Adult Monteggia Fracture-Dislocation — ORIF

Indication. Virtually every adult Monteggia fracture-dislocation (Bado Types I-IV) is managed operatively. Non-operative treatment in adults fails at unacceptable rates — redislocation of the radial head, painful proximal radioulnar joint instability, restricted forearm rotation, malunion, and early post-traumatic arthritis. The standard of care is open reduction and internal fixation (ORIF) of the ulna for all Bado types. The one paediatric exception does not transfer to adults: in children the annular ligament heals well, the ulna remodels, and closed reduction with casting succeeds in most cases, but the adult proximal ulna has minimal remodelling potential and the ligament will not hold the head reduced without anatomic ulnar fixation. Absolute indications - All adult Monteggia fracture-dislocations (Bado Types I-IV)

• An irreducible radial head after attempted closed reduction, suggesting interposition of the annular ligament, capsule, or a fracture fragment
• Open Monteggia fractures — urgent debridement and fixation regardless of Bado type
• Monteggia fracture with associated neurovascular injury — PIN palsy with clinical evidence of entrapment, or vascular injury Relative indications - Bado Type II with an associated radial-head fracture — requires radial-head fixation or replacement in addition to ulna plating
• Bado Type II with a coronoid fracture involving greater than 50 percent of coronoid height — requires coronoid fixation for elbow stability
• Chronic unreduced Monteggia (presenting greater than 6 weeks after injury) — requires ulna osteotomy, plate fixation, and annular ligament reconstruction (Bell-Tawse procedure)
• Pathological fracture of the proximal ulna with radial-head dislocation in metastatic disease Contraindications are essentially all relative, because the injury itself virtually always warrants fixation: severe medical comorbidity precluding anaesthesia, active infection at the surgical site (defer until resolved), or the non-ambulatory patient with end-stage disease in whom the functional demands do not justify surgical risk.

Consent specifically for PIN palsy (5 to 10 percent, usually transient), nonunion (5 to 10 percent), malunion, recurrent instability, stiffness (loss of terminal extension or forearm rotation), infection (less than 2 percent), and the possibility of further surgery — hardware removal, radial-head excision, or secondary reconstruction.

The goal is anatomic restoration of the proximal ulna so that the radial head reduces indirectly, with all associated injuries addressed and elbow stability confirmed before closure. The exposure is the posterior approach to the proximal ulna (the workhorse), with a Kocher lateral approach added whenever the radial head needs fixation, replacement, or open reduction. The operation is laid out step by step below, with the exposure built in as the early steps — this is the heart of the procedure.

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Special case — chronic unreduced Monteggia (greater than 6 weeks). The radial head stays dislocated, the ulna has usually malunited, and the annular ligament is scarred and shortened so that simple open reduction will fail. Through a posterior approach, perform an osteotomy at the malunion site and correct the ulnar alignment, length and sag with a long 3.5 mm plate — this restores the bony architecture that drives the radial-head position. Then through a Kocher approach, reduce the radial head and reconstruct the annular ligament with a strip of triceps fascia or flexor carpi ulnaris (the Bell-Tawse procedure), tensioned with the head reduced and the forearm in neutral. Protect the reconstruction in a long-arm cast for 4 to 6 weeks. Outcomes are inferior to acute fixation: permanent restriction of forearm rotation, particularly supination, is expected and must be counselled preoperatively.

Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0 to 2 weeks | Long-arm posterior splint, elbow 90 degrees, forearm neutral | Finger, wrist and thumb active range of motion from day 1; elevate | | 2 | 2 to 4 weeks | Splint removed at 7 to 14 days if fixation stable | Active-assisted elbow flexion/extension; gentle forearm rotation in the pain-free range | | 3 | 4 to 12 weeks | Splint for heavy tasks only | Progressive resistance; full active motion; physiotherapy if a flexion contracture greater than 30 degrees persists at 4 weeks | | 4 | 3 to 6 months | — | Graded return to heavy manual work and sport after confirmed union | Most patients return to office work at 2 to 4 weeks, light manual work at 8 to 12 weeks, and heavy manual work or sport at 3 to 6 months. Driving resumes when the patient can grip the wheel and perform an emergency stop, typically 6 to 8 weeks. Complications

Epidemiology and mechanism. The Monteggia lesion is a fracture of the proximal ulna with dislocation of the radial head. By Bado type, Type I accounts for roughly 60 percent of cases, Type II (the most common adult pattern) for 15 to 20 percent, Type III for about 5 percent, and Type IV is rare. Mechanism varies by type: a Type I lesion typically follows a direct blow to the posterior forearm with the elbow flexed and forearm pronated; a Type II lesion a fall onto a flexed elbow with an axial load driving the olecranon into the trochlea; and a Type III lesion an abduction force on the extended elbow. Surgical anatomy that governs the operation. The olecranon forms the proximal articular surface of the ulnohumeral joint; the coronoid process projects anteriorly from its base and is the primary anterior buttress against posterior subluxation — the keystone of elbow stability. The trochlear notch (sigmoid notch) is the deep concavity between them, oriented about 45 degrees to the long axis of the ulna. The proximal dorsal angulation (the sag) at the metaphyseal-diaphyseal junction is the contour that must be restored, because it sets the orientation of the proximal radioulnar joint and therefore the position of the radial head. The annular ligament encircles the radial head, attaching to the anterior and posterior margins of the radial (lesser sigmoid) notch of the ulna; in a Monteggia lesion it is torn from its ulnar attachment, but after anatomic ulna plating it heals with the head reduced, so primary repair is rarely needed acutely. The posterior interosseous nerve branches from the radial nerve about 2 to 3 cm distal to the lateral epicondyle, enters the supinator through the fibrous arcade of Frohse, wraps the proximal radial neck, and exits the distal supinator border 5 to 6 cm distal to the radial head; it supplies extensor carpi ulnaris, extensor digitorum, extensor digiti minimi, extensor pollicis longus and brevis, extensor indicis and abductor pollicis longus — but NOT extensor carpi radialis brevis, which is supplied proximal to the PIN branch.

Key evidence. The principle that anatomic ulna fixation reduces the radial head indirectly was established by case series from the 1980s through the 2000s, showing reliable radial-head reduction after ulna plating in greater than 90 percent of cases. Reckling and Cordell (1968) set the foundation by recommending open reduction and internal fixation of the ulna as the primary adult treatment and warning of the danger of missed or late-diagnosed lesions. Ring, Jupiter and Simpson (1998) showed in 38 adult Monteggia fractures that outcomes correlated with the accuracy of ulnar reduction — malreduction produced poor forearm rotation and elbow pain — and that Bado Type II fractures with associated radial-head and coronoid fractures did worst. Jupiter and colleagues (1991) characterised the posterior (Type II) lesion and its high rate of associated injuries. Weber and colleagues (2023), in a systematic review of 21 studies, confirmed that plate fixation of the ulna produces reliable radial-head reduction in the majority, that Bado Type II outcomes lag because of associated injuries, and that functional outcome correlates with Bado type and quality of ulnar reduction. The consistent message — the ulna is the key, and all associated injuries must be addressed at the index operation — is the backbone of modern adult Monteggia management.