How should an acute Monteggia fracture be managed in an otherwise healthy adult or adolescent?

Management of Monteggia Fractures

All acute Monteggia fractures in adults and adolescents require operative fixation with anatomic reduction and stable internal fixation of the ulna to restore ulnar length and alignment, which indirectly reduces the radiocapitellar joint. 1, 2

Initial Recognition and Diagnosis

• Confirm the diagnosis on elbow radiographs by drawing a line through the radial head extending from the radial shaft—this line must penetrate the capitellum in all views; failure to do so indicates radiocapitellar dislocation 1
• Obtain CT imaging with 3-D reconstruction for pre-operative planning, particularly when comminution of the proximal ulna, radial head fragmentation, or coronoid involvement is suspected 3
• Use the Bado classification to characterize the direction of radial head dislocation, and apply the Jupiter subtype classification for Bado II fractures to assess proximal ulna comminution and coronoid involvement, as this better predicts surgical complexity and outcomes 2

Operative Management Strategy

The primary surgical goal is anatomic reduction and rigid fixation of the ulna, which indirectly reduces the radiocapitellar joint. 2

Ulnar Fixation Technique

• Apply compression plating for the ulna fracture in adults and adolescents, as this provides the most reliable maintenance of ulnar length and alignment 3, 2
• In adolescents with transverse or short oblique ulnar fractures and minimal comminution, consider intramedullary pin fixation as an alternative that offers shorter operative time, less scarring, and avoids symptomatic hardware along the subcutaneous ulnar border 4
• Reserve intramedullary fixation only for length-stable fractures; comminuted or long oblique fractures require plate-and-screw constructs to maintain ulnar length 4
• If plastic deformation of the ulna persists with residual radiocapitellar subluxation after ulnar reduction, elongate the ulna through the fracture site using plate fixation to allow radial head reduction 4

Radial Head Management

• Reconstruct the radial head whenever possible, as this provides better long-term elbow stability and function 3
• Excise the radial head only when severe comminution precludes reconstruction (this occurred in 6 of 18 patients in one series) 3
• Assess for radial head or neck fractures in all cases, as Monteggia variants (proximal ulna fracture with radial head/neck fracture rather than pure dislocation) require additional fixation or reconstruction 3

Coronoid and Ulnohumeral Stability

• Address coronoid fractures operatively when present, as coronoid involvement correlates with poorer outcomes and increased ulnohumeral instability 3, 2
• Assess ulnohumeral stability intraoperatively after ulnar and radial head fixation; if instability persists, consider additional ligamentous repair or temporary external fixation 2

Surgical Timing and Approach

• Perform surgery urgently (within 24 hours) in hemodynamically stable patients to optimize outcomes and reduce complications 5
• Expect to perform open reduction of the radiocapitellar joint more frequently in comminuted fractures compared to other fracture patterns 6
• Immobilize the forearm postoperatively in the position of maximal radiocapitellar stability, typically in supination 4

Postoperative Rehabilitation

• Initiate early range-of-motion exercises for the shoulder, elbow, wrist, and hand within the first postoperative days 7
• Use slings only for comfort and discontinue as pain permits, but restrict activities above chest level until radiographic healing is evident 7
• Balance early mobilization with protection of the surgical construct, as overly aggressive physiotherapy increases the risk of fixation failure 7
• Progress to weight-bearing and structured exercise programs once orthopedically permissible 7

Common Pitfalls and Complications

• Failure to recognize the injury: Always draw the radiocapitellar line on all elbow radiographs to avoid missing the dislocation 1
• Inadequate ulnar reduction: Angulation and shortening of the ulna commonly occur after closed reduction in adults, mandating operative intervention 1
• Residual radiocapitellar subluxation: Any residual subluxation after ulnar reduction indicates inadequate restoration of ulnar length and requires more aggressive fixation 6, 4
• Underestimating injury complexity: Intraarticular damage, coronoid fractures, and comminution of the ulna and radial head all correlate with poorer outcomes 3
• Heterotopic ossification and elbow stiffness: These complications occur in approximately 11% of cases and are managed with aggressive early mobilization 3
• Compartment syndrome: Monitor closely postoperatively, as this occurred in 2 of 112 patients in one pediatric series and risk increases with multiple closed reduction attempts 6

Expected Outcomes

• When anatomic reduction is achieved and maintained, expect excellent to good results in approximately 78% of adult patients (14 of 18 in one series) 3
• Mean range of motion at final follow-up typically achieves 20° extension, 116° flexion, 50° pronation, and 55° supination 3
• Poor results correlate with extent of intraarticular damage, coronoid fractures, and comminuted fractures of the ulna and radial head 3