Monteggia fractures in children and adults

[Radial head and neck fractures in children]

OBJECTIVE

To analyse cases of radial head and neck fractures in children and compare them with the literature.

METHOD

Retrospective and descriptive study of 21 children with radial head and neck fractures. The following parameters were collected: demographics, comorbidity, classification, treatment, need for rehabilitation, lack of range of motion (ROM), time for recovery and complications.

RESULTS

The series included 11 males, and the mean age was 8.3 years. The right side was affected in 14 patients. Twelve cases had an associated ipsilateral elbow injury. According to the Chambers classification, 15 cases belonged to group A, while in the Steele-Graham classification, 12 cases were in group I. Eleven patients were treated with immobilization only, 4 percutaneously, and 6 by open reduction and internal fixation (ORIF). Eleven of them needed rehabilitation and despite this, 8 did not achieve full mobility. The mean time to obtain the greatest ROM was 4.71 months. Eight patients had complications, with the most common being neuroapraxia and valgus deformity of the elbow.

DISCUSSION AND CONCLUSIONS

Treatment of paediatric radius head and neck fractures must be step-wise, from immobilization only, manual and/or percutaneous reduction, to ORIF, whichever is less indicated. In this respect, both the transcapital needle and/or removal the radius head should be avoided. The most common complication is lack of supination, especially in cases treated by ORIF. The posterior interosseous neuroapraxia was the most common of the rest of complications.

Monteggia fractures

Monteggia described a fracture of the proximal third of the ulna with anterior dislocation of the radial head from both the proximal radioulnar and radiocapitellar joints. Application of this eponym to all injuries with radiocapitellar subluxation or dislocation has led to some confusion. In addition, there are substantial differences between Monteggia injuries in children and adults. With careful definition, specific subsets of patients may benefit from consideration as a separate type of Monteggia injury.

Pediatric Monteggia fractures: a single-center study of the management of 40 patients

INTRODUCTION

Early identification and conservative management of pediatric Monteggia fractures has been shown to correlate with good results. Nevertheless, several authors advocate more aggressive management with open reduction and internal fixation (ORIF) for unstable fractures. We herein present the experience of a tertiary pediatric hospital in the management of Monteggia fractures.

METHODS

Forty patients with Monteggia fractures (26 male and 14 female) were admitted and treated over a period of 20 years (1989 to 2009). The age of the patients ranged between 3 and 14 years (mean 7.5 y). On the basis of the Bado classification, 28 fractures were type I, 3 were type II, 8 type III, and 1 fracture was classified as type IV. Out of the 40 patients, 32 were managed with manipulation under anesthesia (MUA) and above-elbow plaster, whereas 8 underwent ORIF of the ulna.

RESULTS

To assess outcomes, the Bruce, Harvey, and Wilson scoring system was used. Range of movement, pain, and deformity were evaluated to class an outcome as excellent, good, fair, or poor. Patients were followed up for an average of 4.6 years (range, 1 to 7 y). All patients in the MUA group had excellent results. In the ORIF group, 8 out of 9 patients had good results.

DISCUSSION AND CONCLUSIONS

According to our recorded experience, conservative management of Monteggia fractures, when indicated, results in excellent outcomes. In cases where emergency MUA fails to achieve or maintain reduction, the choice of ORIF has also demonstrated good results. Early diagnosis and management are of paramount importance as mismanaged cases demonstrate less satisfactory results.

LEVEL OF EVIDENCE

Level IV. Case series.

Ulnar fracture with late radial head dislocation: delayed Monteggia fracture

Monteggia fractures are rare but commonly discussed lesions, with increasing complications due to late diagnosis. This article describes a case of a Monteggia fracture with delayed dislocation of the radial head. Previous radiographs of a 2-year 8-month-old boy show complete fracture of the distal ulna, with no radial head dislocation. The radial head remained well positioned after 4 weeks. Seven years later, he sustained another arm injury. He was diagnosed with a hematoma but was later believed to have nursemaid's elbow. He presented to our institution 5 weeks after the injury, and the radial head was found to be chronically dislocated, indicating a displacement occurring sometime during the past 7 years. After failing conservative treatment, the patient underwent surgical repair. The annular ligament was reconstructed using a harvested triceps fascia band, and an ulnar osteotomy was performed. A review of the literature found few reports of delayed Monteggia fractures, which accounted the delayed dislocations to ulnar angulation. However, our patient showed minimal ulnar angular deformity. We propose that the initial fracture disrupted the annular ligament and the radial head spontaneously relocated prior to being seen, which put the radial head at risk for later dislocation. We present an alternative hypothesis of dislocation after fracture healing and report the longest known period of delay between fracture and dislocation.

Monteggia fractures in pediatric and adult populations

A Monteggia fracture is a fracture of the proximal ulna coupled with a radial head dislocation. These fractures are an uncommon class of forearm fractures. Numerous classification systems have been developed to characterize these fractures, with the Bado classification being the most common. Elbow radiographs are the primary diagnostic modality, demonstrating dislocation when a line drawn extending through the radial head from the radial shaft does not penetrate the capitellum in all views. Notable differences exist in the prevalence, treatment, and outcomes of Monteggia fractures for pediatric and adult patient populations, with adolescents often achieving a better prognosis. Nonoperative management with closed reduction and cast immobilization often prevails in pediatric patients, dictated by the pattern of the ulnar fracture more so than the direction of the radial head dislocation. However, in adults, operative intervention is frequently indicated because angulation and shortening of the ulna often occur after closed reduction. Although the orthopedic community's understanding of these fractures has evolved, the fractures themselves remain a challenging clinical phenomenon. This article reviews the relevant anatomy and pathogenesis, classification, clinical presentation, diagnostic studies, management, outcomes, and complications of Monteggia fractures in children and adults.

Use of intra-medullary stacked nailing in the reduction of proximal plastic deformity in a pediatric Monteggia fracture: a case report

INTRODUCTION

In a Monteggia fracture dislocation, it is important to reduce the ulnar fracture completely. Extensive plastic deformation of the proximal ulna may make reduction by closed manipulation impossible.

CASE PRESENTATION

We report the case of a four-year-old Caucasian boy in whom the plastic deformation of the proximal ulna was reduced, and this reduction was maintained, using intra-medullary stacked nailing.

CONCLUSION

The technique of stacked nailing is a useful addition to the armamentarium in the management of the potentially awkward Monteggia fracture.

Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic injuries

Avoiding legal pitfalls of orthopedic injuries in the emergency department (ED) requires an understanding of certain high-risk injuries, their presentation, evaluation, and disposition. Various pitfalls pertaining to both upper and lower extremity injuries are discussed in detail, with recommendations regarding the history, physical examination, and radiographic techniques that minimize the risk inherent in these injuries. When approaching these injuries in the ED, a high level of suspicion coupled with appropriate evaluation and management will allow the practitioner to avoid mismanagement of these potential pitfall cases.

Monteggia and Monteggia-like-lesions: Classification, Indication, and Techniques in Operative Treatment

Monteggia fractures consist of an ulna fracture accompanied by radial head dislocation. Such fractures are easily overlooked due to the prominence of the ulna fracture. Earlier studies have reported on the results of treating Monteggia fractures in children and adults even though this type of fracture is different in these two patient populations. As such they should be considered as separate entities due to the different injury pattern, the prognosis, and the preferred method of treatment. For a good postoperative result, an early detection of the Monteggia dislocation, an efficient operative treatment of the ulna fracture, and reposition of the radial head are essential. The goal of reconstruction is an early mobilization within a stable arc of motion. Here, we provide an overview of the classification of Monteggia fractures, the mechanism of injury, and treatment options with the aim of providing sufficient information to reduce the possibility of underestimating forearm injuries in adults.

Chronic post-traumatic radial head dislocation associated with dissociation of distal radio-ulnar joint: a case report

We present an unusual case of an isolated interosseous membrane disruption of the forearm without any fracture pattern. Dislocation of both radial head and distal radio-ulnar joint was presented. Open reduction of the radial head with radial neck shortening osteotomy was performed.

Monteggia fractures in adults: long-term results and prognostic factors

The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery. Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.

Late radial head dislocation with radial head fracture and ulnar plastic deformation

Type II Monteggia lesion equivalents produced by plastic deformation of the ulna are rare. Radial head fractures in skeletally immature patients are also uncommon. We report a late presentation of a Type II Monteggia equivalent injury with a fracture of the radial head and neck and plastic deformation of the ulna in an 11-year-old boy. The radial head was located on the initial injury radiographs and subsequently dislocated in a posterior direction. The radial head fracture was misdiagnosed as a coronoid fracture at presentation. The plastic deformation of the ulna was diagnosed several weeks after the injury when the dislocation was first noted. Magnetic resonance imaging was used to establish the diagnosis of a radial head fracture at the same time. The patient was treated successfully with an open reduction and internal fixation of the radial head combined with a dorsal closing-wedge ulnar osteotomy.

The forearm complex: anatomy, biomechanics and clinical considerations

The forearm complex is comprised of the proximal radioulnar joint, middle radioulnar joint/interosseous membrane, and the distal radioulnar joint. These three areas function in a coordinated manner to rotate the hand in space and allow performance of functional tasks. If a structure or structures in one of these three areas is disrupted, this can adversely affect the function at any of the other two remaining areas. Surgical intervention focuses on restoring anatomical alignment to preserve the function of the forearm complex. Rehabilitation is guided by the relationships between the three areas of the forearm complex and the awareness of clinical signs, symptoms, and complications. The purposes of this paper are to 1) describe the anatomy and biomechanical function of the forearm complex and 2) discuss clinical correlates pertaining to select forearm injuries (excluding peripheral nerve injuries) that may affect forearm function.

Chronic posttraumatic anterior dislocation of the radial head in children: thirteen cases treated by open reduction, ulnar osteotomy, and annular ligament reconstruction through a Boyd incision

OBJECTIVE

To report the results of open reduction, ulnar osteotomy, and annular ligament reconstruction all through a Boyd incision for chronic radial head dislocations in children.

DESIGN

Retrospective review.

SETTING

Tertiary pediatric orthopaedic care unit at a general hospital in Taichung, Taiwan.

PATIENTS/PARTICIPANTS

From 1986 to 2003, 13 children, aged 4 to 13 (mean, 8.3) years, who had a chronic traumatic anterior dislocation of the radial head were treated at our institute. These patients were seen at our hospital 2 to 36 (mean, 8.2) months after injury.

INTERVENTION

Open reduction of the radial head, ulnar osteotomy, then rigid fixation with plate/screws, and annular ligament reconstruction with forearm fascia, all performed through a Boyd incision.

MAIN OUTCOME MEASUREMENTS

Forearm radiographs for reduction and osteotomy site union, physical examinations for elbow mobility, and Kim's elbow performance scores for overall elbow function. Evaluations were done at a special follow-up clinic for this study by a pediatric orthopaedic surgeon who was not involved in the patients' previous care.

RESULTS

Patient follow-up averaged 7.8 (range, 1-16.9) years after surgery. Twelve of our cases had successful radial head reductions, satisfactory elbow mobility, and excellent functional outcome. One case had a redislocation, was retreated, and had a fair result. Other complications included 1 patient with transient posterior interosseous nerve palsy, and 1 delayed union of an ulnar osteotomy site, which healed without further intervention at 1 year with an excellent result.

CONCLUSION

This surgical procedure provides a high success rate with a low level of complications for chronic radial head dislocations in children.

Does a Monteggia variant lesion result in a poor functional outcome?: A retrospective study

We retrospectively reviewed the clinical and functional outcomes after operative fixation of ipsilateral fractures of the proximal ulna, radial head or neck, and radial head dislocation (Monteggia variant). Twenty of 25 patients who sustained this injury returned for followup at a mean of 2.3 years and were evaluated by an independent examiner. Radiographically, 17 of 20 fractures united after the index surgery. The three patients who had nonunions develop had Bado Type 2 fracture patterns. The fractures of two patients united after revision internal fixation, and bone grafting. Seven patients had heterotopic ossification develop and 14 of 20 patients had arthritic changes develop. The mean Broberg and Morrey score was 79.1 (range, 32.5-100) and the mean disability of the arm, shoulder and hand score was 64.1 (worse outcome than the general population). Eight of 20 patients required revision surgery (three for recurrent instability, three for nonunion of the ulna, one for radial head excision and hardware removal, and one for hardware removal alone). Nine of 20 patients had fair or poor outcomes according to the Broberg and Morrey scale. Physicians should counsel patients that functional impairment is common after these complex high-energy injuries.

LEVEL OF EVIDENCE

Prognostic study, Level IV (case series). See the Guideline for Authors for a complete description of levels of evidence.

Anterior dislocation of the radial head with fractures of the olecranon and radial neck in a young child: a Monteggia equivalent fracture-dislocation variant

We present a case of a type I Monteggia equivalent lesion in a 7-year-old child consisting of anterior dislocation of the radial head, radial neck fracture, and a fracture of the olecranon without an associated fracture of the ulnar diaphysis or metaphysis. After a review of the literature, we report this fracture pattern as a rare type I Monteggia equivalent fracture-dislocation variant. This report describes delayed surgical treatment and outcome after close follow-up of a rare type I Monteggia equivalent lesion. Diagnostic challenges with and treatment options for pediatric Monteggia equivalent fracture-dislocations are discussed.

Monteggia-Verletzungen im Erwachsenenalter

BACKGROUND

Complications, revision surgery, and unsatisfactory functional results after operative management of Monteggia fractures are frequent. Moreover, hardly any studies exist that deal exclusively with the therapeutic concept for adults.

PATIENTS AND METHODS

Between January 1988 and December 2001, 68 patients with Monteggia fractures or equivalent injury were surgically treated. A total of 49 patients could be followed up after 83 months (25-176). Fracture type was assessed according to Bado's classification, functional results according to the Mayo elbow performance score, and the extent of osteoarthritis based on the criteria of Baird and Johnson.

RESULTS

The median age of the follow-up patients was 38 years (18-89, 31 men, 18 women). Corresponding to Bado's classification the following injuries were observed: 18 cases of type 1, 22 of type 2, 5 of type 3, and 4 cases of type 4. After surgical intervention, 14 patients achieved "very good", 21 "good", 9 "satisfactory", and 5 "poor" results. Of the 14 patients with either "satisfactory" or "poor" results, 9 manifested a type 2 injury. Complications requiring revision surgery occurred in 14 patients and complications not requiring revision in another 14. Severe osteoarthritic changes in the humeral or radioulnar joint were observed in 4 cases.

CONCLUSIONS

Monteggia fractures in adults are fraught with complications despite good functional results in the majority of cases. The patient should be made aware early on of the risk of residual functional deficits and the need for further surgical intervention.

Chronic Monteggia fractures in children: outcome after treatment with the Bell-Tawse procedure

Late recognition of Monteggia fracture-dislocations of the elbow continues to pose a treatment challenge. The 15 children in our series with such chronic injuries were all treated with the modified Bell-Tawse annular ligament reconstruction. At an average follow-up of 30 months, all regained flexion-extension arcs in the functional range and no nerve palsies were noted. Some loss of pronation and supination was common, but none had activity restrictions or functional deficits. Four children had recurrent, asymptomatic radial head subluxation; measuring 3-4 mm in the anterior direction. We recommend that late annular ligament reconstruction be considered for most chronic Monteggia fractures to improve long-term function and prevent the need for late excision of the painful, chronically dislocated radial head.

Evaluation and management of the high-risk orthopedic emergency

Orthopedic injuries are frequently seen in the ED. Whereas the diagnosis and management of most of these injuries is straightforward, there are distinct pitfalls to avoid. The common theme among the high-risk "pitfall" injuries discussed in this article, besides a thorough patient history and careful physical examination with appropriate radiographs, is a high suspicion for the presence of these injuries. When the EP is knowledgeable about these orthopedic pitfalls, these injuries are much less likely to slip by in clinical practice.

Ipsilateral supracondylar humerus fracture and Monteggia lesion: a case report

Two to 13% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, most of which are distal radius fractures. We present an unusual case of a 2-year-old girl with an ipsilateral supracondylar humerus fracture and a Monteggia lesion. Our management consisted of percutaneous K-wire fixation of the supracondylar humerus fracture and percutaneous insertion of an intramedullary K-wire for stabilization of the ulna fracture. Our patient had an excellent result, and we would recommend this method of fixation for similar injuries.

Isolated and combined fractures of the diaphysis of the radius and ulna

In summary, treatment of diaphyseal fractures requires accurate assessment of the injury to rule out concomitant ligamentous injury at the wrist or the elbow. Minimally displaced ulnar fractures can be managed with bracing. Displaced diaphyseal fractures of the radius and ulna should be plated, usually with 3.5-mm compression plates using AO technique. Complications may still occur but can be minimized if strict attention to technique is followed.

Type I Monteggia fracture dislocation associated with ipsilateral distal radial epiphyseal injury

SUMMARY

Ipsilateral elbow and wrist injuries are rare in children. We present a previously undescribed case of a Bado Type I Monteggia fracture with a Salter-Harris Type II epiphyseal injury of the distal radius. A satisfactory result was achieved but required surgical intervention. Complete diagnostic evaluation is imperative to avoid missed injuries and achieve satisfactory outcome.

Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation

Occult dislocations at the wrist and elbow frequently accompany forearm fractures. When left unrecognized and untreated, these injuries lead to a high incidence of long-term functional disability and chronic pain. Emergency medicine practitioners need to be vigilant for both Galeazzi (distal radius fracture with radioulnar joint disruption), and Monteggia (proximal ulna fracture with radial head dislocation) fracture-dislocations. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.

Comminuted fracture-dislocations of the elbow treated with an AO wrist fusion plate

Comminuted fracture-dislocations of the elbow are complex injuries that can result in significant postoperative loss of motion. Rigid anatomic fixation with early range of motion is the required treatment. Because of the local anatomy of the proximal ulna, it often is difficult to achieve a rigid fixation construct. A fixation technique of a dorsally applied AO limited contact-dynamic compression wrist fusion plate contoured to fit the anatomy of the proximal ulna is presented. Advantages of the AO wrist fusion plate in comminuted olecranon fractures include the ease of contouring, a low profile, and the use of variable screw hole sizing to achieve stable fixation. The hybrid design allows for rigid 3.5-mm plate fixation distally while providing low profile 2.7-mm plate fixation over the subcutaneous olecranon. The technical and biomechanical features of this plate make it an ideal alternative for fixation of these complex injuries.

Operative treatment of nonunions about the elbow

Nonunions about the elbow present a great challenge to the orthopaedic surgeon. Recent advances have enabled the surgeon to achieve much improved results. The current study outlines the treatment of nonunions of the distal humerus, proximal ulna (including olecranon, Monteggia, and coronoid nonunions), and radial head and neck nonunions. The historic problems of treating these nonunions included the use of inadequate fixation, the poor understanding of the role of soft tissue surgery in the treatment of the stiff elbow, and the failure of previous postoperative rehabilitation protocols. Advances made in the techniques of soft tissue treatment, modern methods of stable internal fixation, and early postoperative rehabilitation all have made an exceptional difference in the surgeon's ability to treat these most complex problems. The current study will provide the reader with a greater understanding of nonunions about the elbow, clinical and technical details for their treatment, and the expected results after treatment.

Mangling upper limb injuries in industry

The salvage of upper limbs mangled by industrial machinery became possible with the development of predictable techniques of vascular and microvascular anastamosis. Unfortunately, many of these salvaged limbs are associated with fair and poor functional outcomes. The quality of the skeletal fixation can have a substantial effect on the functional outcome and should be a major focus of the limb repair process. Internal plate fixation facilitates wound care and limb mobilization without tethering muscle-tendon units and is safe in the majority of severe upper limb injuries provided that all devitalized tissue is debrided and, if necessary, reconstructed using microvascular tissue transfers. Injury patterns, especially those which involve associated injury of the elbow or forearm ligaments, must be identified and treated appropriately. Internal fixation should restore anatomical alignment and provide sufficient stability to allow immediate active mobilization of the limb without contributing to devascularization of the soft tissues or skeleton.