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Background: Monteggia-equivalent fractures are similar to Monteggia fractures but involve different patterns and locations. When these fractures include a severe radial head fracture, radial head arthroplasty (RHA) should be considered. RHA can be performed using Kocher's approach or the less commonly used trans-olecranon approach, which has been less studied. This study evaluates the clinical and radiological outcomes of the trans-olecranon approach for RHA over 15 years. Methods: In this retrospective study, 45 cases of Monteggia-equivalent fractures were analyzed, focusing on patients over 18 with radial head fractures, treated by the same surgeon with RHA and open reduction and internal fixation (ORIF) of the proximal ulna via the trans-olecranon approach. Results: The cohort of 45 patients showed a mean flexion of 112.37° ± 13.7°, mean extension of 24.27° ± 17.9°, mean supination of 57.63° ± 28.9°, and mean pronation of 62.16° ± 29.07°. Clinical and radiographic measurements indicated satisfactory results, with acceptable complication and secondary procedure rates. Conclusion: The trans-olecranon, single-incision approach is effective for managing fractures involving the proximal ulna and radial head, offering adequate access to lateral elbow structures while minimizing damage to surrounding soft tissue. Therefore, this approach should be considered for patients presented with a Monteggia-equivalent fracture and an indication for RHA. [ABSTRACT FROM AUTHOR]