If the reduction of the ulna cannot be maintained, internal fixation may be necessary. The arm is then immobilized in a long arm cast with sufficient extension. The forearm should also be supinating while a direct ulnarward pressure is applied over the dislocated radial head. Closed manipulation should consist of restoring the alignment of the ulna fracture and strong supination to reduce both the radial head dislocation and the radial fracture. However, these fractures are difficult to reduced by closed manipulation.
First step is accurate reduction of the ulna with either intramedullary fixation or plating.
Following this, if closed manipulation of the radius fails, the radial shaft should be exposed as well as the radial head if needed. If the annular ligament cannot be repaired, consider the Bell-Tawse procedure for reconstructing the annular ligament . J.L. The Monteggia lesion. N.R.M. Unusual Monteggia lesions in children. S.P. Monteggia-type elbow fractures in childhood.