A 35-year-old construction worker is brought to the emergency department after a fall from a height onto his outstretched right arm in a pronated position. Clinical examination reveals swelling and tenderness over the proximal forearm, and the radial head is palpable anteriorly in the antecubital fossa. Radiographs show a fracture of the proximal third of the radius with anterior angulation. The ulna is intact. What is the most appropriate initial management?

Explanation

## Management of Monteggia Fracture-Dislocation **Key Point:** Monteggia fractures are fractures of the proximal or middle third of the radius with an anterior dislocation of the radial head. The radial head dislocation is often missed on initial radiographs, leading to poor functional outcomes if not recognized and treated early. ### Diagnosis Recognition **High-Yield:** Always draw a line through the radial head on all forearm radiographs — this line should bisect the capitellum on lateral view. If it does not, radial head dislocation is present. **Mnemonic:** **MONTEGGIA = Proximal Radius + Anterior Radial Head Dislocation** (remember: *proximal* is the key location, and the dislocation is *anterior*) ### Treatment Algorithm ```mermaid flowchart TD A[Monteggia Fracture-Dislocation]:::outcome --> B{Displacement/Angulation?}:::decision B -->|Minimal/Undisplaced| C[Attempt closed reduction]:::action B -->|Displaced/Angulated| D[ORIF radius with plate]:::action C --> E{Reduction successful & stable?}:::decision E -->|Yes| F[Long-arm cast 6-8 weeks]:::action E -->|No| D D --> G[Reduce radial head under fluoroscopy]:::action G --> H[Long-arm cast 4-6 weeks]:::action F --> I[Early ROM exercises at 6-8 weeks]:::action H --> I ``` ### Why ORIF Is Preferred in This Case | Factor | Closed Reduction | ORIF | |--------|------------------|------| | **Displacement** | Acceptable for minimal | Indicated for displaced | | **Angulation** | Difficult to maintain | Anatomic restoration | | **Radial head reduction** | May be difficult to maintain | More stable reduction | | **Functional outcome** | Risk of loss of reduction | Better pronation/supination | | **Malunion rate** | 10–15% | <5% | **Clinical Pearl:** The radial head dislocation in Monteggia is often missed because clinicians focus on the radial fracture. Always assess the radial head position on both AP and lateral views before declaring the fracture "reduced." ### Why Closed Reduction Alone Fails 1. **Angulated fractures** — difficult to maintain alignment in cast alone 2. **Radial head dislocation** — tends to re-dislocate if the radius is not anatomically reduced 3. **Loss of pronation/supination** — results from malunion or persistent DRUJ dysfunction 4. **High malunion rate** — up to 15% with closed treatment alone **High-Yield:** In displaced Monteggia fractures (especially in adults), ORIF with plate fixation of the radius, followed by closed reduction of the radial head under fluoroscopy, is the gold standard. This allows early mobilization and prevents loss of reduction.