1
|
Wintges K, Cramer C, Mader K. Missed Monteggia Injuries in Children and Adolescents: A Treatment Algorithm. CHILDREN (BASEL, SWITZERLAND) 2024; 11:391. [PMID: 38671608 PMCID: PMC11049118 DOI: 10.3390/children11040391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
Monteggia injuries are rare childhood injuries. In 25-50% of cases, however, they continue to be overlooked, leading to a chronic Monteggia injury. Initially, the chronic Monteggia injury is only characterized by a moderate motion deficit, which is often masked by compensatory movements. Later, however, there is a progressive valgus deformity, neuropathy of the ulnar nerve and a progressive deformity of the radial head ("mushroom deformity") with ultimately painful radiocapitellar arthrosis. In the early stages, when the radial head is not yet deformed and there is no osteoarthritis in the humeroradial joint, these injuries can be treated with reconstruction procedures. This can be achieved either by an osteotomy of the proximal ulna with or without gradual lengthening. If there is already a severe deformity of the radial head and painful osteoarthritis, only rescue procedures such as functional radial head resection or radial head resection with or without hemi-interposition arthroplasty can be used to improve mobility and, above all, to eliminate pain. In this review article, we provide an overview of the current treatment options of chronic Monteggia injury in children and adolescents and present a structured treatment algorithm depending on the chronicity and dysplastic changes.
Collapse
Affiliation(s)
- Kristofer Wintges
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Christopher Cramer
- Division Hand, Forearm and Elbow Surgery, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Konrad Mader
- Division Hand, Forearm and Elbow Surgery, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| |
Collapse
|
2
|
Langenberg LC, Janssen SJ, Eygendaal D. Radial head volume measurements using quantitative three-dimensional computed tomography images for radial head deformation following missed Monteggia lesions. JSES Int 2023; 7:2612-2616. [PMID: 37969504 PMCID: PMC10638549 DOI: 10.1016/j.jseint.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background In chronic radial head dislocation cases, the radial head may enlarge and become dome-shaped. To date, there is no validated tool to quantify radial head deformation and predict its influence on surgical outcomes. This study assesses the potential value of volume and surface calculations obtained by quantitative three-dimensional computed tomography scanning (Q3DCT) in the workup for a corrective surgery in pediatric patients with missed Monteggia lesions. Material and methods Ten consecutive pediatric patients with a missed Monteggia lesion were included (2012-2020). The volume and articular surface size of the radial head were calculated using Q3DCT, and a three-dimensional reconstruction of the articular surface relief was depicted in a heat map. The head-neck ratio was calculated and compared to Q3DCT data of missed Monteggia patients and their age-/sex-matched controls. Results The radial head volume and radial articular surface size did not differ significantly between patients with missed Monteggia lesions and age-/sex-matched controls (volume 1487 mm3 vs. 1163 mm3, P = .32; articular surface size 282 mm3 vs. 236 mm3, P = .33). Optically, heat maps of the articular surface of missed Monteggia patients did not differ notably from control heat maps. A higher head-neck ratio correlated to a larger radial head volume (Pearson r = 0.73; P = .2). Discussion and conclusion Q3DCT may be an interesting tool in the preoperative workup of pediatric missed Monteggia lesions. Prospective research with larger cohort sizes and data that compares the affected side to the contralateral elbow is needed to assess its true clinical potential.
Collapse
Affiliation(s)
- Lisette C. Langenberg
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Orthopaedic Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
- Department of Orthopaedic Surgery, Amphia, Breda, the Netherlands
| | - Stein J. Janssen
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences (AMS), Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Orthopaedic Surgery, Amphia, Breda, the Netherlands
| |
Collapse
|
3
|
Loose O, Morrison SG, Langendoerfer M, Eberhardt O, Wirth T, Fernandez FF. Radial head distalisation with an external ring fixator as a therapy option in children with chronic posttraumatic radiocapitellar dislocations. Eur J Trauma Emerg Surg 2023; 49:1803-1810. [PMID: 36422659 DOI: 10.1007/s00068-022-02173-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Missed monteggia-type injuries in children can result in chronic radial head dislocation with anatomic changes and osteoarticular remodeling of the radial head. In later stages, joint reconstruction is impossible and a functional radial head distalization can be a therapy option in symptomatic patients. METHODS From 2010 to 2018, 46 patients (18 female and 28 male, mean age 11.8 (4-20)) with chronic radius head dislocation treated in our institution were retrospectively analyzed. A radial head distalization was performed in symptomatic patients at the time of ulna lengthening and angulation by use of an external ring fixator. We analyzed the surgical and radiographic data as well as the clinical outcome of the patients measured by DASH and Mayo Elbow score. RESULTS 16 patients (6 female, 10 male) fulfilled the criteria for functional radial head distalization. Main reason was Monteggia injury in 11 cases, and radial head fracture in 5 cases. Average follow-up was 5.1 years (range 1-9, SD 2.1). Mean time from injury was 4.14 years (range: 4 months to 12 years, SD 3.5 years). Mean duration of external fixation was 106 days (range 56-182, SD 31.2), lengthening was 21.3 mm (range 12-42, SD 8.8). Average degree of sagittal angulation 14.8° (0-32°, SD 10.7°), coronal angulation 4.4° (0-25°, SD 7.3°). DASH score showed a good result with 2.4, and the MAYO Elbow Score was excellent (95/100). No secondary luxation of the radius head was detected. CONCLUSION Radial head distalization with external ring fixator can be a therapy option for chronic radius head dislocations in symptomatic patients without losing stability of the elbow joint in contrast to radial head resection.
Collapse
Affiliation(s)
- O Loose
- Department of Orthopedics, Olga Hospital, Klinikum Stuttgart, Kriegsbergstr. 62, 70174, Stuttgart, Germany.
- Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany.
| | - S G Morrison
- Department of Orthopedics, The Royal Children's Hospital, Parkville, Australia
- Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | - M Langendoerfer
- Department of Orthopedics, Olga Hospital, Klinikum Stuttgart, Kriegsbergstr. 62, 70174, Stuttgart, Germany
| | - O Eberhardt
- Department of Orthopedics, Olga Hospital, Klinikum Stuttgart, Kriegsbergstr. 62, 70174, Stuttgart, Germany
| | - T Wirth
- Department of Orthopedics, Olga Hospital, Klinikum Stuttgart, Kriegsbergstr. 62, 70174, Stuttgart, Germany
| | - F F Fernandez
- Department of Orthopedics, Olga Hospital, Klinikum Stuttgart, Kriegsbergstr. 62, 70174, Stuttgart, Germany
| |
Collapse
|
4
|
Raux S, Madelaine A. Sequelae of childhood elbow fracture. Orthop Traumatol Surg Res 2023; 109:103454. [PMID: 36302449 DOI: 10.1016/j.otsr.2022.103454] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/08/2022] [Accepted: 05/18/2022] [Indexed: 12/24/2022]
Abstract
Elbow fracture is frequent in children, and often requires surgery. There are many potential sequelae: neurovascular, ligamentous and osseous. Some are liable to be overlooked, due to young age and the cartilaginous nature of the joint. There is little bone remodeling in the elbow and displacement fracture, and especially supracondylar or lateral condyle fracture, has to be corrected rigorously, notably in older children. In case of lateral tilt in fracture of the neck of the radial head, on the other hand, remodeling is effective. Deformity in cubitus varus and cubitus valgus leads to neurological lesions and instability. Treatment should be early, with adapted surgery in expert hands. Post-traumatic stiffness is rare. Early intensive physiotherapy is unsuited to children and could worsen the stiffness due to inflammation. Lateral condyle non-union is a classic complication of fracture. Simple percutaneous screwing is a useful option. The equivalent in the medial epicondyle is well-tolerated, and simple monitoring now suffices. Late posterolateral rotational instability is a poorly known complication. It should be considered in case of cubitus varus that becomes painful after a long asymptomatic course. Radiocapitellar subluxation is seen on X-ray. Residual radial head dislocation after primary treatment (Monteggia lesion) responds well to the Bouyala technique of ulnar flexion osteotomy associated to annular ligament repair, without requiring ligament reconstruction.
Collapse
Affiliation(s)
- Sébastien Raux
- HFME Lyon, département de chirurgie infantile, 59, boulevard Pinel, 69500 Bron, France.
| | - Anya Madelaine
- Hôpital Nord-Ouest-Villefranche sur Saône, Plateau d'Ouilly, 69400 Gleizé, France
| |
Collapse
|
5
|
Zivanovic D, Marjanovic Z, Bojovic N, Djordjevic I, Zecevic M, Budic I. Neglected Monteggia Fractures in Children—A Retrospective Study. CHILDREN 2022; 9:children9081100. [PMID: 35892603 PMCID: PMC9332205 DOI: 10.3390/children9081100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022]
Abstract
(1) Background: A Monteggia fracture is an infrequent injury in children. It can be missed during an initial consultation in 20–50% of patients. Chronic radial head dislocation may lead to several complications. Thus, surgical reconstruction of chronic Monteggia injuries is justified. The aim of this study is to analyze the single tertiary center experience in the treatment of neglected Monteggia fractures. (2) Methods: A retrospective study of patients treated for missed Monteggia fractures was conducted. Hospital records, operative charts, follow-up records and a set of X-rays were analyzed for each patient. Radiographic results were graded as good, moderate or poor. The functional status of elbows was estimated using the Mayo Elbow Performance Index. (3) Results: A total of 13 patients (8 boys and 5 girls) aged 4–12 years (mean 7.15) were treated during the study period. An angulation osteotomy of the ulna was performed in ten patients and a radial shortening osteotomy in three patients. A Bell–Tawse annular ligament reconstruction was performed in five patients, and a direct repair was performed in two patients. Eight patients had radiocapitellar trans-fixation. There were nine good radiographic results, three moderate and one poor. The functional result was excellent in nine patients, good in three and poor in one. (4) Conclusions: Our work has many limitations (only 13 patients and different types of operations), and conclusions should be drawn very carefully from such a small and diverse group. The surgical reconstruction of neglected Monteggia fractures in children should be attempted in all patients. Angulation and elongation osteotomies of the ulna are suitable for most patients. If there is a marked overgrowth of the radius, gradual ulnar lengthening and radial head reduction using the Ilizarov method may be a better option. Annular ligament reconstruction is not mandatory.
Collapse
Affiliation(s)
- Dragoljub Zivanovic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia; (Z.M.); (I.D.); (I.B.)
- Clinic for Pediatric Surgery, Pediatric Orthopedics and Traumatology, University Clinical Centre Nis, 18000 Nis, Serbia; (N.B.); (M.Z.)
- Correspondence: ; Tel.: +381-18-4532098
| | - Zoran Marjanovic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia; (Z.M.); (I.D.); (I.B.)
- Clinic for Pediatric Surgery, Pediatric Orthopedics and Traumatology, University Clinical Centre Nis, 18000 Nis, Serbia; (N.B.); (M.Z.)
| | - Nikola Bojovic
- Clinic for Pediatric Surgery, Pediatric Orthopedics and Traumatology, University Clinical Centre Nis, 18000 Nis, Serbia; (N.B.); (M.Z.)
| | - Ivona Djordjevic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia; (Z.M.); (I.D.); (I.B.)
- Clinic for Pediatric Surgery, Pediatric Orthopedics and Traumatology, University Clinical Centre Nis, 18000 Nis, Serbia; (N.B.); (M.Z.)
| | - Maja Zecevic
- Clinic for Pediatric Surgery, Pediatric Orthopedics and Traumatology, University Clinical Centre Nis, 18000 Nis, Serbia; (N.B.); (M.Z.)
| | - Ivana Budic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia; (Z.M.); (I.D.); (I.B.)
- Clinic for Anesthesia and Intensive Therapy, University Clinical Centre Nis, 18000 Nis, Serbia
| |
Collapse
|
6
|
Tan SHS, Low JY, Chen H, Tan JYH, Lim AKS, Hui JH. Surgical Management of Missed Pediatric Monteggia Fractures: A Systematic Review and Meta-Analysis. J Orthop Trauma 2022; 36:65-73. [PMID: 34282094 DOI: 10.1097/bot.0000000000002219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review surgical management and outcomes of missed pediatric Monteggia fractures. DATA SOURCES A systematic review was conducted using PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library from inception through March 2, 2020. The keywords were "Monteggia fracture," "missed Monteggia," "neglected Monteggia," "chronic Monteggia," and "chronic radial head dislocation." STUDY SELECTION All original human studies on missed pediatric Monteggia fractures were included. Congenital Monteggia fractures and isolated radial head dislocations were excluded. DATA EXTRACTION The revised Methodological Index for Nonrandomised Studies tool was used to assess the quality of studies. DATA SYNTHESIS Each patient's data were retrieved individually. The χ2 test and Fisher exact test were used to analyze the difference in outcomes for different surgical managements. Multivariate analysis was performed for variables that were significant on univariate analysis. CONCLUSIONS Thirty studies with 600 patients were included. Proximal ulnar osteotomies (P = 0.016) and the absence of transcapitellar pinning (P = 0.001) were the most significant predictors for eventual reduction of radial head. Other surgical management variables were not significant predictors. These include open or closed reduction approach of radial head reduction; presence or absence of ulnar osteotomy; presence or absence of lengthening, angular correction, overcorrection, or bone grafting of ulnar osteotomy; type of fixation for ulnar osteotomy; presence or absence of radial osteotomy; presence or absence of annular ligament repair or reconstruction; and repair or reconstruction of annular ligament. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Si Heng Sharon Tan
- Department of Orthopaedic Surgery, National University Health System (NUHS), Singapore
| | | | | | | | | | | |
Collapse
|
7
|
Closed reduction by trans-physealantegrade elastic stable intramedullary nailing in acute pediatric Monteggia fractures: a report of 22 cases. J Pediatr Orthop B 2022; 31:43-49. [PMID: 33165215 DOI: 10.1097/bpb.0000000000000831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Treatment of acute pediatric Monteggia fractures is still debated. The aim of this study was to assess the efficacy of strategy based on closed reduction by trans-physeal antegrade elastic stable intramedullary nailing (ESIN) of the ulnar fracture. Retrospective analysis of 22 patients (13 boys and nine girls) treated for acute Monteggia fractures between May 2008 and August 2018 was performed. Mean age at injury was 6.6 years. Mean follow-up was 4.5 years. On the basis of the Bado classification, 15 lesions were of type I, three types III and four types IV. All the patients were managed with closed reduction and ESIN of the ulna fracture within 2-19 h of arrival. Intraoperative stability of reduction of the radial head was checked under fluoroscopic control in pronation and supination. Outcomes were assessed with the Bruce et al. scoring system. Closed alignment of the ulnar fracture by ESIN had simultaneously reduced and stabilized the radial head dislocation in all patients. At the final follow-up, all the patients had excellent results. Complete healing of the fracture occurred in 6 weeks and the elastic nail removed at 3-6 months postoperatively. There was no case of instability or subluxation or re-dislocation of the radial head. No olecranon epiphysiodesis or growth disorders were noticed. Early diagnosis and management of acute pediatric Monteggia fractures by closed reduction and ESIN achieve excellent clinical and radiographic outcomes.
Collapse
|
8
|
Langenberg LC, Beumer ACH, The B, Koenraadt KLM, Eygendaal D. Surgical treatment of chronic anterior radial head dislocations in missed Monteggia lesions in children: A rationale for treatment and pearls and pitfalls of surgery. Shoulder Elbow 2020; 12:422-431. [PMID: 33281947 PMCID: PMC7689610 DOI: 10.1177/1758573219839225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/19/2019] [Accepted: 02/21/2019] [Indexed: 11/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- LC Langenberg
- Department of Orthopaedic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, Amsterdam University Medical Center, The Netherlands
| | - ACH Beumer
- Department of Orthopaedic Surgery, Upper Limb Unit, Amphia, Breda, The Netherlands
| | - B The
- Department of Orthopaedic Surgery, Upper Limb Unit, Amphia, Breda, The Netherlands
| | - KLM Koenraadt
- Foundation for Orthopedic Research, Care & Education (FORCE), Amphia, Breda, The Netherlands
| | - D Eygendaal
- Department of Orthopaedic Surgery, Amsterdam University Medical Center, The Netherlands
- Department of Orthopaedic Surgery, Upper Limb Unit, Amphia, Breda, The Netherlands
| |
Collapse
|
9
|
Abstract
Monteggia fracture-dislocations in the pediatric population have unique patterns of injury that require distinct considerations in diagnosis and management. When appropriately diagnosed and treated early, acute pediatric Monteggia injuries have favorable outcomes. Missed or inadequately treated injuries result in chronic Monteggia lesions that require more complex surgical reconstructions and are associated with less predictable outcomes. This article reviews the classification, diagnosis, and treatment of acute and chronic pediatric Monteggia injuries as well as the controversies there in.
Collapse
Affiliation(s)
- Tyler C Miller
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Maguire Center, Suite 1700, Maywood, IL 60153, USA
| | - Felicity G Fishman
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Maguire Center, Suite 1700, Maywood, IL 60153, USA.
| |
Collapse
|
10
|
Zhou W, Li L, Mu M. Treatment of missed Monteggia fracture with intact annular ligament after an interval of 9 years: a case report and literature review. J Int Med Res 2020; 48:300060520949079. [PMID: 32814487 PMCID: PMC7444132 DOI: 10.1177/0300060520949079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Missed Monteggia fractures are commonly observed among children. Both the interval from the injury to surgery and the patient’s age at operation are thought to be correlated directly with the success of the surgery and prognosis. The aim of the present work was to report one interesting adult case of a missed Monteggia fracture with an intact annular ligament 9 years after injury and the outcomes at a 7-year follow-up. Case description One missed lesion with a 9-year delay for surgery occurred in a skeletally mature individual, and it was treated by open reduction and ulnar angulation and elongation osteotomy. The annular ligament was interpositioned intact in the radiocapitellar joint, and therefore, instead of the annular ligament reconstruction (ALR), relocation was performed. Results After one revision surgery for the complication of nonunion, good radiographic and functional outcomes were eventually sustained at the 7-year follow up. Conclusion Good radiographic and functional outcomes can be expected in adult patients in whom the annular ligament is intact and interpositioned, and this was treated by open reduction and ulnar osteotomy 9 years after the initial injury in our patient.
Collapse
Affiliation(s)
- Weizheng Zhou
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Lianyong Li
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Mingzhang Mu
- Department of Orthopedic Surgery, Yantaishan Hospital, Yantai City, Shandong Province, China
| |
Collapse
|
11
|
Jamieson RP, Ek ET. Isolated Proximal Radioulnar Joint Instability: Anatomy, Clinical Presentation, and Current Treatment Options. JBJS Rev 2020; 8:e0169. [PMID: 32539266 DOI: 10.2106/jbjs.rvw.19.00169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Isolated proximal radioulnar joint instability is an uncommon and often challenging problem that may manifest as recurrent instability of the proximal aspect of the radius, usually during forearm pronation and supination. Instability is due to deficiency of the stabilizing structures around the proximal aspect of the radius, and biomechanical studies have highlighted the importance of the annular ligament and the interosseous membrane in both transverse and longitudinal plane stability. Reconstruction of the stabilizing structures around the radial head often is indicated in cases of recurrent instability and includes joint-preserving procedures such as annular ligament reconstruction, proximal ulnar osteotomy, and interosseous membrane reconstruction. Rarely, salvage procedures such as interpositional arthroplasty or 1-bone forearm reconstruction are necessary. A thorough understanding of the anatomic structures that stabilize the proximal aspect of the radius and the complexities of forearm biomechanics is required in order to successfully diagnose and manage this condition.
Collapse
Affiliation(s)
| | - Eugene T Ek
- Melbourne Orthopaedic Group, Melbourne, Victoria, Australia.,Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
12
|
Yuan Z, Xu HW, Liu YZ, Li YQ, Li JC, Canavese F. The use of external fixation for the management of acute and chronic Monteggia fractures in children. J Child Orthop 2019; 13:551-559. [PMID: 31908671 PMCID: PMC6924126 DOI: 10.1302/1863-2548.13.190115] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The main objective of this study was to retrospectively evaluate the clinical and radiological outcomes of acute (AMF) and chronic Monteggia fractures (CMF) in children treated by closed or open reduction and external fixation (EF). METHODS This is a retrospective review of 26 patients with Monteggia fracture. Patients with AMF (time between trauma and surgery less than two weeks) were treated by closed reduction and EF of the ulna (Group A; 15 patients) while those with CMF (time between trauma and surgery more than three weeks) were managed by closed or open reduction and EF of the ulna (Group B; 11 patients). Clinical outcome was evaluated with radiography and the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH). Complications were recorded in both groups. RESULTS No secondary displacement, wire migration, consolidation delays, nonunion, malunion or re-fracture was noted. However, one patient in Group A (6.7%) developed heterotopic ossification of the ulna; the final functional outcome was good (Quick DASH score: 18.2). One case of postoperative redislocation of the radial head was detected in Group B (9.1%). Two patients (7.6%) developed transient pin tract infection. Despite the fact that 16 out of 26 patients (six in Group A and ten in Group B) complained of the clinical appearance and/or had intermittent residual pain on the injured side, the results were essentially the same between the two groups of patients (p > 0.05). CONCLUSION EF is an alternative for the management of acute and chronic paediatric Monteggia fractures. It provides satisfactory radiological and clinical outcomes with relatively low rates of complications. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Z. Yuan
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - H. W. Xu
- University Hospital Estaing, Department of Pediatric Surgery, Clermont Ferrand, France
| | - Y. Z. Liu
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - Y. Q. Li
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - J. C. Li
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China
| | - F. Canavese
- GuangZhou Women and Children’s Medical Center, GuangZhou Medical University, GuangZhou, China,University Hospital Estaing, Department of Pediatric Surgery, Clermont Ferrand, France,Correspondence should be sent to F. Canavese, Department of Pediatric Orthopaedics, GuangZhou Women and Children’s Medical Center, 9th JinSui Road, GuangZhou, 510623, China. E-mail:
| |
Collapse
|
13
|
Hubbard J, Chauhan A, Fitzgerald R, Abrams R, Mubarak S, Sangimino M. Missed Pediatric Monteggia Fractures. JBJS Rev 2019; 6:e2. [PMID: 29870420 DOI: 10.2106/jbjs.rvw.17.00116] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- James Hubbard
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), San Diego, California.,Department of Pediatric Orthopaedic Surgery, Rady Children's Hospital, San Diego, California
| | - Aakash Chauhan
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), San Diego, California
| | - Ryan Fitzgerald
- Department of Pediatric Orthopaedic Surgery, Riley Children's Hospital, Indianapolis, Indiana
| | - Reid Abrams
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), San Diego, California
| | - Scott Mubarak
- Department of Pediatric Orthopaedic Surgery, Rady Children's Hospital, San Diego, California
| | - Mark Sangimino
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| |
Collapse
|
14
|
Complications during the treatment of missed Monteggia fractures with unilateral external fixation: a report on 20 patients in a 10-year period in a tertiary referral center. J Pediatr Orthop B 2019; 28:256-266. [PMID: 30789537 DOI: 10.1097/bpb.0000000000000592] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The treatment of a missed Monteggia (MM) fracture dislocation is still controversial. We describe our initial experience with ulnar osteotomy and progressive correction with unilateral external fixator in MM. We retrospectively evaluated 20 children undergoing ulnar osteotomy and progressive distraction angulation by unilateral external fixator to treat MM. Nine patients had closed reduction, whereas 11 patients had simultaneous open reduction, repair, or reconstruction of the annular ligament and K-wire stabilization of the radiocapitellar joint. Patients were followed for an average of 3 (1-11) years. Three children developed aseptic nonunion and one child had delayed union. A distal level of the osteotomy significantly increased the rate of nonunion or delayed union. At the final follow-up, eight children had complete reduction of the radial head, six children had partial reduction, whereas in six cases, the radial head remained dislocated. The angulation and the level of the osteotomy significantly influenced the relocation, whereas the open reduction had no significant effect on the final position of the radial head. At the final follow-up, the Kim's score averaged 93.25. The flexion-extension arc significantly improved postoperatively, and it was positively correlated with the angulation. The ulnar osteotomy and progressive traction-angulation by unilateral external fixator can achieve satisfactory results in MM, if a meticulous surgical technique is applied; care must be taken regarding the level of osteotomy and the progressive traction-angulation.
Collapse
|
15
|
Wang Q, Du MM, Pei XJ, Luo JZ, Li YZ, Liu YC, Wang X, Cao JC, Han JH. External Fixator-assisted Ulnar Osteotomy: A Novel Technique to Treat Missed Monteggia Fracture in Children. Orthop Surg 2019; 11:102-108. [PMID: 30714691 PMCID: PMC6430468 DOI: 10.1111/os.12426] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 12/26/2017] [Accepted: 01/28/2018] [Indexed: 11/30/2022] Open
Abstract
Objective The treatment of missed Monteggia fracture remains a challenge, despite the various surgical methods described. The purpose of this study was to explore a new surgical technique utilizing external fixator‐assisted ulnar osteotomy and to assess the surgical results in a case series. Methods Thirteen patients with missed Monteggia fractures were treated at our institution using this new surgical technique from August 2012 to January 2016. Our series included 11 boys and 2 girls. The left elbow was involved in 6 patients and the right elbow was involved in 7 patients. According to the Bado classification, 10 fractures were classified as Bado type I with anterior radial head dislocation and 3 were classified as Bado type III with anterolateral dislocation. The average age at the time of surgery was 5 years 8 months (range, 2 years 2 months–10 years). The mean trauma‐to‐surgery interval was 12 months (range, 2–36 months). All patients underwent ulnar osteotomy with angulation and lengthening using a temporary external fixator, plate fixation of the osteotomy, and open reduction of the radial head dislocation without annular ligament reconstruction. Results The average follow‐up was 27 months (range, 16–44 months). The average operation time was 175 min (range, 140–215 min). The average length of distraction was 0.7 cm (range, 0.5–1.2 cm) and the average angulation was 28° (range, 20°–30°) at the ulnar osteotomy site intraoperatively. The elbow performance score (Kim's) was excellent in 10 cases and good in 3 cases. No neurovascular complications, compartment syndrome or implant breakage occurred. No pain in the distal radioulnar joint or limited range of motion of the wrist occurred in any patient. The radial head remained reduced in all patients with no subluxation or redislocation. However, delayed ulnar union occurred in 3 cases, all of which were successfully treated with plaster cast immobilization within approximately 6 months postoperatively. One patient presented with cubitus valgus postoperatively with a carrying angle of 30°, which was 10° greater than the contralateral carrying angle. Conclusions External fixator‐assisted ulnar osteotomy offers substantial flexibility for achieving the optimal positioning of the transected ulna to reduce the radial head prior to the final ulnar osteotomy fixation with a plate, thereby facilitating an effective operative performance. Our procedure is a safe and effective method to treat missed pediatric Monteggia fractures.
Collapse
Affiliation(s)
- Qiang Wang
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meng-Meng Du
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xin-Jian Pei
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jun-Zhong Luo
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ya-Zhou Li
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu-Chang Liu
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuan Wang
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jin-Chao Cao
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jiu-Hui Han
- Department of Pediatric Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW The chronic Monteggia may lead to pain, mobility limitation, progressive valgus deformity, lateral elbow instability, late ulnar nerve paralysis, and degenerative changes. In this review, we discuss the current procedures in the literature focused on correcting chronic Monteggia to avoid these complications. RECENT FINDINGS Correction of the ulnar deformity with elongation and angulation of the ulna in the opposite direction of the dislocation of the radial head is the most important factor for the reduction and consequent preservation of the radial head. This correction reestablishes the relation of the ulna with the radius and increases the space of the interosseous membrane, providing greater stability after the reduction. The correction may be performed in the acute phase and stabilized with a properly molded plate and screws, or done progressively with an external fixator. SUMMARY The chronic Monteggia may occur along with undiagnosed lesions, such as plastic deformation of the ulna with radial head dislocation, or after an unsuccessfully treated acute Monteggia lesion. This condition may go unnoticed, thus requiring attention to the physical examination and imaging tests. Chronic Monteggia may be treated by ulnar osteotomy with progressive correction with an external fixator. However, the most common treatment is transverse proximal ulnar osteotomy, capsulotomy and removal interposed tissue, reduction of the radial head to the capitellum and temporary transcapitellar fixation, ulnar fixation with a straight plate molded to the ulnar deformity, which is usually deviated dorsally, removal of the transcapitellar Kirschner-wire, stability test, and, if necessary, annular ligament reconstruction.
Collapse
|
17
|
Take M, Tomori Y, Sawaizumi T, Majima T, Nanno M, Takai S. Ulnar osteotomy and the ilizarov mini-fixator for pediatric chronic monteggia fracture-dislocations. Medicine (Baltimore) 2019; 98:e13978. [PMID: 30608438 PMCID: PMC6344151 DOI: 10.1097/md.0000000000013978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Treatment of chronic Monteggia fracture-dislocations remains controversial in skeletally immature patients. The present study aimed to review the clinical outcomes of surgical treatment with an Ilizarov mini-fixator for chronic Monteggia fracture-dislocations in children. From April 2003 to March 2014, 5 pediatric patients (4 males, 1 female) with chronic Monteggia fracture-dislocation were treated with an Ilizarov mini-fixator at our institution. The median age at the time of surgery was 9 years (range 5-14 years), median duration from injury to surgery was 31 months (range 2-125 months), and median duration of follow-up was 12 months (range 11 months-10 years). All patients underwent opening wedge osteotomy of the proximal ulna followed by the application of an Ilizarov mini-fixator. Although closed reduction was attempted after ulnar osteotomy and application of the Ilizarov mini-fixator, open reduction of the radial head was required in all patients. In 4 patients, dense scar tissue in the radiocapitellar joint was excised to enable reduction of the radial head; the remaining patient had traumatic radioulnar synostosis, and underwent separation of the synostosis followed by anconeus interposition arthroplasty. No patient received bone grafting at the ulnar osteotomy site, repair or reconstruction of the annular ligament, or temporary fixation of the radial head with transarticular wire. The median period of external fixation was 10 weeks (range 8-13 weeks). Although there were no severe complications such as deep infection and neurovascular disturbance, asymptomatic radial head subluxation occurred in 2 patients. The patient with traumatic synostosis had residual posterior subluxation with limitation of forearm rotation, and another patient with radial head enlargement had residual anterior subluxation. The median postoperative ranges of motion in pronation, supination, extension, and flexion were 90°, 90°, 0°, and 140°, respectively. The median Kim's elbow performance score was 65 (range 50-75) preoperatively, which improved to 94 (range 80-100) at final follow-up. The outcome was rated as excellent in 4 cases, and good in 1. In pediatric chronic Monteggia fracture-dislocations, ulnar osteotomy followed by the application of an Ilizarov mini-fixator is a viable option that is less invasive than plate fixation.
Collapse
|
18
|
Liu W, Sui X, Ye L, Zhao L. Ultrasonographic evaluation of radial nerve injuries associated with pediatric chronic monteggia lesions. Muscle Nerve 2018; 59:326-330. [PMID: 30390392 DOI: 10.1002/mus.26376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/27/2018] [Accepted: 10/30/2018] [Indexed: 11/05/2022]
Abstract
INTRODUCTION To determine the ultrasonographic evaluation of the radial nerve (RN) before correction of chronic pediatric Monteggia lesions in patients with suspected nerve injury. METHODS Twelve consecutive children with Monteggia lesions were investigated. The cross-sectional area (CSA) of the nerve and the nerve-to-skin (N-S) distance were determined by ultrasonography at 3 levels: 5 cm proximal to the humeroradial joint (L_prox), a horizontal line through the humeroradial joint (L_mid), and 2.5 cm distal to the humeroradial joint (L_dist). RESULTS The CSA was greater on the injured side than on the unaffected side at L_prox and at L_mid (P < 0.01), but no difference was noted for posterior interosseous nerve (PIN) at L_dist (P = 0.445). The N-S values were greater on the unaffected side than on the injured side (P < 0.01), but there was no difference at L_dist in superficial RN and PIN. DISCUSSION Ultrasonography allowed the preoperative assessment of the severity of RN injuries in chronic pediatric Monteggia lesions. Muscle Nerve 59:326-330, 2019.
Collapse
Affiliation(s)
- Weiyong Liu
- Department of Ultrasound, Anhui Province Hospital, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, China
| | - Xiufang Sui
- Department of Ultrasound, Anhui Province Hospital, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, China
| | - Lei Ye
- Department of Ultrasound, Anhui Province Hospital, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, China
| | - Li Zhao
- Department of Pediatric Orthopedics, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
19
|
Annular ligament reconstruction in chronic Monteggia fracture-dislocations in the adult population: indications and surgical technique. Musculoskelet Surg 2018; 102:93-102. [PMID: 30343474 DOI: 10.1007/s12306-018-0564-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
Chronic Monteggia fracture is defined as dislocation of the radial head that is still present 4 weeks after injury. The cause may reside in residual ulnar deformity after internal fixation, in failure of annular ligament healing, or both. This situation may lead to elbow pain, decreased motion, neurologic problems and valgus deformity. The aim of the present study is to investigate indications and surgical technique for annular ligament reconstruction (ALR) in chronic Monteggia fractures. Relevant articles on annular ligament anatomy and biomechanics, clinical-radiographic evaluation of chronic Monteggia lesions and surgical techniques for ALR were reviewed. A case of an ALR in chronic Monteggia injury using a modified Bell Tawse surgical technique with triceps tendon autograft is presented. Little data exist on chronic Monteggia injury in the adult population. The annular ligament has a critical role in radial head stability. Nonetheless, bony alignment of the ulna is confirmed to be the most relevant feature to address in chronic Monteggia fractures. ALR has been advocated to address radial head instability both combined with ulna osteotomy and as a single procedure, with several surgical techniques described and controversial results reported. A modified Bell Tawse surgical technique resulted to be effective in the presented case. ALR seems to be indicated in chronic Monteggia fractures with normal bony alignment, without conclusive evidence on a preferable surgical technique.
Collapse
|
20
|
Delpont M, Louahem D, Cottalorda J. Monteggia injuries. Orthop Traumatol Surg Res 2018; 104:S113-S120. [PMID: 29174872 DOI: 10.1016/j.otsr.2017.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/30/2017] [Accepted: 04/06/2017] [Indexed: 02/02/2023]
Abstract
The Monteggia injury is defined as radial head dislocation with a fracture of the ulnar shaft. This combination should be sought routinely in patients with ulnar fractures, even when the displacement is small. The emergent management is simple, as reducing the ulnar fracture is usually sufficient to stabilise the radial head. Internal fixation of the ulna deserves to be widely used to fully stabilise the radial head. Irreducibility of the radial head at the acute stage may indicate an interposition, which requires open surgery on the joint. Radial head dislocation may occur even with minimal displacement of the ulnar fragment. Chronic Monteggia fractures are more challenging to treat and their outcomes are more variable. The radial head becomes irreducible after 2 to 3 weeks. When a simple surgical approach fails to ensure stable reduction, the most widely used method at present is open reduction of the radial head and proximal osteotomy of the ulnar shaft. Stability must be obtained intra-operatively. Without treatment, radial head dislocation may be well tolerated for several months or even years. In the long term, however, osteoarticular remodelling results in loss of joint congruence, pain and, eventually, osteoarthritis. Radiographs must therefore be obtained on an emergency basis and analysed with great care to avoid missing a Monteggia fracture.
Collapse
Affiliation(s)
- M Delpont
- Service de chirurgie pédiatrique, hôpital Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France.
| | - D Louahem
- Service de chirurgie pédiatrique, hôpital Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - J Cottalorda
- Service de chirurgie pédiatrique, hôpital Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
| |
Collapse
|
21
|
Yıldırım A, Nas K. Rehabilitation of neglected Monteggia fracture: Dislocations in children. J Back Musculoskelet Rehabil 2017; 30:1251-1257. [PMID: 29154266 DOI: 10.3233/bmr-169621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE There are limited studies related to the rehabilitation of neglected Monteggia fracture-dislocations. This study reports the results of the rehabilitation of neglected Monteggia fractures and dislocations and the best treatment options available. MATERIAL AND METHODS Thirteen children were rehabilitated between 2009 and 2012. A retrospective chart review was conducted to record the following: age, gender, anatomic region of fractures, time delay from symptom onset to fracture, Bado classification, Mayo Elbow Performance Index (MEPI) which includes pain, range of motion and daily life comfort, surgeries, length of hospitalization, location and pattern of fracture, length of follow-up and complications. RESULTS The study group included thirteen children and adolescents; eleven males and two females with a mean age of 8.5 (range 2-15) years. According to the Bado classification, 11 patients had type 1, one had type 3 and one had type 4 fracture-dislocations. For Mayo Elbow Performance Index (MEPI) scales, patients that were less than ten years old had greater mean scores. Two patients had superficial infection, one had subluxation, one had osteoarthritis, one had delayed bone union and two had rigidity at the elbow. CONCLUSION The goals of elbow rehabilitation following Neglected Monteggia cases include restoring function by restoring motion and muscle performance; influencing scar remodeling and preventing joint contracture; and restoring or maintaining joint stability. Patients aged younger than 10 years and intervals of less than one-year, between trauma and diagnosis, as well as early and effective rehabilitation were found as important parameters regarding favorable outcomes.
Collapse
Affiliation(s)
- Azad Yıldırım
- Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Kemal Nas
- Physical Medicine and Rehabilitation, Sakarya University Medicine Faculty, Sakarya, Turkey
| |
Collapse
|
22
|
Xu Z, Li Y, Wang Z, Cai H. Open reduction combined with CORA-based osteotomy of the ulna in the treatment of missed Bado type I Monteggia injury: A retrospective study of 5 cases. Medicine (Baltimore) 2017; 96:e8609. [PMID: 29381932 PMCID: PMC5708931 DOI: 10.1097/md.0000000000008609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Open reduction combined with ulnar osteotomy is the most common approach to treating missed Monteggia injuries. The osteotomy is usually performed at the proximal ulna to ensure better healing and fewer complications. The purpose of this study is to present a center of rotation angulation (CORA)-based osteotomy of the ulna for treating Bado type I Monteggia injuries.We retrospectively reviewed the cases of patients who were treated with open reduction combined with a CORA-based ulnar osteotomy between February 2014 and December 2016. Each patient provided his or her internal control, and paired data of the involved and uninvolved sides were analyzed to evaluate forearm rotation function.Five patients (3 male, 2 female) with median age 5.7 years (range, 3.4-6.8 years) were operated on by the senior author in our hospital. The median interval between the original injury and the corrective surgery was 3 months (range, 1-4 months). In a median follow-up of 10 months (range, 6-17 months), all patients obtained stable reduction of the radial head and uneventful healing of the ulnar osteotomy. All patients had pain-free elbows with no neurological or vascular complications and no implant breakage. Patients showed excellent outcomes evaluated using the Broberg and Morrey index.Open reduction with a CORA-based osteotomy of the ulna for the treatment of missed Bado type I Monteggia injury with an obvious ulnar bowing deformity resulted in stable reduction of the radial head and excellent forearm function.
Collapse
|
23
|
Park H, Park KW, Park KB, Kim HW, Eom NK, Lee DH. Impact of Open Reduction on Surgical Strategies for Missed Monteggia Fracture in Children. Yonsei Med J 2017; 58:829-836. [PMID: 28540998 PMCID: PMC5447116 DOI: 10.3349/ymj.2017.58.4.829] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aims of this study were to review our cases of missed Monteggia fracture treated by open reduction of the radial head with or without ulnar osteotomy and to investigate the indications for open reduction alone in surgical treatment of missed Monteggia fracture. MATERIALS AND METHODS We retrospectively reviewed 22 patients who presented with missed Monteggia fracture. The patients' mean age at the time of surgery was 7.6 years. The mean interval from injury to surgery was 16.1 months. The surgical procedure consisted of open reduction of the radiocapitellar joint followed by ulnar osteotomy without reconstruction of the annular ligament. The mean period of follow-up was 3.8 years. Radiographic assessment was performed for the maximum ulnar bow (MUB) and the location of the MUB. Clinical results were evaluated with the Mayo Elbow Performance Index and Kim's scores. RESULTS Five patients underwent open reduction alone, and 17 patients underwent open reduction and ulnar osteotomy. When the MUB was less than 4 mm and the location of the MUB was in the distal 40% of the ulna, we could achieve reduction of the radial head without ulnar osteotomy. The radial head was maintained in a completely reduced position in 21 patients and was dislocated in one patient at final follow-up. CONCLUSION Open reduction alone can be an attractive surgical option in select patients with missed Monteggia fracture with minimal bowing of the distal ulna. However, ulnar osteotomy should be considered in patients with a definite ulnar deformity.
Collapse
Affiliation(s)
- Hoon Park
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Won Park
- Institute for Rare Diseases and Department of Orthopedic Surgery, Korea University Medical Center, Guro Hospital, Seoul, Korea
| | - Kun Bo Park
- Division of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Woo Kim
- Division of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Eom
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Lee
- Division of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
24
|
Prabhu J, Faqi MK, Al Khalifa F, Awad RK. Angulating-Distraction Ulnar Osteotomy and Interpositional Phosphocalcic Ceramic Wedge Graft for a Chronic Monteggia Lesion. Open Orthop J 2017; 11:263-267. [PMID: 28567154 PMCID: PMC5420176 DOI: 10.2174/1874325001711010263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 02/02/2017] [Accepted: 02/27/2017] [Indexed: 12/04/2022] Open
Abstract
Background: Various types of osteotomies have been used to facilitate reduction of the radial head and to prevent recurrent subluxation. The Bouyala technique – open reduction of radial head associated with open wedge ulnar osteotomy with or without annular ligament reconstruction, is presently the most widely used treatment for long- standing traumatic dislocation of the radial head, independently of age, in the absence of osteoarthritis remodeling, and should preferably be performed within 1 year of trauma. Method: In this article, we present a similar case operated by same technique, but we used synthetic phosphocalcic ceramic wedge graft instead of auto bone graft as described in many other studies. We believe that, this will limit the donor site morbidity and also aid in achieving better stability at osteotomy site, which in turn help in proceeding with early active mobilization protocol. Result: We achieved union of the osteotomy by three months. Clinically, there was no deformity and she achieved full pain-free range of motion of elbow joint. Conclusion: We believe that, use of synthetic phosphocalcic ceramic wedge graft allow rigid fixation of osteotomy, provides additional stability, decrease the risk of secondary displacement and allow early mobilization, which may minimize contracture and we could achieve fairly good clinical outcome.
Collapse
Affiliation(s)
- Jagadish Prabhu
- Department of Orthopedics, Bahrain Defence Force Hospital - Royal Medical Services, Kingdom of Bahrain
| | - Mohammed K Faqi
- Department of Orthopedics, Bahrain Defence Force Hospital - Royal Medical Services, Kingdom of Bahrain
| | - Fahad Al Khalifa
- Department of Orthopedics, Bahrain Defence Force Hospital - Royal Medical Services, Kingdom of Bahrain
| | - Rashad K Awad
- Department of Orthopedics, Bahrain Defence Force Hospital - Royal Medical Services, Kingdom of Bahrain
| |
Collapse
|
25
|
Demirel M, Sağlam Y, Tunalı O. Posterior interosseous nerve palsy associated with neglected pediatric Monteggia fracture-dislocation: A case report. Int J Surg Case Rep 2016. [PMID: 27591382 DOI: 10.1016/j.ijscr.2016.08.011.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2022] Open
Abstract
INTRODUCTION The main goal of the treatment is the anatomical reduction of the ulna fracture and the radial head dislocation in acute and chronic Monteggia cases. Acute pediatric Monteggia lesions are generally treated non-surgically; however, the treatment of chronic Monteggia is challenging. The aim of this article is to share our experiences about treatment of neglected Monteggia lesion. PRESENTATION OF CASE A 6-year-old girl who underwent a surgery in our clinic for a missed Bado type-III Monteggia fracture-dislocation of the right elbow with concomitant posterior interosseous nerve (PIN) palsy, which resolved spontaneously after the operation. The operation consisted of open reduction of the radial head, transverse ulnar osteotomy and fixation with an intramedullary Kirchner wire, and annular ligament repair without exploring PIN. The patient was seen in routine follow-up periods until the postoperative first year using plain radiographies. At 16th week follow-up, all functions of the PIN were returned. At first-year follow-up, full range of elbow motion was observed; plain radiographies showed radiocapitellar joint congruency, and Mayo Elbow Performance Index was one hundred. DISCUSSION Treatment planning for chronic, neglected or missed Monteggia fractures is challenging. There is no consensus about the definitive treatment in the literature. CONCLUSION We recommend anatomic and stable restoration of radiocapitellar joint by correcting ulna deformity. Radiocapitellar fixation and PIN exploration may not be necessary in all neglected Monteggia lesions.
Collapse
Affiliation(s)
- Mehmet Demirel
- Department of Orthopaedics and Traumatology, Istanbul University Faculty of Medicine, İstanbul, Turkey.
| | - Yavuz Sağlam
- Department of Orthopaedics and Traumatology, Biruni University Hospital, İstanbul, Turkey
| | - Onur Tunalı
- Department of Orthopaedics and Traumatology, Acıbadem Maslak Hospital, İstanbul, Turkey
| |
Collapse
|
26
|
Demirel M, Sağlam Y, Tunalı O. Posterior interosseous nerve palsy associated with neglected pediatric Monteggia fracture-dislocation: A case report. Int J Surg Case Rep 2016; 27:102-106. [PMID: 27591382 PMCID: PMC5011183 DOI: 10.1016/j.ijscr.2016.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/05/2016] [Accepted: 08/06/2016] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION The main goal of the treatment is the anatomical reduction of the ulna fracture and the radial head dislocation in acute and chronic Monteggia cases. Acute pediatric Monteggia lesions are generally treated non-surgically; however, the treatment of chronic Monteggia is challenging. The aim of this article is to share our experiences about treatment of neglected Monteggia lesion. PRESENTATION OF CASE A 6-year-old girl who underwent a surgery in our clinic for a missed Bado type-III Monteggia fracture-dislocation of the right elbow with concomitant posterior interosseous nerve (PIN) palsy, which resolved spontaneously after the operation. The operation consisted of open reduction of the radial head, transverse ulnar osteotomy and fixation with an intramedullary Kirchner wire, and annular ligament repair without exploring PIN. The patient was seen in routine follow-up periods until the postoperative first year using plain radiographies. At 16th week follow-up, all functions of the PIN were returned. At first-year follow-up, full range of elbow motion was observed; plain radiographies showed radiocapitellar joint congruency, and Mayo Elbow Performance Index was one hundred. DISCUSSION Treatment planning for chronic, neglected or missed Monteggia fractures is challenging. There is no consensus about the definitive treatment in the literature. CONCLUSION We recommend anatomic and stable restoration of radiocapitellar joint by correcting ulna deformity. Radiocapitellar fixation and PIN exploration may not be necessary in all neglected Monteggia lesions.
Collapse
Affiliation(s)
- Mehmet Demirel
- Department of Orthopaedics and Traumatology, Istanbul University Faculty of Medicine, İstanbul, Turkey.
| | - Yavuz Sağlam
- Department of Orthopaedics and Traumatology, Biruni University Hospital, İstanbul, Turkey
| | - Onur Tunalı
- Department of Orthopaedics and Traumatology, Acıbadem Maslak Hospital, İstanbul, Turkey
| |
Collapse
|
27
|
Somford MP, Nieuwe Weme RA, van Dijk CN, IJpma FFA, Eygendaal D. Are eponyms used correctly or not? A literature review with a focus on shoulder and elbow surgery. ACTA ACUST UNITED AC 2016; 21:163-71. [DOI: 10.1136/ebmed-2016-110453] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|