01Approach to the Critical Patient/attcp44

Immediate priorities

›Time-critical recognition

›Proximal ulna fracture with concomitant radial head dislocation

›Radiocapitellar line violation on any view is the sentinel finding

›Missed radial head dislocation in up to 72% of Monteggia-equivalent injuries

›Open fracture recognition

›Skin breach over the proximal forearm or elbow

›Contamination assessment and wound classification

›Neurovascular compromise screen

›Posterior interosseous nerve palsy — inability to extend fingers at MCP joints

›Anterior interosseous nerve palsy — failure of pinch ("OK" sign)

›Radial and ulnar pulses and capillary refill

›Compartment syndrome

›Tense forearm compartments

›Pain with passive finger extension

›Paresthesias in hand

Stabilization and escalation

›Analgesia and splinting

›Long-arm posterior splint at 90 degrees elbow flexion

›Forearm supination for Bado type I (anterior dislocation)

›Forearm neutral for Bado type II (posterior dislocation)

›IV access and analgesia before manipulation

›NSAIDs or opioids for severe pain

›Procedural sedation preparation if closed reduction attempted

›Neurovascular exam documented before and after any manipulation

›Escalation triggers

›Emergent orthopedic consultation for all Monteggia fractures

›Irreducible radial head suggests soft tissue interposition

02History/hx48

Mechanism and presentation

›Mechanism of injury

›Fall on outstretched hand (FOOSH) with elbow extended and forearm hyperpronated

›Most common mechanism

›Results in Bado type I anterior radial head dislocation most often in children

›Direct blow to the posterior forearm (nightstick mechanism)

›Associated with Bado type II posterior dislocation

›Common adult pattern

›High-energy mechanisms in adults

›Motor vehicle collision

›Fall from height

›Symptom characterization

›Acute elbow and forearm pain

›Inability to flex or extend the elbow

›Inability to pronate or supinate the forearm

›Swelling and visible deformity

›Ecchymosis over the proximal forearm

›Palpable fullness in the antecubital fossa (anteriorly dislocated radial head)

›Hand symptoms

›Numbness or tingling in radial nerve distribution

›Inability to extend wrist or fingers (PIN palsy)

›Inability to flex thumb IP or index DIP (AIN palsy)

Risk factors and context

›Patient-specific risk factors

›Pediatric peak incidence ages 4 to 10 years

›Plastic deformation of ulna common — no visible fracture line

›Up to 72% of Monteggia-equivalent injuries missed at initial presentation

›Adult risk factors for complexity

03Physical Exam/exam50

Inspection and palpation

›Upper extremity survey

›Swelling and ecchymosis over the proximal forearm and elbow

›Deformity — angular deformity of the ulna

›Skin breach or puncture wounds for open fracture

›Radial head position

›Palpable anteriorly in the antecubital fossa (Bado type I)

›Absent radial head in normal position lateral to elbow

›Proximal ulna tenderness

›Point tenderness at fracture site

›Crepitus with attempted motion

Range of motion and neurovascular exam

›Motion assessment

›Elbow flexion and extension markedly limited

›Painful block to motion

›Crepitus with motion attempt

›Forearm rotation limited

›Pronation/supination painful and restricted

›Loss of supination particularly in Bado type I

›Neurovascular exam — critical documentation before and after manipulation

›Posterior interosseous nerve function

›Finger extension at MCP joints (not at IP joints — intrinsics compensate)

›Thumb extension and abduction (hitchhiker sign)

›Wrist extension via ECRL preserved with PIN injury

›Anterior interosseous nerve function

›Thumb IP flexion and index finger DIP flexion

›"OK" sign — inability confirms AIN palsy

›Vascular assessment

04Differential Diagnosis/ddx33

Life-threatening and urgent mimics

›Fracture-dislocation spectrum

›Galeazzi fracture — distal or mid-radius fracture with DRUJ dislocation

›ICD-10 S52.37

›Differentiating clue: distal radius fracture + DRUJ instability vs proximal ulna + radial head

›Terrible triad of the elbow — elbow dislocation with radial head fracture and coronoid fracture

›ICD-10 S53.10 with associated fractures

›Differentiating clue: elbow dislocation dominant; all three elements required for diagnosis

›Essex-Lopresti injury — radial head fracture with interosseous membrane disruption and DRUJ instability

›Differentiating clue: radial head fracture (not dislocation) + longitudinal forearm instability

›Isolated injuries

›Isolated ulnar shaft fracture (nightstick fracture)

›ICD-10 S52.20

›Differentiating clue: no radial head dislocation on radiographs — always check elbow

›Isolated radial head dislocation

›Traumatic vs congenital distinction

›Congenital: bilateral, dome-shaped radial head, no ulnar fracture

Pediatric-specific differentials

›Pediatric elbow injuries

›Supracondylar humerus fracture

›ICD-10 S42.41

›Differentiating clue: distal humerus fracture pattern; anterior interosseous nerve most commonly affected

›Lateral condyle fracture

›ICD-10 S42.43

›Differentiating clue: lateral elbow tenderness; physis involved on imaging

›Non-accidental trauma — plastic deformation pattern with inconsistent mechanism

›Consider in children under 3 years with forearm fracture

›Skeletal survey if multiple injuries or suspicious history

05Laboratory Tests/lt31

Pre-procedural and surgical labs

›Pre-operative panel for planned operative fixation

›Complete blood count

›Baseline hemoglobin and platelet count for surgical planning

›Leukocytosis screen if infection or open fracture concern

›Basic metabolic panel

›Renal function for contrast consideration and antibiotic dosing

›Electrolytes for procedural sedation safety

›Coagulation studies

›PT and INR if anticoagulant use or coagulopathy concern

›Adjust anticoagulation before elective operative fixation

›Type and screen

›Complex adult Monteggia with planned ORIF

›Open fracture or polytrauma presentation

Labs for specific scenarios

›Open fracture workup

›Wound culture not routinely taken in acute phase

›Intraoperative cultures preferred

›Gram stain of deep tissue at time of debridement

›Blood glucose

›Diabetes screening if unknown status

›Hyperglycemia as surgical risk factor

›Pathologic fracture concern

›Inflammatory markers

›CRP and ESR if infection or neoplasm suspected

›Alkaline phosphatase if metabolic bone disease suspected

›Calcium and phosphate

›Metabolic bone disease workup

06Diagnostic Tests/dt84

Scoring Systems

›Bado classification — standard system for all Monteggia fractures

›Type I — anterior radial head dislocation with apex anterior ulnar fracture

›Frequency in adults approximately 30%

›Most common type in children

›Mechanism: FOOSH with hyperpronation

›Type II — posterior or posterolateral radial head dislocation with apex posterior ulnar fracture

›Frequency in adults approximately 60% — most common adult type

›Mean adult age approximately 52 years

›Associated radial head and coronoid fractures common

›Type III — lateral radial head dislocation with proximal ulna metaphysis fracture

›Frequency approximately 5%

›Predominantly pediatric

›Type IV — anterior radial head dislocation with both radius and ulna fractures at same level

›Frequency approximately 3%

›Rarest type

›Jupiter subclassification of Bado type II

›Further characterizes coronoid involvement and proximal ulna comminution

›Guides surgical complexity and implant selection

›Type IIA: fracture at ulnohumeral joint level

›Type IIB: fracture at coronoid level

›Type IIC: fracture at distal coronoid level

›Type IID: proximal ulna comminution

›Mayo Elbow Performance Score (MEPS)

›Used for outcome assessment post-treatment

›Pain, range of motion, stability, and function domains

›Good to excellent score defined as 75 or above

›Guides expected functional recovery

MRI

›MRI indications for Monteggia fracture

›Chronic and missed Monteggia lesions

›Annular ligament integrity assessment

›Radial head cartilage and morphology

›Nerve pathology evaluation

›Annular ligament injury characterization

›Disruption indicates need for ligament reconstruction at surgery

›MRI can identify interposition preventing reduction

›Sensitivity for annular ligament tear in pediatric cases

›Preoperative planning in complex cases

›Articular cartilage assessment

›Soft tissue interposition identification

›ACR Appropriateness Criteria support MRI for chronic Monteggia evaluation

›MRI protocol considerations

›Small field of view elbow MRI

›3 Tesla preferred for resolution

›Coronal and axial planes for ligament assessment

›Contraindications and limitations

›Implanted hardware from prior surgery may degrade image quality

›Not indicated for acute diagnosis — plain radiography sufficient

CT

›CT indications in Monteggia fracture

›Complex fracture morphology characterization

›Bado type II adult fractures — coronoid involvement extent

›Radial head fragmentation and reconstructability

›Proximal ulna comminution for fixation planning

›Preoperative surgical planning

›3D reconstruction for implant selection

›Coronoid fracture pattern guides approach

›ACR Appropriateness Criteria — CT recommended for complex elbow fracture-dislocations

›Diagnostic uncertainty

›When plain radiographs equivocal for radial head position

›Intra-articular fragment identification

›CT protocol

›CT elbow without contrast

›Thin-slice 1 mm axial acquisition

›Multiplanar and 3D reconstructions

›CT angiography if vascular injury suspected

›Expanding hematoma or absent pulse after reduction attempt

›Brachial artery at risk with high-energy mechanism

Ultrasound

›Ultrasound role in Monteggia fracture

›Radial head position confirmation in pediatric patients

›Real-time dynamic assessment of radiocapitellar articulation

›Useful when radiographs inconclusive in young children

›Operator-dependent technique

›Hematoma and soft tissue assessment

›Periosteal elevation in pediatric plastic deformation

›Soft tissue mass at radial head for interposition assessment

›Vascular assessment adjunct

›Brachial artery flow with color Doppler if pulse asymmetry

›Not a substitute for formal CT angiography in significant vascular injury

›Procedural guidance

›Reduction confirmation under ultrasound guidance in select pediatric cases

›Avoids additional radiation

›Real-time assessment of radiocapitellar alignment

›Limitations

›Cannot replace plain radiograph as primary diagnostic tool

›Bone cortex limits deep structure visualization

07Disposition/dispo40

Admission and operative criteria

›Admission indications

›Open fracture

›All open fractures require operative irrigation and debridement

›Admit pending OR availability

›Neurovascular compromise

›PIN or AIN palsy requiring monitoring

›Vascular injury requiring surgical repair

›Compartment syndrome

›Emergent admission for fasciotomy

›ICU-level monitoring post-fasciotomy

›Adult Monteggia fracture requiring operative fixation

›All adult true Monteggia fractures warrant admission for ORIF

›Timing dependent on swelling and patient comorbidities

›Polytrauma

›Associated injuries determine level of care

›Trauma surgery or orthopedic surgery co-management

›Orthopedic consultation triggers

›All confirmed or suspected Monteggia fractures

›Emergent consultation if neurovascular compromise

›Urgent consultation (within hours) for all others

›Irreducible radial head after closed reduction attempt

›Indicates soft tissue interposition — operative management

›Annular ligament or nerve may be incarcerated

Discharge criteria and follow-up

›Discharge eligibility

›Pediatric closed Monteggia after successful closed reduction

›Documented maintained radiographic reduction

08Treatment/t84

Immediate ED management

›Initial stabilization

›Long-arm posterior splint

›Elbow at 90 degrees flexion

›Forearm in supination for Bado type I

›Forearm neutral for Bado type II

›Analgesia

›Ibuprofen 400 to 600 mg PO or IV ketorolac 15 to 30 mg IV for moderate pain

›Morphine 0.1 mg/kg IV or hydromorphone 0.015 mg/kg IV for severe pain

›Acetaminophen 1000 mg IV or PO as adjunct

›Neurovascular documentation before and after any manipulation

›Formal charted exam with PIN and AIN testing

›Photograph open wounds for surgical record

Closed reduction technique

›Procedural sedation for closed reduction

›Ketamine 1 to 2 mg/kg IV for pediatric patients

›Onset 1 to 2 minutes; duration 10 to 15 minutes

›Glycopyrrolate 0.01 mg/kg IV to reduce secretions if needed

›Propofol 1 to 2 mg/kg IV for adults

›Titrate to effect; airway support at bedside

›Midazolam 0.05 to 0.1 mg/kg IV plus fentanyl 1 to 2 mcg/kg IV as alternative

›Closed reduction technique for Bado type I

›Longitudinal traction on the forearm with elbow extended

›Restore ulnar length first — radial head typically reduces indirectly

›Supinate the forearm while flexing the elbow to 90 to 110 degrees

›Direct pressure over anteriorly displaced radial head if needed

›Confirm reduction with clinical reassessment and imaging

›Post-reduction long-arm cast in supination

›3 to 6 weeks immobilization for pediatric patients

›Serial radiographs to confirm maintained reduction

›Open fractures — antibiotic prophylaxis

›Cefazolin 2 g IV (pediatric 50 mg/kg IV) for Gustilo-Anderson grade I and II

›First dose within 1 hour of presentation

›Continue for 24 hours post-operative

›Add gentamicin 5 mg/kg IV daily for Gustilo-Anderson grade III

›Monitor renal function

›Penicillin G 2 to 4 million units IV every 4 to 6 hours for soil-contaminated wounds

Operative management — pediatric

›Pediatric indications for operative fixation

›Complete ulnar fracture with inability to maintain closed reduction

›Elastic stable intramedullary nailing (ESIN) commonly used

›Plate and screw fixation for complex or comminuted patterns

›Failed closed reduction of radial head

›Open reduction to remove soft tissue interposition

›Annular ligament reconstruction if disrupted

›Chronic missed Monteggia in children

›Open reduction of radial head plus corrective ulnar osteotomy

›Annular ligament reconstruction frequently required

›Outcomes significantly better when treated within 6 months of injury

›Pediatric post-operative immobilization

›Long-arm cast for 4 to 6 weeks

›Elbow at 90 to 110 degrees flexion

›Forearm in supination for type I lesions

›Supervised range of motion exercises after cast removal

›Occupational or physical therapy referral

›Full ROM expected in most pediatric cases with timely treatment

Operative management — adult

›Ulnar fixation — standard of care for all adult Monteggia fractures

›Locking plate and screw fixation preferred

›Associated with fewer non-unions and revisions than non-locking constructs

›Minimum 3 bicortical screws on each side of fracture

›Anatomic reduction of ulna is the key to indirect radial head reduction

›If radial head does not reduce after ulnar fixation, open reduction required

›Persistent radial head dislocation after anatomic ulnar reduction indicates soft tissue block

›Radial head management in Bado type II

›ORIF if radial head reconstructable

›Screws and plate for head and neck fractures

›Goal: restore radial length and lateral column stability

›Radial head arthroplasty if comminuted beyond reconstruction

›Metal prosthesis preferred over excision

›Modular implants for size matching

›Radial head excision is last resort — do not excise acutely in Monteggia

›Leads to instability and proximal radius migration

›Associated with worse functional outcomes

›Coronoid fracture fixation — critical for Bado type II stability

›Suture lasso technique for small fragments

›Transosseous sutures through anterior capsule

›Restore ulnohumeral stability

›Plate fixation or screw fixation for larger coronoid fragments

›Medial approach for isolated coronoid fixation

›Combined with ulnar plate in complex patterns

›Post-operative rehabilitation in adults

›Hinged elbow orthosis at 2 to 4 weeks post-operative

›Allows controlled range of motion

›Prevents stiffness while protecting fixation

›Mean revision rate approximately 23%

›Most achieve good to excellent outcomes with anatomic fixation

›Class IIa recommendation for operative fixation based on expert consensus

09Special Populations/sp68

Pregnancy

›Pregnant patient considerations

›Mechanism assessment

›Fall risk increased in pregnancy due to altered center of gravity

›Third trimester balance changes predispose to FOOSH injuries

›Analgesia selection

›Acetaminophen 1000 mg IV or PO — first-line safe in all trimesters

›NSAIDs — avoid after 20 weeks gestation due to premature ductal closure risk

›Opioids acceptable for severe acute pain with fetal monitoring

›Avoid ketorolac in third trimester

›Procedural sedation in pregnancy

›Ketamine associated with increased uterine tone — use with caution

›Propofol acceptable for short procedures with anesthesia support

›Fetal heart rate monitoring before and after sedation

›Imaging

›Plain radiographs with lead shielding of uterus when feasible

›CT only when clinical need outweighs radiation risk

›MRI preferred over CT for complex characterization after first trimester

Geriatric

›Older adult presentation features

›Mechanism often lower energy due to osteoporosis

›Ground-level falls sufficient to cause complex comminuted patterns

›Higher rate of Bado type II with associated radial head fragmentation

›Bone quality implications

›Locking plate fixation essential due to poor bone density

›Increased non-union risk — ulnar non-union rate 28% overall

›Vitamin D and calcium supplementation perioperatively

›Analgesia considerations

›NSAIDs with caution — renal impairment and GI risk

›Opioid dosing reduction by 25 to 50% in frail elderly

›Acetaminophen 650 mg every 6 hours as preferred baseline

›Surgical risk assessment

›Cardiovascular and pulmonary comorbidities increase perioperative risk

›Frailty scoring for operative risk stratification

›Pre-operative ECG and anesthesia consultation for complex comorbidities

›Rehabilitation

›Increased stiffness risk — early physiotherapy referral

›Fall prevention assessment before discharge

›Bone health management referral

Pediatrics

›Pediatric fracture characteristics

›Plastic deformation of ulna — most common cause of missed Monteggia in children

›Bowing without cortical break causes radial head dislocation

›Up to 72% of Monteggia-equivalent injuries missed at initial presentation

›Bado type I predominant in children

›Concomitant injuries in up to 7% of pediatric Monteggia fractures

›Ipsilateral distal radius fracture

›Supracondylar humerus fracture

›Full extremity exam and imaging required

›Pediatric management specifics

›Closed reduction under procedural sedation for greenstick and plastic deformation

›Ketamine 1 to 2 mg/kg IV — preferred agent

›Adequate ulnar reduction restores radiocapitellar alignment indirectly

›Long-arm cast in supination for 3 to 6 weeks

›ESIN for complete ulnar fractures requiring operative stabilization

›Flexible intramedullary nail sized 40% of medullary diameter

›Retrograde insertion from distal ulna

›Maintains length and alignment

›Nerve injury in pediatric Monteggia

›PIN palsy most common — spontaneous recovery expected

›Mean recovery time approximately 64 days (range 8 to 150 days)

›Early operative exploration generally unnecessary

›Chronic missed Monteggia in children

›Open reduction of radial head plus corrective ulnar osteotomy

›Annular ligament reconstruction

›Surgery within 6 months of injury strongly preferred for optimal outcomes

›Child protection considerations

›Non-accidental trauma screening

›Mechanism inconsistent with injury pattern or developmental stage

›Multiple fractures at different healing stages on skeletal survey

›Social work consultation and mandatory reporting as appropriate

10Background/b88

Epidemiology

›Incidence and frequency

›Accounts for approximately 0.7% of all elbow fractures in adults

›1.5 to 3% of childhood elbow injuries

›Relatively uncommon but clinically critical diagnosis

›Adult distribution

›Mean age approximately 52 years for adult Monteggia fractures

›Bado type II comprises approximately 60% of adult cases

›Female predominance in elderly due to osteoporosis burden

›Pediatric distribution

›Peak incidence ages 4 to 10 years

›Bado type I (anterior dislocation) most common in children

›Boys slightly more commonly affected

›Missed diagnosis burden

›Up to 72% of Monteggia-equivalent injuries missed at initial presentation

›Radial head dislocation overlooked without systematic radiocapitellar line check

›Delayed diagnosis leads to chronic Monteggia with significantly higher complication rates

›Chronic Monteggia complications

›Irreducible radial head after 2 to 3 weeks

›Requires complex corrective osteotomy and reconstruction

›Outcomes significantly inferior to timely acute management

›Complication rates

›Ulnar non-union in approximately 28%

›Limited range of motion in approximately 22%

›Recurrent radial head dislocation with inadequate fixation

›Adult operative revision rate approximately 23%

›PIN palsy complicates 10 to 20% of pediatric cases

›Late post-traumatic arthritis with joint incongruity

Pathophysiology

›Injury mechanism and biomechanics

›FOOSH with hyperpronation mechanism

›Axial load transmitted through outstretched hand

›Forearm hyperpronation applies torsional stress to proximal ulna

›Apex anterior ulnar fracture with anterior radial head dislocation (Bado type I)

›Direct blow or high-energy mechanism

›Posterior or posterolateral radial head dislocation (Bado type II)

›Apex posterior ulnar fracture pattern

›Coronoid fracture common with high-energy Bado type II

›Ulna acts as rigid strut

›Fracture disrupts ulnar length and allows radiocapitellar dislocation

›Anatomic ulnar restoration restores radiocapitellar articulation indirectly

›Soft tissue injury pattern

›Annular ligament disruption

›Encircles radial neck and maintains radiocapitellar articulation

›Disruption allows persistent radial head dislocation despite ulnar reduction

›Interposition into joint prevents closed reduction

›Interosseous membrane contribution

›Partial tears contribute to forearm instability

›Complete disruption leads to Essex-Lopresti pattern

›Posterior interosseous nerve at risk

›Wraps around radial neck at the level of radial head dislocation

›Traction or direct compression with anterior or lateral dislocation

›Neuropraxia most common — axonotmesis rare

›Plastic deformation in children

›Immature bone deforms plastically before fracture

›Periosteum thick and resilient in pediatric bone

›Bowing without cortical break still disrupts radiocapitellar alignment

›Reduction requires three-point molding force to correct deformity

Therapeutic Considerations

›Timing importance

›Acute Monteggia (within 2 to 3 weeks)

›Closed reduction feasible in pediatric plastic deformation

›Operative fixation for adult and complete pediatric fractures

›Outcomes generally good to excellent with timely anatomic treatment

›Chronic Monteggia (beyond 2 to 3 weeks)

›Radial head becomes irreducible due to soft tissue contracture

›Corrective ulnar osteotomy required to restore length and alignment

›Annular ligament reconstruction frequently necessary

›Surgery within 6 months of injury strongly preferred

›Ulnar fixation principles

›Anatomic reduction is the cornerstone of treatment

›Restores ulnar length and angular alignment

›Indirect reduction of radial head follows ulnar anatomic restoration

›Locking plate superior to non-locking plate

›Associated with fewer non-unions and revision surgeries

›Angle-stable fixation essential in osteoporotic bone

›Nerve injury management

›Observation for PIN and AIN palsy

›Spontaneous recovery expected in majority of cases

›Mean recovery time approximately 64 days

›EMG at 6 to 12 weeks if no recovery to assess reinnervation

›Surgical nerve exploration indications

›No recovery at 3 to 4 months with EMG showing no reinnervation

›Nerve laceration identified intraoperatively (rare)

›Radial head treatment philosophy

›Preserve radial head whenever possible — critical for longitudinal stability

›Radial head transmits approximately 60% of axial load through forearm

›Excision causes proximal radial migration and wrist instability

›Arthroplasty preferred over excision when head not reconstructable

›Maintains radial length and lateral elbow stability

›Modular implant sizing critical for kinematics

11Patient Discharge Instructions/pdi39

copy discharge instructions

›Monteggia fracture home care after splinting or casting

›Keep the splint or cast dry and intact at all times

›Waterproof cover for bathing

›Do not insert objects inside the cast to scratch the skin

›Elevate the arm above heart level when resting

›Reduces swelling for the first 48 to 72 hours

›Prop on pillows when sleeping

›Ice pack over the cast for 20 minutes every 2 hours for the first 2 days

›Do not place ice directly on skin

›Protect with a towel

›Pain medications as prescribed

›Take with food to avoid stomach upset

›Do not drive or operate machinery if taking opioid pain medication

›Activity restrictions

›No weight-bearing on the injured arm until cleared by orthopedics

›No lifting, pushing, or pulling with the injured arm

›Use the other arm for daily activities

›Return to work and sport restricted until follow-up assessment

›Expect 6 to 12 weeks minimum immobilization and recovery for most cases

›Adult operative cases may require 3 to 6 months for return to heavy work

›Warning signs to return to the emergency department immediately

›Increasing pain or pressure inside the cast not relieved by elevation and ice

›Severe tightness or pressure sensation in the forearm

›Burning or crushing pain — compartment syndrome warning

›Numbness or tingling in the hand or fingers

›Inability to move the fingers

›Hand appears pale, blue, or cold

12References/r39

Guidelines and key sources

›Primary evidence sources

›Delpont M, Louahem D, Cottalorda J — Monteggia Injuries — Orthopaedics and Traumatology Surgery and Research 2018

›PMID 29174872

›Comprehensive review of classification, management, and outcomes

›Beutel BG — Monteggia Fractures in Pediatric and Adult Populations — Orthopedics 2012

›PMID 22300997

›Comparative pediatric and adult management review

›Ring D, Jupiter JB, Simpson NS — Monteggia Fractures in Adults — Journal of Bone and Joint Surgery 1998

›PMID 9875931

›Landmark adult series establishing operative management principles

›Patel DS, Statuta SM, Ahmed N — Common Fractures of the Radius and Ulna — American Family Physician 2021

›PMID 33719378

›Practical clinical management guidance including chronic Monteggia

›Pediatric-specific evidence

›Amaral JZ et al — Preoperative Risk Factors for Nerve Injury in Pediatric Monteggia Fracture-Dislocations — JBJS 2025

›PMID 40048500

›Risk stratification for PIN and AIN injury

›Hart CM et al — Operative vs Nonoperative Management of Acute Pediatric Monteggia Injuries With Complete Ulna Fractures — Journal of Pediatric Orthopedics 2021

›PMID 34074958

›Guidance on operative vs nonoperative selection

›Bae DS — Successful Strategies for Managing Monteggia Injuries — Journal of Pediatric Orthopedics 2016

›PMID 27100040

›Expert technique and outcome review

›Imaging and classification evidence

›Chen KC et al — ACR Appropriateness Criteria: Acute Elbow and Forearm Pain — JACR 2024

›Radiograph as first-line; CT for complex fractures; MRI for chronic cases

›Guideline-level imaging recommendations

Evidence & Review

Evidence & Review