Monteggia Fracture Dislocation: Bado Classification, Treatment and Complications

Monteggia fracture dislocation is any fracture of the ulna associated with a radial head dislocation

Monteggia occur more commonly in children and rarely in adults

Diagnosed by forearm X-rays and treated either operatively or non operatively

Mechanism of injury

• Monteggia result from a fall on the outstretched hand with twisting force or a force that lead to hyperextension of the elbow joint
• It also can occur from direct blow to the forearm and from high energy injuries

Classification

Classified according to Bado classification

Bado classifies Monteggia fractures according to the direction of the radial head dislocation and the direction of the angulation of the ulna fracture into four types, those include:

• Type I
• Type II
• Type III
• Type IV

Bado Type IV Monteggia fracture; by Benoudina Samir, CC BY-SA 4.0, via Wikimedia Commons

Bado Type IV Monteggia fracture; by Benoudina Samir, CC BY-SA 4.0, via Wikimedia Commons

Clinical features

Symptoms

• Patient present with pain in the forearm and elbow

Physical examination

Look

• Look for Swelling
• Deformity of the ulna is obvious, but the elbow deformity is masked by swelling
• Inspect the lacerations for any evidence of open fracture

Feel

• Feel for tenderness (esp. on the lateral side of the forearm)
• Neurovascular examination is done to look for nerve/vessel injury (esp. radial nerve)

Move

• Patient refuse movement due to pain
• Examination is repeated multiple times to exclude compartment syndrome

Imaging

• Plain radiographs (AP and lateral) are enough for diagnosis
• The radiograph should include the elbow and wrist to detect any injuries to the proximal or distal radioulnar joints
• Radial head is dislocated and does not point to the capitulum anymore (because normally the radius points to the capitulum in all elbow X ray views)
• Ulnar fracture might by incomplete (greenstick) in children and the radial head is not completely ossified so it can be easily missed on X-rays

Lateral forearm X-ray showing Monteggia fracture dislocation; by Jane Agnes, CC BY-SA 3.0>, via Wikimedia Commons

Lateral forearm X-ray showing Monteggia fracture dislocation; by Jane Agnes, CC BY-SA 3.0>, via Wikimedia Commons

Emergency management

• Grossly displaced fracture should be reduced in the emergency department
• Above elbow backslab is applied to support the fracture and prevent forearm rotation

Treatment

• Non operative
• Operative

Non operative

• Non operative treatment is done in children for the incomplete fractures only (greenstick fractures)
• reduction is achieved by restoring the ulna to its normal length by traction
• Then the forearm is immobilized in above elbow cast for 3 weeks and Re examination is done and radiographs are repeated
• Exercises are started as soon as possible

Operative

• Operative treatment is done when ulnar fracture is a complete fractures
• Operative treatment is achieved with closed reduction of the radial head and ORIF and plating of the ulnar fracture
• Radial head is reduced by closed reduction, if it remains stable throughout full range of motion of the elbow then no further management needed; but if it re dislocates or it can’t be reduced then it has to be explored and repaired

Complications

Early Complications

• Nerve injury: mostly iatrogenic happen during reduction or during surgery, and they are mostly neuropraxias that will recover on their own
• Vascular injury
• Compartment syndrome

Late Complications

• Malunion: occur when the ulna is not perfectly reduced which lead to the radial head remains dislocated and limits elbow flexion
• Non union: treated by plating and bone grafting
• Elbow stiffness: occur especially when the radial head dislocation is missed and when the elbow is immobilized for a longer period of time

Course Menu

This article is apart from The Elbow and Forearm Trauma Free Course; This course contains a number of lectures listed below:

• Course Introduction
• Distal humerus Fractures
• Radial head Fractures
• Olecranon Fractures
• Elbow Dislocation
• Radius and Ulna Shaft Fractures
• Monteggia Fracture Dislocation
• Galeazzi Fracture Dislocation
• Elbow X-ray Interpretation