A 30-year-old presents 6 weeks after a Monteggia fracture that was treated conservatively in a cast. Radiograph now shows a healed ulnar fracture with persistent radial head dislocation. The most appropriate management is:

• A Observation with physiotherapy as the radial head will spontaneously reduce
• B Excision of the radial head in adults
• C Open reduction of radial head and annular ligament reconstruction alone without addressing the ulna
• D Surgical intervention: ulnar re-osteotomy to restore ulnar length and correct angulation, which indirectly reduces the radial head ✓

Explanation

Chronic unreduced Monteggia injury (missed radial head dislocation) in adults requires reconstructive surgery. The key principle is that the radial head dislocation in Monteggia fracture is always secondary to the ulnar fracture — ulnar shortening/angulation causes radial head displacement. Re-osteotomy of the ulna (restoring proper length and alignment) is the essential step, which allows the radial head to reduce. If the radial head does not reduce after ulnar correction, annular ligament reconstruction (Bell–Tawse procedure) may be added. Radial head excision alone worsens instability.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.