Successful Treatment of Chronic Monteggia Fracture-dislocations in Children---A New Reference

BackgroundGreat difficulty and more failures were the descriptions of a chronic Monteggia fracture-dislocation. The treatment of chronic Monteggia lesion remains controversial and challenging for surgeons. This study aims to introduce our experience of a new reference in the treatment of chronic Monteggia fracture-dislocation in children and evaluate outcomes from clinical and radiographic findings.MethodsWe retrospectively reviewed 18 children who underwent surgical treatment because of chronic Monteggia lesion. Electronic medical records of clinical data, radiographic parameters, and operative details, were reviewed for study analysis. Parameters were compared at the time of pre-operation and the last follow-up. The relationship of lengthening and angulation of ulnar was calculated.ResultsMean interval time was 11.1 ± 15.7 months and follow-up time was 34.6 ± 23.7 months in this study. A congruent radiocapitellar reduction was observed in 15 (83.3%) patients, while 2 (11.1%) patients developed subluxation, and 1 (5.6%) patient had redislocation. The mean posterior bending angle was 12.88° (range, 3 to 25°), and the mean amount of elongation of the ulnar was 8.78 mm (range, 3.6 to 17.5 mm). The lengthening was significantly proportional to the magnitude of angulation of ulnar in good outcome patients (r = 0.637, p = 0.009), and the index was larger than the failed ones. Postoperatively, the Kim scores were obviously improved, from 59.17 ± 18.17 to 90 ± 6.64.ConclusionsWe highlight the ulnar osteotomy as the essential procedure during the reconstruction surgeries. Enough elongation and balanced angulation of the osteotomy is warranted to keep satisfactory outcomes. The ulnar should be lengthened to more than normal proportional ulnar length to stable the radial head reduction. Iliac crest autograft is recommended to avoid nonunion of ulnar osteotomy after enough lengthening.Level of evidenceLevel IV; Case Series; Treatment Study

Monteggia equivalent lesion in children: a narrative review

BackgroundMonteggia equivalent lesion represents a group of injury or combined injury patterns that resemble the Monteggia lesion in its presentations and mechanisms. Unlike Monteggia lesions, the equivalent ones, which share vague definitions and mostly occur as sporadic single case reports in the literature, have not been thoroughly reviewed since Bado first proposed the term, especially in the pediatric population. The objective of this review was to elucidate the definition by elaborating on its clinical styles and thus analyzing the mechanism, diagnosis, and management through related literature.Data sourcesBased on the terms of ‘Monteggia equivalent’, ‘radial neck fracture’ and ‘pediatric’, all of the related literature was searched on the PubMed and Google Scholar search engine.ResultsThe advance of the definitions for pediatric Monteggia equivalent lesion (PMEL) was reviewed. The functional roles of the ulnar and the related mechanism theories in this injury were analyzed. The status of the radiocapitellar joint in this injury was emphasized. According to the previous statements, a new classification model was proposed and proper diagnosis and treatment approaches were suggested.ConclusionsPMEL should be defined as an ulnar fracture at any level combined with a proximal radial fracture. According to the status of the radiocapitellar joint, it could be divided into three groups. The occult ulnar bowing and delayed radial head dislocation should be a serious concern of orthopedists. Surgical need is usually warranted. Maintaining the ulnar length and securing the radiocapitellar joint are highly recommended.

Retrograde Intramedullary Nailing for Proximal Monteggia Fractures in Children

IntroductionMonteggia fractures are defined as fractures of the ulna’s proximal third with associated dislocation of the radial head and were further described and classified by Bado. They are very rare in adults and even rare in children reaching an incidence of 1.5 - 3% of all pediatric forearm fractures. The treatment’s primary goal is the anatomical reduction of the ulnar fracture, and with that, the following indirect anatomic reduction of the radial head. Different modalities for the treatment of Monteggia fractures in children are reported.We present possible closed reduction techniques and internal fixation based on the type of Bado classification in pediatric patients. We illustrate these techniques as a case series discussing the strengths, risks, and pitfalls of the ulna’s retrograde nailing.Materials and MethodsFor this case series, we included all pediatric patients who got surgical treatment at our institution for a Monteggia lesion from November 2000 to August 2019. Preoperative imaging consisted of conventional radiographs of the elbow and the forearm in two planes. Results This case series reports about six pediatric cases (age two to six years, two girls and four boys). They all had a proximal Monteggia fracture. In all cases, closed indirect reduction of the ulnar fracture and reposition of the radial head was achieved utilizing retrograde nailing of the ulna employing an intramedullary nail or Kirschner-Wire according to the instructions. No infection, vascular or nerve injuries, or other complications occurred. All were pain-free and regained full range of motion compared to the contralateral side.ConclusionIndirect reduction and intramedullary retrograde nailing are minimally invasive techniques that do not harm the blood supply to the bone and soft tissues. It may be a safe and effective procedure.

Monteggia lesion and its equivalents in children

Purpose The aim of the study is to evaluate our group of paediatric patients with Monteggia lesion and its equivalents and to compare the characteristics of basic types of these lesions concerning therapeutic approach and results of the treatment. Methods Retrospective study of 111 children treated in the Department of Pediatric and Trauma Surgery of the Thomayer Hospital in Prague between 2001 and 2013 (13 years). When evaluating the outcome of the therapy, Bruce’s criteria modified by Letts that assesses range of movement, pain and deformity of the elbow joint were applied. Regarding the therapeutic approach, four groups were compared: nonoperative treatment, reduction and casting, closed reduction and internal fixation (CRIF) and opened reduction and internal fixation (ORIF). Results were compared between three groups of patients (Monteggia lesions, displaced equivalents and non-displaced equivalents) using Fisher´s exact test with α set to 0.05. Results In all, 46 patients were treated for (true) Monteggia lesion, 27 for non-displaced Monteggia equivalent and 38 for displaced equivalent. There is a statistically significant difference in therapeutic approach between all three groups of patients. There is no significant difference in outcome between Monteggia lesions and both types of Monteggia equivalents, but there is a statistically significant difference between displaced and non-displaced equivalents. Conclusion There are only two lesions that meet the criteria of Monteggia – (true) Monteggia lesion and displaced Monteggia equivalent. The non-displaced equivalent does not meet the criteria of Monteggia and, therefore, should not be termed a Monteggia equivalent. Level of Evidence Level III – Retrospective comparative study

The mechanism of injury of a hybrid Bado type I/III Monteggia lesion: Analysis of a live recording from a gymnastics injury

The injury mechanism of a case of hybrid Bado type I/III Monteggia fracture had been recorded live by the parent of a gymnast in a competition. This live recording was generously offered by the parent to the treating surgeon to study the injury mechanism. The video captured was segmented by slow motion frames to study the whole process of the injury mechanism. The injury mechanism was analyzed by the authors jointly to verify the interpretation of the loading mechanism and the resultant injury. The patient had been treated with conventional method with satisfactory result.

A youngest reported case of type II Monteggia lesion associated with a posterior ulnohumeral dislocation

Monteggia fractures are uncommon injuries, despite a high incidence of upper limb fractures in teenage children. We describe a case of a type 2 Monteggia variant in an adolescent. This injury pattern consisted of ulnohumeral dislocation in combination with type 2 Monteggia lesion. We discuss the possible injury mechanisms of this rare injury and review available literature.

Surgical treatment of chronic anterior radial head dislocations in missed Monteggia lesions in children: A rationale for treatment and pearls and pitfalls of surgery

Introduction The treatment of chronic radial head dislocations after Monteggia lesions in children can be challenging. This article provides a detailed description of the most frequently performed surgical technique: an ulna osteotomy followed by annular ligament reconstruction. Accordingly, we present the clinical and radiological results of 10 paediatric cases. Material and methods All paediatric patients that had a corrective osteotomy of the ulna for a missed Monteggia lesion between 2008 and 2014 were evaluated with standard radiographs and clinical examination. A literature search was performed to identify the relevant pearls and pitfalls of surgery. Primary outcome was range of motion. Results We included 10 patients, with a mean follow-up of 2.5 years. Postoperative range of motion generally improved 30.7°. Even in a patient with obvious deformity of the radial head, range of motion improved after surgery, without residual dislocation of the radial head. Conclusion Corrective proximal ulna osteotomy with rigid plate fixation and annular ligament reconstruction yields good results in patients with chronic radial head dislocation following a Monteggia lesion. Surgery should be considered regardless of patient age or time since trauma. Given substantial arguments in literature, we discourage surgery if a CT scan shows dome-shaped radial head dysmorphic features in work-up to surgery.