Adult Monteggia fractures rarely yield to closed reduction. Most of the time operative treatment is needed. The goal is to fix ulna in anatomical position and reduce radial head. Ulna is usually fixed by a 3.5-mm limited-contact dynamic compression plate .
Monteggia fractures should be operated as soon as feasible. patient is placed in supine or lateral position depending upon surgeon’s convenience.
After stabilization of the ulna, the elbow is passively ranged to assess the stability of the radial head. An image intensifier can help assess radial head stability. After the surgery wound is closed in layers without closure of fascia.
If there is a radial or posterior interosseous nerve palsy that has occurred with injury, the course of action depends on reduction of radial head. if the reduction of radial head occurs easily, exploration of the radial or posterior interosseous is not indicated.
The kind of injury is usually a neuropraxia, and function returns within 6 to 12 weeks after injury in the most of cases.
If the nerve does
Extensive comminution of the ulna can present problems with regaining anatomic length of the ulna. If the radial head is reduced and is stable, this often facilitates reconstruction of the length of ulna so that it can be plated to its normal anatomic length.
However, if the radial head is unstable, the radial head must be reduced after opening elbow joint and then restore the length to the ulna.
If both the radius and the ulna are fractured (type IV Bado lesion) it is better to fix the ulna first. This would usually reduce the radial head before open reduction of the radial shaft fracture.
Irreducible radial head dislocations require open reduction. In case radial head is fractured it should be reconstructed as far as possible.
Postoperative Management
First dressing is changed on 5th day or earlier if needed.A long-arm cast or brace is given depending on of stability at the time of surgery. In best of cases the patient is encouraged mobilization after 7 to 10 days. X-rays are taken weekly for the first 3 weeks and then monthly until the ulnar fracture unites.
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