Open Journal of Orthopedics, 2013, 3, 311-313
Published Online November 2013 (http://www.scirp.org/journal/ojo)
http://dx.doi.org/10.4236/ojo.2013.37057
Open Access OJO
311
Unusual Combination of Monteggia, Radius Shaft, and
Scaphoid Fractures*
A. Mechchat#, A. Mardy, M. Shimi, A. Elibrahimi, A. Elmrini
Department of Orthopaedics and Trauma Surgery B4, UH Hassan II, Fez, Morocco.
Received September 5th, 2013; revised October 8th, 2013; accepted October 21st, 2013
Copyright © 2013 A. Mechchat et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
A rare combination of an ulnar fracture with posterior dislocation of the head of the radius and fracture of the radius
shaft concomitant with an ipsilateral scaphoid fracture is presented. To the best of our knowledge, no such case has
been reported. The mechanism of this fracture combination is discussed with respect to its role in producing the
Monteggia type II fracture. Treatment consisted of a combination of closed and open reduction with external fixation.
Keywords: Monteggia; Scaphoid; Radius; Posterior; Herbert
1. Introduction
The case of a young adult who sustained a posterior
Monteggia lesion with fracture of radius shaft and an
ipsilateral navicular fracture is presented. This is an ex-
tremely unusual injury. The mechanism of injury is dis-
cussed.
2. Case Report
A 26-year-old man fell backwards off a tree onto his
outstretched left arm. He described a twisting injury to
the arm at the time. The patient presented to a tertiary
trauma centre was seen with an obvious deformity of the
distal forearm and tenderness over the ipsilateral elbow.
Movements at the wrist and elbow were painful and re-
stricted, and no neurological or vascular deficits were
noted. Radiographs showed anulnar fracture with poste-
rior dislocation of the radial head and fracture of the ra-
dius shaft concomitant with an ipsilateral navicular frac-
ture. At the elbow the radial head was dislocated
posteriorly (Figure 1(a)). All injuries were of the closed
type. At surgery, the ulnar fracture was openly reduced
and fixed with a plate.The dislocation wasreduced by
manipulation after open reduction of the radial shaft
fracture, which was then fixed with a plate. The dislo-
cated radial head reduced spontaneously, and the wound
was sutured (Figure 1(b)). Open reduction and internal
fixation with the Herbert-Whipple screw was used for
navicular fracture (Figure 1(c)). The upper lumb was im-
mobilized in a light, above-elbow, full cast. The patient
made an uneventful recovery, and the cast was removed
at three weeks. Then active mobilization was started.
Consolidation was observed in 10 weeks. At his last re-
view eighteen month after injury, he had excellent wrist
and elbow movement, with full range of pronation and
supination.
3. Discussion
Any dislocation of the radial head with an ulnar fracture
constitutes a Monteggia lesion. Of the various classifica-
tions available, Bado’s [1] is the one that is almost uni-
versally in use.
Type I: anterior dislocation of the radial head, fracture
of the ulnar diaphysis at any level with anterior (volar)
angulation.
Type II: posterior or posterolateral dislocation of the
radial head, fracture of the ulnar diaphysis with posterior
(dorsal) angulation.
Type III: lateral or anterolateral dislocation of the ra-
dial head with fracture of the ulnar metaphysis or diaphy-
sis.
*Conflit of interest: No benefits in any form have been received or will
b
e received from a commercialparty related directly or indirectly to the
subject of this article.
#Corresponding author.
Type IV: anterior dislocation of the radial head, frac-
ture proximal third radius and fracture of the ulna at the
same level.

Unusual Combination of Monteggia, Radius Shaft, and Scaphoid Fractures 312
(a)
(b)
(c)
Figure 1. (a) ulnar fracture with posterior dislocation of the
radial head and fracture of the radius shaft concomitant
with an ipsilateral navicular fracture. (b) ulnar fracture
and radius shaft fracture were openly reduced and fixed
with a plate.The dislocated radial head reduced spon-
taneously. (c) the Herbert-Whipple screw was used for
navicular fracture.
Other type I variants include isolated anterior disloca-
tion of the radial head, fracture of the ulnar diaphysis
with fracture of the neck or proximal radius, associated
olecrenon fractures, distal epiphyseal facture of the ra-
dius, etc, all of which occur after a hyperpronation injury.
Some variants have also been described for type II, III
and IV injuries too [2,3].
The Bado type II lesion with posterior dislocation of
thehead of the radius accounts for 70% to 80% of such
injuries [4,5]. Jupiter et al. [6] further subdivided the
type II injuries based on the pattern of damage to the
head of the radiusand the site of the fracture of the ulna.
They noted that fracturesof the ulna, including the
coronoid process (type A), and those distal to the coron-
oid process at the junction ofthe metaphysis and diaphy-
sis (type B) were relatively common,whereas fractures
involving the diaphysis (type C) and those extending
from the olecranon to the diaphysis (type D) were rare.
Ring et al. [4] noted that Bado type II lesions occurred
following two different mechanisms of injury. Fractures
resulting from low-energy injuries tended to occur in
elderly female patients, whereas those associated with a
higher-energy were seen in younger, male patients. An
associated fracture of the head of the radius occurred in
68% of Type II inj u ries.
Mullan et al. [7] reported a case of an adult Monteggia
lesion associated with a Smith fracture and a fracture of
the scaphoid waist, both occurring on the ipsilateral wrist
—a very rare combination.
In our case, by falling backwards on the outstretched
hand,radially deviated wrist, which results in extreme
dorsiflexion at the wrist and compression to the radial
side of the hand the patient’s forearm locked in supina-
tion, and the weight of the body pronated the limb
against a hand fixed on the ground. This produced the
Monteggia lesion after a scaphpoid fracture. When this
twisting force combines with a heavy compressional
force, fractures of the wrist may also theoretically occur
[7-9].
It is important to restore normal length and achieve
ananatomical alignment of the forearm bones, as other-
wise the radial head will not reduce back into place. If
good reduction can not be obtained closed, the threshold
for open reduction must be very low.
4. Conclusions
A combination of an ulnar fracture with posterior dislo-
cation of the radial head and fracture of radius shaft con-
comitant with an ipsilateral navicular fracture is rare.
The mechanism of injury giving rise to this rare com-
bination of fractures as well as a review of the literature
is discussed.
The factors we believe contributed to the excellent re-
sult were early diagnosis, anatomic reduction, stable fixa-
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Unusual Combination of Monteggia, Radius Shaft, and Scaphoid Fractures
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tion, and early physical exercise.
REFERENCES
[1] J. L. Bado, “The Monteggia Lesion,” Clinical Ortho-
paedics and Relat e d R e s e ar c h, Vol. 50, 1967, pp. 71-86.
[2] B. Kristiansen and A. F. Eriksen, “Simultaneous Type II
Monteggia Lesion and Fracture Separation of the Lower
Radial Epiphysis,” Injury, Vol. 17, No. 1, 1986, pp. 51-52.
http://dx.doi.org/10.1016/0020-1383(86)90019-7
[3] N. Bhandari and P. Jindal, “Monteggia Lesion in a Child:
Variant of a Bado Type IV Lesion. A Case Report,” The
Journal of Bone & Joint Surgery, Vol. 78, No. 8, 1996,
pp. 1252-1255.
[4] D. Ring, J. B. Jupiter and N. S..Simpson, “Monteggia
fractures in adults,” The Journal of Bone & Joint Surgery,
Vol. 80-A, 1998, pp. 1733-1744.
[5] J. H. Penrose, “The Monteggia Fracture with Posterior
Dislocation of the Radial Head,” The Journal of Bone &
Joint Surgery, Vol. 33-B, 1951, pp. 65-73.
[6] J. B. Jupiter, S. J. Leibovic, W. Ribbans and R. M. Wilk,
“The Posterior Monteggia Lesion,” Journal of Ortho-
paedic Trauma, Vol. 5, 1991, pp. 395-402.
http://dx.doi.org/10.1097/00005131-199112000-00003
[7] G. B. Mulian, A. Franklin and N. P. Tbomas, “Adult
Monteggia Lesion with Ipsilateral Wrist Injuries,” Injury,
Vol. 12, No. 5, 1981, pp. 413-416.
http://dx.doi.org/10.1016/0020-1383(81)90013-9
[8] A. D. Perron, W. J. Brady, T. E. Keats and R. E. Hersh,
“Orthopedic Pitfalls in the ED: Scaphoid Fracture,”
American Journal of Emergency Medicine, Vol. 19, No. 4,
2001, pp. 310-316.
http://dx.doi.org/10.1053/ajem.2001.24449
[9] J. M. Simpson, T. G. Adreshak and A. Patel, “Ipsilateral
Radialhead Dislocation and Radial Shaft Fracture. A Case
Report,” Clinical Orthopaedics and Related Research,
Vol. 266, 1991, p. 205.