Courtesy: Dr. Alvin Crawford, Dr Ashok Shyam, Ortho TV
Monteggia fracture-dislocation – Practical Concepts & Management
Definition
- Injury consisting of:
- Fracture of ulna
- Dislocation of radial head
Key Principle (Most Important Point)
“Ulna is the key to management”
- Proper ulnar alignment – spontaneous reduction of radial head
- Focus should be on:
- Restoring ulna anatomy, not chasing the radial head
Why the Ulna is Critical
- Acts as a template for forearm alignment
If Ulna is Properly Reduced
- Radial head usually relocates automatically
If Ulna is Not Stabilized
- ~20% risk of:
- Loss of reduction
- Persistent radial head dislocation
Types of Ulnar Fractures
- Greenstick fracture
- Plastic deformation (bowing)
- Complete fracture
- Long oblique fracture
Key Point
- Even non-displaced fractures must be stabilized
Management Principles
1. Reduction
- Attempt closed reduction first
- Aim:
- Anatomical alignment of ulna
2. Stabilization (Essential Step)
Fixation Options
- K-wires
- Rush rod (commonly preferred)
- Plates / intramedullary implants
Role of Implant
- Acts as:
- Reduction joystick
- Maintains alignment
3. Radial Head Management
- Usually reduces automatically after ulnar fixation
If Radial Head Does NOT Reduce
Check for:
- Malreduction of ulna
- Soft tissue interposition
- Associated fractures
Associated Injuries
- Radial neck fractures (commonly missed)
- Radial head fractures
- Capitellar alignment abnormalities
Radiological Rule
Line drawn along radial shaft must pass through:
- Capitellum (in all views)
Mnemonic to Avoid Missing Injury
RAMBO
- R – Radial
- A – Articulation
- M – Missed
- B – By
- O – Orthopedists
Meaning
- Always check:
- Radiocapitellar alignment
Techniques Used
- Closed reduction + casting
- Open reduction + internal fixation (ORIF)
- Ulnar osteotomy (chronic cases)
- Annular ligament repair (if required)
What NOT to Do
- Trans-capitellar pinning
- Ignoring ulnar fracture
- Accepting unstable reduction
Failure Indicators
- Radial head not stable in:
- Pronation
- Supination
- Persistent dislocation
- Inadequate ulnar alignment
Complications
- Loss of reduction
- Chronic radial head dislocation
- Elbow stiffness
- Arthrosis
- Malunion
Important Clinical Advice
- If uncertain:
- Seek expert opinion
Key Insight
- Avoid:
- Trial-and-error surgical approaches
- Inadequate fixation
Take-Home Messages
- Always fix the ulna first
- Stabilize even greenstick fractures
- Radial head usually reduces automatically
- Always check radiocapitellar alignment (RAMBO)
- Avoid unstable or incomplete reduction
Final Message
- Successful management depends on:
- Recognizing the injury early
- Restoring ulnar anatomy precisely
- Confirming stable radial head reduction
Leave a Reply