracture of the proximal ulna and an accompanying dislocation of the radial head even before X-rays were available [Figure 1]. This injury complex has carried his name ever since.
Figure 1: Giovanni Monteggia and the description of the injury which made him immortal in history of pediatric trauma

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During the 1900s following his original description, many other authors, such as Smith (1947), Speed and Boyd,[2] Evans et al.,[3] Wright (1963), Penrose,[4] and Tompkins,[5] produced articles that theorized the mechanisms of the various types of Monteggia fractures.

Still, the best and most complete description of the various patterns was the work of Bado[6] of Montevideo, Uruguay.[2] He coined the term Monteggia lesions subdividing this general group of injuries into four types with equivalents of each type. His work has stood the test of time.


  What Classification Do We Use for Monteggia Fracture-Dislocation? Top


Bado[6] of Montevideo, Uruguay, proposed his classification scheme in 1967 in a classic monogram based on the direction of displacement of the radial head and the fracture pattern of the proximal ulna [Figure 2] and [Table 2].
Figure 2: Bado classification of Monteggia fracture-dislocation

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Table 2: Summary of Bado classification of Monteggia fracture-dislocation

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Bodo's classification clarifies the mechanism of injury and approach to closed reduction but does not suggest indication for ulna fracture management.

Type I (70%)

In this type, the radial head is displaced anteriorly and there is an oblique fracture of the proximal shaft of the ulna. This type usually occurs as the result of a hyperextension force to the forearm and elbow.

Type II (6%)

This type is extremely rare in children. The fracture pattern is a flexion type of injury to the proximal ulnar metaphysis. The radial head dislocates posteriorly. The mechanism is usually the same as for traumatic dislocation of the elbow, in which a linear force is applied proximally up the forearm to a semiflexed elbow.

Type III (23%)

This is the result of application of a varus force to the extended elbow. The injury includes a greenstick varus fracture of the proximal ulna or olecranon and a lateral dislocation of the radial head.

Type IV (1%)

This is a fracture involving the shafts of both the radius and the ulna (usually at different levels) and an associated dislocation of the radial head, which is usually either anterior or lateral.


  What Are Monteggia Equivalents? Top


These are injuries involving the proximal radius or ulna, for which Bado believed the mechanism of injury was similar to that of a classic Monteggia lesion. With the exception of the Type IV lesion, equivalents have been described for each of the major types of lesions. For example, an isolated traumatic dislocation of the radial head is classified as a Type I equivalent [Figure 3].
Figure 3: Type I equivalents. (a) Isolated anterior radial head dislocation. (b) Ulnar fracture with fracture of the radial neck. (c) Isolated radial neck fractures. (d) Elbow (ulnohumeral) dislocation with or without fracture of the proximal radius

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[TAG:2]What Is Lett's Classification? [/TAG:2]

It is based on direction of radial head dislocation and the morphology of ulna fracture and helps in deciding appropriate management of ulna fracture [Figure 4].[3]
Figure 4: Lett Classification Lett type A : Type 1 Bado plus plastic deformation ulna Lett type B : Type 1 Bado plus Greenstick fracture ulna Lett type C : Type 1 Bado plus Complete fracture ulna Lett type D: Type 2 Bado Lett type E: Type 3 Bado

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  • Lett Type A: Type 1 Bado plus plastic deformation ulna
  • Lett Type B: Type 1 Bado plus greenstick fracture ulna
  • Lett type C: Type 1 Bado plus complete fracture ulna
  • Lett type D: Type 2 Bado
  • Lett type E: Type 3 Bado.



  How Not to Miss Monteggia on X-rays Top


  1. In all forearm injuries include X-ray of elbow with forearm and wrist
  2. In all cases in which the ulnar shaft is fractured to inspect the relationship of the radial head to the ossification center of the lateral condyle carefully to be sure that there is not a coexistent disruption of this joint. This is done by drawing the radiocapitellar line which is: It is a line drawn proximally up the long axis of the proximal radius through the radial head. It should always pass proximally through the center of the ossification center of the lateral condyle, regardless of the radiographic position [Figure 5].
  3. In all cases of anterior radial dislocation without obvious ulna fracture draw Mubarak line along posterior border of ulna on lateral view. An anterior bow of ulna away from this line is suggestive of plastic deformation of ulna [Figure 6].
Figure 5: Radio capitellar line: It is a line drawn proximally up the long axis of the proximal radius through the radial head

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Figure 6: Mubarak's posterior ulna line

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How not to mistake congenital radial head dislocation for traumatic one?

The diagnosis of congenital dislocation can be made (a) if the condition is bilateral or (b) if unilateral, when the affected radius is longer, the radial head misshapen, the capitellum hypoplastic, the distal humerus grooved, and/or ossification more advanced than on the opposite side.

[TAG:2]What Is Ring and Waters Surgical Treatment Algorithm for Acute Monteggia Injuries [Table 3][4],[5][/TAG:2]
Table 3: Treatment algorithm for acute Monteggia fracture-dislocations based on ulnar fracture pattern: ring and waters

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It is based on the Letts et al.'s[7] classification and concepts of ulnar fracture stability. Closed reduction and cast immobilization are recommended for plastic deformation and greenstick injuries with careful serial radiographic checks to confirm maintenance of alignment. Patients with transverse or short oblique ulnar fractures have “length stable” injuries; in these patients, closed reduction and intramedullary fixation of the ulna will allow for maintained alignment and avoidance of lost reduction [Case Example 1]. Conversely, patients with long oblique or comminuted fractures have complete but “length unstable” injuries and undergo reduction and internal fixation using appropriately sized plate-and-screw constructs.




  How Does One Do Closed Reduction of Monteggia's Type I Lesion? Top


Treatment of the Type I lesion requires two steps. First, the length of the ulnar shaft, which is usually angulated anteriorly, must be reestablished by reducing the fracture. This is done by traction, supination, and manual pressure over angulation. Once the ulnar length has been reestablished, the second step is to reduce the radial head. This is usually easily performed by applying a force directly over the head in a posterior direction while hyperflexing the elbow. After reduction, the elbow is immobilized in some degree of hyperflexion to decrease the deforming force on the biceps muscle [Figure 7] / [Case Example 2].
Figure 7: Reduction of Type 1 Monteggia: Step 1: Restoration of ulnar length and angulation is achieved by traction, supination, and manual pressure. Step 2: Radial head reduces in hyperflexion or may need direct pressure in posterior direction

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A chest X-ray is done after 1 and immobilization is maintained for 6 weeks. Some prefer to convert above elbow plaster to below elbow cast after 3 weeks for 3 more weeks to mobilize elbow joint.


  How Does the Treatment Procedure in Type 2 Monteggia Differ from That of the Type I Lesion? Top


The reduction mechanism is usually the opposite. The olecranon fracture and radial head are usually both reduced by extending, rather than flexing, the elbow and immobilizing it in extension rather than in flexion [Figure 8].
Figure 8: Reduction technique for type 2 Monteggia fracture-dislocation: Reduction of ulna is done by traction in 60° flexion of elbow after which elbow is hyperextended to reduce the radial head. Occasionally radial head reduction may require direct pressure in anterior direction

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  How Do You Reduce Type 3 Bado Monteggia? Top


These are essentially extension varus greenstick fractures of the olecranon. The olecranon fracture is first reduced by extending and applying a valgus force to the elbow. This usually simultaneously reduces the radial head. Sometimes direct pressure over the radial head may be necessary to achieve the final reduction. Occasionally, as with Type I lesions, the orbicular ligament becomes interposed and may require surgical extraction [Figure 9]/[Case Example 3].
Figure 9: Reduction of type 3 Monteggia: With elbow in extension, valgus force is applied to correct ulnar angulation. Radial head may spontaneously correct or may need medial push. The immobilization is done in 90° flexion or extension depending on choice of surgeon and stability of fracture

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  How Do You Treat Type 4 Monteggia Fracture-Dislocation? Top


In Type 4 Bado, because the radius is a free segment, it is difficult to reduce it by manipulation alone. Thus, the Type IV lesion is first converted to a Type I lesion by surgically stabilizing the shafts of the radius and generally the ulna as well with either intramedullary fixation or plates and screws. Once the shafts have been stabilized, the radial head usually is easier to reduce by manipulation in the same manner as for a Type I lesion [Case Example 4].




  Are Nerve Injuries Common with Monteggia Lesions? Top


Nerve lesions occur primarily with Type III lesions. They are extremely rare in Type I and II lesions. The anterolateral displacement of the radial head may produce compression of the posterior interosseous branch of the radial nerve. This results in a loss of wrist and finger extension. Almost all of these nerve injuries resolve following reduction of the radial head.


  Why Monteggia Should Not Be Missed? Top


Left untreated, this injury can lead to restricted motion, instability, and valgus deformities of the elbow.[6]

The cost and complexity of secondary surgical treatment of chronic dislocations of the radial head is far greater than primary therapy.

The older the dislocation, the less certain will be the results of secondary treatment. This is in stark contrast to the results of timely, conservative primary treatment.


  How Do We Manage Chronic Monteggia? Top


Indications for operative management[7] include:

  1. Progressive radial capitellar subluxation or dislocation
  2. Progressive valgus deformity
  3. A limited range of available or forearm motion
  4. Pain at the malaligned radial capitellar or radial ulnar articulations.


Principles of management include:[8]

  1. Restoration of ulnar length and alignment: By angulation lengthening ulnar acute osteotomy or gradual distraction
  2. Congruent reduction of radiocapitellar joint: Closed reduction or open reduction if radial head is irreducible to remove fibrous tissue and other soft-tissue blocks to radial head reduction
  3. Stability of radial head in radiocapitellar joint in all degrees of flexion-extension and pronosupination: Either inherently stable after closed or open reduction or annular ligament repair or reconstruction to provide additional stabilizers to the elbow joint.



  What Is Step by Step Approach to Management of Chronic Monteggia Top


  1. Ulnar osteotomy: To be done at original fracture if recognizable or in proximal ulna at 4 cm from olecranon tip to allow two-third holes hold in proximal fragment. We prefer transverse osteotomy as easy to perform and heal well. Step-cut osteotomies offer the advantage of better contact but can be messy sometimes [Case Example 5] and [Case Example 6].
  2. Distract the ulnar osteotomy and angulate to attempt to reduce radial head. If radial head reduces concentrically and is stable fix ulna in angulation required to keep radial head stable
  3. If radial head irreducible or unstable expose radiocapitellar joint through Kocher approach[9] and remove interposing tissue preserving remnants of annular ligament
  4. If radial head not stable after closed or open reduction.



  1. Pass radial head through a hole made in the remnant of annular ligament
  2. Repair annular ligament
  3. Reconstruct annular ligament with triceps[10] or ECU fascia.



  Summary Top


  1. Acute Monteggia fracture-dislocation is classified by Bado classification according to direction of radial head dislocation and Lett classification according to type of ulnar fracture
  2. Closed reduction of the injury involves restoration of ulnar length and angulation and reduction of radial head with immobilization in stable position depending upon Bado type
  3. The choice between closed methods and internal fixation is guided by Ring and Waters treatment algorithm depending on type of ulnar fracture
  4. In chronic Monteggia, indications for treatment include pain.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Monteggia, G.B.: Instituzioni Chirurgiche. Milan, Maspero, 1814.  Back to cited text no. 1
    
2.
Bado, J.L. The Monteggia Lesion. Clin Orthop Rel Res1967; 50:71-86.  Back to cited text no. 2
    
3.
Letts M, Locht R, Wiens J. Monteggia Fracture – Dislocations in Children. J Bone Joint Surg 1985;67B:724-7.  Back to cited text no. 3
    
4.
Ring D, Jupiter JB, Waters PM. Monteggia Fractures in Children and Adults. J Am Acad Ortho Surg 1998;6:215-24.  Back to cited text no. 4
    
5.
Donald S Bae. Successful Strategies for Managing Monteggia Injuries J Pediatr Orthop 2016;36:S67-70.doi: 10.1097/BPO.0000000000000765.  Back to cited text no. 5
    
6.
Chin K, Kozin SH, Herman M, Horn BD, Eberson CP, Bae DS, et al. Pediatric Monteggia Fracture-Dislocations: Avoiding Problems and Managing Complications Instr Course Lect 2016;65:399-407.  Back to cited text no. 6
    
7.
Papandrea R, Waters PM. Posttraumatic Reconstruction of the Elbow in the Pediatric Patient. Clin Orthop 2000;370:115-26. doi: 10.1097/00003086-200001000-00011. PMID: 10660706.  Back to cited text no. 7
    
8.
Peter Waters Dolald Bae. Surgical Treatment of Acute and Chronic Monteggia Fracture-Dislocations Operative Techniques in Orthopaedics 2005;15:308-14.  Back to cited text no. 8
    
9.
Boyd H.B. Surgical Exposure of the Ulna and Proximal One-Third of the Radius Through One Incision. Surg Gynecol Obstet 1940;71:86-8.  Back to cited text no. 9
    
10.
Bell-Tawse A.J. The Treatment of Malunited Anterior Monteggia Fractures in Children. J Bone Joint Surg 1965;47B:718-23.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
Abstract
Introduction
From the Past
What Classificat...
What Are Montegg...
What Is Lett'...
How Not to Miss ...
What Is Ring and...
How Does One Do ...
How Does the Tre...
How Do You Reduc...
How Do You Treat...
Are Nerve Injuri...
Why Monteggia Sh...
How Do We Manage...
What Is Step by ...
Summary
References
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