CHRONIC MONTEGGIA FRACTURE-DISLOCATION IN CHILDREN SURGICAL STRATEGY AND RESULTS

Evaluation of Monteggia Fracture Outcomes: Acute to Chronic

INTRODUCTION

Our study aims to characterize the results of Monteggia fractures treated in our practice and to determine factors associated with good or poor outcomes.

METHODS

A retrospective review of children aged 17 and under with acute, subacute, or chronic Monteggia fractures who were treated at our institution was performed. The primary outcomes were initial reduction and maintenance of joint reduction, while the secondary outcomes were elbow flexion/extension and forearm supination/pronation.

RESULTS

Seventeen patients with Monteggia fractures were identified. Two patients were excluded: 1 was lost to follow-up and 1 had congenital absence of the elbow flexors. Thus, our final cohort was 15 patients (acute n = 3, subacute n = 4, chronic group n = 8). Median final follow-up was 1.9 years (range = 34 days-8 years).

CONCLUSION

Preoperative range of motion (ROM) was the most important factor in determining postoperative ROM in this cohort of patients with chronic Monteggia fractures. All patients who presented with excellent preoperative ROM, regardless of their timing category, had an excellent ROM outcome. Time from initial injury also played an important role. All patients in the acute and subacute categories had good or excellent postoperative ROM. Patients who were further from the initial injury were more likely to present with worse preoperative ROM and, in turn, had worse outcomes with postoperative ROM.

What do we need to address when we treat neglected Monteggia fracture in children

Monteggia fracture is a relatively uncommon injury in pediatric patients, accounting for less than 2% of forearm fractures, characterized by a combination of ulna fracture and radial head dislocation. Neglected Monteggia fractures define as those that have not received treatment within 3 weeks. In children, ulna fractures are easily diagnosed while radial head dislocation may be overlooked, necessitating open reduction after neglecting the Monteggia fracture and potentially causing additional trauma to the child. This study aims to review the pathological characteristics of neglected Monteggia fractures based on the length ratio of the ulna and radius, relative positions between the proximal ends of the ulna and radius, the integrality of annular ligament and the pathological change of proximal radioulnar joint. The findings will provide valuable insights and guidance for managing neglected Monteggia fractures.

Risk factors for unsuccessful reduction of chronic Monteggia fractures in children treated surgically

Aims

To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

Methods

A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples t-test, chi-squared test, and logistic regression analysis were used to identify the risk factors associated with unsuccessful RHR.

Results

Redislocation occurred during surgery in 48 patients (23%), and during follow-up in 44 (21.1%). The mean follow-up of patients with successful RHR was 13.25 months (6 to 78). According to the univariable analysis, time from injury to surgery (p = 0.002) and preoperative dislocation distance (p = 0.042) were identified as potential risk factors for unsuccessful RHR. However, only time from injury to surgery (p = 0.007) was confirmed as a risk factor by logistic regression analysis. Receiver operating characteristic curve analysis and chi-squared test confirmed that a time from injury to surgery greater than 1.75 months increased the rate of unsuccessful RHR above the cutoff (p = 0.002).

Conclusion

Time from injury to surgery is the primary independent risk factor for unsuccessful RHR in surgically treated children with CMFs, particularly in those with a time from injury to surgery of more than 1.75 months. No other factors were found to influence the incidence of unsuccessful RHR. Surgical reduction of paediatric CMFs should be performed within the first two months of injury whenever possible.

Ulnar osteotomy and monolateral external fixator for the treatment of chronic Monteggia fractures in children: comparison between gradual and acute radial head reduction

This study evaluated the outcomes of chronic Monteggia fractures (CMFs) treated by ulnar osteotomy and monolateral external fixator (MEF), and compare the outcome of gradual versus acute radial head reduction. Two groups of patients were identified. Group 1: gradual reduction of the radial head ( n = 13); group 2: acute reduction ( n = 6). Clinical outcome was evaluated by Kim Elbow Score, whereas radiographic outcome was assessed on plain radiographs. The effect of age, side, time from initial trauma to surgery, rate of unplanned surgery, amount of angulation and lengthening, and final outcome were evaluated. Univariate analysis was performed to identify factors associated with good radiographic outcome. Thirteen patients underwent gradual correction of the ulna. The mean duration of correction was 43.4 days (range, 21-82); the mean angulation and lengthening of the ulna were 22.8° (range, 0°-35°) and 22.2 mm (range, 12.2-40.9), respectively. Six patients underwent acute reduction intraoperatively, the mean angulation and lengthening of the ulna were 17.2° (range, 4°-33.9°) and 5.2 mm (range, 2.5-12.2), respectively. CMF treated by ulnar osteotomy and gradual distraction had better radiological outcome (Group 1; 92.3% 12/13) than those treated by acute reduction of the radial head (Group 2; 3/6, 50%) ( P = 0.071). Reoperation rate was found to be significantly correlated with a fair or poor radiographic results ( P = 0.016). Good clinical and radiological outcomes should be expected in CMF patients treated by gradual lengthening and angulation of the ulna with a MEF.

To Angulate or Not to Angulate the Ulna during the Progressive Distraction Period Performed with a Monolateral External Fixator in Paediatric Patients with a Chronic Monteggia Fracture?

Background and Objectives: The purpose of this study was to compare the clinical and radiographic evolution of chronic Monteggia fractures (CMFs) treated by ulnar osteotomy and monolateral external fixators (MEFs) with or without angulation of the ulna during the distraction period. Materials and Methods: This retrospective study evaluated 20 children (14 boys and 6 girls) with CMFs. According to the strategy of ulnar lengthening, two groups of patients were identified: patients undergoing gradual lengthening with (Group A, n = 11) or without ulna angulation (Group B, n = 9). The mean age at the time of surgery was 7.7 years old (range, 5.4−12.9). The mean time from initial trauma to surgery was 26.3 months (range, 1−96), and the mean follow-up was 24.6 months (range, 5.5−45.4). Clinical outcomes were evaluated by Kim et al.’s Elbow Performance Score, while radiographic outcomes were assessed on plain radiographs. Results: Age at surgery, sex, laterality, time between trauma and surgery, and time of follow up in the two groups of patients showed no significant differences. The radial head was successfully reduced in 9 of 9 and 10 of 11 patients in Groups B and A, respectively (p = 1.00). The mean time to achieve radial head reduction was shorter in Group B (18.1 ± 5.3 days) than in Group A (39.2 ± 18.7 days; p = 0.004). The mean angulation of the ulna at the end of treatment was significantly lower in Group B (0.6° ± 1.1°) than in Group A (25.9° ± 6.3°; p < 0.0001). The average ulnar lengthening at the end of treatment in Group B (14.1 ± 5.8 mm) was, on average, 7.7 mm less than that in Group A (21.8 ± 9.7 mm; p = 0.05). The Kim et al. Elbow Performance Score at the last follow-up visit was comparable between the two groups of patients (p = 1.00). Conclusions: A shorter time to achieve radial head reduction and less deformity of the ulna can be expected in paediatric patients with CMFs undergoing intraoperative restoration of ulnar alignment and gradual lengthening without angulation postoperatively.

Neglected Monteggia Fractures in Children—A Retrospective Study

(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.

Outcomes and experience after open reduction for chronic Monteggia fracture in children

BACKGROUND

The treatment of chronic Monteggia fracture-dislocation (CMF) remains controversial and challenging for surgeons. We describe our initial experience with ulnar osteotomy and angulation on correction with modified open surgery and evaluate outcomes from clinical and radiographic findings.

METHODS

We retrospectively reviewed 18 children with a mean age of 6.78±2.67 years old who underwent surgical treatment because of CMF. Electronic medical records of Bado type, complaints, Kim scores, and complications were recorded. Radiographic parameters of maximum interosseous distance (MID), proportional ulnar length (PUL), lengthening, and bending angle of the ulna were summarized. The final reduction statuses of the radial head were reviewed. Parameters were compared at the time of pre-operation and the last follow-up. The relationship between the lengthening and angulation of ulna and the interval was calculated.

RESULTS

The mean interval was 11.1 [1-48] months and the follow-up time was 46.6 [24-96] months. A good reduction was observed in 15 (83.33%) patients, while 3 (16.67%) patients were fair. Postoperatively, the Kim scores were improved, from 59.17±18.17 to 90±6.64 (P=0.000). The mean posterior bending angle was 12.88° (range, 3 to 25°), and the mean amount of elongation of the ulna was 8.78 mm (range, 3.61 to 17.52 mm). The lengthening of the ulna was proportional to the magnitude of angulation of the ulna (r=0.648, P=0.004), and a positive correlation was also seen between the lengthening and the interval (r=0.632, P=0.005) and the angulation and the interval (r=0.502, P=0.034). The PUL and MID were significantly increased from 1.06±0.03 and 1.11±0.26 to 1.13±0.11 (P=0.047) and 1.28±0.27 (P=0.021), separately.

CONCLUSIONS

We highlight ulnar osteotomy as the essential procedure during reconstruction surgeries. Stabilization of the radial head with adequate elongation and balanced angulation of the osteotomy through direct observation is the main way to ensure and maintain satisfactory outcomes. With the extension of the interval, it is more necessary to increase the lengthening and angulation in positive proportion. PUL is a useful parameter in evaluating the mismatch between ulna and radius in CMF.

The management of chronic paediatric Monteggia fracture-dislocation

Background

Monteggia fracture-dislocation is a rare and often missed injury in the paediatric population. The neglected radial head dislocation might go unnoticed for several months, but usually becomes symptomatic at a certain point in time, posing a complex clinical problem. Management strategies for chronic Monteggia lesions have been proposed by many authors. A consensus therapy is nonetheless lacking. In recent years an increasing number of case series reporting the outcomes of various treatment options have been published to gain insight into this challenging pathology. The purpose of this review is to provide a general background on chronic, paediatric Monteggia fracture-dislocation, followed by a systematic analysis and discussion of various management strategies and their outcomes, described in recent outcome studies.

Methods

A literature search was conducted within the online databases PubMed, Cochrane Central, EMBASE and Google Scholar, to identify outcome studies on the management of chronic Monteggia lesions published between January 2015 and April 2020. A total of 23 outcome studies were identified and included in this study.

Results

Obtaining stable radial head reduction can be regarded as the main objective of any management strategy for chronic, paediatric Monteggia fracture-dislocation. In recent literature, many surgical techniques have been put forward to obtain this goal, with the mainstay of most treatment strategies being ulnar osteotomy and open reduction with or without reconstruction of the annular ligament. Watchful neglect is a strategy that got more or less abandoned and is challenged in recent literature.

Conclusions

Due to the complexity of long-standing radial head dislocation and the unpredictability of outcomes in the treatment of chronic Monteggia lesions, early diagnosis and achieving a stable reduction, preferably in the acute setting, are paramount. Because of the tendency to obtain more satisfactory radiological and clinical results in younger patients, with a short injury-to-surgery interval, it is advisable to promptly proceed to surgical treatment when chronic Monteggia fracture-dislocation is diagnosed.