The aim of this study was to compare the clinical and radiological outcomes in children with acute Monteggia fracture treated by two different surgical techniques. Twenty-six children treated by either closed reduction and external fixation (group A) or elastic stable intramedullary nails (group B) were retrospectively reviewed. Clinical outcome was evaluated with the Quick DASH questionnaire. Overall, both surgical techniques provided similar excellent healing rates and good clinical outcomes (P > 0.05), as well as radiological outcomes (P > 0.05). Radiographically, no secondary displacement, wire migration, consolidation delays, non-union, malunion or re-fractures were noted. However, two patients (7.6%), one in group A (1/15; 6.7%) and one in group B (1/11; 9.1%), developed heterotopic ossification at the level of the ulna. Clinical functional outcomes were similar between the two groups of patients. The mean overall Quick DASH score was 0.79 (range, 0-18.2). However, six in group A (40%) and one in group B (9.1%) complained of the clinical appearance and had intermittent residual pain on the injured side. In conclusion, both elastic stable intramedullary nailing and external fixation can achieve satisfactory clinical and radiographic outcomes in children with acute Monteggia fractures. However, the rate of residual pain and less satisfactory clinical appearance was higher in patients managed by external fixation compared to those treated by elastic stable intramedullary nailing. According to our results, elastic stable intramedullary nailing should be used as primary treatment option in children with acute Monteggia fracture requiring surgical management.