A Long-standing Monteggia Fracture in a Child who underwent Bone Lengthening and Annular Ligament Reconstruction: A Case Report

External fixators and lengthening systems in pediatric upper limb

The use of external fixators is part of the cultural background of orthopedic surgeons in treating numerous clinical conditions. Over the years, fixator design and biomechanical knowledge have led to different solutions and techniques, and bone lengthening and its better understanding come together with the development of external fixators and the application of the biological principle of distraction osteogenesis. The authors conducted a literature review about using external fixators and lengthening systems in pediatric upper limbs. Despite the applications of external fixators in upper limbs remaining much more limited than those of the lower limbs, there are indications of traumatic, congenital, tumor, and infectious etiologies. However, despite the spread of new systems of plate and screws and intramedullary lengthening nails, the problems about when to use external fixation remain unsolved. Another debated point is about using monolateral or circular frames for humeral lengthening and the correction of forearm deformities in multiple hereditary exostoses disease (MHE) or radial longitudinal deficiency sequelae. Monoaxial fixators retain a prominent role for skeletal lengthening in all the districts examined, although their role could be outclassed by the motorized intramedullary nails, especially for humeral lengthening. Hexapod systems are likely to represent the future for the correction of multiplanar forearm deformities; however, multicenter studies on larger series will be necessary to better validate their applications and advantages.

Ulnar osteotomy between the proximal 1/3 and 1/5 provides a stable radiocapitellar joint in chronic Monteggia fracture

Background

The precise location of unlar osteotomy remains a subject of ongoing controversy in chronic Monteggia fracture (CMF). The purpose of this study was to analyze the influence of different levels of ulnar osteotomy on redislocation in CMF.

Methods

We retrospectively reviewed 18 children following our previous series. Except the baseline characteristics and radiographic parameters such as ulnar osteotomy angle, maximum interosseous distance (MID) and proportional ulnar length (PUL), we introduced a new parameter: proportional ulnar osteotomy (PUO) which represents the quantitative level of proximal ulnar osteotomy. Based on the value of PUO, we divided it into two intervals: appropriate PUO range (1/5< PUO <1/3) and inappropriate PUO range (PUO >1/3; PUO <1/5). The relationship between these indexes and redislocation was analyzed.

Results

According to the reduction state of radial head, patients were divided in two groups: reduced (15/18) and redislocation (3/18). Only PUO range differed significantly (P=0.043) between the two groups, with a notably higher number of patients showed an osteotomy between 1/5 and 1/3 of ulna in reduced group. Combining PUO range with radiographic parameters (osteotomy angle and post-PUL) improved the accuracy and specificity over using osteotomy angle and post-PUL (accuracy, 94.44% vs. 83.33%) (specificity, 93.33% vs. 86.67%, P=0.008). This combination further enhanced the predictive capability for detecting the risk of redislocation in CMFs.

Conclusions

Ulnar osteotomy between the proximal 1/3 and 1/5 appears to provide a much safer and more stable radiocapitellar joint in CMF.

Risk factors for redislocation of chronic Monteggia fracture-dislocation in children after reconstruction surgery

INTRODUCTION

Monteggia fracture-dislocation refers to traumatic ulnar fractures and dislocation of the radial head, which is one of the most frequently missed injuries, especially in children. The most widespread attitude towards chronic Monteggia lesion is the open reduction of the radial head associated with ulnar osteotomy with or without annular ligament reconstruction. Our study aimed to analyze the risk factors for redislocation after surgical management of chronic Monteggia lesion and the benefits of annular ligament reconstruction and radiocapitellar pinning in paediatric.

MATERIALS AND METHODS

We retrospectively reviewed patients treated with reconstruction surgery for chronic Monteggia fracture-dislocation in our department between 2005 and 2017, with a minimum two years' follow-up. The reconstruction surgery included ulnar osteotomy performed in all patients, annular ligament repair or reconstruction or fixation of radiocapitellar joint, or radial osteotomy in some patients. We collected the related clinical data and evaluated the risk factors of redislocation using logistic regression analyses and a two-piecewise linear regression model with a smoothing function, after reconstruction.

RESULTS

Throughout a mean six years' follow-up (range, 2-14 years), 62 patients (42 males, 20 females; average age 6.49 years range, 2-13 years) were reviewed. Of the radiocapitellar joints, 16.1% was noted to have redislocation. Univariate risk analysis showed age, time from injury to surgery, and radial osteotomy were risk factors for a recurrent radiocapitellar redislocation. Time from injury to surgery was found to be independent predictor of redislocation in multivariate analysis. However, there were significant nonlinear associations between time from injury to surgery and redislocation in multivariate logistic regression analysis after multivariate adjustment (p for nonlinear = 0.023). Every one month increase was associated with a 1.37-fold increase in redislocation, in participants within one year after injury.

CONCLUSION

In conclusion, the surgery of chronic Monteggia fracture-dislocation should be done as quickly as possible within one year after injury. Associated annular ligament reconstruction or fixation of radiocapitellar joint does not seem to be helpful.

Missed Monteggia Fracture Dislocation in a 10-year-old Child - A Step-by-Step Approach to Properly Solving a Complex Problem: A Case Report

Introduction

Monteggia injuries are relatively rare in the pediatric population. They can be missed leading to complications arising from a chronic radial head dislocation. There is limited information about their proper management in the literature. Thus, their treatment remains controversial.

Case Report

We present a case of a 10-year-old boy who was examined in the orthopedic outpatient clinic of our hospital, due to limited range of motion of his left elbow and difficulty in extending his left thumb, after a forearm injury which occurred 9 months before and was initially treated conservatively. After appropriate imaging was obtained, a Bado type I Monteggia lesion was diagnosed. This was treated by open reduction of the head of radius, osteotomy of the ulna and lengthening using an external fixator, as well as annular ligament reconstruction by the use of synthetic tendon graft. The patient was followed up for 18 months after surgery and during his last examination showed very good clinical and functional results.

Conclusion

Missed Monteggia injuries in children are complex problems warranting a step-by-step approach. Their management with ulnar osteotomy, bone lengthening, and reconstruction of the annular ligament presents a viable option with excellent clinical, functional, and radiological outcomes.