Subcutaneous enucleation of the radial neck in a Monteggia-like fracture: an exceptional variant.

introduction and importanceMonteggia lesions combine a fracture of the ulna with dislocation of the radial head. Monteggia-like variants add a radial head fracture. We report a unique Monteggia-like injury with a bifocal radial fracture and subcutaneous enucleation of the radial neck, which does not fit existing classifications. CASE PRESENTATION: A 29-year-old male sustained a high-energy axial trauma to the flexed, supinated left elbow. Examination showed isolated swelling without neurovascular injury. X-rays revealed a transverse ulnar fracture with a multifragmentary radial head fracture and a bifocal metaphyso-diaphyseal radial fracture. The intermediate radial fragment was displaced posterolaterally into subcutaneous tissue. Surgical treatment included ORIF of the ulna and excision of the subcutaneous radial fragment; the radial head was left in place under the capitellum. Postoperative care involved immobilization for three weeks with early mobilization. At two years, the patient had minimal pain but marked limitation in rotation (70° pronation, 30° supination); flexion-extension was 0-130°, and the DASH score was 32/100. CLINICAL DISCUSSION: No similar fracture pattern has been reported. The injury likely resulted from an unusual combination of significant elbow flexion and full supination under axial load, preserving the annular ligament and radial head position. Reconstruction of the radial neck was not possible due to comminution, risk of nonunion, and lack of hardware. Importantly, the treatment context involved significant technical limitations influencing the surgical strategy. Functional limitation highlights the importance of restoring radial neck anatomy to maintain supination and pronation.

conclusionThis rare variant underscores the need for awareness of atypical Monteggia-like patterns and the importance of anatomical reconstruction for optimal functional recovery. CONSENT: Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.