Monteggia Variant with Salter-Harris Fracture of the Radial Head: Case Report and Litergature Review

Introduction:The Monteggia fracture is a fracture to the proximal third of ulna associated with a radial head dislocation. Although this is well described and classified in adults, it is uncommon in children. Identifying growth plate trauma and subsequent surgical management are of critical importance. This report identifies a unique variant of Monteggia fracture with a Salter-Harris Type I injury of the radial head instead of a dislocation, and how it was successfully stabilised with a closed reduction. Case Rport: We present a case of a nine 9 year-old female admitted to our unit with a deformed upper extremity following a fall from height. This was a closed and isolated injury without neurovascular compromise. Radiographs revealed a displaced fracture to the proximal ulna shaft. Unlike a true Monteggia, the radial fracture went through the proximal physis with anterior divergence of the distal fragment. The radiocapitellar joint remained congruent. The ulna fracture was stabilized with open reduction and plate osteosynthesis whilst the radial injury underwent closed reduction and intramedullary pinning with excellent outcomes and maintenance of full range of motion. Conclusion: This case highlights a new variant and successful outcome following a closed reduction intramedullary fixation technique in this emergent pattern of injury. We highlight the need for a classification of these fractures in children. Keywords: Case report, Monteggia, growth plate, pediatric, fracture, trauma, variant.

A hybrid technique combining intramedullary pinning with extramedullary plate fixation in unstable and comminuted radial head fractures following on-table reconstruction

Background Management of comminuted radial fractures remains controversial. Currently, the emergence of on-table reconstruction technique has made fixation in comminuted radial head fractures more viable. However, the present study reported an intro-operative unstable displacement from the reconstructed radial head to the neck during plate fixation, characterized by a poor radiocapitellar contact and incongruity between the radial head and neck. A hybrid technique combining with intramedullary pining was performed in our study to restore the normal alignment and maintain the stability of fixation. Therefore, the purpose of this article aimed to prove the feasibility of unstable comminuted radial head fractures treated with the extramedullary plate and intramedullary pinning fixation using titanium elastic nails. Methods The clinical, functional and radiographic outcomes of the groups were compared during follow-up. The radiographic examination was conducted to evaluate the status of bone union, heterotopic ossification and post-traumatic arthritis. The functional assessment was performed to evaluate clinical effects, which included measurements of range of motion (ROM) in the elbow, Visual Analog Scale (VAS) score, Elbow Self-Assessment score (ESAS), Mayo Elbow Performance score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH)Outcome Measure score. Results Thirteen patients with unstable fractures were participated with an average follow-up of (38.6 ± 4.5) months for the experimental group and (32.0 ± 6.3) months for the control group, respectively. The functional outcomes in the experimental group, including MEPS and DASH, were significantly superior to the control group. However, no significant difference was observed in the elbow ROM and VAS score between two groups. In the last follow-up, one patient with post-traumatic arthritis rated as grades 1 and two with heterotopic ossifications were observed in the experimental group. In the control group, degenerative changes were observed in three cases (grade 1 in two cases and grade 2 in one case) and heterotopic ossifications rated as grade I were found in two patients. Conclusion Collectively, intramedullary pinning with extramedullary plate fixation is feasible in unstable comminuted radial head fractures, which can be considered as a remedial surgery for on-table reconstruction technique.

Evaluation of β-Tricalcium Phosphate Biomaterial in Femur Fracture Repair in Dogs

Background: Fracture repair is one of most common procedure carried out by veterinary clinicians. Fracture healing most of the time associated with delayed union, non-union and mal-uinon. Therefore, the objective of this study was to evaluate the clinical, haemato-biochemical and radiological outcome in patients after implantation of β-tricalcium phosphate as a bone graft substitute to promote the fracture healing.Methods: Eight clinical cases brought to the clinics with femur fracture were divided into two groups viz. A and B, with four animals in each group. Femur fractures were stabilized with intramedullary pinning and β-TCP biomaterial and intramedullary pinning and β-TCP plus autologous bone marrow aspirate (BMA) composite in group A and B respectively. The efficacy of fixation was studied on the basis of clinical evaluation, haemato-biochemical and radiographical parameters on day 0 and on 7th, 15th, 30th, 45th and 60th post-operative day. Result: Excellent weight bearing was noticed in group B. The overall functional outcome in group B was better in comparison to group A animals. Haematological parameters viz. haemoglobin, packed cell volume, total leukocyte count and differential leukocyte count did not differ significantly within and between the groups. The biochemical parameters viz. serum calcium increased significantly (P less than 0.05) on 7th and 15th post-operative day. A significant reduction in serum alkaline phosphatase level observed on successive post-operative days in both groups. Radiographs of fractures treated in both the groups showed good reduction and fracture fixation, early signs of fracture healing in group B than group A animals. The size of callus formation was more in group A than group B. No any graft related complications observed during the study period. The β-tricalcium phosphate facilitated fracture healing and early ambulation of affected limb.

A hybrid technique combining intramedullary pinning with extramedullary plate fixation in unstable and comminuted radial head fractures following on-table reconstruction

Background: Management of comminuted radial fractures remains controversial. Currently, the emergence of on-table reconstruction technique has made fixation in comminuted radial head fractures more viable. However, the present study reported an intro-operative unstable displacement from the reconstructed radial head to the neck during plate fixation, characterized by a poor radiocapitellar contact and incongruity between the radial head and neck. A hybrid technique combining with intramedullary pining was performed in our study to restore the normal alignment and maintain the stability of fixation. Therefore, the purpose of this article aimed to prove the feasibility of unstable comminuted radial head fractures treated with the extramedullary plate and intramedullary pinning fixation using titanium elastic nails. Methods: The clinical, functional and radiographic outcomes of the groups were compared during follow-up. The radiographic examination was conducted to evaluate the status of bone union, heterotopic ossification and post-traumatic arthritis. The functional assessment was performed to evaluate clinical effects, which included measurements of range of motion (ROM) in the elbow, Visual Analog Scale (VAS) score, Elbow Self-Assessment score (ESAS), Mayo Elbow Performance score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH)Outcome Measure score.Results: Fifteen patients with unstable fractures were participated with an average follow-up of (37.2±5.8) months for the experimental group and (33.2±7.1) months for the control group, respectively. The ROM of the elbow and functional outcomes in the experimental group, including MEPS and DASH, were significantly superior to the control group. However, no significant difference was observed in the mean VAS score between two groups. In the last follow-up, two patients with post-traumatic arthritis rated as grades 1 and two with heterotopic ossifications were observed in the experimental group. In the control group, degenerative changes were observed in four cases (grade 1 in three cases and grade 2 in one case) and heterotopic ossifications rated as grade I were found in two patients. Conclusion: Collectively, intramedullary pinning with extramedullary plate fixation is feasible in unstable comminuted radial head fractures, which can be considered as a remedial surgery for on-table reconstruction technique. Trial registration: This study was retrospectively registered

Management of Infected Charcot Neuroarthropathy due to Diabetes Mellitus with Half Pins External Fixator and Pinning: A Case Series

BACKGROUND: Charcot neuroarthropathy (CN) of the foot and ankle, which is complicated with infection, is debilitating disease and presents challenges until now. External fixation with half-pins is useful as provisional treatment. AIM: The purpose of this retrospective case series is to summarize the patient characteristic, type of surgical intervention, outcome, and complication of infected CN treated in our hospital. MATERIALS AND METHODS: This case series studied retrospectively patients with CN of the foot and ankle due to diabetes mellitus type II, complicated by infection, who required surgical treatment in a single institution, from 2018 to 2019. Diagnosis was based on chronic deformity (fracture or dislocation) as proven on X-ray and recently developed infection as shown through clinical, laboratory, and radiological evaluation. RESULTS: We studied seven patients with CN classified as Eichenholtz Stage 3 (100%) and Brodsky type 3A alone (n = 3) (Figure 1), and type 3A with other types (n = 4). The mean age is 44.6 years old (range, 35–60) and mean body mass index was 24.08 kg/m2 (range, 21.45–25.39). Signs of infection include leukocytosis (n = 6), soft-tissue swelling (n = 4), ulcer (n = 4), and osteomyelitis (n = 1) at presentation. Operative treatment consisted of debridement, followed by external fixation only (n = 4), combined external fixation and pinning (n = 2), and intramedullary pinning only (n = 1). The mean hospital length of stay was 4.5 days (range, 3–7). We performed short-term follow-up after a mean of 4.12 months (range, 1.3–5.3) and long-term after a mean of 15.02 months (range, 11.27–16.8), the limb salvage rate was 100% in both. One patient had revision of external fixation. As for functional outcome, at the time of long-term follow-up mean visual analogue scale was 0.75 (range, 0–2) and American Orthopaedic Foot and Ankle Score was 66.25 (range, 57–77). CONCLUSION: In this study, mostly external fixation with half-pins and methyl metacrylate was used based on the bone condition and patient’s compliance. Despite of its limitation, this method is effective when it is combined with strict blood glucose level and infection control.

Treatment Outcome of Métaizeau Technique of Intramedullary Pinning in Pediatric Displaced Radial Neck Fracture

Introduction: Displaced radial neck fracture in children when poorly managed results in deformity of elbow and incapacitates patient’s daily activities due to compromised forearm motion, hence they require careful attention. Aims: The aim of this study is to assess the outcome of Métaizeau Technique in displaced radial neck fracture in Children. Methods: This hospital based study evaluated the treatment outcome of 35 patients with an average age of 9.34 years (range, 6 – 14 years), who presented with displaced radial neck fracture; and were treated by Métaizeau technique of intramedullary pinning by Kirschners (K) wire at Nepalgunj Medical College, Kohalpur from April 2017 to January 2020. Only Judet’s type 3 and 4 fractures were included in this study. Close reduction was attempted in all cases. All patients were followed up for an average of 8.4 months (range, 6-12 months). Functional outcome was assessed as per Métaizeau functional score. Results: All fractures united at an average of 3.77 0.84 months (meanSD). Twenty seven patients had type 3 fracture and remaining 8 had type 4a fracture. Twenty five (92.5%) patients with type 3 fracture exhibited excellent results; while three patients (37.5%) with type 4a fracture had excellent outcome. Closed reduction produced excellent outcome in all patients while 80.95% patients with percutaneous reduction had excellent result. Conclusion: Outcome depends on initial fracture type and mode of reduction. Closed reduction should be preferred over an open reduction in order to achieve superior outcome.