A 32-year-old male presents with a fall on an outstretched hand (FOOSH injury). Radiographs reveal a fracture of the proximal third of the radius with an anterior dislocation of the radial head. All of the following statements regarding Monteggia fracture are true EXCEPT:

Explanation

## Monteggia Fracture: Definition and Classification **Key Point:** A Monteggia fracture is a fracture of the proximal or middle third of the ulna combined with anterior dislocation of the radial head. It accounts for 5–10% of forearm fractures. ### Bado Classification | Type | Ulnar Fracture Location | Radial Head Dislocation | Mechanism | Frequency | |------|------------------------|------------------------|-----------|----------| | I (Classic) | Proximal/middle third | Anterior | FOOSH, forced pronation + extension | 60% | | II | Middle/distal third | Anterior | Fall on extended elbow | 15% | | III | Metaphyseal (distal) | Anterior | Fall on supinated hand | 20% | | IV | Proximal/middle third of radius AND ulna | Anterior | High-energy trauma | 5% | ### Mechanism of Injury 1. Fall on outstretched hand (FOOSH) with forearm pronated 2. Forced extension at the elbow 3. Results in ulnar fracture + radial head displacement **Clinical Pearl:** The radial head dislocation is **almost always anterior** in Monteggia injuries, regardless of type. Posterior dislocation is exceedingly rare and should raise suspicion for a different diagnosis. ### Treatment Approach **High-Yield:** Treatment depends on fracture type and stability: - **Type I & II (most common):** Closed reduction + long arm cast/splint for 6–8 weeks is often successful - **Type III (metaphyseal):** May be treated conservatively in children; adults often require ORIF - **Type IV:** High-energy injury — usually requires ORIF of both bones - **Unstable or irreducible cases:** ORIF of ulna ± radial head reduction/repair **Warning:** The statement "non-operative treatment is the gold standard for ALL types" is incorrect. While Type I and II may respond to closed reduction, Type III and IV, as well as unstable or irreducible injuries, require operative fixation. ### Why Option 3 Is Wrong The fracture classically involves the **proximal and middle third** of the ulna (not just proximal two-thirds as stated — this is actually correct anatomically, but the key error is claiming non-op is gold standard for all types). The critical error is in the treatment claim: not all Monteggia fractures can be managed non-operatively. Type III and IV injuries, and any irreducible or unstable pattern, mandate surgical intervention.