3 y/o male presenting with significant left arm pain and swelling. He was jumping on the bed when he fell off and landed on his left arm. There were no open wounds or lacerations of the arm. He cried immediately and was brought directly to the emergency department. He was noted to have significant swelling and tenderness of the left elbow and was neurovascularly intact. What’s the diagnosis?
Answer: Monteggia fracture
- This patient has a proximal ulnar fracture with radial head dislocation. This fracture can be distinguished from a Galeazzi’s fracture as this fracture involves a radial shaft fracture with distal radioulnar joint dislocation.
- In Monteggia’s fracture, the radiocapitellar line is disrupted, the apex of the ulnar fracture points in the direction of the radial head dislocation.
- This fracture can frequently be missed in the emergency department if the joint alignment is not carefully examined.
- Mechanism: fall on outstretched and or direct blow to the forearm with the elbow extended and forearm in hyperpronation
- Radiocapitellar joint disruption occurs from the energy from the ulnar fracture that transmits along the interosseous membrane leading to rupture of the proximal quadrate and annular ligaments
- Exam: significant swelling and pain of the elbow, may palpate the radial head
- Diagnosis: anterior posterior and lateral elbow x-rays to assess for the radiocapitellar line
- 4 different types based on the Bado classification
| Bado Type | Fracture | Radial head dislocation direction |
| I | Ulnar shaft | Anterior |
| II | Ulna | Posterior |
| III | Ulna | Lateral |
| IV | Radius and ulna | Anterior |
- Treatment of Monteggia fracture involves reduction with long arm splint in the arm in 110 degrees. It is typically recommended to consult Orthopaedic surgery as these fractures can be unstable and occasionally require open reduction and internal fixation
- Complications: radial nerve injury, posterior interosseous nerve injury, nonunion, recurrent dislocation
References:
Johnson NP, Silberman M. Monteggia Fractures. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470575/
Mathur N, Lau KK. Monteggia fracture: an easy fracture to miss. Emerg Radiol. 2020 Aug;27(4):377-381. doi: 10.1007/s10140-020-01763-8. Epub 2020 Feb 21. PMID: 32086608.
The Royal Children’s hospital melbourne. The Royal Children’s Hospital Melbourne. (n.d.). https://www.rch.org.au/clinicalguide/guideline_index/fractures/monteggia_fracturedislocations_emergency_department_setting/#ED_management
Tintinalli’s Emergency Medicine (9th ed). Chow, Y. Lee, S. McGraw Hill, 2018. Chapter 270 and Page 1820-1821.
