Monteggia and Galeazzi Fractures

Monteggia and Galeazzi fractures are the two classic forearm fracture-dislocations, and both test the ring concept: because the radius and ulna are bound at both ends and along the shaft, a displaced fracture of one bone mandates a corresponding joint or bony disruption elsewhere. Missing the associated joint injury is the central pitfall in both. Across all settings the governing principle is identical: fix the fractured bone anatomically and the joint usually reduces.

Monteggia. A fracture of the proximal ulna with dislocation of the radial head, classified by Bado into types I to IV. Type I (anterior) is the most common overall and the dominant paediatric pattern; Type II (posterior) is the commonest pattern in adults (Ring, JBJS Am 1998). Monteggia lesions account for roughly 1-2% of forearm fractures, with a bimodal distribution: a paediatric peak after a fall on the outstretched hand and an adult peak after higher-energy trauma, often Bado II.

Galeazzi. A fracture of the distal third of the radius with disruption of the DRUJ. It is the "fracture of necessity": conservative treatment fails in about 80% of adults (Mikic, JBJS Am 1975), so adults require ORIF. Galeazzi fracture-dislocations comprise about 3-7% of forearm fractures, predominantly in adults aged 30-50, and are frequently work- or sport-related.

The forearm ring. The forearm functions as a closed ring whose three links must all be intact for normal rotation. If one bone fractures and displaces, the ring must fail elsewhere, either in the other bone or at a joint, and any distal radius fracture therefore demands assessment of the DRUJ.

• Proximal radioulnar joint (PRUJ) - the radial head in the radial notch of the ulna, stabilised by the annular ligament. Disrupted in Monteggia.
• Interosseous membrane (IOM) - its central band transmits about 70% of axial load from the radius to the ulna. The key longitudinal stabiliser, lost in the Essex-Lopresti lesion.
• Distal radioulnar joint (DRUJ) - the ulnar head in the sigmoid notch of the radius. Disrupted in Galeazzi.

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The DRUJ stabilisers. The TFCC is the primary stabiliser, through its dorsal and palmar radioulnar ligaments; the interosseous membrane, pronator quadratus and the ECU subsheath add to it. The distal interosseous membrane may contain a discrete distal oblique bundle running from ulna to radius near the DRUJ, and together with the TFCC it resists longitudinal separation and abnormal translation after a radial-shaft injury. Restoring radial length, bow and rotation retensions this linkage, and persistent malalignment leaves the DRUJ incongruent.

Rotation and DRUJ stability. The DRUJ is most stable in supination, when the palmar radioulnar ligament and the DRUJ capsule are tight. It is moderately stable in neutral and least stable in pronation. Supination is the position of immobilisation for an unstable Galeazzi DRUJ.

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Monteggia. Three mechanisms are described:

• A fall on the outstretched hand with forced hyperpronation, classically producing Type I (anterior)
• A direct blow to the posterior proximal forearm
• Axial load through a supinated forearm, associated with Type II in adults

Galeazzi. Three mechanisms are described here too:

• A fall on the outstretched hand with the forearm pronated
• A direct dorsoradial blow to the wrist
• Axial load with rotation

Monteggia. Pain, swelling and deformity of the proximal forearm and elbow, with a palpable, dislocated radial head and reduced elbow flexion-extension and forearm rotation. Always test PIN function, in every type and with the highest suspicion in Type III, and document it before and after surgery; the examination is described under nerve injuries below.

Galeazzi. Wrist pain and swelling with tenderness over the DRUJ and the ulnar fovea. The ulnar head is prominent, dorsally or palmarly depending on rotation, and forearm rotation is painful and restricted. Assess the median nerve and AIN, which lie in the volar surgical territory.

Radiographs. Always image the entire forearm, including the joint above and the joint below; missing a joint injury is a major pitfall.

• AP and lateral of the entire forearm
• Dedicated elbow views (AP, lateral) - mandatory for any ulna fracture
• Dedicated wrist views (PA, lateral) - mandatory for any distal radius fracture
• Contralateral comparison views - invaluable for ulnar variance and DRUJ width

The rule. Any isolated ulna fracture is a Monteggia until proven otherwise. Obtain dedicated elbow views and check the radiocapitellar line on every one of them.

CT is for complex adult patterns and operative planning, not a substitute for complete initial radiographs. It is indicated for:

• Complex or comminuted proximal ulna or radial head fractures (Bado II planning)
• Articular involvement of the radial head or DRUJ
• Assessment of chronic malunion before reconstruction

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The differential is about recognising the whole injury rather than the obvious fracture, and distinguishing the fracture-dislocations from their mimics.

Monteggia in adults. Operative. ORIF of the ulna restores length, alignment and IOM tension, and anatomic reduction of the ulna is the single most important step. The radial head is then assessed, and in Bado II the associated radial head and coronoid fractures are addressed.

Monteggia in children. Closed reduction of the ulna often restores the radial head. Fix the ulna, with a flexible nail or a plate, if the reduction is unstable or the pattern is length-unstable.

Galeazzi in adults. Almost always operative, because this is the fracture of necessity. The radius is fixed first, then the DRUJ is tested: a stable DRUJ needs no further treatment and moves early, and an unstable one is stabilised by one of the options under Surgical Technique.

Galeazzi in children. Closed reduction may be attempted, proceeding to ORIF of the radius if it is unstable.

Monteggia. Five complications need to be anticipated:

• Missed diagnosis - the most important and most preventable complication. Up to half are missed initially, leaving a chronic radial head dislocation that is difficult to reconstruct (see Controversies).
• Radial head instability - usually from inadequate ulnar reduction, occasionally from interposed annular ligament. Re-examine ulnar alignment first (see the irreducible joint, below).
• PIN palsy - classically Bado III; covered under nerve injuries below.
• Proximal radioulnar synostosis / heterotopic ossification - more frequent after high-energy Bado II and radial head fixation.
• Stiffness - mitigated by early mobilisation once fixation is stable.

Galeazzi. Four need to be anticipated:

• DRUJ instability - persistent if not recognised and addressed intraoperatively; may need delayed TFCC reconstruction.
• Malunion / radial shortening - causes ulnocarpal impaction and may require ulnar shortening osteotomy.
• Stiffness / loss of forearm rotation - early range of motion is critical once the construct, and the DRUJ, is stable.
• AIN / median nerve irritation - related to the volar approach and usually transient.

The chronic Monteggia. A missed radial head dislocation remodels the radiocapitellar joint and the ulna. Correcting ulnar alignment with an osteotomy can restore a stable radiocapitellar relationship, but a healed osteotomy does not guarantee joint stability.

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Each injury carries a characteristic, and different, neurological risk. Document nerve function before and after any manipulation or surgery.

The PIN in Monteggia. The posterior interosseous nerve, the deep motor continuation of the radial nerve, winds around the radial neck and passes between the two heads of supinator, entering beneath its proximal fibrous edge, the arcade of Frohse. A displaced radial head therefore stretches or compresses it, and PIN palsy is the commonest nerve lesion in Monteggia. It is classically the Bado III association, because the lateral dislocation stretches the nerve round the radial neck, and it also occurs with anterior (Bado I) displacement, especially in children.

Examining the PIN. The deficit is purely motor, with no sensory loss. Test extension of the fingers and thumb at the MCP joints, and wrist extension: the wrist still extends but drifts into radial deviation, because ECRL (innervated proximal to the PIN) is spared while ECU is denervated.

Natural history. Most are a neurapraxia that recovers spontaneously once the radial head is reduced, typically over roughly 8 to 12 weeks. Observe after anatomic reduction, obtain nerve conduction studies if there is no recovery by about three months, and consider exploration then. Explore earlier if the nerve is suspected to be entrapped at open reduction. A radial head that will not reduce also raises the suspicion of entrapment, and is a reason to explore.

The AIN and median nerve in Galeazzi. The anterior interosseous nerve, a motor branch of the median nerve, and the median nerve itself lie in the volar (Henry) territory used for radial fixation. A deficit is therefore usually an iatrogenic retraction neurapraxia rather than a primary injury, and recovery is the rule. Test the AIN with the "OK" sign (FPL and index FDP: flexion of the thumb IP and index DIP joints), and check median sensation over the volar radial three-and-a-half digits.

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The governing rule, fix the fractured bone and the joint reduces, fails in a minority, and the reason differs at each end of the forearm. Distinguish a joint that is reducible but unstable, which is immobilised or transfixed, from one that is irreducible because a structure is mechanically blocking it, which mandates open reduction. Never transfix or cast a joint that is not concentrically reduced.

The radial head that will not reduce: re-check the ulna. The commonest reason a radial head stays dislocated after fixation is inadequate ulnar reduction, a residual loss of length or angulation. Revise the osteosynthesis before blaming soft tissue.

The radial head that will not reduce: the mechanical block. A true block is usually the torn or inverted annular ligament, interposed capsule, or an osteochondral or radial head fragment lying in the joint. It requires open reduction through the lateral (Kocher) interval to extract the interposed tissue and repair or reconstruct the annular ligament.

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The DRUJ that will not reduce. After anatomic radial fixation most DRUJs reduce. If one remains frankly dislocated rather than merely lax, suspect an interposed structure. The classic culprit is the ECU tendon and its subsheath displaced into the joint, sometimes with the extensor digiti minimi or EDC tendons or an entrapped ulnar styloid fragment, or the volar capsule buttonholed by the ulnar head.

Open reduction of the DRUJ. An irreducible DRUJ needs open reduction, usually through a dorsal approach, to lift the interposed tendon out of the joint and repair the TFCC and subsheath. It cannot be solved by forcing supination or by transfixing an unreduced joint.

Early motion. Early motion prevents stiffness, the main functional problem in both injuries.

Monteggia. A brief backslab, for about 2 weeks, rests the wound and soft tissues, followed by early elbow and rotation range of motion. Avoid forced rotation initially and extremes of pronation and supination for 4-6 weeks, aiming for full range by 8-12 weeks.

Galeazzi with a stable DRUJ. A removable splint for comfort for about 2 weeks, then early active range of motion, with progressive strengthening from about 6 weeks.

Galeazzi with an unstable DRUJ. A supination cast or K-wires for about 6 weeks, then range of motion. The start is delayed, but the aim is still full range.

Return to work and sport. Manual work at about 8-12 weeks (union); contact sport at about 12-16 weeks.

Acute Monteggia. Anatomic ulna fixation gives good or excellent results in the majority: in Ring's adult series 40 of 48 were excellent or good. Unsatisfactory outcomes cluster in Bado II with associated radial head or coronoid injury. Minor loss of terminal extension is common, and forearm rotation is usually preserved.

Acute Galeazzi. Anatomic radial fixation with a stable, or stabilised, DRUJ gives good results.

Chronic and missed injuries. Results are significantly poorer. Chronic Monteggia reconstruction in children gives meaningful but incomplete gains, and results are best when surgery is within one year (Chen 2018). Reconstruction for chronic DRUJ instability gives variable results.

Prognostic factors. Four carry prognostic weight:

• Anatomic reduction of the fractured bone is the dominant prognostic factor
• Early (acute) treatment beats delayed or chronic surgery
• Associated injuries worsen outcome: radial head and coronoid fractures in Bado II, open fracture, nerve injury
• Persistent radial shortening or DRUJ instability predicts poor Galeazzi results

OrthoVellum is a global resource - the principles below hold across training systems and examination boards worldwide.

Global epidemiology:

• Monteggia lesions: ~1-2% of forearm fractures; paediatric peak (Type I/III) and adult peak (Type II, higher-energy).
• Galeazzi: ~3-7% of forearm fractures; adults 30-50, often occupational/sport.

Side-by-side guidance and consensus (recommendations are broadly concordant):

• Reconstruct vs accept the chronically dislocated radial head (paediatric Monteggia): Reconstruction (ulnar osteotomy +/- open reduction +/- annular ligament reconstruction) improves stability and pain but carries notable complication rates and unpredictable rotation, and outcomes deteriorate beyond one year. Some advocate observation in late/minimally symptomatic presentations. There is genuine debate over whether annular ligament reconstruction is necessary at all - Chen et al achieved maintained reduction in 18 of 20 children without it, relying on ulnar lengthening/angulation osteotomy.
• Need for trans-capitellar K-wires: Useful when radial head reduction is unstable, but they risk breakage and are avoided by some surgeons in favour of robust osteotomy correction.
• Bado II radial head and coronoid management: The decision to fix, replace or excise the radial head, and whether to fix small coronoid fragments, drives outcome in adult Monteggia and remains individualised.
• Galeazzi DRUJ: how to stabilise: Choice between K-wire transfixation, supination immobilisation, TFCC repair and ulnar styloid fixation is not standardised; the unifying principle is anatomic radial length restoration first, then test and treat residual instability.
• Ulnar styloid fixation: Whether to fix a styloid base fragment in an otherwise stable DRUJ is contested; isolated tip fractures generally do not need fixation.

Related pages: Radial Head Fractures and Coronoid Fractures for the two injuries that decide the outcome of a Bado II, with Radial Head Arthroplasty when the head is unreconstructable; Radial Head Dislocations for the isolated dislocation and the congenital mimic; Forearm Shaft Fracture (Adult) and Both-Bone Forearm Fractures for the ring concept applied to the diaphysis, and Paediatric Forearm Fractures for the plastically deformed ulna that hides a Monteggia in children; Distal Radius Fractures and TFCC Injuries for the Galeazzi end of the forearm; and Radioulnar Synostosis for the complication both operations risk.

For each injury in full depth rather than in comparison, see Monteggia Fractures - which carries the Jupiter subclassification, the Bell Tawse and ulnar-osteotomy techniques for chronic cases, and the population-based complication data by Bado type - and Galeazzi Fractures.

Full reference list:

1. Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71-86.
2. Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am. 1998;80(12):1733-44. PMID 9875931.
3. Mikic ZD. Galeazzi fracture-dislocations. J Bone Joint Surg Am. 1975;57(8):1071-80. PMID 1201989.
4. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg Am. 2001;26(2):228-35. PMID 11279568.
5. Chen HY, Wu KW, Dong ZR, et al. The treatment of chronic radial head dislocation in Monteggia fracture without annular ligament reconstruction. Int Orthop. 2018;42(9):2165-72. PMID 29713746.