A New Pediatric Monteggia Fracture Type 4 Variant

Introduction: Monteggia fracture-dislocations are rare and complex injuries that usually involve a fracture of the proximal ulna associated with a proximal radioulnar and radiocapitellar joint dislocations. These injuries comprise <1% of all pediatric forearm fractures. We report on a pediatric Monteggia fracture-dislocation variant that included an irreducible divergent ulnohumeral joint dislocation, an irreducible anterior radial head dislocation, and a proximal and distal radius and ulna fracture. Case Report: A 6-year-old female came to our emergency room with a right elbow and forearm pain and deformity after a fall from a slide on the same day. X-rays revealed a divergent ulnohumeral joint dislocation, an anterior radiocapitellar joint dislocation, a proximal radioulnar joint dislocation, and a proximal and distal ulna and radius fracture. Closed reduction under sedation in the emergency room was not successful, with persistent ulnohumeral, ulnoradial, and radiocapitellar joint dislocations. The patient was taken to the operating room the next morning. She underwent open reduction and internal fixation of the proximal ulna fracture with a one-third tubular locking plate, and radial head dislocation open reduction. A stable reduction of the ulnohumeral joint was only possible after the fixation of the proximal ulna fracture. The most stable position for the radiocapitellar joint after its open reduction was at 70o of elbow extension and full forearm supination; the patient was casted in that position for 6 weeks. Conclusion: Pediatric Monteggia fracture-dislocations are rare and complex childhood fractures, and new variants of this injury can have even more complex presentations. Open reduction and stable internal fixation addressing all components of this injury will lead to an excellent outcome. Keywords: Pediatric monteggia fracture-dislocation, new type four variant, divergent ulnohumeral joint dislocation, irreducible dislocation.

Study of the Various Factors Involved in Monteggia Fractures Treated by Open Reduction and Internal Fixation in Government Medical College, Trichur

BACKGROUND The various factors involved in Monteggia fractures treated by open reduction and internal fixation (ORIF) were studied in patients presenting to Government Medical College, Trichur. Its distribution based on age, gender, and nature of trauma, were observed in the patients. METHODS This study was a prospective descriptive study, conducted in Department of Orthopaedics, Medical College, Thrissur from 1, January, 2016 to 1, July, 2017. Patients were assessed according to age, sex, side of injury, co-morbidities and final functional assessment was made according to Broberg and Morrey score. A total of 37 patients were observed. The patients were assessed, deemed fit for the study, and subjected to operation. Radial head reduction, fixation if needed, then ulna fracture was opened, reduced, and fixed with plate and screws. Postoperative plaster slab was applied, then converted to full above elbow cast, and retained for as long as needed. Post-operative mobilization was by home physiotherapy only. RESULTS Our study showed that open reduction and internal fixation of ulna outcome in Monteggia fractures leads to good elbow function and minimal loss of physical capacity. Immobilization of more than 2 months have very high chances of elbow stiffness. Early active mobilization after surgery is necessary for good functional outcome. Other than mild stiffness and loss of range of motion in some cases, very few other complications were found in our series. CONCLUSIONS Rigid internal fixation of ulna and early active mobilization is the key to achieve a good functional outcome and minimal loss of physical capacity in Monteggia fractures. Very few of the complications that were described in the literature were seen in the study. Even with restricted resources and minimal facilities, almost no permanent or debilitating morbidity or complications were seen in our series. Early active mobilization after surgery was the most important deciding factor for good functional outcome. Prolonged immobilization of more than one month consistently produces poor results. KEYWORDS Monteggia, Broberg and Morrey, Bado Classification, Internal Fixation, Ulna Fracture

Bilateral Traumatic Nightstick Fracture of the Ulna – A Rare Case Report and Review of the Literature

Introduction: Unilateral isolated ulna fracture secondary to trauma are common but the bilateral nightstick fractures are quite rare in the clinical scenario. These are managed conservatively or surgically depending upon the degree of displacement, location of the fracture, fracture pattern and associated injury to other bones. Proper management of these fractures helps in getting a better outcome. The purpose of the study was to present a case of bilateral traumatic isolated ulna fracture and its management. Case Report: A 33-year-old male presented to the emergency department with complaints of pain and swelling over the dorsum of both forearms with a history of assault with a bamboo stick. The mechanism of the injury was, the patient placed his both the forearms in front of the face as a defense during the assault and sustained injury to both forearms. On examination, the patient had bilateral forearm swelling with tenderness. Bony crepitus was present over both the ulna on palpation. X-ray of both forearms (radius and ulna) revealed the fracture of both right and left ulna without any associated fractures/injuries. The patient was managed surgically with open reduction and internal fixation using a 3.5 mm locking compression plate. At present, 1-year follow-up, the patient is having complete wrist, elbow ROM and supination, pronation without any pain. Conclusion: Bilateral traumatic Nightstick fractures of the ulna are rare and this is the first reported case of traumatic bilateral isolated ulna fracture according to author’s best knowledge and literature review. Open reduction and stable internal fixation using the principles of fracture fixation along with early mobilization helps in getting better functional outcome and prevents further complications and secondary procedures. This case is unique as it helps in identifying the mode of trauma in medico legal cases like assault in cases of bilateral ulna fracture. The mode and the mechanism of injury are differe

CHARACTERISTICS OF FOREARM RE-FRACTURE IN YOUTH ATHLETES

Background: The forearm is the most common site of fracture, and perhaps re-fracture, in the pediatric population. Although both bone forearm (BBFA) fractures represent approximately 30% of pediatric upper extremity fractures, little is known about BBFA re-fractures, particularly among youth athletes. Purpose: To evaluate characteristics of BBFA re-fracture and recurrent fractures. Methods: An IRB-approved retrospective chart review based on CPT and ICD-9/10 codes of forearm fractures (ages 10-18 years) treated by a single academic pediatric orthopedic group from June 2009 to May 2020 was conducted. All BBFA, radial, or ulnar fractures with ipsilateral same-site, or non-identical ipsilateral or contralateral forearm fracture were included. Demographics, injury characteristics, length of immobilization, timing of return to activity, and radiographic data (angulation, distance between radius fracture and ulna fracture [in mm], position of fracture within bone, and radiographic healing). An analysis was performed to evaluate associations of ipsilateral same-site re-fracture versus ipsilateral or contra-lateral non-identical site fractures. Results: Twenty-nine of 686 BBFA and distal radius fractures were identified to have recurrent fracture (4.23%), with an average age of 11.5 years and male-to-female ratio of 6.25:1. 67% of ipsilateral same-site re-fractures occurred within one year. The most common mechanisms of primary fracture were contact sports (40%) and tumbling (30%), and re-fracture occurred 182 days after original fracture. 52% percent of recurrent fractures were ipsilateral same-site re-fractures, while 48% occurred in a non-identical site, either ipsilaterally or contralaterally. The most common mechanisms of recurrent fracture were contact sports (38%), falls (38%), and tumbling (14%). Ipsilateral same-site re-fractures compared to other recurrent fractures, were significantly associated with a mid-shaft location (p=0.0029), increased radius to ulna fracture distance (21.14 mm versus 11.3 mm, p=0.0277) [Figure 1], and earlier occurrence following index fracture (re-fracture= 397.33 days versus non-identical recurrent fracture= 884.07 days, p=0.0056). Degree of angulation was not significantly associated with re-fracture. Conclusion: Recurrent fracture may occur at different times and locations following primary injury treatment. Ipsilateral same-site re-fractures tend to occur within the first year of treatment following mid-shaft fractures incurred during contact sports and tumbling, with widely spaced radial and ulnar fracture sites. Further research may be warranted to evaluate biologic, bone health, or personality traits that may lead to recurrent and re-fractures in pediatric forearm fractures. [Figure: see text]

391 Multiple Unilateral Upper Limb Fractures in The Paediatric Setting – A Case Report

Introduction 5% of forearm fractures in children have associated supracondylar fractures, hence any forearm fractures warrant careful examination of the elbow, and radiographs taken should visualise the elbow and wrist joint for other injuries. We report a case of multiple upper limb fracture in a child, comprising of lateral condyle and both-bone forearm fracture. Case Presentation: A 5-year-old boy was admitted having fallen from a ladder approximately 1.5 metres high in a playground. The left limb was significantly deformed, with no open injury, and neurovascularly intact throughout. Radiographs demonstrated a minimally displaced lateral condyle fracture of the left elbow, a mid-shaft ulna fracture and a displaced off-ended distal third radius and ulna fracture of the left wrist. Any metabolic bone disease and non-accidental injury was ruled out. CT imaging was performed to completely assess the fracture pattern and discussion with our local regional trauma centre. Given the minimal displacement of the lateral epicondyle, conservative management was decided for this. The displaced distal radial fracture was managed with open reduction and internal fixation with a plate, and the ulna shaft fracture with manipulation and plaster cast application. By 12 weeks after surgery there was full range of movement of the elbow, wrist, and forearm, with complete radiological union.

Radial Head Dislocation with Ipsilateral Proximal Shaft of Radius Fracture: A Case Report

Radial head dislocations are uncommon in adults. They are commonly seen in children and aregenerally associated with proximal ulna fracture. Radial head dislocation with associated proximalradial shaft fracture is rarer than isolated radial head dislocation in adults. Due to the rarity of thiscomplex injury, in the absence of keen observation and meticulous attention, the correct diagnosismight be missed leading to unsatisfactory management and related complications. Here, a similarcase of radial head dislocation with associated proximal radial shaft fracture has been presented.