Acute Pediatric Monteggia Fractures: A Conservative Approach to Stabilization.

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Abstract

[Indexed for MEDLINE] 17. J Clin Med. 2025 Jul 2;14(13):4694. doi: 10.3390/jcm14134694. Bifocal Radial Fracture/Dislocation and Distal Ulnar Fracture-A Rare Case of Proximal Forearm Instability Not Yet Classified and Literature Review. Gurzì MD(1), Capece G(2)(3)(4), Bocchino G(2)(4), El Motassime A(2)(4), Comodo RM(2)(4), Nannerini M(1), Maccauro G(2)(4), Vitiello R(2)(4). Author information: (1)Aurelia Hospital-U.O.C. Orthopaedics and Traumatology, 00165 Rome, Italy. (2)Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy. (3)Pellegrini Hospital-U.O.C. Orthopaedics and Traumatology, 80134 Naples, Italy. (4)Department of Orthopedics and Geriatric Sciences, Catholic University of the Sacred Heart, Largo Francesco Vito, 8, 00168 Rome, Italy. INTRODUCTION: Monteggia fractures, first described by Giovanni Battista Monteggia, involve a fracture of the proximal ulna with anterior dislocation of the radial head. Bado's 1967 classification divides these injuries into four types. Rare mixed patterns exist, overlapping with other forearm injuries such as Galeazzi and Essex-Lopresti lesions. These complex fractures/dislocations pose significant diagnostic and therapeutic challenges and are not adequately represented in current classification systems. Methods and Case Presentation: We report the case of a 56-year-old woman with a complex forearm injury sustained from a fall, presenting with radial head fracture/dislocation, mid-shaft radial fracture, distal ulna fracture, and ulnar collateral ligament rupture. Intraoperative imaging confirmed DRUJ stability and partial interosseous membrane disruption. Surgical management included radial head prosthesis implantation, radial shaft fixation with an anatomical locking plate, intramedullary nailing of the distal ulna, and ligament reconstruction. At two-year follow-up, the patient demonstrated full recovery of elbow flexion-extension and satisfactory forearm function. A narrative literature review was also conducted, focusing on hybrid injury variants. RESULTS: Intraoperative examination under anesthesia revealed good elbow stability with 130° flexion, 15° extension lag, and forearm pronation/supination of 70°/60°. An initial Mayo Elbow Performance Score (MEPS) of 65 was recorded, limited by range of motion and stability. Pain during passive mobilization was mild, with a Visual Analogue Scale (VAS) score of 3/10. Postoperative recovery included 15 days of immobilization followed by structured rehabilitation. At two years, the patient regained full elbow flexion-extension but had residual deficits in pronation-supination, attributed to pre-existing conditions. CONCLUSIONS: This case illustrates a previously unreported hybrid Monteggia variant, combining features of Monteggia, Galeazzi, and Essex-Lopresti injuries. It highlights the limitations of current classification systems and supports the need for an expanded diagnostic framework. Successful management required a multidisciplinary surgical approach tailored to the injury's complexity. Further studies are warranted to refine classification and treatment strategies for these rare combined injuries. DOI: 10.3390/jcm14134694 PMCID: PMC12250124