Functional and radiological outcome in patients with acute Monteggia fracture treated surgically: a comparison between closed reduction and external fixation versus closed reduction and elastic stable intramedullary nailing

Ultrasound, a new adjuvant method for treating acute Monteggia fracture in children

PURPOSE

This study aims to evaluate the feasibility of using ultrasound-guided Kirschner wire or elastic intramedullary nail for fixation in the treatment of acute Monteggia fracture in children.

METHODS

A retrospective analysis was conducted on 31 cases of acute Monteggia fracture in children treated with ultrasound-guided Kirschner wire or elastic intramedullary nail fixation between April 2020 and December 2022, including 14 cases of Kirschner wire fixation and 17 cases of elastic intramedullary nail fixation. During the operation, soft tissue compression and nerve and vascular injuries were explored, fracture reduction was performed under ultrasound guidance, and operation time was recorded. After the operation, X-ray examination was conducted to assess the quality of fracture reduction. At the last follow-up, the flexion, extension, pronation, and supination angles of both affected and unaffected elbow joints were measured, and the Mayo score was used to evaluate elbow joint function.

RESULTS

The average duration of surgery was 50.16 ± 19.21 min (ranging from 20 to 100 min). Based on the evaluation criteria for assessing reduction quality, 28 cases were deemed excellent, while 3 cases were considered good. After immobilization with long-arm cast for 4-6 weeks postoperatively, elbow and forearm rotation exercises were performed. Kirschner wires were removed after an average of 6.64 ± 0.93 weeks (ranging from 6 to 9 weeks) postoperatively, and elastic intramedullary nails were removed after an average of 5.12 ± 1.54 months (ranging from 4 to 10 months) postoperatively. The average follow-up time was 19.13 ± 11.22 months (ranging from 4 to 36 months). During the final follow-up, the affected limb's range of motion in flexion, extension, pronation, and supination was (141.16 ± 4.24)°, (4.61 ± 2.81)°, (84.52 ± 3.74)°, and (84.23 ± 3.69)°, respectively. There was no notable variance when compared to the healthy limb, which had a range of motion of (141.81 ± 2.99)°, (4.81 ± 2.50)°, (85.61 ± 3.12)°, and (85.03 ± 2.73)° (P > 0.05). The Mayo Elbow Performance index classified 29 cases as excellent and 2 cases as good.

CONCLUSION

Ultrasound-guided Kirschner wire or elastic intramedullary nail fixation can be used for the treatment of acute Monteggia fracture in children, which can explore the surrounding nerves, blood vessels, and soft tissue compression, reduce the difficulty of reduction, and cause minimal trauma. It can greatly reduce the risk of radiation exposure and complications such as vascular and nerve injury during the operation.

Outcomes After Operative Treatment of Pediatric Monteggia Fracture-Dislocations: Comparison Between Open and Closed Injuries

BACKGROUND

Open pediatric Monteggia fracture-dislocations are a relatively uncommon injury pattern, with limited numbers reported in previous series. Open fracture-dislocations frequently represent more severe injury patterns with potential for contamination. We aim to determine differences in long-term clinical and functional outcomes in the operative management of closed versus open pediatric Monteggia fracture-dislocations.

METHODS

A retrospective review of operatively treated pediatric Monteggia fracture-dislocations was performed. Closed versus open injuries were compared in both clinical outcomes, as well as patient-reported outcomes through Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire.

RESULTS

Of 30 operatively treated injuries, 12/30 (40%) were open fracture-dislocations. Patients were followed clinically for an average of 15.65 months in open injuries and an average of 4.61 months in closed injuries. A trend toward increased time to union was observed, however, significance was not achieved; open injuries averaged 8.0 versus 5.8 weeks for closed injuries ( P =0.07). Two patients (11%) in the closed fracture group experienced postoperative complications; both were minor. Five patients (42%) in the open fracture-dislocation group experienced a total of 6 postoperative complications; 5 of the 6 complications were major. QuickDASH scores were obtained at an average of 5 years postoperatively; mean QuickDASH scores were higher in the open fracture group, 13.1, compared with the closed fracture group, 5.9 ( P =0.038). Increased QuickDASH scores were independently associated with presence of postoperative complications. QuickDASH score could be expected to increase by 12.5 points in those with major complications ( P =0.044).

CONCLUSION

We present the largest single cohort of pediatric open Monteggia fracture-dislocation injuries to date. These injuries are predictive of poorer outcomes including trend toward increased time to union, increased risk of major complication, and can independently predict worse long-term patient-reported functional outcomes.

LEVEL OF EVIDENCE

Level III-these data represent a retrospective comparative study of clinical and functional outcomes.

Review of pediatric functional outcomes measures used to evaluate surgical management in pediatric patients with an upper extremity fracture

For two decades, many scores, questionnaires, and rating systems have been used to evaluate the functional outcome of children with an upper extremity fracture (UEF). However, only a few of these were created specifically for children, and many assess only elbow function. In the absence of any published review on this topic, we set out to identify and categorize different scores used to evaluate the clinical and functional outcomes of surgically treated pediatric UEFs. A literature search was performed, and 38 studies were identified. The scores used more often were the shortened version of the Disability of the Arm, Shoulder and Hand questionnaire and the Mayo Elbow Performance Score/Index. In a lower number of studies, authors used other scoring systems, including the Mayo Wrist Score, the Patient-Rated Wrist Evaluation, the Patient-Rated Elbow Evaluation, the Métaizeau functional scoring system, the Oxford Elbow Score, the Price and Flynn criteria, the Hardacre Functional Score, the Neer Shoulder Score, the Constant-Murley Shoulder Score, the Modified Orthopedic Trauma Association Score, the Medical Outcomes Study Short Form-36, and the Pediatric Outcomes Data Collection Instrument. Some specific pediatric scoring systems to evaluate the functional outcome of children with a UEF have been suggested, but a single tool that is valid and reliable for skeletally immature patients of all ages is not yet available. Further studies are needed to identify specific pediatric measurements to increase validity, responsiveness, sensitivity, and interpretability of upper limb functional outcome scores in common clinical practice.

Closed reduction by trans-physealantegrade elastic stable intramedullary nailing in acute pediatric Monteggia fractures: a report of 22 cases

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.

Management of acute length-unstable Monteggia fractures in children: A case report

BACKGROUND

Monteggia fractures are uncommon injuries in paediatric age. Treatment algorithms assert that length-unstable fractures are treated with plate fixation. In this case report, intramedullary fixation of an acute length-unstable Monteggia fracture allowed a stable reduction to be achieved, along with an appropriate ulnar length and alignment as well as radio capitellar reduction despite the fact that the orthopaedic surgeon did not use a plate for the ulnar fracture. The scope of treatment is to avoid the use of a plate that causes periosteal stripping and blood circulation disruption around the fracture.

CASE SUMMARY

A four-year-old girl presented at the Emergency Department following an accidental fall off a chair onto the right forearm. The X-ray highlighted a length-unstable acute Bado type 1 Monteggia fracture of the right forearm. On the same day, the patient underwent surgical treatment of the Monteggia fracture. The surgeon preferred not to use a plate to avoid a delay in fracture healing and to allow the micromotion necessary for callus formation. The operation comprised percutaneous fixation with an elastic intramedullary K-wire of the ulnar fracture and, subsequently, humeroradial joint reduction through manual manipulation. The orthopaedic surgeon assessed the stability of the radial head reduction under fluoroscopic control through flexion, extension, pronation and supination of the forearm. Healing of the fracture occurred within six weeks after surgery, as indicated by the presence of calluses on at least three cortices on standard radiographs. Dislocation/subluxation or loss of ulnar reduction was not apparent at the final X-ray examination.

CONCLUSION

Intramedullary fixation of unstable Monteggia fractures results in excellent outcomes, provides reliable reduction and causes fewer complications.