Monteggia fractures in children and adults

Examining Preoperative Risk Factors for Nerve Injury in Pediatric Monteggia Fracture-Dislocations

BACKGROUND

The risk factors for fracture-related nerve injury in pediatric Monteggia fracture-dislocations are not well understood. As such, this study aimed to determine the incidence of, and preoperative risk factors for, nerve injury in pediatric Monteggia fracture-dislocations.

METHODS

Patients aged ≤18 years with acute Monteggia or Monteggia-equivalent fracture-dislocations that underwent reduction in the operating room, including closed reduction and casting under general anesthesia and internal fixation of the ulnar fracture with or without opening the radiocapitellar joint, from 2011 to 2021 were retrospectively identified. Exclusion criteria included reduction in the emergency department, concomitant ipsilateral upper-extremity fractures, malunions, or patients without preoperative imaging. Nerve function was assessed preoperatively, and nerve injury was defined as persistent motor and/or sensory deficits on postoperative examination. Patients were followed until nerve-related symptoms resolved. Logistic regression controlled for age and fracture pattern to determine preoperative risk factors.

RESULTS

Of 148 patients (mean age, 6.4 ± 2.8 years), 18.2% (27) had preoperative nerve injury. The posterior interosseous nerve (PIN) was injured in 15 patients, the anterior interosseous nerve (AIN) was injured in 7 patients, and other nerves were injured in 6 patients. All the nerve injuries resolved spontaneously, with a mean resolution time of 63.6 days (range, 8 to 150 days). Risk factors for nerve injury included patient age of ≥8 years (odds ratio [OR], 7.7; 95% confidence interval [CI], 2.6 to 22.8; p < 0.001), lateral radial head dislocation (OR, 6.8; 95% CI, 2.0 to 22.4; p = 0.002), an open fracture (OR, 4.5; 95% CI, 1.2 to 16.5; p = 0.025), and a comminuted ulnar fracture (OR, 4.1; 95% CI, 1.4 to 12.2; p = 0.012). PIN injury was associated with lateral radial head dislocation (p < 0.001) and a comminuted ulnar fracture (p < 0.001). AIN injury was associated with an open fracture (p = 0.002) and diaphyseal ulnar fracture (p = 0.004).

CONCLUSIONS

The incidence of preoperative nerve-related injury in pediatric Monteggia fracture-dislocations was 18.2%. Risk factors for preoperative nerve injury included patient age of ≥8 years, lateral radial head dislocation, an open fracture, and a comminuted ulnar fracture. All the nerve injuries resolved within 150 days, suggesting that early operative intervention may be unnecessary.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Correlation between inner epiphysis ulna radius length ratio and prognosis of Monteggia fractures in children: a multicenter study

The forearm function in children is influenced by several factors, with the length relationship between the ulna and radius being particularly important. However, due to the underdevelopment of cartilage in children, assessing this length relationship through imaging techniques is challenging. This study aims to identify a reliable method for evaluating the lengths of the ulna and radius in children, establish normal values for the ratio of the epiphyseal plate lengths of these bones, examine this ratio in children with Monteggia fractures, and investigate its role in determining forearm function in the pediatric population. This multicenter study involved 432 normal children under 15 years of age as controls. A retrospective analysis was conducted on anteroposterior and lateral radiographs from 58 children with Monteggia fractures after surgery. The correlation between the inner-epiphysis ulna-radius length ratio, postoperative Mayo elbow joint function score, and radiographic reduction quality of the brachioradial joint was analyzed. The mean inner-epiphysis ulna-radius length ratio was 1.094, with a standard deviation of 0.024. The maximum value ranged from 1.0336 to 1.168. The medical reference range, with a 95% confidence level, was calculated as 1.047 to 1.141. In children with Monteggia fractures, the postoperative inner-epiphysis ulna-radius length ratio showed significant correlations (P < 0.05) with postoperative imaging reduction quality, as well as the range of pronation, supination, flexion, and extension, and the Mayo elbow score. In normal children, the inner-epiphysis ulna-radius length ratio ranges from 1.0336 to 1.168, with a medical reference range of 1.047 to 1.141 at a 95% confidence level. Restoring this ratio (1.047-1.141) in children with Monteggia fractures can improve elbow function and radiographic radiocapitellar joint reduction quality.

Pediatric Monteggia Fracture-dislocations and Their Variants: An Analysis of Outcomes and Complications Over a 10-year Period

OBJECTIVE

Monteggia fracture-dislocation variants have been well documented in adults, but most of the literature in the pediatric population is in the form of case reports. These injuries present differently in children due to the presence of immature radiocapitellar epiphyses and the flexibility of the joint that is more prone to subluxation, contributing to occult presentations and/or misdiagnoses. The purpose of this study is to investigate the outcomes and complications of true Monteggia fracture-dislocations compared with their variants in the pediatric population.

METHODS

A retrospective review was performed of all patients 17 years of age and younger who sustained a true Monteggia fracture-dislocation or a Monteggia fracture-dislocation variant over a 10-year period. Patient demographics, mechanisms of injury, fracture pattern, Bado and Letts classification, treatment (operative or conservative), and complications were recorded.

RESULTS

Of the 89 patients identified, 17 (19.1%) had true Monteggia fracture dislocations, and 72 (80.9%) had a Monteggia fracture-dislocation variant. The most common Monteggia fracture-dislocation variant was an olecranon fracture and concomitant radial neck fracture (65.3%, n = 47). Of the Monteggia fracture-dislocation variants, 83.3% (n = 60) were treated nonoperatively with closed reduction and immobilization or immobilization alone, whereas only 23.5% (n = 4) of the true Monteggia fracture-dislocation injuries were treated nonoperatively with closed reduction and immobilization. Overall, 14 (15.7%) patients had complications during the course of treatment, including 12 (16.7%) Monteggia fracture-dislocation variants and 2 (11.8%) true Monteggia fracture-dislocations. The most common complications were loss of range of motion (n = 6, 42.9%, all of which were nondisplaced variants), loss of reduction (n = 4, 28.6%, including 2 nondisplaced variants, 1 displaced variant, and 1 true Monteggia fracture dislocation), and malunion or nonunion (n = 2, 14.3%, both nondisplaced variants).

CONCLUSION

Pediatric Monteggia fracture-dislocation variants are much more common than true pediatric Monteggia fracture-dislocations. Monteggia fracture-dislocation variants have similar complication rates to true Monteggia fracture-dislocations overall, however, nondisplaced variants exhibited a higher complication rate when treated operatively. Further studies are warranted to assess specific fracture patterns and their associated treatments that result in varying complication rates.

LEVEL OF EVIDENCE

Level III-retrospective comparison study.

Monteggia Fracture Dislocation

SUMMARY

Monteggia fracture is a complex fracture consisting of a proximal ulna fracture with a dislocation of the radial head. This review article highlights the relevant anatomy, clinical evaluation, classification, surgical management, recent innovation, and advancements with treating these injuries. A thorough understanding of these fractures allows for detailed operative plans and reconstitution of normal anatomy.

A novel variant of type-II Monteggia equivalent in an adult: A case report with a 6-year follow-up

Case

An 18-year-old right-handed male student presented after a road-traffic-accident; he had type-II Monteggia fracture dislocation associated with ipsilateral type-I capitellum fracture and comminuted lateral condyle avulsion fracture. He underwent open reduction and fixation of ulna with 3.5 DCP with autologous olecranon bone grafting and fixation of capitellum using Herbert screw along with lateral collateral ligament (LCL) repair using fiber wire. At 6-years follow-up good outcome was seen without functional restrictions despite 15 degrees of restriction in pronation.

Conclusion

Monteggia type-II variant with type-I capitellum fracture and LCL avulsion is a unique combination that represents a novel variant of type-II Monteggia equivalent, which adds to the existing classification of Monteggia equivalents.

[Monteggia lesions and equivalent lesions in children]

BACKGROUND

Missed Monteggia lesions results in chronic luxation and deficits in the range of motion. The overall therapeutic goal is a quick and stable anatomical repositioning of the lesion. The prognosis of Monteggia lesions in comparison to its equivalents is better, especially with early diagnosis.

OBJECTIVE

Comparison of the types of lesion, treatment modalities, hospitalization, immobilization, movement deficits, perioperative complications and outcome.

MATERIAL AND METHODS

Retrospective study of 62 patients treated with acute Monteggia lesions and its equivalents during the period of 2009-2020.

RESULTS

2 patients were treated with cast immobilization only, 11 with repositioning under general anesthesia, 39 with intramedullary nailing and 10 with screw osteosynthesis. The average observation period was 4.1 months. Patients with cast immobilization needed only a short hospitalization (2 days), patients with repositioning or osteosynthesis had longer hospitalization (3.4 or 4.3 days, respectively). Deficits of the range of motion did not appear in simple cast immobilization or intramedullary nailing without reduction; however, patients with closed reduction or screw osteosynthesis showed some degree of deficits (9% and 40%, respectively). Monteggia lesions needed shorter hospitalization than their equivalents (3.7 vs. 4.5 days) and had less deficits in the range of motion (7% vs. 21%).

CONCLUSION

Most patients were treated with osteosynthesis (79%). Patients with Monteggia lesions had a better outcome than patients with equivalent lesions.

Exposed Intramedullary Fixation Produces Similar Outcomes to Buried Fixation for Acute Pediatric Monteggia Fractures

BACKGROUND

Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal.

METHODS

A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion.

RESULTS

Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients.

CONCLUSION

Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization.

LEVEL OF EVIDENCE

III.

Outcomes After Operative Treatment of Pediatric Monteggia Fracture-Dislocations: Comparison Between Open and Closed Injuries

BACKGROUND

Open pediatric Monteggia fracture-dislocations are a relatively uncommon injury pattern, with limited numbers reported in previous series. Open fracture-dislocations frequently represent more severe injury patterns with potential for contamination. We aim to determine differences in long-term clinical and functional outcomes in the operative management of closed versus open pediatric Monteggia fracture-dislocations.

METHODS

A retrospective review of operatively treated pediatric Monteggia fracture-dislocations was performed. Closed versus open injuries were compared in both clinical outcomes, as well as patient-reported outcomes through Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire.

RESULTS

Of 30 operatively treated injuries, 12/30 (40%) were open fracture-dislocations. Patients were followed clinically for an average of 15.65 months in open injuries and an average of 4.61 months in closed injuries. A trend toward increased time to union was observed, however, significance was not achieved; open injuries averaged 8.0 versus 5.8 weeks for closed injuries ( P =0.07). Two patients (11%) in the closed fracture group experienced postoperative complications; both were minor. Five patients (42%) in the open fracture-dislocation group experienced a total of 6 postoperative complications; 5 of the 6 complications were major. QuickDASH scores were obtained at an average of 5 years postoperatively; mean QuickDASH scores were higher in the open fracture group, 13.1, compared with the closed fracture group, 5.9 ( P =0.038). Increased QuickDASH scores were independently associated with presence of postoperative complications. QuickDASH score could be expected to increase by 12.5 points in those with major complications ( P =0.044).

CONCLUSION

We present the largest single cohort of pediatric open Monteggia fracture-dislocation injuries to date. These injuries are predictive of poorer outcomes including trend toward increased time to union, increased risk of major complication, and can independently predict worse long-term patient-reported functional outcomes.

LEVEL OF EVIDENCE

Level III-these data represent a retrospective comparative study of clinical and functional outcomes.

The radiological findings in complex elbow fracture-dislocation injuries

Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.

The role of biceps loading and muscle activation on radial head stability in anterior Monteggia injuries: An in vitro biomechanical study

INTRODUCTION

Little evidence-based information is available to direct the optimal rehabilitation of patients with anterior Monteggia injuries.

PURPOSE OF THE STUDY

The aims of this biomechanical investigation were to (1) quantify the effect of biceps loading and (2) to compare the effect of simulated active and passive elbow flexion on radial head stability in anterior Monteggia injuries.

STUDY DESIGN

In vitro biomechanical study.

METHODS

Six cadaveric arms were mounted in an elbow motion simulator. The effect of biceps loading, simulated active and passive elbow flexion motions was examined with application of 0N, 20N, 40N, 60N, 80N, and 100N of load. Simulated active and passive elbow flexion motions were then performed with the forearm supinated. Radial head translation relative to the capitellum was measured using an optical tracking system. After testing the intact elbows, the proximal ulna was osteotomized and realigned using a custom jig to simulate an anatomical reduction. We then sequentially sectioned the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane to simulate soft tissue injuries commonly associated with anterior Monteggia fractures.

RESULTS

Greater magnitudes of biceps loading significantly increased anterior radial head translation. However, there was no significant difference in radial head translation between simulated active and passive elbow flexion except in the final stage of soft tissue sectioning. There was a significant increase in anterior radial head translation with progressive injury states with both isometric biceps loading and simulated active and passive motion.

CONCLUSIONS

Our results demonstrate that anatomic reduction of the ulna may not be sufficient to restore radial head alignment in anterior Monteggia injuries with a greater magnitude of soft tissue injury. In cases with significant soft tissue injury, the elbow should be immobilized in a flexed and supinated position to allow relaxation of the biceps and avoid movement of the elbow in the early postoperative period.

Management of acute length-unstable Monteggia fractures in children: A case report

BACKGROUND

Monteggia fractures are uncommon injuries in paediatric age. Treatment algorithms assert that length-unstable fractures are treated with plate fixation. In this case report, intramedullary fixation of an acute length-unstable Monteggia fracture allowed a stable reduction to be achieved, along with an appropriate ulnar length and alignment as well as radio capitellar reduction despite the fact that the orthopaedic surgeon did not use a plate for the ulnar fracture. The scope of treatment is to avoid the use of a plate that causes periosteal stripping and blood circulation disruption around the fracture.

CASE SUMMARY

A four-year-old girl presented at the Emergency Department following an accidental fall off a chair onto the right forearm. The X-ray highlighted a length-unstable acute Bado type 1 Monteggia fracture of the right forearm. On the same day, the patient underwent surgical treatment of the Monteggia fracture. The surgeon preferred not to use a plate to avoid a delay in fracture healing and to allow the micromotion necessary for callus formation. The operation comprised percutaneous fixation with an elastic intramedullary K-wire of the ulnar fracture and, subsequently, humeroradial joint reduction through manual manipulation. The orthopaedic surgeon assessed the stability of the radial head reduction under fluoroscopic control through flexion, extension, pronation and supination of the forearm. Healing of the fracture occurred within six weeks after surgery, as indicated by the presence of calluses on at least three cortices on standard radiographs. Dislocation/subluxation or loss of ulnar reduction was not apparent at the final X-ray examination.

CONCLUSION

Intramedullary fixation of unstable Monteggia fractures results in excellent outcomes, provides reliable reduction and causes fewer complications.

Radiographic Evaluation of Elbow Fractures

Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.

Irreducible Monteggia Fracture-Dislocation Secondary to an Entrapped Brachialis Tendon: A Case Report

CASE

A 7-year-old boy sustained a Monteggia fracture-dislocation. Corrective osteotomy of the ulna was performed to restore proper forearm anatomy and achieve radial head reduction. Recurrent radial head instability was noted postoperatively, and magnetic resonance imaging indicated recurrent dislocation of the radial head with, notably, an entrapped brachialis tendon and annular ligament. Open reduction of the elbow was performed. Anatomic reduction of the radiocapitellar joint and full range of motion without instability was achieved.

CONCLUSION

To the best of our knowledge, this is the first report of persistent radial head instability because of an entrapped brachialis tendon.

The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging

Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.

Role of the interosseous membrane in post-traumatic forearm instability: instructional review

PURPOSE

In the last two decades, a strong interest on the interosseous membrane (IOM) has developed.

METHODS

The authors present a review of the new concepts regarding the understanding of forearm physiology and pathology, with current trends in the surgical management of these rare and debilitating injuries.

RESULTS

Anatomical and biomechanical studies have clarified the anatomy of forearm constrains and their role in forearm longitudinal and transverse stability. The radial pull test, a new intraoperative test, has been developed that might increase the detection on IOM injuries. The forearm is now considered a "functional unit" and, consequently, a new classification has been proposed. Uncommon variants and rare patterns of forearm fracture dislocations have been reported in the literature and could not be classified to those commonly referred to using eponyms (Monteggia, Galeazzi, Essex-Lopresti). The new Artiaco et al. classification includes all injury patterns, thus avoids confusion in the nomenclature, and helps surgeon with detection of lesions and guiding surgical treatment.

CONCLUSION

Based on the new classification and after current literature review, authors propose a management flowchart for treatment of forearm instability injuries.

Surgical treatment of chronic anterior radial head dislocations in missed Monteggia lesions in children: A rationale for treatment and pearls and pitfalls of surgery

INTRODUCTION

The treatment of chronic radial head dislocations after Monteggia lesions in children can be challenging. This article provides a detailed description of the most frequently performed surgical technique: an ulna osteotomy followed by annular ligament reconstruction. Accordingly, we present the clinical and radiological results of 10 paediatric cases.

MATERIAL AND METHODS

All paediatric patients that had a corrective osteotomy of the ulna for a missed Monteggia lesion between 2008 and 2014 were evaluated with standard radiographs and clinical examination. A literature search was performed to identify the relevant pearls and pitfalls of surgery. Primary outcome was range of motion.

RESULTS

We included 10 patients, with a mean follow-up of 2.5 years. Postoperative range of motion generally improved 30.7°. Even in a patient with obvious deformity of the radial head, range of motion improved after surgery, without residual dislocation of the radial head.

CONCLUSION

Corrective proximal ulna osteotomy with rigid plate fixation and annular ligament reconstruction yields good results in patients with chronic radial head dislocation following a Monteggia lesion. Surgery should be considered regardless of patient age or time since trauma. Given substantial arguments in literature, we discourage surgery if a CT scan shows dome-shaped radial head dysmorphic features in work-up to surgery.

Monteggia-like lesions: preliminary reports and mid-term results of a single center

Background and aim of the work:

Monteggia-like lesions are complex and rare elbow injuries. A detailed classification and a proper surgical treatment can provide quite good functional and radiological outcomes. The aim of this retrospective study was to evaluate the mid-term results of Monteggia-like lesions surgical treatment. The other purpose was to investigate whether the complexity of ulna and radius fractures could be prognostic factors of insufficient functional results.

Methods:

Seven women and five men, with a mean age of 59,25 years who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QUICK-DASH) score were used for evaluation at a mean of 17,5 months postoperatively (12-26). The range of movement (ROM), patients’ satisfaction and neurological symptoms were also investigated. Osteolysis, implant loosening and heterotopic ossification were graded. Pearson’s test was used to correlate the different classification systems used (AO/OTA, Bado and Jupiter, PURCCS, Mason) with MEPS and QUICK-DASH score.

Results:

The mean MEPS was 84,92 (65 to 100). The mean QUICK-DASH score was 18,75 (0 to 34,1). The mean active pronation and supination was 72,5° and 59,17°, respectively. The mean active ROM of the elbow was 101,43°. Heterotopic ossifications were absent in six cases but were found in six. No statistically significant correlation was found between the analyzed variables.

Conclusions:

Quite good functional results can be obtained in Monteggia-like lesions if injury pattern is recognized and each component of the injury is addressed. Further studies are needed to determine any prognostic factors. (www.actabiomedica.it)

Management of Monteggia Injuries in the Pediatric Patient

Monteggia fracture-dislocations in the pediatric population have unique patterns of injury that require distinct considerations in diagnosis and management. When appropriately diagnosed and treated early, acute pediatric Monteggia injuries have favorable outcomes. Missed or inadequately treated injuries result in chronic Monteggia lesions that require more complex surgical reconstructions and are associated with less predictable outcomes. This article reviews the classification, diagnosis, and treatment of acute and chronic pediatric Monteggia injuries as well as the controversies there in.

Problems of Eponymous Proportions: The History Behind Recognizing Forearm Instability Issues

Three predictable patterns of forearm fracture-dislocation-Essex-Lopresti, Monteggia, and Galeazzi-can occur and are eponymously labeled for the investigators who appreciated their unique characteristics and offered a framework by which to understand them. Recognition of these injuries and subsequent investigation and increased understanding of these lesions have resulted in improved understanding about forearm anatomy and stability. Management of the component of instability differs based on the type of fracture-dislocation, the timing of intervention, and surgeon preference. Despite advances in understanding and treating these injuries, nuances of these lesions may remain challenging to modern-day surgeons.

Management of Monteggia Injuries in the Adult

Monteggia fracture-dislocation of the elbow is a fracture of the proximal ulna with associated dislocation of the radial head or radial neck fracture. In adults, this injury is managed with open reduction and internal fixation of the ulna fracture. Care should be taken to ensure anatomic reduction of the proximal ulna. If radial head dislocation or subluxation persists, reduction of the ulna should be reassessed. Rarely, interposed soft tissue may block radial head reduction, and requires removal. Complications include hardware prominence, stiffness, infection, heterotopic ossification, nerve injury, malunion or nonunion of the ulna, radioulnar synostosis, and persistent radial head instability.

Functional and radiological outcome in patients with acute Monteggia fracture treated surgically: a comparison between closed reduction and external fixation versus closed reduction and elastic stable intramedullary nailing

The aim of this study was to compare the clinical and radiological outcomes in children with acute Monteggia fracture treated by two different surgical techniques. Twenty-six children treated by either closed reduction and external fixation (group A) or elastic stable intramedullary nails (group B) were retrospectively reviewed. Clinical outcome was evaluated with the Quick DASH questionnaire. Overall, both surgical techniques provided similar excellent healing rates and good clinical outcomes (P > 0.05), as well as radiological outcomes (P > 0.05). Radiographically, no secondary displacement, wire migration, consolidation delays, non-union, malunion or re-fractures were noted. However, two patients (7.6%), one in group A (1/15; 6.7%) and one in group B (1/11; 9.1%), developed heterotopic ossification at the level of the ulna. Clinical functional outcomes were similar between the two groups of patients. The mean overall Quick DASH score was 0.79 (range, 0-18.2). However, six in group A (40%) and one in group B (9.1%) complained of the clinical appearance and had intermittent residual pain on the injured side. In conclusion, both elastic stable intramedullary nailing and external fixation can achieve satisfactory clinical and radiographic outcomes in children with acute Monteggia fractures. However, the rate of residual pain and less satisfactory clinical appearance was higher in patients managed by external fixation compared to those treated by elastic stable intramedullary nailing. According to our results, elastic stable intramedullary nailing should be used as primary treatment option in children with acute Monteggia fracture requiring surgical management.

Monteggia-like lesions in adults treated with radial head arthroplasty-mid-term follow-up of 27 cases

Background

The aim of the study was to analyze the functional and radiological outcome of Monteggia-like lesions in adults with unreconstructible fracture of the radial head and treatment with radial head arthroplasty.

Methods

Twenty-seven patients (mean age 56 years; range 36 to 79 years) with a Monteggia-like lesion and treatment with radial head replacement were included in this retrospective study. Minimum follow-up was 2 years. Clinical assessment included the pain level with the visual analog scale in rest (VAS_R) and under pressure (VAS_P), range of motion, Mayo Elbow Performance Score (MEPS), and Disability of the Arm, Shoulder, and Hand score (DASH). A detailed radiological evaluation was performed. Complications and revisions were also analyzed.

Results

After a mean follow-up period of 69 months (range, 24 to 170) the mean DASH score was 30 ± 24, the MEPS averaged 77 ± 20 points, the mean VAS_R was 2.1 ± 2.4, and VAS_P was 4.5 ± 3.5. Mean loss of extension was 24° ± 18 and flexion was 124° ± 20. Heterotopic ossifications were noted in 12 patients (44%). A total of 17 complications were noted in 11 patients (41%), leading to 15 revision surgeries in 9 patients (33%). Patients with a complicated postoperative course showed a worse clinical outcome compared with patients without complications measured by MEPS (68 ± 22 vs. 84 ± 16), DASH (49 ± 16 vs. 20 ± 22) and ulnohumeral motion (77° ± 31 vs. 117° ± 23).

Conclusions

Monteggia-like lesions with unreconstructible radial head fracture and treatment with radial head replacement are prone to complications and revisions.

Instability of the proximal radioulnar joint in Monteggia fractures-an experimental study

Background

A Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach.

Methods

Eight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane.

Results

An anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures.

Conclusion

On the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.

A Long-standing Monteggia Fracture in a Child who underwent Bone Lengthening and Annular Ligament Reconstruction: A Case Report

Introduction:

Monteggia fractures are rare and account for 1% of all pediatric forearm fractures. Dislocation of the radial head with plastic deformation of the ulna is particularly rare and can be overlooked, thereby resulting in long effects. Here, we report the treatment of a case of a long-standing Monteggia fracture in a child.

Case Report:

A 6-year-old girl who was injured by a fall was examined by a local physician. 4 weeks later, she was referred to our hospital. Plain X-ray and computed tomography revealed a long-standing Monteggia fracture. Ulnar osteotomy was performed; however, complete realignment was not achieved. Scar tissue and the annular ligament remained intact, thereby hindering complete reduction. The scar tissue surrounding the radial head was surgically removed, and subluxation was reduced. The annular ligament was reconstructed, and the ulna was lengthened by external fixation. 1 year postoperatively, the patient’s elbow range of motion is good, and there has been no recurrence of radial head dislocation.

Conclusions:

The patient achieved good progress through the use of annular ligament reconstruction and ulnar osteotomy to straighten and anatomically realign the ulna. Post-operative repeat dislocation was avoided by reducing radial head dislocation, removing the scar tissue, and reconstructing the annular ligament.

Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique

INTRODUCTION

Monteggia fractures are rare, although complex elbow injuries. Bado II Monteggia fractures are characterized by posterior dislocation of the radial head and concurrent fracture of the proximal or middle third of the ulna. This video demonstrates the open reduction and internal fixation of a complex Bado II Monteggia fracture dislocation.

METHODS

The patient is a 65-year-old woman with a Bado II Monteggia fracture after a low-energy fall from standing height. Given the extent of comminution and the instability of the elbow, the patient was indicated for surgical fixation.

RESULTS

This video demonstrates a locking plate technique for repair of a comminuted fracture of the proximal ulna. Anatomical reduction of ulnohumeral and radiocapitellar joints and stable fixation with bone grafting of the fracture are achieved with a medial 2.0/2.4-mm plate and a dorsal precontoured variable-angle locking plate. Demonstration of radial head arthroplasty is provided as an alternative for utilization in cases with a radial head fracture.

CONCLUSIONS

Anatomical reduction and fixation of complex Monteggia fracture dislocations can be achieved with adherence to standard aspects of bony reconstruction. In this video we present the case of a Bado II Monteggia fracture surgically repaired with a locking plate construct.

External Fixator-assisted Ulnar Osteotomy: A Novel Technique to Treat Missed Monteggia Fracture in Children

Objective

The treatment of missed Monteggia fracture remains a challenge, despite the various surgical methods described. The purpose of this study was to explore a new surgical technique utilizing external fixator‐assisted ulnar osteotomy and to assess the surgical results in a case series.

Methods

Thirteen patients with missed Monteggia fractures were treated at our institution using this new surgical technique from August 2012 to January 2016. Our series included 11 boys and 2 girls. The left elbow was involved in 6 patients and the right elbow was involved in 7 patients. According to the Bado classification, 10 fractures were classified as Bado type I with anterior radial head dislocation and 3 were classified as Bado type III with anterolateral dislocation. The average age at the time of surgery was 5 years 8 months (range, 2 years 2 months–10 years). The mean trauma‐to‐surgery interval was 12 months (range, 2–36 months). All patients underwent ulnar osteotomy with angulation and lengthening using a temporary external fixator, plate fixation of the osteotomy, and open reduction of the radial head dislocation without annular ligament reconstruction.

Results

The average follow‐up was 27 months (range, 16–44 months). The average operation time was 175 min (range, 140–215 min). The average length of distraction was 0.7 cm (range, 0.5–1.2 cm) and the average angulation was 28° (range, 20°–30°) at the ulnar osteotomy site intraoperatively. The elbow performance score (Kim's) was excellent in 10 cases and good in 3 cases. No neurovascular complications, compartment syndrome or implant breakage occurred. No pain in the distal radioulnar joint or limited range of motion of the wrist occurred in any patient. The radial head remained reduced in all patients with no subluxation or redislocation. However, delayed ulnar union occurred in 3 cases, all of which were successfully treated with plaster cast immobilization within approximately 6 months postoperatively. One patient presented with cubitus valgus postoperatively with a carrying angle of 30°, which was 10° greater than the contralateral carrying angle.

Conclusions

External fixator‐assisted ulnar osteotomy offers substantial flexibility for achieving the optimal positioning of the transected ulna to reduce the radial head prior to the final ulnar osteotomy fixation with a plate, thereby facilitating an effective operative performance. Our procedure is a safe and effective method to treat missed pediatric Monteggia fractures.

The relationship between the morphological axis and the kinematic axis of the proximal radius

PURPOSE

Surgical procedures for impaired forearm rotation such as for chronic radial head dislocation remain controversial. We hypothesized that the morphological axis of the proximal radius is important for stable forearm rotation, and we aimed to clarify the relationship between the morphological axis and the kinematic axis of the proximal radius using four-dimensional computed tomography (4DCT).

METHODS

Ten healthy volunteers were enrolled. Four-dimensional CT of the dominant forearm during supination and pronation was obtained. The rotation axis of forearm rotation was calculated from all frames during supination and pronation. The principle axis of inertia, which represents the most stable rotation axis of a rigid body, was calculated for the proximal radius by extending its surface data incrementally by 1% from the proximal end. The angle between the kinematic rotation axis and the morphological rotation axis of each length was calculated.

RESULTS

The rotation axis of the forearm was positioned on the radial head 0.0 mm radial and 0.4 mm posterior to the center of the radial head proximally and 2.0 mm radial and 1.2 mm volar to the fovea of the ulnar head distally. The principle axis at 15.9% of the length of the proximal radius coincided with the forearm rotation axis (kinematic axis). Individual differences were very small (SD 1.4%).

CONCLUSION

Forearm rotation was based on the axis at 16% of the length of the proximal radius. This portion should be aligned in cases of severe morphological deformity of the radial head that cause "rattling motion" of the radial head after reduction procedures.

Anterior Dislocation of the Radial Head Combined with Plastic Deformity of the Ulnar Shaft in an Adult: A Case Report

A 25-year-old woman presented to the emergency room with a painful and swollen right forearm. She had just sustained an injury from an accident during which her arm was tightly wound by a rope as she was lowering a net from a fishing boat. Before being released, her arm was rigidly trapped in the rope for approximately ten minutes. Radiographs revealed anterior dislocation of the radial head that was accompanied by plastic deformation of the proximal ulna, manifested as a reversal of the proximal dorsal angulation of the ulna (PUDA); suggested a Monteggia equivalent fracture. With the patient under general anesthesia, we reduced the radial head by posterior compression at 90° of elbow flexion and at neutral rotation of the forearm. However, the reduction was easily lost and the elbow re-dislocated with even slight supination or extension of the arm. After the osteotomy of the ulnar deformity to restore the PUDA to normal, the reduction remained stable even with manipulation of the arm. We found that the patient could exercise a full range of motion without pain at the 3-month follow-up, and neither residual instability nor degenerative changes were observed at the final 3-year follow-up.

The Adult Monteggia Fracture: Patterns and Incidence of Annular Ligament Incarceration Among 121 Cases at a Single Institution Over 19 Years

PURPOSE

The purposes of this study were to identify the relative frequency of Monteggia fracture patterns and to investigate the required frequency of open reduction of the proximal radiocapitellar joint.

METHODS

We identified 121 Monteggia fractures at a Level I trauma center from 1996 to 2015 and included 119 in this study. These fractures were identified using a database search for the appropriate International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes as well as individual surgeons' logs. Two fellowship-trained hand surgeons reviewed the identified patients' x-rays and operative notes. Each fracture was classified using Bado's original description, excluding transolecranon and Monteggia variants.

RESULTS

Bado I lesion represented 68% (81 of 119) of Monteggia fractures. Annular ligament incarceration preventing radial head reduction occurred in approximately 17% (14 of 81) of this Bado type. Revision fixation of the ulna was not necessary (none of 119 cases) and functional range of motion (average arc, 117°) was recovered in most patients. The reoperation rate of 20% (23 of 119) was related to the severity of the presenting injury and hardware prominence.

CONCLUSIONS

Most radial head dislocations associated with Monteggia fractures occur anteriorly and will reduce with anatomic plating of the ulna. In cases where the radial head fails to reduce, entrapment of the annular ligament can be expected and open reduction is required. Revision fixation of the ulna to achieve reduction of the radial head is uncommon in our experience.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Acute Pediatric Monteggia Fractures: A Conservative Approach to Stabilization

BACKGROUND

In 2015, a multicenter study group proposed a treatment algorithm for pediatric Monteggia fractures based upon the ulnar fracture pattern. This strategy recommends surgical stabilization for all complete ulna fractures. The purpose of this study was to evaluate whether an initial nonoperative approach to pediatric Monteggia fractures resulted in poorer outcomes and a higher rate of complications.

METHODS

This institutional review board approved retrospective study evaluated all Monteggia fractures presenting to a level 1 pediatric trauma center between 2008 and 2014. Chart and radiographic reviews were performed on 94 patients who met inclusion criteria. The mean age was 5.5 years (range, 1 to 13 y). The mean clinical follow-up was 18 weeks. Major complications were defined as those requiring an unplanned second procedure (other than implant removal) or that may result in long-term disability (residual radial head subluxation/dislocation). Univariate (P<0.05) and Multivariate Classification and Regression Tree (CART) (P<0.05) analyses were used to identify variables associated with the need for surgical stabilization.

RESULTS

At final follow-up, there were no cases of residual radiocapitellar joint subluxation or dislocation and all fractures had healed. The majority (83%) of patients were successfully managed with a cast. Univariate analysis found Bado type and maximum ulna angulation as significant predictors (P<0.05), whereas the CART analysis found ulna angulation >36.5 degrees as the only primary predictor of requiring surgical stabilization. Overall, good outcomes were achieved in all patients with few major complications.

CONCLUSIONS

Although treatment algorithms are intended to minimize complications and maximize good outcomes, we believe that an unintentional consequence of the recently proposed pediatric Monteggia fracture treatment guideline may be the overtreatment of these injuries. In our cohort, the majority of patients were able to avoid the operating room and surgical implants without compromising outcomes or complications. This more conservative approach, however, requires close monitoring of patients in the first 3 weeks during which most reductions were lost.

LEVEL OF EVIDENCE

Level IV-therapeutic studies, case series.

Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures: A retrospective study of 202 cases

Elastic stable intramedullary nailing (ESIN) has been established as state of the art treatment for forearm fractures in children, if operative stabilization is required. Their use has been expanded to single bone shaft fractures, and also more complex injuries such as Monteggia fractures or Monteggia-like lesions. A wide range of complications has been reported in the literature, up to 70% in certain investigations. The purpose of this study was to assess the complication rate after ESIN treatment of forearm fractures in children and adolescents in a representative cohort of patients from a level 1 trauma center in Germany.Between 2000 and 2015, we retrospectively analyzed all patients, up to the age of 16 years, with forearm fractures, who were operatively treated using ESIN in our department of general and trauma surgery. The main outcome measurements were the rates of postoperative complications after ESIN such as re-fracture, malunion, nonunion, tendon lesion, wound infection, and limited range of motion.In all, 201 consecutive patients with 202 forearm fractures were included in this study. Age averaged 9.7 years (range 3-16 years). Fifteen (7.4%) fractures were open. Fractures were 82.2% diaphyseal both-bone forearm fractures. Follow-up averaged 10.2 months (range 0.7-176.3 months). Complications were 10 re-fractures, 2 malunions, 3 extensor pollicis longus tendon ruptures, 1 superficial wound infection, and 2 limited range of motions. Fourteen (6.9%) children required a secondary operative intervention for their complication. Time to implant removal averaged 3.8 months (range 0.4-16.3 months).Elastic stable intramedullary nailing is a minimally invasive and reliable technique with a low complication rate. Both-bone forearm fractures and single bone fractures, and also Monteggia and Monteggia-equivalent fractures can be successfully treated with this method. As a major complication, re-fractures are frequently seen, even with ESIN in situ.

Forearm Instability: Anatomy, Biomechanics, and Treatment Options

The forearm unit consists of the radius and ulna, a complex and interrelated set of joints (distal radioulnar joint, proximal radioulnar joint) and the soft tissue stabilizers between the 3 bones. Distally, this is represented by the triangular fibrocartilage complex at the wrist, proximally by the annular ligament at the elbow, and in the forearm by the interosseous membrane. Disruptions in any of these structures may lead to forearm instability, with consequences at each of the remaining structures.

Monteggia fractures in adults

Monteggia fractures are part of a spectrum of forearm injuries and commonly result either from a fall on the outstretched arm with forced pronation or from a direct injury. An understanding of the mechanism of injury and an appropriate clinical examination followed by operative intervention is the basis of present day good practice. This paper reviews the literature and presents a contemporary overview of the Monteggia fracture in adults.

Type IIA Monteggia Fracture Dislocation with Ipsilateral Distal Radius Fracture in Adult - A Rare Association

Monteggia fracture constitutes about 5-10% of the forearm fractures. Monteggia fracture by definition is proximal ulnar fracture with disruption of proximal radioulnar joint. Bado classified Monteggia fracture dislocation into four types and Jupiter subclassified type II Bado's fractures into four types. The associated injury in the form of distal radial fractures and distal humerus fractures are rare though many cases of distal radial physeal injuries have been reported in paediatric population. Hereby we report a rare association of type IIA Monteggia fracture dislocation with ipsilateral distal radius fracture in an adult patient. This case report also highlights on proper examination and full length radiographs of forearm to avoid missing injury at wrist in cases of elbow injuries. Management of such complex injuries included open reduction and internal fixation of olecronon fracture, distal radius fracture and radial head resection. Functional outcome at six months was good at wrist whereas at elbow, stiffness was a major concern with elbow range of movement from 40°-110°.

Complications of Pediatric Elbow Fractures

Fractures about the elbow in children are common and varied. Both diagnosis and treatment can be challenging, and optimal treatment protocols continue to evolve with new research data. This article reviews common complications related to pediatric elbow fractures and presents recent literature to help guide treatment.

Neglected Monteggia fracture dislocations in children: a systematic review

Monteggia fractures are uncommon and frequently missed injuries in children. This article aims to study, in a systematic manner, the surgical management and complications of treatment of chronic radial head dislocations. After screening of relevant abstracts, a total of 28 studies were included in the systematic review. A narrative synthesis of various treatment modalities has been discussed. This article concludes that open reduction should be attempted unless dysmorphism of the radial head restricts it. Open reduction with ulnar osteotomy with or without annular ligament reconstruction is the most commonly performed procedure and is expected to result in reduced pain and elbow deformity.

Management of complications of forearm fractures

Forearm fractures may be complicated by the disruption of the distal radioulnar, proximal radioulnar, or radiocapitellar joints. The key principles in treating this unique subset of fractures include early recognition and management of the injury and restoration and maintenance of the anatomic alignment. This articles addresses radial diaphyseal fractures with distal radioulnar joint disruption, proximal ulnar fractures with radiocapitellar disruption, and disruption of the forearm longitudinal axis and how to properly recognize and manage these forearm fracture-dislocations.

Percutaneous reduction and flexible intramedullary nailing for monteggia fracture in a skeletally mature patient

INTRODUCTION

Monteggia lesions are defined as a fracture of the proximal ulna with an associated radial head dislocation. Management of these injuries varies depending upon the patient population, ranging from non-operative treatment with closed reduction and immobilization to surgical fixation. Percutaneous techniques of radial head reduction are often reserved for skeletally immature patients.

PRESENTATION OF CASE

In this case report, a 14-year-old female presented with left elbow pain three days after a fall. Radiographs and CT images from an outside hospital revealed a displaced left radial head fracture and a non-displaced proximal olecranon fracture, consistent with a Monteggia equivalent fracture. The patient underwent percutaneous reduction and internal fixation of the radial head with a flexible intramedullary nail (Metaizeau technique), and open reduction and internal fixation of the olecranon. She developed a 25 degree left elbow flexion contracture and, five months after her index procedure, underwent arthroscopic release and removal of hardware. The radial head reduction was near anatomic and she regained full extension.

DISCUSSION

This report demonstrates that percutaneous reduction with intramedullary nailing and fixation techniques can be performed successfully in skeletally mature patients.

CONCLUSION

Given their less invasive nature, we recommend attempting percutaneous interventions in some skeletally mature individuals for fracture reduction and fixation.

Misses and errors in upper extremity trauma radiographs

OBJECTIVE

The article reviews a select group of traumatic upper extremity injuries that can be easily misinterpreted on radiographs.

CONCLUSION

The awareness of these specific injuries and an understanding of their underlying pathophysiology and the role that radiographs can play in their evaluation will give the reader the best opportunity to make the important imaging findings and guide appropriate treatment.

Treatment of late-presenting Monteggia variant with an isolated, simple flexion ulnar osteotomy

Radial head dislocation in children is usually associated with complete elbow dislocation or occurs as a part of a Monteggia injury. In patients without an obvious fracture of the ulna, recognizing that plastic deformation of the ulna leads to pathological bowing is a key concept in the management of this injury. Although good results have been published using osteotomy of the ulna to maintain stability after open reduction, we hypothesize that ulnar osteotomy alone may be enough to enable stable enlocation of an irreducible radial head in patients who are identified early. We present two cases of irreducible radial head dislocation, treated with ulnar osteotomy and closed radial head reduction. Both osteotomies united and both patients had an excellent functional outcome with the absence of pain or deformity and early return to function. We explain the surgical technique and compare the outcomes with alternative surgical treatments.

Nonacute Treatment of Elbow Fracture with Persistent Ulnohumeral Dislocation or Subluxation

➤ There are patterns of traumatic elbow instability that help a surgeon to anticipate which structures are injured.➤ Patients treated for persistent subluxation or dislocation of the elbow more than two weeks after injury regain less motion and experience more adverse events.➤ The primary goal of treatment is stable reduction of the ulnohumeral joint and functional elbow motion.➤ Motion and pain are affected by contracture and scarring of the soft tissues, malalignment of the joint, fracture malunion, damage to the articular surface, and ulnar neuropathy.➤ Biomechanical and clinical studies support treatment with radial head arthroplasty and/or coronoid reconstruction for patients who have osseous insufficiency.

Monteggia fracture dislocations: a historical review

The eponym Monteggia fracture dislocation originally referred to a fracture of the shaft of the ulna accompanied by anterior dislocation of the radial head that was described by Giovanni Battista Monteggia of Italy in 1814. Subsequently, a further classification system based on the direction of the radial head dislocation and associated fractures of the radius and ulna was proposed by Jose Luis Bado of Uruguay in 1958. This article investigates the evolution of treatment, classification, and outcomes of the Monteggia injury and sheds light on the lives and contributions of Monteggia and Bado.

Severe forearm deformity and instability after Monteggia fracture-dislocation: a case report

A 16-year-old boy presented with a painful deformity of the forearm. At the age of 11 years, he had sustained a Monteggia fracture-dislocation. Radiographs indicated nonunion of the ulna, radial head dislocation, and degenerative changes of the radiocapitellar joint. The longstanding nonunion of the ulna had caused very severe growth disturbance. Despite severe deformity, the patient had had relatively good motion. To regain forearm stability with maintaining motion, we corrected the deformity and stabilized the ulna with a vascularized fibular graft. Two years after surgery, the patient had a good range of motion without pain and grip strength was increased.