originally described by giovanni monteggia in 1814 , the monteggia fracture pattern has gone through a few revisions . further subclassified by bado and later by jupiter , this fracture pattern warrants immediate attention and ( usually ) a trip to the operating room for definitive reconstruction [ 25 ] . in general , fracture involvement of both the radius and ulna with a concomitant radial head dislocation describes the fracture pattern . in attempts to further understand the injury , other monteggia fracture variants and equivalents have also been described [ 2 , 7 ] . however , to our knowledge , no report has described the injury sustained in our patient : divergent elbow dislocation with concomitant radial shaft fracture , plastic deformation of the distal ulna shaft , and distal radioulnar joint ( druj ) instability  a unique fracture pattern that has similar characteristics to the monteggia lesion , but with obvious differences . herein , we report the reconstruction and outcome of a novel monteggia fracture variant in which the radial head and ulna dislocate in opposite directions  a contradistinction to the original observations that served as the basis for bado s classification scheme . a 47-year - old female presented to the outpatient office complaining of right elbow pain after falling down two flights of stairs onto an outstretched hand while intoxicated , 10  days prior to presentation . initial treatment at an outside institution included attempted closed reduction and posterior splint placement . upon examination , she was found to have limited range of motion ( rom ) , intact skin , motor , and neurologic function , and palpable distal pulses in the right upper extremity . furthermore , she also had limited rom of the right wrist with laxity to druj shuck as compared to the contralateral limb . radiographs demonstrated a comminuted and displaced proximal third radial shaft fracture with associated proximal radioulnar , radiocapitellar , and ulnohumeral joint dislocations ( fig . distally , druj disruption was obvious both radiographically and clinically ( fig .  2 ) . advanced ct imaging revealed radial head and coronoid process fractures along with posterior dislocation of the ulna and anterior dislocation of the radius in relation to the humerus ( fig . 1ap ( a ) and lateral ( b ) radiographs of the right elbow reveal a fracture of the radial shaft with the apex dorsal . the proximal radius is dislocated anteriorly and the ulna posteriorly with respect to the humerusfig . 2lateral radiographs of the right wrist demonstrating distal radioulnar joint disruption and dorsal ulnar dislocation ( green arrow)fig . the coronoid process is abutting the posterior cortex of the medial humeral condyle . a tiny bone fragment off the coronoid process is seen between the olecranon fossa and humerus ( arrowhead ) ap ( a ) and lateral ( b ) radiographs of the right elbow reveal a fracture of the radial shaft with the apex dorsal . the proximal radius is dislocated anteriorly and the ulna posteriorly with respect to the humerus lateral radiographs of the right wrist demonstrating distal radioulnar joint disruption and dorsal ulnar dislocation ( green arrow ) lateral 3d reconstruction of ct scans of the right elbow confirm the divergent dislocation . the coronoid process is abutting the posterior cortex of the medial humeral condyle . a tiny bone fragment off the coronoid process is seen between the olecranon fossa and humerus ( arrowhead ) the patient was taken to the operating room for definitive reconstruction . first , the proximal third radial shaft fracture was addressed via a volar henry approach and a small fragment plate employing both non - locked and locked fixation . the comminuted fragments of the radial head and coronoid process were debrided . in an attempt to stimulate fibrocartilaginous synthesis , a 1.6  mm kirschner wire was then used to drill approximately 1  cm of osteochondral loss on the radial head , the coronoid process , and the medial epicondyle of the distal humerus . a completely avulsed mcl was noted during ulnar nerve transposition and was repaired using a 3.5  mm suture anchor inserted into the distal - most aspect of the midsagittal plane of the medial epicondyle . the stability of the elbow joint was assessed while maintaining manual tension of the lcl , with sutures ultimately incorporated into its definitive repair . the elbow was stable in flexion , varus and valgus , but unstable anteriorly when extended to less than 40. to supplement the repair for 6  weeks , a unilateral hinged external fixator was placed . next , the lcl was repaired utilizing the ex - fix guide pinhole as the isometric point for insertion of a 5.5  mm suture anchor . following repair of the annular ligament , the elbow next , attention was turned to the druj . shuck testing under fluoroscopy confirmed clinical findings . the joint was reduced in supination and stabilized with two parallel 2.0  k - wires to engage four cortices from the distal ulna to the distal radius . finally , the external fixation device was then locked in 70 of flexion , and all wounds were closed primarily . her external fixator was locked at 70 of flexion for the first 2  weeks of follow - up . at the 2-week follow - up , her external fixation device was unlocked , allowing full range of motion , and occupational therapy at the 3-week follow - up , her active rom was 070. at the 5-week follow - up , the patient reported hyperextending her elbow a few days prior when inebriated and falling against a wall . her elbow arom was painless and improved to 090 with mild but improving wrist stiffness . radiographs revealed a stable reduced druj and proximal radioulnar joint ( pruj ) , although there was some concern regarding the ulnohumeral articulation . she was then placed in a posterior splint at 90 of flexion , and she was taken to the operating room for ex - fix adjustment , manipulation under anesthesia , and removal of the druj k - wires at 6 weeks postoperatively . in the operating room , the elbow exhibited stable rom from 0 to 130 and a concentrically reduced elbow was obtained via ex - fix adjustment . owing to the patient s previous slight posterior subluxation and concerns with compliance , the hinge was re - locked for one more week to allow further soft tissue healing . hardware was removed from the druj and shuck testing demonstrated a stable , well - reduced druj . the patient tolerated the procedure well and was discharged the same day . at the 9-week follow - up , the patient noted increased rom in the wrist as well as pain - free rom of the elbow and shoulder . x - ray examination revealed a well - reduced druj , pruj , and elbow joint with radial shaft union . at this time , the calculated dash score was 38.8 ( fig . she remained in outpatient physical and occupational therapy for 15  weeks , and continued the exercises at home . at the 1-year follow - up she was able to supinate her forearm to approximately 45 and pronate it to approximately 80 ( fig . 4ap ( a ) and lateral ( b ) radiographs of the elbow exhibiting a well - healed and concentrically maintained elbow with a stable distal druj ( c  d)fig . 5photographs at the 1-year follow - up clinical examination demonstrating supination of 45 ( a ) , pronation of 80 ( b ) extension of 5 ( c ) , and flexion of 95  ( d ) in the affected extremity ap ( a ) and lateral ( b ) radiographs of the elbow exhibiting a well - healed and concentrically maintained elbow with a stable distal druj ( c  d ) photographs at the 1-year follow - up clinical examination demonstrating supination of 45 ( a ) , pronation of 80 ( b ) extension of 5 ( c ) , and flexion of 95  ( d ) in the affected extremity monteggia fractures are typically associated with high - energy impact  they are most commonly due to a fall on an outstretched hand in forced pronation , as was evidenced in our case . as ulnar displacement increases , the radial head is levered out of the joint , resulting in the classic deformity [ 8 , 9 ] . despite this , monteggia fractures and although rare , the monteggia fracture has gained notoriety among the orthopedic community in light of its notoriously poor outcomes . the displacement by muscle forces across the fracture site and associated ligamentous injury has been shown to be a source of significant morbidity in the past , especially before the routine use of contoured compression plates for treatment [ 10 , 11 ] . bado type ii and injuries with associated radial head and coronoid fractures have historically portended poor clinical outcomes . potential complications of monteggia fractures include persistent dislocation of the radial head , elbow stiffness , forearm synostosis , nerve palsy , and residual forearm deformity . there have been reports of persistent dislocation of the radial head caused by median and radial nerve entrapment , resulting in subsequent nerve palsy [ 13 , 14 ] . although closed treatment remains standard for most pediatric monteggia fractures , internal fixation is mandatory in adults . despite the potentially disabling and often unpredictable complications inherent to open fixation , recent studies have shown satisfactory results in 5583  % of monteggia fractures when treated with anatomic reduction and stable plate fixation that permits early mobilization [ 4 , 16 ] . anatomic alignment of the ulnar fracture with restoration of the trochlear notch typically allows for a manageable reduction of the proximal radiocapitellar joint and , consequently , a satisfactory result . achieving a satisfactory result for our patient coincided with the aforementioned goals for reconstruction anatomic and stable reconstruction of the pruj with definitive restoration of the forearm ring . representing an unclassifiable monteggia variant - type injury , however , paying particular attention to maintaining concentric stability at the elbow along with early , protected rom via plate fixation and combined hinged ex - fix utilization resulted in a good clinical outcome , despite the nonadherent efforts put forth by our patient . while the overall use of microfracture remains controversial , it was utilized in our case to provide our patient with every chance of maintaining long - term painless , full elbow rom and function . long - term follow - up with possible re - exploration will be necessary to truly assess the role of microfracture in this setting . in summary , combined plate fixation , ligamentous repair , druj stabilization , and placement of a hinged external fixator proved to be an effective strategy to achieve union and restore functional status in our patient with a high - energy , unclassifiable monteggia fracture variant . paying particular attention to anatomic restoration of the forearm ring with concentric elbow stability is of paramount importance . however , this represents just one case in an already rarely occurring fracture pattern , and additional studies will be necessary to prove the true efficacy and reproducibility of this treatment strategy . furthermore , the role of microfracture in this injury setting also needs to be further explored , as it may prove as a useful adjunct in maintaining fluid elbow function .
originally described by monteggia and later classified by bado , elbow dislocations with concurrent radial and ulnar shaft fractures with distal radioulnar joint ( druj ) disruption are considered operative cases with high - energy injurious etiologies . here 
 , we present an unclassifiable monteggia variant fracture suffered through a high axial load mechanism in a 47-year - old female . 
 the fracture pattern initially exhibited included a divergent elbow dislocation , a radial shaft fracture , plastic deformation of the distal ulna , and druj instability . 
 here we describe the pattern in detail , along with definitive treatment and clinical outcome at 1  year follow - up .