Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.
We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.
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Introduction
In 1814, Giovanni Battista Monteggia first described a Monteggia fracture as a fracture of the proximal ulna combined with a dislocation of the radial head [1]. Overall, Monteggia injuries are rare and account for only 1–5% of all fractures around the elbow [2]. Today, the eponym of Monteggia fracture, Monteggia-like-lesion or Monteggia-lesion includes multiple patterns of injury of the proximal ulna and the radial head [3]. Bado classified Monteggia fractures by defining four subtypes depending on the direction of radial head dislocation [4]. Jupiter subclassified the Bado type II fracture with regard to the location of the ulna fracture and included radial head fractures [5]. Giannicola identified six injury patterns in Monteggia lesions: (1) ulna fracture, (2) radio-humeral dislocation, (3) ulno-humeral dislocation, (4) proximal radio-ulnar dislocation, (5) radial fracture and (6) distal radio-ulnar joint lesion [3]. Today, treatment of these injuries is still a topic of debate resulting in widely different treatment strategies. Also, definition of the various injury patterns is inconsistent throughout the literature. Therefore, due to the rarity of these injuries, it is difficult to compare and evaluate different treatment strategies for these injuries.
Our goal with this systematic review was to clarify the incidence of different injuries within Monteggia injuries such as ulna fractures, coronoid fractures and radial head fractures. Furthermore, we aimed to investigate the main reasons leading to revision surgery and explore whether certain surgical treatments should be favored to achieve satisfactory clinical results.
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Materials and methods
We applied the “Preffered Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) guidelines to guarantee methodical transparency. We included all studies published in English or German language since 1990 that used the Bado/Jupiter classification for Monteggia fractures and Monteggia-like-lesions. The research excluded studies without Bado classification, biomechanical studies, or anatomically studies. We also excluded review articles, case reports and studies which lack basic information such as mean follow-up or mean age of patients.
The MEDLINE database using the PubMed interface was investigated using the search terms “Monteggia fracture “OR” Monteggia-like-lesion “OR” Monteggia injury” NOT child NOT pediatric. The research was completed on 15.12.2021.
The studies identified were examined by two independent reviewers (MMW and VR). First, title and abstracts were checked for exclusion criteria. Subsequently, the full text was evaluated wether inclusion criteria were met by the study. In case of borderline decisions, a third reviewer was consulted to reach a consensus decision (MK). All borderline cases could be resolved by a consensus decision. The process of decision-making is depicted in the PRISMA-adapted flow diagram (Fig. 1).
Fig. 1
PRISMA-adapted flowchart illustrating study selection and exclusion criteria
×
All data of the 17 included studies regarding number of patients, mean age, gender, mean follow-up, trauma mechanism, fracture classification (Bado/Jupiter, Mason, O’Driscoll, Regan&Morrey), range-of-motion, surgical procedures, outcome scores (Disability of the arm and shoulder (DASH); Mayo Elbow Performance Score (MEPS); Mayo Modified Wrist Score (MMWS); Broberg and Morrey), complications and revision rates were extracted and transferred into tables.
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Microsoft® Excel® 2011 for Mac and GraphPad PRISM 6 (Graphpad Software, Inc) were used for data collection, data visualization and statistical analyses.
Results
We identified 182 studies in relation to our search terms. After exclusion of 145 abstracts that failed to meet the inclusion criteria, 37 full-text articles were assessed for eligibility. As demonstrated in Fig. 1, we excluded 20 articles that did not fulfill the inclusion criteria. Seventeen articles were finally included in qualitative synthesis.
Characteristics of the included publications are depicted in Table 1. In total, 651 patients with a mean age of 48.4 years were included. Gender ratio was nearly balanced with 343 male (53%) and 304 female (47%) reported patients. The mean follow-up was 52.9 months (10–234.5 months). Eleven publications reported the mechanism leading to the Monteggia injury. We identified traffic accidents (35%), low-energy falls (defined as a fall from less than 2 m; 32%) and high-energy falls (14%) as the main reasons for Monteggia injuries. In 52 cases (13%), the height of the fall was not further described. Work-related accidents (4%) and other trauma mechanisms (2%) like gun shots are rare injury causes (Table 2).
Table 1
Overview of the publications included, depicting number of patients, mean patient age, gender and mean follow-up in months
First author
Number of patients
Mean age
Male
Female
Mean follow-up (months)
Calderazzi et al. 2020
12
59.25
5
7
17.5
Eden et al. 2019
40
49
23
17
36
Egol et al. 2005
20
52.6
7
13
28.8
Guiton et al. 2009
11
54.6
6
5
234.55
Hamaker et al. 2017
119
37
77
42
10
Jung et al. 2020
27
56
11
16
69
Jungbluth et al. 2017
46
57.7
19
27
65.3
Jupiter et al. 1991
13
56.1
4
9
39.6
Klug et al. 2019
78
54.7
34
44
55.2
Konrad et al. 2007
63
42.1
41
22
100.8
Korner et al. 2004
49
38 (Median)
31
18
83 (Median)
Laun et al. 2015
10
52.4
4
6
12.3
Perez et al. 2002
54
41
37
17
24
Ring et al. 1998
48
52
23
25
78
Schmalzl et al. 2019
14
63
2
14
21,9
Simpson et al. 1996
24
51
14
10
24
Strauß et al. 2006
23
52.9
5
12
29
651
48.38
343
304
52.87
53%
47%
Table 2
Most common trauma causes leading to Monteggia injuries
First author
Number of patients
High-energy fall
Low-energy fall
Traffic accident
Not specified fall
Work related
Other reasons
Egol et al. 2005
20
3
17
Jungbluth et al. 2017
46
13
14
19
Jupiter et al. 1991
13
3
10
0
0
Klug et al. 2019
78
20
44
14
0
Konrad et al. 2007
63
32
19
12
Korner et al. 2004
49
28
16
5
Laun et al. 2015
10
3
3
4
Perez et al. 2002
54
0
21
32
1
Ring et al. 1998
48
8
29
5
6
Simpson et al. 1996
24
6
12
5
1
Strauß et al. 2006
6
4
2
411
57.00
133.00
144.00
52.00
17.00
8.00
14%
32%
35%
13%
4%
2%
All patients were classified using the Bado classification for Monteggia fractures [4]. 31.5% were Bado type I fractures, 60.4% were Bado type II fractures. Bado type III and IV fractures are rare and represented only 5 and 3% of all Monteggia injuries, respectively. Thirteen of the 17 studies also provided information about the subclassification of Bado II fractures according to Jupiter [5]. There were 79 type IIa, 132 type IIb, 47 type IIc and 61 type IId injuries (Fig. 2).
Fig. 2
Bado classification of 651 patients and subclassification of 370 Bado type II fractures according to Jupiter
×
290 radial head fractures were reported in 14 of the 17 publications. According to the Mason classification, 28% were classified as Mason type II fractures, 55% were classified as Mason type III fractures. Mason type I and IV constituted only 11 and 3% of all reported radial head fractures, respectively [6].
Seven publications additionally classified coronoid fractures. Jungbluth et al., Klug et al., Korner et al., Laun et al., Jung et al., and Strauss et al. used the Regan and Morrey classification [7‐13]. Schmalzl and colleagues applied the O’Driscoll classification of coronoid process fractures [14, 15]. Altogether, there were 162 coronoid fractures reported.
There were 148 reported revisions, leading to a mean revision rate of 23% (0 to 63%). Main complications leading to additional surgery were ulna non-union (28%), limited range-of-motion, including elbow stiffness (22%), failed osteo-synthesis of ulna or radial head (13% and 11%), persistent instability (12%) and infection (9%). In 5% of the cases, revision was necessary due to other reasons that were not declared further (Table 3).
Table 3
Causes for revision surgery in Monteggia injuries
Number of patients
Number of revisions
Revision rate
Ulna non-union
Infection
Failed osteo-synthesis ulna
Failed osteo-synthesis radial head
Limited ROM
Instability
Other reasons
Calderazzi et al. 2020
12
0
0
0
0
0
0
0
0
0
Eden et al. 2019
40
6
0.15
1
0
2
2
0
0
1
Egol et al. 2005
20
11
0.55
6
0
0
1
0
3
1
Guiton et al. 2009
11
2
0.18
2
0
0
0
0
0
0
Hamaker et al. 2017
119
23
0.19
4
5
0
0
3
1
1
Jung et al. 2020
27
17
0.63
0
0
0
5
5
0
0
Jungbluth et al. 2017
46
6
0.13
4
2
0
0
0
0
0
Jupiter et al. 1991
13
2
0.15
0
0
2
0
0
0
0
Klug et al. 2019
78
23
0.29
5
3
0
2
7
4
2
Konrad et al. 2007
63
10
0.16
6
0
0
2
2
0
0
Korner et al. 2004
49
14
0.29
4
1
0
1
5
3
0
Laun et al. 2015
10
0
0
0
0
0
0
0
0
0
Perez et al. 2002
54
14
0.26
4
1
0
0
4
4
0
Ring et al. 1998
48
12
0.25
1
0
6
3
1
1
0
Schmalzl et al. 2019
14
3
0.21
0
0
1
1
0
0
1
Simpson et al. 1996
24
5
0.21
0
0
3
0
2
0
0
Straus et al. 2006
6
2
0.33
2
0
0
0
0
0
0
Total
634
148.00
23%
37.00
12.00
14.00
17.00
29.00
16.00
6.00
percentage
105%
23%
28%
9%
11%
13%
22%
12%
5%
Ulna fractures were mainly treated using locking compression plates (LCP) or dynamic compression plates (including low contact dynamic compression plates, DCP or LCDCP), but ulna reconstruction plates, 1/3 tubular plates and tension wire were also used for internal fixation. In nine cases, external fixation was applied, and in one case, the surgeon decided to use a 6.5 mm cancellous bone screw (Table 4). Seven studies nearly exclusively used LCPs (222 LCPs in 227 cases), whereas nine studies mainly used LCDCPs or DCPs for Ulna reconstruction. Egol and colleagues utilized LCDCPs in 12 patients, LCDCP/DCPs in five patients and ulna reconstruction plates in three cases.
Table 4
Different treatment strategies and fixation devices for fixation of the Ulna in Monteggia injuries
Number of patients
Ulna locking compression plate
Ulna LCDCP/DCP
Ulna reconstruction plate
1/3 tubular Plate
Ulna tension wire
6.5 mm cancellous bone screw
External fixation
Calderazzi et al. 2020
12
11
0
1
0
0
0
0
Eden et al. 2019
40
40
0
0
0
0
0
0
Egol et al. 2005
20
12
5
3
0
0
0
0
Guiton et al. 2009
11
0
10
0
0
0
0
1
Hamaker et al. 2017
119
0
119
0
0
0
0
0
Jung et al. 2020
27
24
0
0
0
3
0
0
Jungbluth et al. 2017
46
46
0
0
0
0
0
0
Jupiter et al. 1991
13
0
9
1
3
0
0
0
Klug et al. 2019
78
78
0
0
0
0
0
4
Konrad et al. 2007
63
0
52
0
0
11
0
0
Korner et al. 2004
49
0
15
21
3
8
0
2
Laun et al. 2015
10
10
0
0
0
0
0
0
Perez et al. 2002
54
0
35
11
3
3
1
1
Ring et al. 1998
48
0
37
2
0
3
0
0
Schmalzl et al. 2019
14
13
0
0
0
1
0
0
Simpson et al. 1996
24
0
24
0
0
0
0
0
Strauss et al. 2006
6
0
3
3
0
0
0
1
Total
634
234
309
42
9
29
1
9
Percentage
100%
37%
49%
7%
1%
5%
0%
1%
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There was limited information about the approach used to treat the ulna fracture and, if present, the radial head fracture. Six studies used the posterior approach to reduce and fix the ulna fracture. To address radial head fractures, Schmalzl et al. and Simpson et al. used the Boyd approach, and Calderazzi et al., Hamaker et al. and Klug et al. used a lateral approach. Eleven studies did not provide any information regarding the approach they used.
In six studies, reconstruction of the lateral collateral ligament with suture anchors was performed if necessary [7, 8, 11, 12, 14, 16]. The other 11 studies did not provide any information whether they performed ligament reconstruction.
In 14 studies, a total of 255 radial head fractures were surgically treated. Open reduction and internal fixation were applied in 117 cases. Partial resection of radial head was performed in eight patients. Ninety-one radial head prostheses were implanted and 39 patients underwent total radial head resection (Table 5).
Table 5
Different treatment strategies and procedures addressing radial head fractures in Monteggia injuries
ORIF
Partial resection
Prostheses
Resection
Calderazzi et al. 2020
2
2
5
1
Eden et al. 2019
19
0
1
1
Egol et al. 2005
3
0
4
0
Guiton et al. 2009
0
0
0
0
Hamaker et al. 2017
0
0
0
0
Jung et al. 2020
0
0
27
0
Jungbluth et al. 2017
15
0
22
0
Jupiter et al. 1991
3
0
1
6
Klug et al. 2019
26
0
19
7
Konrad et al. 2007
12
0
0
4
Korner et al. 2004
9
0
4
3
Laun et al. 2015
3
0
5
0
Perez et al. 2002
10
0
0
3
Ring et al. 1998
10
2
0
10
Schmalzl et al. 2019
Simpson et al. 1996
2
4
0
4
Strauss et al. 2006
3
0
3
0
Total
117
8
91
39
Percentage
46%
3%
36%
15%
All but one publication reported about the range-of-motion (ROM) for extension-flexion and pronation-supination. Korner and colleagues reported the median ROM, and the other 15 studies reported mean range-of-motion. Disability of arm, shoulder and hand (DASH) score was used to asses clinical and functional outcome in 11 publications, Mayo elbow performance score (MEPS) was used in seven and Broberg and Morrey Score (BMS) in nine studies [17]. Mayo modified wrist score (MMWS) was reported in three publications. All publications report that revision surgery was associated with a worse outcome (Table 6).
Table 6
Overview of ROM and different outcome scores after Monteggia injuries
Number of patients
ROM ex-flex
ROM pro-sup
MEPS
DASH
Broberg&Morrey
Mayo modified wrist score (MMWS)
Calderazzi et al. 2020
12
106.9
131.7
84.9
18.8
Eden et al. 2019
40
117
136
84.0
28
Egol et al. 2005
20
95
105
64.1
79.1
Guiton et al. 2009
11
120.0
136.4
94.5
7.6
94.2
Hamaker et al. 2017
119
121.36
138.40
Jung et al. 2022
27
100.00
131.00
77.0
30.00
Jungbluth et al. 2017
46
125.2
168.5
90.7
15.1
86.6
88.4
Jupiter et al. 1991
13
115.0
128.5
82.3
Klug et al. 2019
78
114
155
88.9
14.7
88.1
Konrad et al. 2007
47
109.7
134.212766
17.4
87.2
Korner et al. 2004
49
115 (Median)
130 (Median)
Laun et al. 2015
10
121
160
89.2
20.1
86.5
86.5
Perez et al. 2002
54
Ring et al. 1998
48
112
128
86
Schmalzl et al. 2019
14
116
138
82.0
23.6
79
Simpson et al. 1996
24
109.3
125.4
Strauß et al. 2006
23
116.0
122.0
26.0
80.0
Mean
114.90
140.24
87.99
18.02
85.50
88,08
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We hypothesized that surgical management of the ulna is crucial for preventing ulnar non-union and revision surgery in general. We compared seven studies mainly using locking compression plates (LCP in 222 of 227 cases) with nine studies mainly using non-locking fixation techniques. Mean revision rate of the LCP group was 0.2 (STD ± 0.08172; n = 7) compared to 0.22 (STD ± 002056; n = 9) in the non-LCP group. Mean rate of ulna non-union was 0.0257 (STD ± 0.01378; n = 7) in the LCP group and 0.09 (STD ± 0.0355; n = 9) in the non-LCP group. No significant difference with p < 0.05 was found using unpaired t test with Welch’s correction (Fig. 3).
Fig. 3
A Comparison of mean revision rates between publications using locking compression plates (LCP) for ulna fixation (n = 7) with publications not using locking compression plates (non-LCP; n = 9) rates. B overview of revision rates in 17 publications treating Monteggia injuries. C Comparison of ulna non-union rates between publications using locking compression plates (LCP) for ulna fixation (n = 7) with publications not using locking compression plates (non-LCP; n = 9). D Overview of ulna non-union rates in 17 publications treating Monteggia injuries
×
Discussion
In this systematic review on Monteggia injuries, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. The use of locking compression plates for ulna fixation might help reducing those complications.
The term “Monteggia fracture” or “Monteggia-like-lesion” does not clearly define injuries which makes it difficult to compare different publications regarding these subjects. Giannicola and colleagues [18] proposed a different approach to classify and determine Monteggia injuries, but the Bado/Jupiter classification remains the most common classification systems. The epidemiology within these classifications was not well investigated. Bado based his classification on a cohort of 22 adults and 18 children leading to a statistical distribution of 25% type I, 70% injuries [4]. Evans reported a distribution of 15% type I, 80% [19]. In our meta-analysis, Bado type II injuries remain the most common type (60.5%), but with a less frequent occurrence than previously reported. According to Jupiter et al., type IIc and IId injuries only account for 8% of the Bado type II injuries. Following our research, subtype IIb and IIa are the most common subtypes, but subtype IIc and IId seem to be more common than previously expected. Our meta-analysis provides more precise data about the epidemiology and incidents of different subtypes of Monteggia injuries than previous studies.
The mean revision rate in our meta-analysis was 23%, indicating that Monteggia injuries are still difficult to treat. By analyzing reasons for revision, we could point out that ulna non-union (28%) and failed osteo-synthesis of ulna (11%) were common reasons for revision surgery. These findings suggest a lack of stability of the ulna fixation and therefore raise the question for the best treatment strategy for theses fractures. Biomechanical investigations show that fixation locking compression plates show less axial displacement than reconstruction plates and 1/3 tubular plates and therefore suggest that locking compression plates are favorable in complex ulna fractures [20]. Eden and colleagues used different types of locking compression plates including variable-angle locking double mini-plates, straight and pre-contoured plates with overall good results [21]. Comparing the LCP with the non-LCP group in our meta-analysis, we could see a lower revision rate (20% vs. 22%) and a lower rate of ulna non-unions in the LCP group (2.6% vs. 9%). Nevertheless, no significant differences could be found, presumably due to the underpowered t test. Considering the current biomechanical investigations and the favorable tendencies in our meta-analysis, we recommend using locking compression plates for the fixation of Monteggia injuries.
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Complications in radial head osteo-synthesis (13%) and persistent instability (12%) are also common reasons for revision surgery in Monteggia injuries. Since postero-lateral instability of the radial head is one of the main reasons for persistent instability, the management of radial head fractures seems crucial to avoid instability and failed osteo-synthesis [9, 21, 22]. Especially, Mason III fractures raise the question whether they should be treated via ORIF, prostheses or radial head resection. Klug et al. showed that reconstruction of Mason III fractures in Monteggia injuries leads to better clinical results than resection or arthroplasty. There was no significant difference between radial head resection and radial head arthroplasty. Thus, more research is needed to clarify whether radial head arthroplasty or radial head resection leads to significant differences for the overall outcome after Monteggia injuries.
Conclusion
In conclusion, we could present new insights regarding the epidemiology of Monteggia injuries regarding the Bado/Jupiter classification, could show that revisions in Monteggia injuries are still frequent and highlight the main complications leading to revision surgery. There are hints that using locking compression plates for ulna fixation could lead to less revision surgery and prevent ulna non-union, but more research is necessary to support these tendencies. Coronoid fractures and reconstructable radial head fractures should be addressed with open reduction and internal fixation. Whether radial head arthroplasty shows significant advantages over radial head resection remains debatable.
Acknowledgements
The authors have no competing interests to declare that are relevant to the content of this article.
Declarations
Conflicts of interest
No conflicts of interest or financial funding are declared by the authors.
Compliance with ethical standards
All included articles state that procedures involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants involved in the included articles.
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