Minimally displaced radial head/neck fractures (Mason type-I, OTA types 21A2.2 and 21B2.1): are we ‘over treating’ our patients?

Monteggia fractures are rare in children, and subtle radial head dislocations, with minor plastic deformation of the ulna, may be missed in up to a third of cases. Complications of Monteggia fractures-dislocations include persistent radial head dislocation, forearm deformity, elbow stiffness, and nerve palsies at the time of presentation. An unusual case of median nerve palsy following elastic stable intramedullary nailing of a type I Monteggia lesion in a 6-year-old girl is presented, and we highlight that, although most nerve palsies associated with a Monteggia fracture-dislocations are treated expectantly in children, early intervention here probably provided the best outcome.

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Influence of Ulnar Bow Sign on Surgical Treatment of Missed Bado Type I Monteggia Fracture in Children

10.21203/rs.3.rs-101496/v1 ◽

2020 ◽

Author(s):

Shijie Liao ◽

Tiantian Wang ◽

Qian Huang ◽

Yun Liu ◽

Rongbin Lu ◽

...

Keyword(s):

Surgical Treatment ◽

Radial Head ◽

Monteggia Fracture ◽

Type I ◽

Ulnar Osteotomy ◽

Group A ◽

The Mean ◽

Group B ◽

Stable Reduction

Abstract PurposeThe present study aimed to explore the influence of ulnar bow on the surgical treatment of Bado type I missed Monteggia fracture in children.MethodsThis study is a retrospective review of 24 patients between November 2010 and March 2019. All patients were treated with open reduction of the radial head and ulnar opening wedge osteotomy without annular ligament reconstruction. The mean interval between injury onset and surgery was five months (range: 2–12 months). The average age of participants at the time of surgery was 6.4 years (range: 3–10 years). We evaluated the maximum ulnar bow (MUB) and MUB position (P-MUB) via radiography. The patients were divided into middle group (group A: 14 cases, MUB located at 40% to 60% of the distal ulna) and distal group (group B: 10 cases, MUB located at 20% to 40% from the distal end of the ulna) based on P-MUB. The mean period of follow-up was 37 months (range: 6–102 months).ResultsAt the last follow-up, all the children showed stable reduction of the radial head, and the flexion function of elbow joint improved after operation (P<0.05). Group A presented a larger the ratio of maximum ulnar bow(R-MUB) and angle of ulnar osteotomy(OA) than group B (P<0.05). There was statistically significant difference between group A and Group B in the P-MUB (P < 0.05). The osteotomy angle was positively correlated with the R-MUB (R2 =0.497,P=0.013), The osteotomy angle was positively correlated with the P-MUB (R2=0.731,P=0.000), The R-MUB is proportional to the P-MUB (R2 =0.597,P=0.002). The regression equation of P-MUB and osteotomy angle: Angle=7.064+33.227* P-MUB (R2=0.459, P =0.000).ConclusionWhen the ulnar bow is positioned at the middle ulna, a stable reduction of radial head need to be achieved through a larger angle in the ulnar osteotomy. If the position of maximum ulnar bow (P-MUB) is closer to the middle of the ulna or the ratio of maximum ulnar bow (R-MUB) is larger, the osteotomy angle is larger.

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Fractures of the Olecranon, Radial Head/Neck, and Coronoid Process

European Surgical Orthopaedics and Traumatology ◽

10.1007/978-3-642-34746-7_228 ◽

2014 ◽

pp. 1451-1478

Author(s):

Peter Kloen ◽

Thomas Christian Koslowsky ◽

Konrad Mader

Keyword(s):

Radial Head ◽

Coronoid Process ◽

Head Neck

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Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Mid-Term Postoperative Outcomes Following a Standardized Protocol

Journal of Clinical Medicine ◽

10.3390/jcm9113500 ◽

2020 ◽

Vol 9 (11) ◽

pp. 3500

Author(s):

Beom-Soo Kim ◽

Du-Han Kim ◽

Seok-Ho Byun ◽

Chul-Hyun Cho

Keyword(s):

Operative Treatment ◽

Radial Head ◽

Lateral Collateral Ligament ◽

Type I ◽

Dash Score ◽

Terrible Triad ◽

Collateral Ligament ◽

Recurrent Instability ◽

Standardized Protocol ◽

Coronoid Fractures

The purpose of this study was to investigate mid-term outcomes and complications after operative treatment according to a standardized protocol for terrible triad injuries. Twenty-four patients that were treated by a single surgeon with a standardized surgical protocol were retrospectively reviewed. After the complete reconstruction of radial head and/or lateral collateral ligament (LCL) complex through a lateral approach, coronoid process, and/or medial collateral ligament (MCL) complex through a medial approach were fixed if the elbow is unstable. For coronoid fractures, only type III were fixed in four cases (16.7%). Twenty-two LCL (91.7%) and five MCL (20.8%) complexes were repaired. At the final follow-up, the mean MEPS and Quick-DASH score were 91.5 and 17.3, respectively. There was no recurrent instability after operation in all cases. This study revealed that operative treatment that was based on our standardized protocol for terrible triad injuries yielded satisfactory mid-term clinical and radiographic outcomes without any recurrent instability. These results suggest that Type I and II coronoid fractures in terrible triad injuries do not need to be fixed if the radial head and ligamentous complex are completely reconstructed.

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Fractures combination of the proximal antebrachium in an immature dog that resembles Monteggia fracture

Veterinary and Comparative Orthopaedics and Traumatology ◽

10.1055/s-0038-1632996 ◽

2006 ◽

Vol 19 (03) ◽

pp. 184-186 ◽

Cited By ~ 3

Author(s):

N. N. Prassinos

Keyword(s):

Growth Plate ◽

Radial Head ◽

Monteggia Fracture ◽

Type I ◽

Distal Fragment ◽

Diaphyseal Fracture ◽

German Shepherd ◽

Physeal Fracture ◽

German Shepherd Dog ◽

Ulnar Fracture

SummaryA 5-month-old German shepherd dog with a combination of a proximal radial physeal fracture and a proximal ulnar diaphyseal comminuted fracture, with cranial displacement of their distal fragment, was presented. This fractures combination resembles type I Monteggia fracture. After surgical reduction of the fractures, three full-cerclage wires were used to stabilize the ulnar fracture, and two positional screws were placed across the radius and ulna immediately distally to the growth plate to hold these bones in apposition. Four weeks post-operatively, the screws were removed since sufficient callus had been formed and the dog was free of lameness. It seems that if the appropriate conditions for a type I Monteggia fracture develop in an immature dog, proximal radial physeal fracture instead of radial head luxation may accompany ulnar diaphyseal fracture.

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Comparison of Exposure in the Kaplan Versus the Kocher Approach in the Treatment of Radial Head Fractures

Hand ◽

10.1177/1558944717745662 ◽

2018 ◽

Vol 14 (2) ◽

pp. 253-258 ◽

Cited By ~ 3

Author(s):

Leslie Fink Barnes ◽

Joseph Lombardi ◽

Thomas R. Gardner ◽

Robert J. Strauch ◽

Melvin P. Rosenwasser

Keyword(s):

Surface Area ◽

Radial Head ◽

Lateral Collateral Ligament ◽

Radial Head Fractures ◽

3 Dimensional ◽

Average Surface Area ◽

The Mean ◽

The Difference ◽

Head Neck

Background: The aim of this study was to compare the complete visible surface area of the radial head, neck, and coronoid in the Kaplan and Kocher approaches to the lateral elbow. The hypothesis was that the Kaplan approach would afford greater visibility due to the differential anatomy of the intermuscular planes. Methods: Ten cadavers were dissected with the Kaplan and Kocher approaches, and the visible surface area was measured in situ using a 3-dimensional digitizer. Six measurements were taken for each approach by 2 surgeons, and the mean of these measurements were analyzed. Results: The mean surface area visible with the lateral collateral ligament (LCL) preserved in the Kaplan approach was 616.6 mm2 in comparison with the surface area of 136.2 mm2 visible in the Kocher approach when the LCL was preserved. Using a 2-way analysis of variance, the difference between these 2 approaches was statistically significant. When the LCL complex was incised in the Kocher approach, the average visible surface area of the Kocher approach was 456.1 mm2 and was statistically less than the Kaplan approach. The average surface area of the coronoid visible using a proximally extended Kaplan approach was 197.8 mm2. Conclusions: The Kaplan approach affords significantly greater visible surface area of the proximal radius than the Kocher approach.

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Surgical treatment of the radial head is crucial for the outcome in terrible triad injuries of the elbow

The Bone & Joint Journal ◽

10.1302/0301-620x.102b12.bjj-2020-0762.r1 ◽

2020 ◽

Vol 102-B (12) ◽

pp. 1620-1628

Author(s):

Alexander Klug ◽

Angela Nagy ◽

Yves Gramlich ◽

Reinhard Hoffmann

Keyword(s):

Surgical Treatment ◽

Radial Head ◽

Independent Effect ◽

Type I ◽

Dash Score ◽

Type Ii ◽

Terrible Triad ◽

Radial Head Fractures ◽

Type Iii

Aims To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes. Methods Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible. Results At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures. Conclusion Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620–1628.

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Surgical treatment of the radial head is critical to the outcome of Monteggia-like lesions

The Bone & Joint Journal ◽

10.1302/0301-620x.101b12.bjj-2019-0547.r1 ◽

2019 ◽

Vol 101-B (12) ◽

pp. 1512-1519 ◽

Cited By ~ 3

Author(s):

Alexander Klug ◽

Felix Konrad ◽

Yves Gramlich ◽

Reinhard Hoffmann ◽

Kay Schmidt-Horlohé

Keyword(s):

Surgical Treatment ◽

Radial Head ◽

Type I ◽

Dash Score ◽

Type Ii ◽

Coronoid Fracture ◽

Radial Head Arthroplasty ◽

Type Iii ◽

Clinical And Radiological Results

Aims The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results. Patients and Methods A total of 78 patients with a Monteggia-like lesion, including 44 women and 34 men with a mean age of 54.7 years (19 to 80), were available for assessment after a mean 4.6 years (2 to 9.2). The outcome was assessed using the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Mayo Modified Wrist Score (MMWS), and The Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiographs were analyzed for all patients. A total of 12 Mason type I, 16 type II, and 36 type III fractures were included. Surgical treatment consisted of screw fixation for all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) or excision was performed if reconstruction was not possible. Results The mean MEPS was 88.9 (40 to 100), mean OES was 40.1 (25 to 48), mean MMWS was 88.1 (50 to 100), mean DASH score was 14.7 (0 to 60.2), and mean movement was 114° (sd 27) in extension/flexion and 155° (sd 37) in pronation/supination. Mason III fractures, particularly those with an associated coronoid fracture treated with RHA, had a significantly poorer outcome. Suboptimal results were also identified in patients who had degenerative changes or heterotopic ossification on their latest radiograph. In contrast, all patients with successful radial head reconstruction or excision had a good outcome. Conclusion Good outcomes can be achieved in Monteggia-like lesions with Mason II and III fractures, when reconstruction is possible. Otherwise, RHA is a reliable option with satisfactory outcomes, especially in patients with ligamenteous instability. Whether the radial head should be excised remains debatable, although good results were achieved in patients with ligamentous stability and in those with complications after RHA. Cite this article: Bone Joint J 2019;101-B:1512–1519

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