A Monteggia variant associated with unusual fracture of radial head in a young child: A case report

IntroductionMonteggia fracture and its variants are not common among children but may be challenging and lead to serious complications if not treated in acute stage. The different types of associated growth plate fractures of proximal radius are not yet clearly defined in any variant classifications.Presentation of caseA 6-year-old girl was brought to the emergency room after a fall on the left elbow. The plain radiographs showed unstable fracture of proximal ulna with a laterally displaced and comminuted radial head fracture. The patient was treated surgically as a case of a Monteggia variant. The case has been re-evaluated twenty months following the surgery and did not show any radiological signs of growth disturbance nor residual deformity.DiscussionThe presented Monteggia variant is rare in terms of associated unique intra-articular fracture of proximal radius. The successful management of the case is based on adhering to the principles of treatment of Monteggia fractures.ConclusionEarly recognition of unusual Monteggia variant patterns is crucial to avoid delay in treatment. Adherence to the principles of surgical management in unstable variants is encouraged.     

Type III monteggia equivalent injury with compartment syndrome in an 8 year old child: A case report

A rare case of a type III Monteggia fracture equivalent with compartment syndrome is reported here. Literature is very scanty about this rare combination of injuries which we are discussing. Timely intervention can lead to a satisfactory outcome even in these complex injuries.     

Missed Monteggia injuries

The classical Monteggia injury comprises a dislocation of the radial head with an associated fracture of the ulna. In the variant type, there is no ulnar fracture merely plastic deformation. We performed a retrospective study of all Monteggia injuries from 1992 to 2001. A total of 39 were reviewed, of which 8 were missed (1 classical and 7 variant). Of those, five were male and three female with a mean age of 6.3 years. The mean follow-up was 2.5 years, with a mean interval between injury and diagnosis of 33.5 weeks. Two Monteggia injuries diagnosed within 4 weeks were successfully treated by closed manipulation. The other six required ulnar osteotomy, repair of the annular ligament and stabilisation of the radial head with a transcapitellar pin. A protocol for the diagnosis of Monteggia injuries is described. Doubtful cases require an immediate review since early treatment improves the outcome. Acceptable clinical and radiological results in late diagnosed Monteggia injuries can result from ulnar osteotomy, open reduction of the radial head with repair of the annular ligament and transcapitellar pin stabilisation of the reduced radial head.     

Monteggia''s骨折脱位的相关内容回顾

Monteggia’s骨折脱位是指任何部位的尺骨骨折合并桡骨头脱位。这种累及前臂和肘部的损伤并不常见，其发生率约占前臂骨折总数的5％。本文通过回顾Monteggia’s骨折脱位的历史发展，进一步明确了其定义分型、损伤机制和治疗原则，并对现有的治疗方法和预后评价标准进行了总结，并指出治疗的关键是及时诊断和及时治疗，使尺骨获得优良的解剖复位和稳定固定，另外必须重视对发生在肘关节水平的合并损伤的处理，包括冠状突骨折、桡骨头骨折、肱尺关节后外侧旋转不稳定等。而尺骨的粉碎骨折合并桡骨头骨折、冠状突骨折都将明显影响预后。     

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

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

RETRACTED ARTICLE: Missed Monteggia fracture in children: is annular ligament reconstruction always required?

Background  

Missed radio-capitellar joint dislocation is one of the feared complications of Monteggia fractures, especially when associated with subtle fractures of the ulna bone. Many treatment strategies have been described to manage the chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. This study is an attempt to address the issue of annular ligament reconstruction in the surgical management of missed Monteggia fracture.     

儿童孟氏骨折的手术治疗及功能康复

目的 对儿童孟氏骨折的手术治疗及功能康复进行评价。方法 1994年～2001年对78例非手术治疗失败的新鲜及陈旧性孟氏骨折全部采用手术治疗，并随机分为两组，第1组(单针固定组)45例，其中新鲜骨折16例，陈旧性骨折29例，复位肱桡关节后，单枚克氏针固定，石膏外固定，尺骨骨折不作内固定；第2组(双针固定组)33例，其中新鲜骨折14例，陈旧性骨折19例，复位肱桡关节及尺骨骨折后，分别用克氏针固定，石膏外固定。结果 术后78例伤口愈合佳，无感染。均获随访，时间6个月～7年，平均4．6年．尺骨骨折愈合好，无骨不连及骨延迟愈合。手术疗效按肘关节屈伸及前臂旋转功能标准评价，第1组优37例，良5例，差3例，优良率93．3％；第2组优22例，良7例，差4例，优良率87．9％，两组比较无统计学意义(P＞0．05)。结论 手术治疗孟氏骨折整合复位肱桡关节，并予单枚克氏针内固定加石膏外固定，其操作简便、安全、组织损伤小及尺骨骨折愈合快，术后肢体功能恢复好。     

尺骨截骨治疗儿童陈旧性孟氏骨折

目的探讨尺骨截骨手术治疗陈旧性儿童孟氏骨折的疗效。方法对28例患儿采取尺骨截骨固定桡骨小头复位,同时行环状韧带重建,其中3例行桡骨中段缩短截骨固定。结果28例均得到随访,时间6个月～8年。肘关节功能：优20例,良8例。4例合并桡神经损伤患儿完全得到恢复。结论尺骨截骨手术是治疗儿童陈旧性孟氏骨折良好术式。     

A rare case of Monteggia's lesion in children

The authors present a rare case of a Monteggia lesion in a child. The fracture of the proximal ulnar metaphysis is associated with a dislocation of the radial head. The outcome is good after closed reduction and six weeks cast. Two years later, the function is normal.     

Missed Monteggia fracture in children: Is annular ligament reconstruction always required?

Background:

Chronic (neglected) radiocapitellar joint dislocation is one of the feared complications of Monteggia fractures especially when associated with subtle fracture of the ulna bone. Many treatment strategies have been described to manage chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. The purpose of this study is to highlight the management of missed Monteggia fracture with particular emphasis on utility of annular ligament reconstruction by comparing the two groups of patients.

Materials and Methods:

In a prospective study 12 patients with mean age of 7.4 years, who presented with neglected Monteggia fractures, were studied. All children underwent open reduction of the radiocapitellar joint. Five children (Group A) were treated with angulation-distraction osteotomy of ulna and annular ligament reconstruction and six cases (Group B) required only angulation-distraction osteotomy of ulna without ligament reconstruction. In one case an open reduction of the radiocapitellar joint was sufficient to reduce the radial head and this was included in Group B. The gap between injury and presentation was from 3 months to 18 months (mean 9 months). Ten patients were classified as Bado I, and one each as Bado II and III respectively. We used the Kim''s criteria to score our results.

Result:

The mean follow-up period was 22 months. All ulna osteotomies healed uneventfully. The mean loss of pronation was 15 degree in Group A and 10 degree in Group B. Elbow flexion improved from the preoperative range and no child complained of pain, deformity and restriction of activity. The elbow score was excellent in 10 cases, and good in two cases.

Conclusion:

Distraction-angulation osteotomy of the ulna suffices in most cases of missed monteggia fracture and the need for annular ligament reconstruction is based on intraoperative findings of radial head instability.     

新鲜儿童孟氏骨折治疗方法的选择

目的探讨新鲜儿童孟氏骨折不同治疗方法的选择。方法复习1995～2004年治疗的86例新鲜儿童孟氏骨折的临床资料,其中A组28例采用手法复位小夹板或石膏外固定;B组35例尺骨骨折采用开放复位内固定,桡骨头手法复位后肘部用护腕固定;C组23例采用开放复位内固定环状韧带修补术治疗,对三组的肘关节及前臂的功能进行分析,比较三组的疗效。结果随访时间8个月～9年,A组优15例,良8例,可3例,差2例;B组优25例,良8例,可2例,差0例;C组优14例,良6例,可2例,差1例。三组间比较,其差异无统计学意义(P>0．05)。结论对损伤程度不同的孟氏骨折应分别选用合适的治疗方式,其中桡骨头复位后护腕固定并配合尺骨骨折切开复位内固定适用于各种类型的孟氏骨折。     

钢丝套环治疗需修复环状韧带的成年新鲜 Monteggia 骨折的初步报告

目的 探讨钢丝套环法治疗需修复环状韧带的成年新鲜Monteggia骨折的初步疗效.方法 2006年5月至2008年3月共收治15例需修补环状韧带的成年新鲜Monteggia骨折患者,其中男9例,女6例;年龄19～46岁,平均29.8岁.骨折按Bado分型:Ⅰ型6例,Ⅱ型4例,Ⅲ型5例.均采用尺骨骨折切开复位钢板内固定,桡骨头切开复位后用直径0.8 mm钢丝套住桡骨颈固定于尺骨近端,修补环状韧带,术后48 h开始肘关节功能锻炼,3周去除内固定钢丝. 结果 15例患者术后获得8～11个月(平均9.5个月)随访.3周取出钢丝未见钢丝断裂患者,12～16个月(平均13.3个月)取出尺骨固定钢板.参照Broberg和Morrey评分标准:优11例,良2例,可2例,优良率为86.7%.1例肘关节有轻度疼痛,2例有中度疼痛.1例桡神经深支损伤患者于术后3个月恢复伸指、伸拇功能.未见尺骨骨不连和桡骨头缺血性坏死等并发症发生. 结论 钢丝套环法是治疗需修补环状韧带的成年新鲜Monteggia骨折的较理想方法.     

Divergent elbow dislocation with radial shaft fracture,distal ulnar deformation,and distal radioulnar joint instability: an unclassifiable Monteggia variant

Originally described by Monteggia and later classified by Bado, elbow dislocations with concurrent radial and ulnar shaft fractures with distal radioulnar joint (DRUJ) disruption are considered operative cases with high-energy injurious etiologies. Here, we present an unclassifiable Monteggia variant fracture suffered through a high axial load mechanism in a 47-year-old female. The fracture pattern initially exhibited included a divergent elbow dislocation, a radial shaft fracture, plastic deformation of the distal ulna, and DRUJ instability. Here we describe the pattern in detail, along with definitive treatment and clinical outcome at 1 year follow-up.     

Posterior interosseous nerve palsy associated with neglected pediatric Monteggia fracture-dislocation: A case report

IntroductionThe 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 caseA 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.DiscussionTreatment planning for chronic, neglected or missed Monteggia fractures is challenging. There is no consensus about the definitive treatment in the literature.ConclusionWe 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.     

Percutaneous reduction and flexible intramedullary nailing for monteggia fracture in a skeletally mature patient

INTRODUCTION

Monteggia lesions are defined as a fracture of the proximal ulna with an associated radial head dislocation. Management of these injuries varies depending upon the patient population, ranging from non-operative treatment with closed reduction and immobilization to surgical fixation. Percutaneous techniques of radial head reduction are often reserved for skeletally immature patients.

PRESENTATION OF CASE

In this case report, a 14-year-old female presented with left elbow pain three days after a fall. Radiographs and CT images from an outside hospital revealed a displaced left radial head fracture and a non-displaced proximal olecranon fracture, consistent with a Monteggia equivalent fracture. The patient underwent percutaneous reduction and internal fixation of the radial head with a flexible intramedullary nail (Metaizeau technique), and open reduction and internal fixation of the olecranon. She developed a 25 degree left elbow flexion contracture and, five months after her index procedure, underwent arthroscopic release and removal of hardware. The radial head reduction was near anatomic and she regained full extension.

DISCUSSION

This report demonstrates that percutaneous reduction with intramedullary nailing and fixation techniques can be performed successfully in skeletally mature patients.

CONCLUSION

Given their less invasive nature, we recommend attempting percutaneous interventions in some skeletally mature individuals for fracture reduction and fixation.     

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

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

低龄儿童2年以内陈旧性孟氏骨折的手术治疗

目的探讨低龄儿童2年以内陈旧性孟氏骨折手术治疗的疗效。方法对38例2年以内陈旧性孟氏骨折低龄患儿采取尺骨近端截骨克氏针内固定,桡骨小头切开复位、肱桡关节克氏针内固定。结果 38例全部得到随访,时间2~12个月。术后2例发生桡骨小头半脱位。4例桡神经损伤患儿功能完全恢复,其余患儿肘关节无畸形,无疼痛。肘关节伸直活动范围0°~20°(6°±4°),屈曲活动120°~135°(130°±5°),旋前平均80°±5°,旋后平均85°±5°。根据Mackay标准评定:优30例(78.9%),良6例(15.8%),差2例(5.3%)。结论尺骨近端截骨克氏针内固定手术治疗低龄儿童2年以内陈旧性孟氏骨折,疗效良好。     

Persistent Posterior Interosseous Nerve Palsy Associated with a Chronic Type I Monteggia Fracture-Dislocation in a Child: A Case Report and Review of the Literature

We present a rare case of persistent complete posterior interosseous nerve palsy associated with a chronic type I Monteggia elbow fracture-dislocation consisting of anterior dislocation of the radial head and malunion of the ulna in an 8-year-old child requiring surgical treatment. Posterior interosseous nerve neuropraxia following acute Monteggia injury patterns about the elbow has been described and is thought to be secondary to traction or direct trauma. The condition typically resolves following successful closed reduction of the radial head. This report describes combined treatment of the nerve and skeletal injury for the chronic type I Monteggia injury. The literature is reviewed, and diagnostic challenges with and treatment options for chronic Monteggia fracture-dislocations in children are discussed.     

手法闭合复位纸夹板外固定治疗Monteggia骨折

目的 :探讨手法闭合复位纸夹板外固定治疗Monteggia骨折的临床疗效。方法:自2010年1月至2018年6月采用闭合手法复位、纸夹板外固定治疗58例儿童Monteggia骨折患者,其中男37例,女21例;年龄3.5～12(8.48±2.29)岁;病程0.5 h～9 d,平均(4.21±1.46) d。分别于治疗前,治疗后1、3、6个月采用Broberg和Morrey评分系统对患肢的临床疗效进行评价。结果:所有患者获得随访,时间1～6(3.35±2.12)个月。治疗前,治疗后1,3,6个月Broberg和Morrey评分分别为7.24±2.81,32.06±8.33,73.18±5.56,95.87±6.75;治疗后各时间点与治疗前比较差异有统计学意义(P0.05);其中优37例,良19例,中1例。结论:手法闭合复位纸夹板外固定治疗Monteggia骨折,实现动静结合治疗,可早期去外固定,短、中期疗效显著。     

Chronic acquired radial head dislocations associated with ulnar bowing in children. Report of three cases

The most common cause of chronic radial head dislocations is Monteggia lesions. Although acute, Monteggia fractures in children are easy to treat; complex reconstruction techniques may be required to reduce and stabilize chronic radial head dislocations. Early, accurate diagnosis and appropriate treatment remain the key factors for successful results in Monteggia or equivalent lesions in children.