Monteggia Fracture: Dislocations
Donald S. Bae, MD
The goal is to preserve elbow and forearm function and prevent chronic Monteggia dislocation by:
Acute accurate identification of lesion (NO missed acute Monteggia) (Figure 11-1)
Restoration of ulna fracture to stable length
Reduction and maintenance of reduction of the radial head
Plastic Deformation and Greenstick Monteggia Fracture
Dislocations can safely be treated acutely with closed reduction of ulna fracture out to stable length and reduction of radial head (Figure 11-2)
Some complete fractures can be similarly treated closed but risk loss of reduction
Therefore, we advocate operative treatment of all acute Monteggia lesions with complete ulna fractures
 Figure 11-1 ▪ Chronic Monteggia identified at 6 weeks after injury with displaced radial head anteriorly and ossification of annular ligament anterior and proximal to radial head. (Reprinted with permission from Waters PM, Skaggs DL, Flynn JM. Rockwood and Wilkins’ Fractures in Children. 9th ed. Philadelphia, PA: Wolters Kluwer; 2019.) |
 Figure 11-2 ▪ Closed reduction maneuver of plastic deformation ulna Monteggia fracture dislocation. This requires significant force. |
Closed Reduction Intramedullary Fixation of Monteggia Fracture: Dislocation
Indications
Complete fracture ulna with loss of length stability and radial head dislocation
Dislocated radial head with displaced unstable Monteggia-equivalent lesion
Operative Fixation Depends on the Ulna Fracture Type
Transverse = IM rodding ulna (Figure 11-3)
Short oblique = IM rodding ulna
Long oblique = IM rodding or plate/screw fixation ulna
Comminuted = plate/screw fixation
Equipment (Depends on the Above-Planned Procedure)
Smooth K-wires
Titanium elastic intramedullary nails (TEIN)
AO small fragment set
Small instrument tray
More extensive open instrument tray nearby but sterile
Power drill
Nonsterile tourniquet
Radiolucent hand table
Fluoroscopy
Positioning (Figure 11-4)
Patient on the edge of operative table, turned 90 degrees
Head supported for traction reduction
Radiolucent hand table for the affected arm
Surgeon in axilla of the patient
Affected arm flexed and externally rotated at the shoulder for IM rodding
Affected limb extended on the arm table for ORIF ulna with plate and screws
Surgeon moves to above arm near shoulder of patient, if open radial head reconstruction is needed
Fluoroscopy from above patient near shoulder parallel to the patient, perpendicular to arm
 Figure 11-3 ▪ A and B, Displaced ulna transverse fracture with anterior radial head dislocation; C, treated with closed reduction IM rod fixation. (Reprinted with permission from Waters PM, Skaggs DL, Flynn JM. Rockwood and Wilkins’ Fractures in Children. 9th ed. Philadelphia, PA: Wolters Kluwer; 2019.) |
 Figure 11-4 ▪ OR positioning with fluoroscopic arm extension table. |
IM Rodding Technique
Surgical Approaches and Techniques
Indicated for Transverse and Short Oblique Complete Ulna Fractures
Percutaneous insertion of TEIN or smooth K-wire
Determine the size of the wire by laying it on skin and checking fluoroscopy (Figure 11-5)
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