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Haft M, Codd CM, May CC, Conroy JL, Abzug JM. Pediatric Monteggia Fracture-dislocations and Their Variants: An Analysis of Outcomes and Complications Over a 10-year Period. J Pediatr Orthop 2025; 45:1-6. [PMID: 39279727 DOI: 10.1097/bpo.0000000000002802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2024]
Abstract
OBJECTIVE Monteggia fracture-dislocation variants have been well documented in adults, but most of the literature in the pediatric population is in the form of case reports. These injuries present differently in children due to the presence of immature radiocapitellar epiphyses and the flexibility of the joint that is more prone to subluxation, contributing to occult presentations and/or misdiagnoses. The purpose of this study is to investigate the outcomes and complications of true Monteggia fracture-dislocations compared with their variants in the pediatric population. METHODS A retrospective review was performed of all patients 17 years of age and younger who sustained a true Monteggia fracture-dislocation or a Monteggia fracture-dislocation variant over a 10-year period. Patient demographics, mechanisms of injury, fracture pattern, Bado and Letts classification, treatment (operative or conservative), and complications were recorded. RESULTS Of the 89 patients identified, 17 (19.1%) had true Monteggia fracture dislocations, and 72 (80.9%) had a Monteggia fracture-dislocation variant. The most common Monteggia fracture-dislocation variant was an olecranon fracture and concomitant radial neck fracture (65.3%, n = 47). Of the Monteggia fracture-dislocation variants, 83.3% (n = 60) were treated nonoperatively with closed reduction and immobilization or immobilization alone, whereas only 23.5% (n = 4) of the true Monteggia fracture-dislocation injuries were treated nonoperatively with closed reduction and immobilization. Overall, 14 (15.7%) patients had complications during the course of treatment, including 12 (16.7%) Monteggia fracture-dislocation variants and 2 (11.8%) true Monteggia fracture-dislocations. The most common complications were loss of range of motion (n = 6, 42.9%, all of which were nondisplaced variants), loss of reduction (n = 4, 28.6%, including 2 nondisplaced variants, 1 displaced variant, and 1 true Monteggia fracture dislocation), and malunion or nonunion (n = 2, 14.3%, both nondisplaced variants). CONCLUSION Pediatric Monteggia fracture-dislocation variants are much more common than true pediatric Monteggia fracture-dislocations. Monteggia fracture-dislocation variants have similar complication rates to true Monteggia fracture-dislocations overall, however, nondisplaced variants exhibited a higher complication rate when treated operatively. Further studies are warranted to assess specific fracture patterns and their associated treatments that result in varying complication rates. LEVEL OF EVIDENCE Level III-retrospective comparison study.
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Affiliation(s)
- Mark Haft
- Department of Orthopaedic Surgery, Riverside University Health Systems, Moreno Valley, CA
| | - Casey M Codd
- Department of Pediatric Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Catherine C May
- Department of Pediatric Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Julia L Conroy
- Department of Pediatric Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Joshua M Abzug
- Department of Pediatric Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
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Wang W, Mei Q, Liu H, Guo Y, Mei H, Canavese F, Andreacchio A, Lyu H, Chen S, He S. Risk factors for proximal radial abnormalities in children with untreated chronic Monteggia fractures: a review of 142 cases. J Orthop Traumatol 2024; 25:60. [PMID: 39614016 PMCID: PMC11607283 DOI: 10.1186/s10195-024-00793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 10/10/2024] [Indexed: 12/01/2024] Open
Abstract
BACKGROUND The risk factors for proximal radial abnormalities (PRA) in paediatric patients with untreated chronic Monteggia fractures (CMFs) are unclear. This multicentre study aimed to evaluate the risk factors for PRA in children with untreated CMFs. MATERIALS AND METHODS The clinical data of 142 patients (mean age at the time of injury: 5.73 years) with untreated unilateral CMFs were retrospectively reviewed. The radial neck-shaft angle (RNSAP) and radial head size (RHL) were measured on anteroposterior (AP) and lateral (L) radiographs, respectively. The RHL size was the ratio of the widest width of the proximal radial metaphysis to the narrowest radial neck width. The En-RNSAP and En-RHL were the ratios of the enlargement (En) of the RNSAP angle and RHL size of the injured elbow to those of the uninjured elbow, respectively. Paired-sample t-tests, single-factor analyses and multiple linear regression analyses were performed to evaluate the correlation between the differences in these parameters between the injured and uninjured elbows and the assessed risk factors. These risk factors included institution, sex, laterality, age at injury, time from injury to diagnosis, direction of RH dislocation, distance of RH dislocation (DD-RH), presence of radial or median nerve injury, heterotopic ossification and immobilization of the elbow after injury. RESULTS In children with untreated CMFs (mean time from injury to diagnosis: 14.6 months), Student's t-test revealed a significant difference in the RHL size (P < 0.001) but not in the RNSAP angle (P = 0.075) between the injured and uninjured elbows. Pearson correlation analysis revealed a potential correlation between En-RHL and age at the time of injury (P = 0.069), time from injury to diagnosis (P < 0.001) and DD-RH (P < 0.001), excluding other risk factors (P > 0.05). Multiple linear regression analysis revealed that age at the time of injury (P = 0.047), time from injury to diagnosis (P = 0.007) and DD-RH (P = 0.001) were risk factors for an increased En-RHL in patients with untreated CMFs; the variability in En-RHL among the other three risk factors was 21.4%. CONCLUSIONS In paediatric patients with unilateral untreated CMFs, PRA of the injured elbow consisted mainly of RH enlargement or radial neck narrowing rather than valgus deformities of the proximal radius. Older age at injury, increased time from injury to diagnosis and DD-RH were risk factors for more severe PRA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- WenTao Wang
- Department of Orthopedics, Shenzhen Traditional Chinese Medicine Hospital, 1st Fuhua Road of Futian District, Shenzhen, 518033, Guangdong, China.
- Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China.
| | - QianQian Mei
- Department of Pediatric Orthopedics, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Hang Liu
- Department of Pediatric Orthopedics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - YueMing Guo
- Department of Pediatric Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, China
| | - HaiBo Mei
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, Hunan, China
| | - Federico Canavese
- Orthopedic and Traumatology Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, Genoa, Italy
- DISC-Dipartimento di scienze chirurgiche e diagnostiche integrate, University of Genova, Viale Benedetto XV No 6, Genova, Italy
| | - Antonio Andreacchio
- Department of Pediatric Orthopaedics, Vittore Buzzi Children's Hospital, 20154, Milan, Italy
| | - HanQing Lyu
- Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China.
- Department of Radiology, Shenzhen Traditional Chinese Medicine Hospital, 1st Fuhua Road of Futian District, Shenzhen, 518033, Guangdong, China.
| | - ShunYou Chen
- Department of Pediatric Orthopedics, Fuzhou Second Hospital, 47th Shangteng Road of Cangshan District, Fuzhou, 350007, Fujian, China.
| | - ShengHua He
- Department of Orthopedics, Shenzhen Traditional Chinese Medicine Hospital, 1st Fuhua Road of Futian District, Shenzhen, 518033, Guangdong, China.
- Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China.
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Bašković M, Pešorda D, Zaninović L, Hasandić D, Lohman Vuga K, Pogorelić Z. Management of Pediatric Elbow Fractures and Dislocations. CHILDREN (BASEL, SWITZERLAND) 2024; 11:906. [PMID: 39201841 PMCID: PMC11352739 DOI: 10.3390/children11080906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 09/03/2024]
Abstract
Pediatric elbow fractures and dislocations have always been a challenge from a diagnostic and therapeutic point of view, primarily due to the complex nature of the pediatric elbow, especially its developmental anatomy. They must be diagnosed and treated on time to prevent numerous complications with long-term consequences. With the development of radiology and pediatric surgery and orthopedics, as well as the development of modern osteosynthesis materials, concerning current scientific and professional knowledge, the outcomes are getting better, with fewer acute and chronic complications. This comprehensive review aims to provide clinicians current knowledge about pediatric elbow fractures and dislocations so that in daily practice they have as few doubts as possible with the best possible treatment outcomes.
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Affiliation(s)
- Marko Bašković
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Domagoj Pešorda
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
| | - Luca Zaninović
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Damir Hasandić
- Department of Pediatric Surgery, Clinical Hospital Center Rijeka, Vjekoslava Dukića 7, 51000 Rijeka, Croatia
- School of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Katarina Lohman Vuga
- Special Hospital for Medical Rehabilitation Varaždinske Toplice, Trg Svetog Martina 1, 42223 Varaždinske Toplice, Croatia
| | - Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Spinčićeva ulica 1, 21000 Split, Croatia
- School of Medicine, University of Split, Šoltanska ulica 2a, 21000 Split, Croatia
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Wang W, Xiong Z, Huang D, Li Y, Huang Y, Guo Y, Andreacchio A, Canavese F, Chen S. Risk factors for unsuccessful reduction of chronic Monteggia fractures in children treated surgically. Bone Jt Open 2024; 5:581-591. [PMID: 38991554 PMCID: PMC11247538 DOI: 10.1302/2633-1462.57.bjo-2024-0004.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
Aims To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically. Methods A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples t-test, chi-squared test, and logistic regression analysis were used to identify the risk factors associated with unsuccessful RHR. Results Redislocation occurred during surgery in 48 patients (23%), and during follow-up in 44 (21.1%). The mean follow-up of patients with successful RHR was 13.25 months (6 to 78). According to the univariable analysis, time from injury to surgery (p = 0.002) and preoperative dislocation distance (p = 0.042) were identified as potential risk factors for unsuccessful RHR. However, only time from injury to surgery (p = 0.007) was confirmed as a risk factor by logistic regression analysis. Receiver operating characteristic curve analysis and chi-squared test confirmed that a time from injury to surgery greater than 1.75 months increased the rate of unsuccessful RHR above the cutoff (p = 0.002). Conclusion Time from injury to surgery is the primary independent risk factor for unsuccessful RHR in surgically treated children with CMFs, particularly in those with a time from injury to surgery of more than 1.75 months. No other factors were found to influence the incidence of unsuccessful RHR. Surgical reduction of paediatric CMFs should be performed within the first two months of injury whenever possible.
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Affiliation(s)
- WenTao Wang
- Department of Orthopedics, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
- Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Zhu Xiong
- Department of Paediatric Orthopedics, Shenzhen Children’s Hospital, Shenzhen, China
| | - DianHua Huang
- Department of Paediatric Orthopedics, Fuzhou Second Hospital, Fuzhou, China
| | - YiQiang Li
- Department of Pediatric Orthopedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - YuLing Huang
- Department of Surgery, Sanming Hospital of Integrated Traditional Chinese and Western Medicine, Sanming, China
| | - YueMing Guo
- Department of Paediatric Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, China
| | - Antonio Andreacchio
- Department of Paediatric Orthopedics, Vittore Buzzi Children’s Hospital, Milan, Italy
| | - Federico Canavese
- Department of Paediatric Orthopedics, Lille University Center, Jeanne de Flandre Hospital, Lille, France
| | - ShunYou Chen
- Department of Paediatric Orthopedics, Fuzhou Second Hospital, Fuzhou, China
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Wintges K, Cramer C, Mader K. Missed Monteggia Injuries in Children and Adolescents: A Treatment Algorithm. CHILDREN (BASEL, SWITZERLAND) 2024; 11:391. [PMID: 38671608 PMCID: PMC11049118 DOI: 10.3390/children11040391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
Monteggia injuries are rare childhood injuries. In 25-50% of cases, however, they continue to be overlooked, leading to a chronic Monteggia injury. Initially, the chronic Monteggia injury is only characterized by a moderate motion deficit, which is often masked by compensatory movements. Later, however, there is a progressive valgus deformity, neuropathy of the ulnar nerve and a progressive deformity of the radial head ("mushroom deformity") with ultimately painful radiocapitellar arthrosis. In the early stages, when the radial head is not yet deformed and there is no osteoarthritis in the humeroradial joint, these injuries can be treated with reconstruction procedures. This can be achieved either by an osteotomy of the proximal ulna with or without gradual lengthening. If there is already a severe deformity of the radial head and painful osteoarthritis, only rescue procedures such as functional radial head resection or radial head resection with or without hemi-interposition arthroplasty can be used to improve mobility and, above all, to eliminate pain. In this review article, we provide an overview of the current treatment options of chronic Monteggia injury in children and adolescents and present a structured treatment algorithm depending on the chronicity and dysplastic changes.
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Affiliation(s)
- Kristofer Wintges
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Christopher Cramer
- Division Hand, Forearm and Elbow Surgery, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Konrad Mader
- Division Hand, Forearm and Elbow Surgery, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
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Freund A, Boemers T, Klein T, Marathovouniotis N, Demian M. [Monteggia lesions and equivalent lesions in children]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:880-885. [PMID: 36048176 DOI: 10.1007/s00113-022-01235-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Missed Monteggia lesions results in chronic luxation and deficits in the range of motion. The overall therapeutic goal is a quick and stable anatomical repositioning of the lesion. The prognosis of Monteggia lesions in comparison to its equivalents is better, especially with early diagnosis. OBJECTIVE Comparison of the types of lesion, treatment modalities, hospitalization, immobilization, movement deficits, perioperative complications and outcome. MATERIAL AND METHODS Retrospective study of 62 patients treated with acute Monteggia lesions and its equivalents during the period of 2009-2020. RESULTS 2 patients were treated with cast immobilization only, 11 with repositioning under general anesthesia, 39 with intramedullary nailing and 10 with screw osteosynthesis. The average observation period was 4.1 months. Patients with cast immobilization needed only a short hospitalization (2 days), patients with repositioning or osteosynthesis had longer hospitalization (3.4 or 4.3 days, respectively). Deficits of the range of motion did not appear in simple cast immobilization or intramedullary nailing without reduction; however, patients with closed reduction or screw osteosynthesis showed some degree of deficits (9% and 40%, respectively). Monteggia lesions needed shorter hospitalization than their equivalents (3.7 vs. 4.5 days) and had less deficits in the range of motion (7% vs. 21%). CONCLUSION Most patients were treated with osteosynthesis (79%). Patients with Monteggia lesions had a better outcome than patients with equivalent lesions.
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Affiliation(s)
- A Freund
- Klinik für Kinder- und Jugendchirurgie und Kinderurologie, Kliniken der Stadt Köln gGmbH - Kinderkrankenhaus, Amsterdamer Str. 59, 50735, Köln, Deutschland.
| | - T Boemers
- Klinik für Kinder- und Jugendchirurgie und Kinderurologie, Kliniken der Stadt Köln gGmbH - Kinderkrankenhaus, Amsterdamer Str. 59, 50735, Köln, Deutschland
| | - T Klein
- Klinik für Kinder- und Jugendchirurgie und Kinderurologie, Kliniken der Stadt Köln gGmbH - Kinderkrankenhaus, Amsterdamer Str. 59, 50735, Köln, Deutschland
| | - N Marathovouniotis
- Klinik für Kinder- und Jugendchirurgie und Kinderurologie, Kliniken der Stadt Köln gGmbH - Kinderkrankenhaus, Amsterdamer Str. 59, 50735, Köln, Deutschland
| | - M Demian
- Klinik für Kinder- und Jugendchirurgie und Kinderurologie, Kliniken der Stadt Köln gGmbH - Kinderkrankenhaus, Amsterdamer Str. 59, 50735, Köln, Deutschland
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Vithran DTA, Song Z, Wang K, Tang Z, Xiang F, Wen J, Xiao S. Comparison of the midterm result between locking plate and elastic intramedullary nail treating oblique ulnar fracture Bado type I acute monteggia fracture in pediatric patients. BMC Musculoskelet Disord 2022; 23:858. [PMID: 36096778 PMCID: PMC9465865 DOI: 10.1186/s12891-022-05809-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Acute Monteggia fracture (AMF) is defined as a fracture of the proximal ulna combined with a dislocation of the radial head, with less than 1 percent prevalence in pediatric patients with an elbow injury. This retrospective study aimed to compare the efficacy of two treatment methods for oblique ulnar fracture AMF Bado type I in children. Methods In this retrospective study, 28 children with oblique ulnar fracture acute Monteggia injury Bado I were included. Patients was divided into two groups: In the EIN group 16 patients were fixed with elastic intramedullary nail after reduction, and in the LCP group 12 patients were fixed with locking compression plate after reduction. Operation time and blood loss were recorded and the patients were assessed clinically by the Mayo Elbow Performance Score (MEPS), range of movement(ROM) and range of rotation(ROR). Results Twenty-eight patients were accessible for durable follow-up, with a mean age of 7.7 ± 1.3 years, follow up by 33.7 ± 5.1 months. The average operation time was 48.1 ± 9.2 min for the EIN group and 67.1 ± 7.2 min for the LCP group. The average blood loss was 8.2 ± 2.3 ml for the EIN group and 18.8 ± 3.8 ml for the LCP group. The average operation time and average blood loss in the EIN group are significant less than the LCP group. Mean MEPS, ROM, ROR in both group improved significantly before sugery to three months after surgery, and maintained very good results at last follow up. There is no significant difference between the EIN group and the LCP group in MEPS, ROM and ROR. Conclusions Oblique ulnar fracture Bado type I acute monteggia fracture in pediatric patients fixed by EIN and LCP can both get good mid-term results measured by MEPS, ROM and ROR, Fixed by EIN have shorter operation time and less blood loss than fixed by LCP.
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Affiliation(s)
- Djandan Tadum Arthur Vithran
- Department of Pediatric Orthopedics, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Zhenqi Song
- Department of Pediatric Orthopedics, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Kongjian Wang
- Department of Pediatric Orthopedics, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Zhongwen Tang
- Department of Pediatric Orthopedics, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Feng Xiang
- Department of Pediatric Orthopedics, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Jie Wen
- Department of Pediatric Orthopedics, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China.
| | - Sheng Xiao
- Department of Pediatric Orthopedics, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China. .,Department of Human Anatomy, Hunan Normal University School of Medicine, Changsha, Hunan, 410013, China.
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Risk factors for redislocation of chronic Monteggia fracture-dislocation in children after reconstruction surgery. INTERNATIONAL ORTHOPAEDICS 2022; 46:2299-2306. [PMID: 35697865 DOI: 10.1007/s00264-022-05473-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Monteggia fracture-dislocation refers to traumatic ulnar fractures and dislocation of the radial head, which is one of the most frequently missed injuries, especially in children. The most widespread attitude towards chronic Monteggia lesion is the open reduction of the radial head associated with ulnar osteotomy with or without annular ligament reconstruction. Our study aimed to analyze the risk factors for redislocation after surgical management of chronic Monteggia lesion and the benefits of annular ligament reconstruction and radiocapitellar pinning in paediatric. MATERIALS AND METHODS We retrospectively reviewed patients treated with reconstruction surgery for chronic Monteggia fracture-dislocation in our department between 2005 and 2017, with a minimum two years' follow-up. The reconstruction surgery included ulnar osteotomy performed in all patients, annular ligament repair or reconstruction or fixation of radiocapitellar joint, or radial osteotomy in some patients. We collected the related clinical data and evaluated the risk factors of redislocation using logistic regression analyses and a two-piecewise linear regression model with a smoothing function, after reconstruction. RESULTS Throughout a mean six years' follow-up (range, 2-14 years), 62 patients (42 males, 20 females; average age 6.49 years range, 2-13 years) were reviewed. Of the radiocapitellar joints, 16.1% was noted to have redislocation. Univariate risk analysis showed age, time from injury to surgery, and radial osteotomy were risk factors for a recurrent radiocapitellar redislocation. Time from injury to surgery was found to be independent predictor of redislocation in multivariate analysis. However, there were significant nonlinear associations between time from injury to surgery and redislocation in multivariate logistic regression analysis after multivariate adjustment (p for nonlinear = 0.023). Every one month increase was associated with a 1.37-fold increase in redislocation, in participants within one year after injury. CONCLUSION In conclusion, the surgery of chronic Monteggia fracture-dislocation should be done as quickly as possible within one year after injury. Associated annular ligament reconstruction or fixation of radiocapitellar joint does not seem to be helpful.
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Closed reduction by trans-physealantegrade elastic stable intramedullary nailing in acute pediatric Monteggia fractures: a report of 22 cases. J Pediatr Orthop B 2022; 31:43-49. [PMID: 33165215 DOI: 10.1097/bpb.0000000000000831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Treatment of acute pediatric Monteggia fractures is still debated. The aim of this study was to assess the efficacy of strategy based on closed reduction by trans-physeal antegrade elastic stable intramedullary nailing (ESIN) of the ulnar fracture. Retrospective analysis of 22 patients (13 boys and nine girls) treated for acute Monteggia fractures between May 2008 and August 2018 was performed. Mean age at injury was 6.6 years. Mean follow-up was 4.5 years. On the basis of the Bado classification, 15 lesions were of type I, three types III and four types IV. All the patients were managed with closed reduction and ESIN of the ulna fracture within 2-19 h of arrival. Intraoperative stability of reduction of the radial head was checked under fluoroscopic control in pronation and supination. Outcomes were assessed with the Bruce et al. scoring system. Closed alignment of the ulnar fracture by ESIN had simultaneously reduced and stabilized the radial head dislocation in all patients. At the final follow-up, all the patients had excellent results. Complete healing of the fracture occurred in 6 weeks and the elastic nail removed at 3-6 months postoperatively. There was no case of instability or subluxation or re-dislocation of the radial head. No olecranon epiphysiodesis or growth disorders were noticed. Early diagnosis and management of acute pediatric Monteggia fractures by closed reduction and ESIN achieve excellent clinical and radiographic outcomes.
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Badre A, Padmore CE, Axford DT, Berkmortel C, Faber KJ, King GJW, Johnson JA. The role of biceps loading and muscle activation on radial head stability in anterior Monteggia injuries: An in vitro biomechanical study. J Hand Ther 2021; 34:376-383. [PMID: 32600743 DOI: 10.1016/j.jht.2020.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/04/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Little evidence-based information is available to direct the optimal rehabilitation of patients with anterior Monteggia injuries. PURPOSE OF THE STUDY The aims of this biomechanical investigation were to (1) quantify the effect of biceps loading and (2) to compare the effect of simulated active and passive elbow flexion on radial head stability in anterior Monteggia injuries. STUDY DESIGN In vitro biomechanical study. METHODS Six cadaveric arms were mounted in an elbow motion simulator. The effect of biceps loading, simulated active and passive elbow flexion motions was examined with application of 0N, 20N, 40N, 60N, 80N, and 100N of load. Simulated active and passive elbow flexion motions were then performed with the forearm supinated. Radial head translation relative to the capitellum was measured using an optical tracking system. After testing the intact elbows, the proximal ulna was osteotomized and realigned using a custom jig to simulate an anatomical reduction. We then sequentially sectioned the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane to simulate soft tissue injuries commonly associated with anterior Monteggia fractures. RESULTS Greater magnitudes of biceps loading significantly increased anterior radial head translation. However, there was no significant difference in radial head translation between simulated active and passive elbow flexion except in the final stage of soft tissue sectioning. There was a significant increase in anterior radial head translation with progressive injury states with both isometric biceps loading and simulated active and passive motion. CONCLUSIONS Our results demonstrate that anatomic reduction of the ulna may not be sufficient to restore radial head alignment in anterior Monteggia injuries with a greater magnitude of soft tissue injury. In cases with significant soft tissue injury, the elbow should be immobilized in a flexed and supinated position to allow relaxation of the biceps and avoid movement of the elbow in the early postoperative period.
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Affiliation(s)
- Armin Badre
- Western Upper Limb Facility, Sturgeon Hospital, St. Albert, Alberta, Canada; Division of Orthopaedic Surgery, Department of Surgery, Edmonton, Alberta, Canada.
| | - Clare E Padmore
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - David T Axford
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Carolyn Berkmortel
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Kenneth J Faber
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, London, Ontario, Canada
| | - Graham J W King
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, London, Ontario, Canada
| | - James A Johnson
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
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Li ML, Zhou WZ, Li LY, Li QW. Monteggia type-I equivalent fracture in a fourteen-month-old child: A case report. World J Clin Cases 2021; 9:9228-9235. [PMID: 34786409 PMCID: PMC8567499 DOI: 10.12998/wjcc.v9.i30.9228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/17/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Monteggia and equivalent lesions are relatively rare but result in severe injuries in childhood, typically affecting children between 4 and 10 years old. The diagnosis and treatment of an equivalent Monteggia lesion is more complicated than those of a typical Monteggia fracture. This type of lesion may be challenging and may lead to serious complications if not treated properly. Pediatric Monteggia equivalent type I lesions have been reported in a few reports, all of which the patients were all over 4 years old.
CASE SUMMARY A 14-mo-old boy was referred to our clinic after falling from his bed 10 d prior. With regard to the clinical examination, an obvious swollen and angular deformity was noted on his right forearm. Plain radiographs and reconstructed computed tomography scans showed a Monteggia type I fracture and dislocation. Magnetic resonance imaging (MRI) confirmed a type I Monteggia equivalent lesion consisting of ulnar fracture and Salter-Harris type I injury in the proximal radius. The radial head was still in the joint, and only the radial metaphysis was displaced anteriorly. Open reduction and pinning of both displaced radial and ulnar fractures achieved an excellent result with full function.
CONCLUSION We recommend MRI examination or arthrography during reduction, especially if the secondary ossification center has not appeared.
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Affiliation(s)
- Ming-Lei Li
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Wei-Zheng Zhou
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Lian-Yong Li
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Qi-Wei Li
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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Li J, Zhao X, Rai S, Ding Y, Zhang Q, Ze R, Tang X, Liu R, Hong P. Two-stage strategy for neglected Monteggia fracture in children: A retrospective study of 51 patients. Medicine (Baltimore) 2021; 100:e25129. [PMID: 33725914 PMCID: PMC7969315 DOI: 10.1097/md.0000000000025129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 02/15/2021] [Indexed: 01/05/2023] Open
Abstract
A neglected Monteggia fracture is defined as the fracture of the proximal ulna associated with radial head dislocation (RHD) without undergoing any treatment for 4 weeks or more after injury. One-stage operation of ulnar corrective osteotomy and open reduction of RHD might result in many complications. Therefore, a two-stage strategy, including ulnar osteotomy (UO) with or without annular ligament reconstruction (ALR), was adopted at our institute since 2010.We performed a retrospective review of 51 patients with neglected Monteggia fracture between January 2010 and January 2018. Patients with bilateral problems or concomitant injuries in the ipsilateral extremity were excluded. Radiological and clinical data were collected from Hospital Database and clinical visits. All patients were divided into 2 groups based on the status of the ALR: the UO alone (UO) group and the ALR group.There were 15 patients in the UO group and 36 patients in the ALR group. The age in the UO group (6.1 ± 2.3, year) was significantly younger than the ALR group (9.8 ± 2.8, year) (P < .001). Concerning the duration from initial injury to surgery, there was a significant difference between the UO group (8.6 ± 3.2 months) and the ALR group (23.3 ± 12.6 months, P < .001). Concerning the preoperative elbow function, there was no significant difference between the UO group (67.6 ± 5.0) and the ALR group (66.6 ± 4.4) according to the Mayo elbow performance score (MEPS) (P = .51). Concerning the postoperative parameters, including postoperative ROM of the joint, removal of external fixator (6.7 ± 0.8, 6.9 ± 0.9 weeks) (P = .55), lengthening (8.9 ± 2.5, 10.3 ± 2.5 mm) (P = .10) and MEPS (92.7 ± 2.1, 91.6 ± 2.1) (P = .08), there was no significant difference between the UO group and ALR group.Two-stage strategy is a reasonable choice for selected patients with long-lasting RHD with ulnar deformity.
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Affiliation(s)
- Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Xiaolong Zhao
- Department of Orthopaedics, First Hospital of Wuhan, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | | | - Qi Zhang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Renhao Ze
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Ruikang Liu
- First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
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Alrashidi Y. A Monteggia variant associated with unusual fracture of radial head in a young child: A case report. Int J Surg Case Rep 2020; 78:42-47. [PMID: 33310469 PMCID: PMC7736760 DOI: 10.1016/j.ijscr.2020.11.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/27/2020] [Accepted: 11/29/2020] [Indexed: 01/09/2023] Open
Abstract
Monteggia fracture is rare among children and its treatment may be challenging. Early recognition of unusual Monteggia variant patterns is crucial to avoid delay in treatment. Adherence to the principles of surgical management in unstable variants is encouraged. Introduction Monteggia fracture and its variants are not common among children but may be challenging and lead to serious complications if not treated in acute stage. The different types of associated growth plate fractures of proximal radius are not yet clearly defined in any variant classifications. Presentation of case A 6-year-old girl was brought to the emergency room after a fall on the left elbow. The plain radiographs showed unstable fracture of proximal ulna with a laterally displaced and comminuted radial head fracture. The patient was treated surgically as a case of a Monteggia variant. The case has been re-evaluated twenty months following the surgery and did not show any radiological signs of growth disturbance nor residual deformity. Discussion The presented Monteggia variant is rare in terms of associated unique intra-articular fracture of proximal radius. The successful management of the case is based on adhering to the principles of treatment of Monteggia fractures. Conclusion Early recognition of unusual Monteggia variant patterns is crucial to avoid delay in treatment. Adherence to the principles of surgical management in unstable variants is encouraged.
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Affiliation(s)
- Yousef Alrashidi
- College of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabia; Department of Orthopedics, King Fahad Hospital, Al-Madinah, Saudi Arabia.
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Hayami N, Omokawa S, Kira T, Hojo J, Mahakkanukrauh P, Tanaka Y. Biomechanical analysis of simultaneous distal and proximal radio-ulnar joint instability. Clin Biomech (Bristol, Avon) 2020; 78:105074. [PMID: 32562881 DOI: 10.1016/j.clinbiomech.2020.105074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Simultaneous dislocation of the proximal and distal radio-ulnar joints without bony injuries has been reported, but the mechanism remains unclear. We investigated concurrent proximal and distal radio-ulnar joint instability after sequential sectioning of the annular ligament, triangular fibrocartilage complex, and quadrate ligament. METHODS We performed this biomechanical study with six fresh-frozen cadaveric upper extremities. Proximal and distal radio-ulnar joint displacement was measured using an electromagnetic tracking device during passive mobility testing with anterior, lateral, and posterior loads on the radial head with pronation, supination, and neutral rotation. Measurements were statistically analyzed using the generalized linear mixed model. FINDINGS Proximal radio-ulnar joint instability was significantly greater after sectioning of the annular (lateral: 1.4%, P < .05; posterior: 0.7%, P < .05) and quadrate (lateral: 43.7%, P < .05; posterior: 29.5%, P < .05) ligament. Distal radio-ulnar joint instability was significantly greater in every sequential stage (final stage: anterior: 24.1%, P < .05; lateral 21.0%, P < .05; posterior: 31.3%, P < .05). Finally, significant simultaneous instability of the joints was observed after sectioning of the annular ligament, triangular fibrocartilage complex, and quadrate ligament, and neutral rotation potentially induced gross instability. INTERPRETATION Our ligament injury model induced simultaneous proximal and distal radio-ulnar joint instability without bony or interosseous membrane injury, probably induced by severe soft tissue injury. Proximal radio-ulnar joint instability may influence distal radio-ulnar joint instability from pivoting of the interosseous membrane. Our findings will help surgeons evaluate the magnitude of soft tissue injury and plan surgery for patients with simultaneous proximal and distal radio-ulnar joint instability.
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Affiliation(s)
- Naoki Hayami
- Department of Orthopedic Surgery, Ishinkai Yao General Hospital, 41, 1, Numa, Yao, Osaka, Japan; Department of Orthopedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Shohei Omokawa
- Department of Hand Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan.
| | - Tsutomu Kira
- Department of Orthopedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Junya Hojo
- Department of Orthopedic Surgery, Heisei Memorial Hospital, 827 Shijo-cho, Kashihara, Nara, Japan
| | - Pasuk Mahakkanukrauh
- Excellence in Osteology Research and Training Center (ORTC), Chiang Mai University, Chiang Mai 50200, Thailand; Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Yasuhito Tanaka
- Department of Orthopedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
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Clinical effect of manual reduction of humeroradial joint in the treatment of type Ⅰ-Ⅲ fresh Monteggia fracture in children. Chin J Traumatol 2020; 23:233-237. [PMID: 32680703 PMCID: PMC7451604 DOI: 10.1016/j.cjtee.2020.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate the efficacy of closed reduction on the humeroradial joint in the treatment of Bado type Ⅰ, Ⅱ and Ⅲ fresh Monteggia fractures in children and investigate the effect of clinical factors, including Bado classification, age and time of treatment on the success rate of closed reduction. METHODS We retrospectively studied the data of children ≤10 years old with fresh Monteggia fractures (injury within two weeks) treated by manual reduction with plaster immobilization from January 2014 to April 2019. All patients were followed up in the outpatient department every two weeks for 4-6 weeks until plaster removal and then 3, 6 and 12 months. Online or telephone interview was provided for some inconvenient patients after 6 months. Mackay criteria were used to evaluate the clinical effect. Radiographic data were collected and reviewed to assess the reduction of the humeroradial joint. Function of the elbow joint and forearm was evaluated and risk factors related to the failure of reduction were assessed. The successful manual reduction was analyzed from three aspects, respectively Bado fracture type (Ⅰ, Ⅱ, Ⅲ), patient age (<3 year, 3-6 years, >6 years) and time interval from injury to treatment (group A, <1 day; group B, 1-3 days; group C, >3 days). RESULTS Altogether 88 patients were employed in this study, including 58 males (65.9%) and 30 females (34.1%) aged from 1 to 10 years. There were 29 cases (33.0%) of Bado type Ⅰ Monteggia fractures, 16 (18.2%) type Ⅱ and 43 (48.7%) type Ⅲ. Successful manual reduction was achieved in 79 children (89.8%) at the last follow-up. The failed 9 patients received open surgery. Mackay criteria showed 100% good-excellent rate for all the patients. The success rate of manual reduction was 89.7%, 87.5% and 90.7% in Bado type Ⅰ, Ⅱ and Ⅲ cases, respectively, revealing no significant differences among different Bado types (χ2 = 0.131, p = 0.937). Successful closed reduction was achieved in 13 toddlers (13/13, 100%), 38 preschool children (28/42, 90.5%) and 28 school-age children (28/33, 84.8%), suggesting no significant difference either (χ2 = 2.375, p = 0.305). However time interval from injury to treatment showed that patients treated within 3 days had a much higher rate of successful manual reduction: 67 cases (67/71, 94.4%) in group A, 10 cases (10/11, 90.9%) in group B, and 2 cases (2/6, 33.3%) in group C (χ2 = 22.464, p < 0.001). Fisher's test further showed significant differences between groups A and C (p = 0.001) and groups B and C (p = 0.028). CONCLUSION Closed reduction is a safe and effective method for treating fresh Monteggia fractures in children. The reduction should be conducted as soon as possible once the diagnosis has been made.
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Badre A, Axford DT, Padmore CE, Berkmortel C, Faber KJ, Johnson JA, King GJW. Effect of ulnar angulation and soft tissue sectioning on radial head stability in anterior Monteggia injuries: an in vitro biomechanical study. J Shoulder Elbow Surg 2020; 29:1249-1258. [PMID: 32044251 DOI: 10.1016/j.jse.2019.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/20/2019] [Accepted: 10/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Radial head instability continues to be a challenge in the management of anterior Monteggia injuries; however, there is a paucity of literature on the factors that contribute to this instability. The aim of this biomechanical investigation was to examine the effects of ulnar angulation and soft tissue insufficiency on radial head stability in anterior Monteggia injuries. METHODS Six cadaveric arms were mounted in an elbow motion simulator. Radial head translation was measured during simulated active elbow flexion with the forearm supinated. After testing the elbows in the intact state, the ulna was osteotomized and tested at 0°, 10°, 20°, and 30° of extension angulation. To examine the effect of soft tissue insufficiency, the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane (IOM) were sequentially sectioned. RESULTS There was a significant increase in anterior radial head translation with greater ulnar extension angulation. Sequential soft tissue sectioning also significantly increased anterior radial head translation. There was no increase in radial head translation with isolated sectioning of the anterior radiocapitellar joint capsule. Additional sectioning of the annular ligament and quadrate ligament slightly increased anterior radial head translation but did not reach statistical significance. Subsequent sectioning of the proximal and middle IOM resulted in significant increases in anterior radial head translation. CONCLUSION Our study demonstrates that progressive ulnar extension angulation results in an incremental increase in anterior radial head translation in anterior Monteggia injuries. Moreover, increasing magnitudes of soft tissue disruption result in greater anterior radial head instability.
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Affiliation(s)
- Armin Badre
- Roth-McFarlane Hand & Upper Limb Centre, St Joseph's Health Care, London, ON, Canada; Division of Orthopaedic Surgery, Department of Surgery, London, ON, Canada.
| | - David T Axford
- Roth-McFarlane Hand & Upper Limb Centre, St Joseph's Health Care, London, ON, Canada; Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Clare E Padmore
- Roth-McFarlane Hand & Upper Limb Centre, St Joseph's Health Care, London, ON, Canada; Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Carolyn Berkmortel
- Roth-McFarlane Hand & Upper Limb Centre, St Joseph's Health Care, London, ON, Canada; Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Kenneth J Faber
- Roth-McFarlane Hand & Upper Limb Centre, St Joseph's Health Care, London, ON, Canada; Division of Orthopaedic Surgery, Department of Surgery, London, ON, Canada
| | - James A Johnson
- Roth-McFarlane Hand & Upper Limb Centre, St Joseph's Health Care, London, ON, Canada; Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Graham J W King
- Roth-McFarlane Hand & Upper Limb Centre, St Joseph's Health Care, London, ON, Canada; Division of Orthopaedic Surgery, Department of Surgery, London, ON, Canada
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An Alternative to the Traditional Radiocapitellar Line for Pediatric Forearm Radiograph Assessment in Monteggia Fracture. J Pediatr Orthop 2020; 40:e216-e221. [PMID: 31385897 DOI: 10.1097/bpo.0000000000001434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To find a new reference for assessment of pediatric forearm radiographs besides the traditional RCL. METHODS RCLs were drawn on the anteroposterior (AP) and lateral radiographs of 170 normal pediatric forearms. Three lines were drawn on each radiograph: the first was drawn along the longitudinal center of the radial neck (N-line); the second, along the radial shaft (S-line); and the third, through the midpoints of the proximal and distal radial physes (P-line). RESULTS The P-line was least likely to miss the capitellum on both AP views and lateral views, and the P-line most frequently passed through the central third of the capitellum on both AP views and lateral views. CONCLUSIONS Our proposed radiocapitellar P-line was found to be much more reliable in younger children than traditional RCLs.
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Yuan Z, Xu HW, Liu YZ, Li YQ, Li JC, Canavese F. The use of external fixation for the management of acute and chronic Monteggia fractures in children. J Child Orthop 2019; 13:551-559. [PMID: 31908671 PMCID: PMC6924126 DOI: 10.1302/1863-2548.13.190115] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The main objective of this study was to retrospectively evaluate the clinical and radiological outcomes of acute (AMF) and chronic Monteggia fractures (CMF) in children treated by closed or open reduction and external fixation (EF). METHODS This is a retrospective review of 26 patients with Monteggia fracture. Patients with AMF (time between trauma and surgery less than two weeks) were treated by closed reduction and EF of the ulna (Group A; 15 patients) while those with CMF (time between trauma and surgery more than three weeks) were managed by closed or open reduction and EF of the ulna (Group B; 11 patients). Clinical outcome was evaluated with radiography and the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH). Complications were recorded in both groups. RESULTS No secondary displacement, wire migration, consolidation delays, nonunion, malunion or re-fracture was noted. However, one patient in Group A (6.7%) developed heterotopic ossification of the ulna; the final functional outcome was good (Quick DASH score: 18.2). One case of postoperative redislocation of the radial head was detected in Group B (9.1%). Two patients (7.6%) developed transient pin tract infection. Despite the fact that 16 out of 26 patients (six in Group A and ten in Group B) complained of the clinical appearance and/or had intermittent residual pain on the injured side, the results were essentially the same between the two groups of patients (p > 0.05). CONCLUSION EF is an alternative for the management of acute and chronic paediatric Monteggia fractures. It provides satisfactory radiological and clinical outcomes with relatively low rates of complications. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Z. Yuan
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - H. W. Xu
- University Hospital Estaing, Department of Pediatric Surgery, Clermont Ferrand, France
| | - Y. Z. Liu
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - Y. Q. Li
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - J. C. Li
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - F. Canavese
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China,University Hospital Estaing, Department of Pediatric Surgery, Clermont Ferrand, France,Correspondence should be sent to F. Canavese, Department of Pediatric Orthopaedics, GuangZhou Women and Children’s Medical Center, 9th JinSui Road, GuangZhou, 510623, China. E-mail:
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Soni JF, Valenza WR, Matsunaga CU, Costa ACP, Faria FF. CHRONIC MONTEGGIA FRACTURE-DISLOCATION IN CHILDREN SURGICAL STRATEGY AND RESULTS. ACTA ORTOPEDICA BRASILEIRA 2019; 27:244-247. [PMID: 31839731 PMCID: PMC6901151 DOI: 10.1590/1413-785220192705215273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To report surgical techniques and results in the treatment of chronic
Monteggia fracture-dislocation in children. Methods: Six pediatric patients who had undergone a procedure involving the following
6 crucial surgical steps were retrospectively evaluated: 1- extended lateral
approach, 2- fibrotic removal, 3-proximal ulnar osteotomy, 4- reduction of
the radial head and transcapitellar temporary fixation, 5- ulnar fixation
with a straight plate shaped according to the deformity generated by
temporary fixation, and 6- transcapitellar Kirschner wire removal. Results: Four patients were women, and four showed the right-sided compromise. The
mean age of patients was 8 years, and the minimum follow-up period was 12
months. The mean time from the onset of fracture to treatment was 6 months.
Six patients underwent complete flexo/extension, and one patient had a
complete prono-supination. In four patients, we observed loss of pronation
(by 10° in two, 15° in one, and 20° in one), and one patient had a 15°
decrease in supination. We did not observe any redislocation of the radial
head in the follow-up evaluation. No complications were observed; the only
complaint was salience of the ulnar plate. Conclusions: Our results demonstrated an effective option for the treatment of chronic
Monteggia fracture-dislocation in children, even with a small study sample,
following the presented technical and surgical strategies. Level of evidence IV, Therapeutic Studies.
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Affiliation(s)
- Jamil Faissal Soni
- Hospital do Trabalhador, Brazil; Pontifícia Universidade Católica do Paraná, Brazil
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Complications during the treatment of missed Monteggia fractures with unilateral external fixation: a report on 20 patients in a 10-year period in a tertiary referral center. J Pediatr Orthop B 2019; 28:256-266. [PMID: 30789537 DOI: 10.1097/bpb.0000000000000592] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The treatment of a missed Monteggia (MM) fracture dislocation is still controversial. We describe our initial experience with ulnar osteotomy and progressive correction with unilateral external fixator in MM. We retrospectively evaluated 20 children undergoing ulnar osteotomy and progressive distraction angulation by unilateral external fixator to treat MM. Nine patients had closed reduction, whereas 11 patients had simultaneous open reduction, repair, or reconstruction of the annular ligament and K-wire stabilization of the radiocapitellar joint. Patients were followed for an average of 3 (1-11) years. Three children developed aseptic nonunion and one child had delayed union. A distal level of the osteotomy significantly increased the rate of nonunion or delayed union. At the final follow-up, eight children had complete reduction of the radial head, six children had partial reduction, whereas in six cases, the radial head remained dislocated. The angulation and the level of the osteotomy significantly influenced the relocation, whereas the open reduction had no significant effect on the final position of the radial head. At the final follow-up, the Kim's score averaged 93.25. The flexion-extension arc significantly improved postoperatively, and it was positively correlated with the angulation. The ulnar osteotomy and progressive traction-angulation by unilateral external fixator can achieve satisfactory results in MM, if a meticulous surgical technique is applied; care must be taken regarding the level of osteotomy and the progressive traction-angulation.
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Abstract
PURPOSE OF REVIEW The chronic Monteggia may lead to pain, mobility limitation, progressive valgus deformity, lateral elbow instability, late ulnar nerve paralysis, and degenerative changes. In this review, we discuss the current procedures in the literature focused on correcting chronic Monteggia to avoid these complications. RECENT FINDINGS Correction of the ulnar deformity with elongation and angulation of the ulna in the opposite direction of the dislocation of the radial head is the most important factor for the reduction and consequent preservation of the radial head. This correction reestablishes the relation of the ulna with the radius and increases the space of the interosseous membrane, providing greater stability after the reduction. The correction may be performed in the acute phase and stabilized with a properly molded plate and screws, or done progressively with an external fixator. SUMMARY The chronic Monteggia may occur along with undiagnosed lesions, such as plastic deformation of the ulna with radial head dislocation, or after an unsuccessfully treated acute Monteggia lesion. This condition may go unnoticed, thus requiring attention to the physical examination and imaging tests. Chronic Monteggia may be treated by ulnar osteotomy with progressive correction with an external fixator. However, the most common treatment is transverse proximal ulnar osteotomy, capsulotomy and removal interposed tissue, reduction of the radial head to the capitellum and temporary transcapitellar fixation, ulnar fixation with a straight plate molded to the ulnar deformity, which is usually deviated dorsally, removal of the transcapitellar Kirschner-wire, stability test, and, if necessary, annular ligament reconstruction.
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Pari C, Puzzo A, Paderni S, Belluati A. Annular ligament repair using allograft for the treatment of chronic radial head dislocation: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 90:154-157. [PMID: 30715016 PMCID: PMC6503397 DOI: 10.23750/abm.v90i1-s.8010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 11/24/2022]
Abstract
Background: The annular ligament has a crucial role in the radial head stability and it is critical to the proper functioning of the proximal radio-capitellar joint. Its chronic injury may lead to radial head instability, elbow pain with decrease in motion and valgus deformity. Method: We present the case of a 53-year-old heavy laborer who reported a complex trauma of the right upper limb with a Floating Elbow Injury, associated to an open Monteggia fracture-dislocation. One month later, despite the definitive fixation with plates of both the forearm and the supracondylar fractures, X-rays showed the persistence of the radial head dislocation. A triceps autograft reconstruction for treating the chronic radial head dislocation, as described in literature, was not indicated in our patient, due to the recent surgery at the distal humerus site. Thus, it was decided to proceed to allograft reconstruction using a peroneal tendon from a cadaveric donor, fixed by modified Bell-Tawse Technique. Results: Two years after the surgery, x-rays showed the complete fractures’ healing; however a radial head notching was found. Conclusions: Allograft reconstruction of the annular ligament deserves to be considered as an adequate technique, whenever the surrounding soft tissues are critically compromised. In literature, the radial head notching complication is reported to be up to 36 %, and it may be related to the surgical technique, regardless of the graft used. (www.actabiomedica.it)
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Affiliation(s)
- Carlotta Pari
- Orthopaedic and Traumatology Department, Hospital Santa Maria delle Croci, Ravenna, Italy.
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Annular ligament reconstruction in chronic Monteggia fracture-dislocations in the adult population: indications and surgical technique. Musculoskelet Surg 2018; 102:93-102. [PMID: 30343474 DOI: 10.1007/s12306-018-0564-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
Chronic Monteggia fracture is defined as dislocation of the radial head that is still present 4 weeks after injury. The cause may reside in residual ulnar deformity after internal fixation, in failure of annular ligament healing, or both. This situation may lead to elbow pain, decreased motion, neurologic problems and valgus deformity. The aim of the present study is to investigate indications and surgical technique for annular ligament reconstruction (ALR) in chronic Monteggia fractures. Relevant articles on annular ligament anatomy and biomechanics, clinical-radiographic evaluation of chronic Monteggia lesions and surgical techniques for ALR were reviewed. A case of an ALR in chronic Monteggia injury using a modified Bell Tawse surgical technique with triceps tendon autograft is presented. Little data exist on chronic Monteggia injury in the adult population. The annular ligament has a critical role in radial head stability. Nonetheless, bony alignment of the ulna is confirmed to be the most relevant feature to address in chronic Monteggia fractures. ALR has been advocated to address radial head instability both combined with ulna osteotomy and as a single procedure, with several surgical techniques described and controversial results reported. A modified Bell Tawse surgical technique resulted to be effective in the presented case. ALR seems to be indicated in chronic Monteggia fractures with normal bony alignment, without conclusive evidence on a preferable surgical technique.
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Park H, Park KW, Park KB, Kim HW, Eom NK, Lee DH. Impact of Open Reduction on Surgical Strategies for Missed Monteggia Fracture in Children. Yonsei Med J 2017; 58:829-836. [PMID: 28540998 PMCID: PMC5447116 DOI: 10.3349/ymj.2017.58.4.829] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aims of this study were to review our cases of missed Monteggia fracture treated by open reduction of the radial head with or without ulnar osteotomy and to investigate the indications for open reduction alone in surgical treatment of missed Monteggia fracture. MATERIALS AND METHODS We retrospectively reviewed 22 patients who presented with missed Monteggia fracture. The patients' mean age at the time of surgery was 7.6 years. The mean interval from injury to surgery was 16.1 months. The surgical procedure consisted of open reduction of the radiocapitellar joint followed by ulnar osteotomy without reconstruction of the annular ligament. The mean period of follow-up was 3.8 years. Radiographic assessment was performed for the maximum ulnar bow (MUB) and the location of the MUB. Clinical results were evaluated with the Mayo Elbow Performance Index and Kim's scores. RESULTS Five patients underwent open reduction alone, and 17 patients underwent open reduction and ulnar osteotomy. When the MUB was less than 4 mm and the location of the MUB was in the distal 40% of the ulna, we could achieve reduction of the radial head without ulnar osteotomy. The radial head was maintained in a completely reduced position in 21 patients and was dislocated in one patient at final follow-up. CONCLUSION Open reduction alone can be an attractive surgical option in select patients with missed Monteggia fracture with minimal bowing of the distal ulna. However, ulnar osteotomy should be considered in patients with a definite ulnar deformity.
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Affiliation(s)
- Hoon Park
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Won Park
- Institute for Rare Diseases and Department of Orthopedic Surgery, Korea University Medical Center, Guro Hospital, Seoul, Korea
| | - Kun Bo Park
- Division of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Woo Kim
- Division of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Eom
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Lee
- Division of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Adams JE. Forearm Instability: Anatomy, Biomechanics, and Treatment Options. J Hand Surg Am 2017; 42:47-52. [PMID: 28052828 DOI: 10.1016/j.jhsa.2016.10.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/22/2016] [Indexed: 02/02/2023]
Abstract
The forearm unit consists of the radius and ulna, a complex and interrelated set of joints (distal radioulnar joint, proximal radioulnar joint) and the soft tissue stabilizers between the 3 bones. Distally, this is represented by the triangular fibrocartilage complex at the wrist, proximally by the annular ligament at the elbow, and in the forearm by the interosseous membrane. Disruptions in any of these structures may lead to forearm instability, with consequences at each of the remaining structures.
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Affiliation(s)
- Julie E Adams
- Department of Orthopedic Surgery, Mayo Clinic Health System, Austin, MN; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
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