Monteggia fracture

Description

Monteggia fracture-dislocation: Fracture of the proximal or middle third of the ulna with associated radial head dislocation or instability. Further classified by José Luis Bado as Type 1 – IV Monteggia Fractures

Monteggia Fracture Type I labelled
Type I Monteggia fracture dislocation

History of the Monteggia fracture-dislocation

1812Giovanni Battista Monteggia (1762 – 1815) recorded two observations of a traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal radius in ‘Lussazioni delle ossa delle estremita superiori.’

La percossa di un bastone ruppe il cubito al terzo superiore e slogò il raggio al lato opposto. In questo caso fu il cubito stesso che cedendo al colpo portò fuor di luogo il raggio adjacente.

Monteggia, Lussazioni delle ossa delle estremita superiori. 1814; V(213): 109.

The strike of a stick broke the ulna in the upper third and dislocated the radius on the opposite side. In this case it was the ulna itself which, giving way to the blow, carried the adjoining radius out of place.

Monteggia, 1814; V(213): 109.

The second case involved a young woman presenting after a fall on her outstretched arm. She was diagnosed with a proximal third ulna fracture, which was reduced and splints applied. After a month, the dressings were removed and much to the embarrassment of the surgeon, upon extending the elbow, the head of the radius could be seen and felt prominently in the antecubital fossa. On flexing the elbow, the radial head could be replaced in a normal relationship, but could not be maintained in position, re-dislocating immediately upon extension

…ma mi sovviene con dispiacere il caso d’una fanciulla, che da una caduta parvemi aver riportata la frattura del cubito al terzo superiore di esso… il fatto è che al fine d’un mese, sfasciato il braccio e dissipata ogni gonfiezza che però nella sola lussazione del raggio suol esser poca, trovai che nello stendere l’antibraccio saltava fuori a fare una forte e deforma prominenza… mostrando in modo troppo visibile e manifesto, che questa era una vera lussazione anteriore.

Monteggia, 1814; V(260): 130-131

…but I can recall with displeasure the case of a girl, who following a fall, it seemed to me, reported with a fracture of the ulna at its upper third… the fact is that at the end of one month, the arm smashed and the swelling dissipated, which in an isolated luxation of the radius would be little, I found that by extending the forearm it jumped out to make a strong and deformed prominence… demonstrating in visible and manifest manner, that this was a true anterior dislocation

Monteggia, 1814; V(260): 130-131

Monteggia appreciated that the ulna fracture was linked to the radial head dislocation and that both needed to be addressed simultaneously. However, his management of the injury by closed reduction and splintage was suboptimal and resulted in recurrence of the radial head subluxation

1824Astley Paston Cooper (1768 – 1841) described anterior, posterior, and lateral dislocations of the radial head with and without fracture of the ulna in his treatise on dislocations, and on fractures of the joints.

LATERAL DISLOCATION OF THE RADIUS. Mr. Freeman, Surgeon, of Spring-gardens, brought to my house a gentleman of the name of Whaley, aged twenty-live years, whose poney having run away with him, when he was twelve years of age, he had struck his elbow against a tree whilst his arm was bent and advanced before his head. The olecranon was broken, and the radius dislocated upwards and outwards, above the external condyle; and when the arm is bent, the head of the radius passes the os humeri. He has an useful motion of the arm, but neither the flexion nor the extension is complete.

Cooper 1824: 444

1853Joseph François Malgaigne (1806-1865) published on the complications of upper and lower limb fractures with associated dislocations. He proposed alternate methods for dislocation reduction in the absence of a ‘lever’ (the broken bone) to assist in the dislocation reduction

1854 – Malgaigne reported on 5 cases of fracture of the shaft of the ulna with dislocation of the head of the radius, and provided more sage advice to young surgeons.

Non que le diagnostic soit difficile une fois l’attention éveillée sur les deux lésions, mais parce que la présence d’une lésion fait trop souvent oublier l’autre . Voici donc l’avis que je donne aux jeunes chirurgiens:

Dans toute fracture du cubitus, méfiez-vous de la luxation de la tête radiale;

Et d’une façon plus générale encore:

Dans toute fracture des os de l’avant -bras où le gonflement se prolonge au delà du coude, souvenez-vous que la fracture simple s’accompagne rarement d’un gonflement si considérable, et explorez scrupuleusement l’articulation.

Malgaigne, Revue médico-chirurgicale de Paris. 1854; 15: 215-220

Not that the diagnosis is difficult once the attention is awakened to the two lesions, but because the presence of one lesion too often makes us forget the other. Here is the advice I give to young surgeons:

In any fracture of the ulna, beware of dislocation of the radial head;

And more generally still:

In any fracture of the bones of the forearm where the swelling extends beyond the elbow, remember that the simple fracture is seldom accompanied by such considerable swelling, and carefully explore the joint.

Malgaigne, Revue médico-chirurgicale de Paris. 1854; 15: 215-220

1886 – Hans Doerfler (1863-1942) reported 4 cases including a patient who experienced paralysis of the extensor muscles of the forearm owing to injury of the posterior interosseous nerve that was caused by the dislocated head of the radius. 

Doerfler 1886 Monteggia fracture dislocation 2
Monteggia fracture dislocation Doerfler 1886

…möchte ich ich nochmals auf die praktische Wichtigkeit dieser Verletzungscombination aufmerksam machen. Wird die Diagnose richtig gestellt, so ist die Prognose ganz günstig; wird jedoch die Luxation des Radius, wie es so oft geschehen, nicht erkannt, so ist die Functionsfähigkeit des verletzten Armes äusserst gefährdet. Jeder Arzt, der eine Fractur der Ulna in Behandlung bekommt, hat daher die Verpflichtung, auf eine allenfallsige Complication mit Radiusluxation seine Aufmerksamkeit zu richten.

Doerfler 1886: 361

I would like to draw your attention to the practical importance of this combination of injuries. If the diagnosis is correct, the prognosis is quite favourable; but if the dislocation of the radius is not recognized, as is so often the case, the functional ability of the injured arm is extremely endangered. Every doctor who manages a fracture of the ulna is obliged to pay close attention to the potential complication of radial dislocation.

Doerfler 1886: 361

1900 – Lewis Atterbury Stimson (1844-1917) published Dislocation of the head of the radius with fracture of the ulna in his book ‘A practical treatise on fractures and dislocations’. His series included 10 patients, and he referred to a chronic case he treated with open reduction and fixation rather than the traditional fracture manipulation and closed reduction. 

1909 – Jules Perin assigned the eponym to the described fracture pattern as Monteggia fracture dislocation in his thesis: Les fractures du cubitus accompagnées d’une luxation de l’extrémité supérieure du radius

1958 – Uruguayan orthopedist José Luis Bado elaborated on the pathology, mechanics and management of the fracture-dislocation first published in Spanish, then in English (1962, 1967). Bado introduced the term Monteggia lesion and Monteggia equivalent injuries. He defined 4 injury patterns incorporating dislocation of the radial head associated with fractures at various levels of the ulna or with injuries at the wrist.

The Bado classification defines a group of traumatic ‘double bone‘ injuries having in common a ‘Monteggia lesion‘ (ulna fracture) with a dislocation of the radio-humero-ulna joint (radial head dislocation either anterior, lateral or posterior)

Bado-Classification-of-Monteggia Type I-IV
Bado Classification of Monteggia Type I-IV

Associated Persons

Alternative names
  • Monteggia lesion
  • Monteggia fracture-dislocation

References

Historical articles

Review articles


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Resident medical officer in emergency medicine MB ChB (Uni. Dundee)  MRCS Ed. Avid traveller, yoga teacher, polylinguist with a passion for discovering cultures.

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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