A new approach for surgical treatment of chronic Monteggia fracture in children

Risk factors for proximal radial abnormalities in children with untreated chronic Monteggia fractures: a review of 142 cases

BACKGROUND

The risk factors for proximal radial abnormalities (PRA) in paediatric patients with untreated chronic Monteggia fractures (CMFs) are unclear. This multicentre study aimed to evaluate the risk factors for PRA in children with untreated CMFs.

MATERIALS AND METHODS

The clinical data of 142 patients (mean age at the time of injury: 5.73 years) with untreated unilateral CMFs were retrospectively reviewed. The radial neck-shaft angle (RNSAP) and radial head size (RHL) were measured on anteroposterior (AP) and lateral (L) radiographs, respectively. The RHL size was the ratio of the widest width of the proximal radial metaphysis to the narrowest radial neck width. The En-RNSAP and En-RHL were the ratios of the enlargement (En) of the RNSAP angle and RHL size of the injured elbow to those of the uninjured elbow, respectively. Paired-sample t-tests, single-factor analyses and multiple linear regression analyses were performed to evaluate the correlation between the differences in these parameters between the injured and uninjured elbows and the assessed risk factors. These risk factors included institution, sex, laterality, age at injury, time from injury to diagnosis, direction of RH dislocation, distance of RH dislocation (DD-RH), presence of radial or median nerve injury, heterotopic ossification and immobilization of the elbow after injury.

RESULTS

In children with untreated CMFs (mean time from injury to diagnosis: 14.6 months), Student's t-test revealed a significant difference in the RHL size (P < 0.001) but not in the RNSAP angle (P = 0.075) between the injured and uninjured elbows. Pearson correlation analysis revealed a potential correlation between En-RHL and age at the time of injury (P = 0.069), time from injury to diagnosis (P < 0.001) and DD-RH (P < 0.001), excluding other risk factors (P > 0.05). Multiple linear regression analysis revealed that age at the time of injury (P = 0.047), time from injury to diagnosis (P = 0.007) and DD-RH (P = 0.001) were risk factors for an increased En-RHL in patients with untreated CMFs; the variability in En-RHL among the other three risk factors was 21.4%.

CONCLUSIONS

In paediatric patients with unilateral untreated CMFs, PRA of the injured elbow consisted mainly of RH enlargement or radial neck narrowing rather than valgus deformities of the proximal radius. Older age at injury, increased time from injury to diagnosis and DD-RH were risk factors for more severe PRA.

LEVEL OF EVIDENCE

III.

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.

Irreducible anteromedial radial head dislocation without fracture caused by transposed biceps tendon in an adult: A case report and literature review

Irreducible anteromedial radial head dislocation (IARHD) caused by transposed biceps tendon is rare. Delayed diagnosis and surgical failure often occur. A 46-year-old fisherman presented with 10 days history of painful swelling and restricted movement of his right elbow due to strangulation injury by a fishing boat cable. On examination, the images of the right elbow reveals in a "semi-extended and pronated" elastic fixation position. Radiography and 3-dimensional reconstruction CT reveals an isolated anteromedial radial head dislocation with extreme protonation of the radius and the bicipital tuberosity towards the posterior aspect of the elbow joint, and MRI shows biceps tendon wrapping around the radial neck, similar to umbilical cord wrapping seen in newborns. The Henry approach was applied for the first time to reduce the biceps tendon. The patient achieved a good functional recovery at 26 months, which represents the first reported case of IARHD without fracture caused by biceps tendon in an adult. In treatment of IARHD, attention should be paid to the phenomenon of biceps tendon transposition. Careful clinical examination, comprehensive imaging modalities, and appropriate surgical approach are the keys to successful management.

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.

Predictors of ideal outcomes after reconstructive surgery for chronic Monteggia fracture in children

BACKGROUND

We aimed to analyze surgical outcomes of reconstructive surgery for chronic Monteggia fracture, which is one of the most challenging problems for orthopaedic surgeons.

METHODS

Twenty-eight patients were followed during 55.6 ± 32.0 months after open reduction of the radial head combined with ulnar osteotomy and annular ligament reconstruction. The mean interval from trauma was 15.1 ± 19.6 months, and the mean age at the surgery was 9.1 ± 3.5 years. In addition to the chronological age, elbow maturity was assessed using the Sauvegrain score. Surgical outcomes were primarily evaluated using the Kim's score. In addition, we newly defined more successful criteria for the ideal surgical outcomes, equivalent to preinjury status.

RESULTS

There were 19 excellent, 3 good, 4 fair, and 2 poor outcomes based on the Kim's scoring system. Among the 19 patients with excellent outcomes, 14 met our criteria for the ideal outcomes. The age (p < 0.001) and the Sauvegrain score (p < 0.001) were lower, and the interval (p = 0.004) was shorter in 14 patients with ideal outcomes. There were 9 patients with preoperative deformation of the radial head, and all of them showed non-ideal outcomes. In regression analyses, lower Sauvegrain score (p = 0.004) and shorter interval (p = 0.012) were associated with higher postoperative Kim's score, and lower Sauvegrain score (p = 0.031) was related to the achievement of the ideal outcomes. With the Sauvegrain score of >21.5, all patients had postoperative re-dislocation or osteoarthritic changes regardless of the interval. With the Sauvegrain score of <21.5 and an interval of ≤7 months, the ideal outcomes were achieved in 85.7%, and no patients had postoperative re-dislocation or osteoarthritic changes.

CONCLUSION

Over the skeletal ages of 14 years in boys and 11.5 years in girls, reconstructive surgery must be cautiously indicated. Under these skeletal ages with an interval of ≤7 months and undeformed radial head, it appears to be ideal.

STUDY DESIGN

Level III, Retrospective comparative study.

Influence of ulnar bow sign on surgical treatment of missed Bado type I Monteggia fracture in children

The present study aimed to explore the influence of ulnar bow on the surgical treatment of Bado type I missed Monteggia fracture in children. A retrospective review of 28 patients was conducted between November 2010 and June 2020. All patients were treated with open reduction of the radial head and ulnar opening wedge osteotomy without annular ligament reconstruction. Four months (range 1–12 months) was the mean interval between injury onset and surgery. The average age of patients at the time of surgery was 6.1 years old (range 2–10 years old). The maximum ulnar bow (MUB) and MUB position (P-MUB) via radiography were evaluated. The patients were divided into two groups according to P-MUB, as follows: middle group (A) included 17 cases, and the MUB was located at 40–60% of the distal ulna; and distal group (B) included 11 cases, and the MUB was located at 20–40% from the distal end of the ulna. The mean follow-up period was 33 months (range 6–102 months). At the last follow-up, all the children showed stable reduction of the radial head, and the flexion function of elbow joint improved after the operation (P < 0.05). Group A presented a larger ratio of maximum ulnar bow (R-MUB) and angle of ulnar osteotomy (OA) than group B (P < 0.05). The osteotomy angle was positively correlated with the R-MUB (R² = 0.394, P = 0.038). The osteotomy angle was positively correlated with the P-MUB (R² = 0.683, P = 0.000). The R-MUB was proportional to the P-MUB (R² = 0.459, P < 0.0001). The regression equation of P-MUB and osteotomy angle was as follows: OA = 32.64* P-MUB + 7.206. If the ulnar bow was positioned at the middle ulna, then a stable reduction of radial head needed to be achieved through a large angle in the ulnar osteotomy. If the position of maximum ulnar bow (P-MUB) was closer to the middle of the ulna, or the ratio of maximum ulnar bow (R-MUB) was larger, then the osteotomy angle was larger.

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.

Surgical Management of Missed Pediatric Monteggia Fractures: A Systematic Review and Meta-Analysis

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.

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.

Surgical Reconstruction of Missed Monteggia Lesions in Children

BACKGROUND

Chronic Monteggia lesions in children may cause pain, deformity, decreased range of motion, and neurological symptoms. Numerous surgical techniques have been advocated to reconstruct long-standing Monteggia injures in efforts to maximize long-term upper limb function. The purpose of this investigation was to assess the clinical and radiographic results of a modified surgical technique for missed Monteggia fracture-dislocations.

METHODS

A retrospective evaluation of 52 patients who underwent surgical reconstruction of missed Monteggia fracture-dislocations at a tertiary pediatric hospital was performed. The median patient age at the time of surgery was 6.8 years, and the median time from injury to surgery was 12.9 weeks. Electronic medical records, including clinic notes, radiographic images, and operative reports, were reviewed for study analysis. Median clinical and radiographic follow-up was 19.1 months.

RESULTS

The median elbow range of motion improved from 108 degrees of flexion and 5 degrees short of full extension preoperatively to 140 degrees of flexion (P<0.001) and full extension (P=0.10) postoperatively. Forearm range of motion also improved from a median of 80 degrees of pronation and 58 degrees of supination preoperatively to 80 degrees of pronation (P=0.54) and 80 degrees of supination (P<0.001) postoperatively. Congruent radiocapitellar alignment was maintained in 39 patients (75%). Nine patients (17%) had redislocation of the radiocapitellar joint, and 4 patients (8%) had radiographic resubluxation. Six of the 9 patients who experienced redislocation underwent early revision and achieved uncomplicated longer term results. Patients who received repair of the native annular ligament were more likely to achieve lasting radiocapitellar joint stability (P=0.03) when compared with patients who received annular ligament reconstruction or if the annular ligament was not addressed.

CONCLUSION

Meaningful improvements in elbow motion and radiocapitellar stability can be safely achieved in the majority of children following surgical reconstruction of missed Monteggia lesions.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

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.

Stabilization of the radial head with the palmaris longus or the gracilis tendon: an anatomical feasibility study

PURPOSE

The proximal radioulnar joint (PRUJ) and the radiocapitellar joint may be destabilized after trauma. Different techniques for stabilization of PRUJ have been proposed, but none of them can stabilize the radiocapitellar joint at the same time. We propose a ligamentoplasty to stabilize the radial head at these two joints by reconstructing the radial head annular ligament and the lateral collateral ulnar ligament (LCUL) with a single graft (palmaris longus or gracilis tendon of the knee).

METHODS

Fifteen cadaveric upper limbs were used to compare the stabilization obtained by performing our ligamentoplasty with the palmaris longus or the gracilis tendon. For each technique, the stabilization obtained was evaluated by measuring the displacement of the radial head in the anterior, lateral and posterior directions when a force of 1 N was applied in maximum supination, neutral rotation and maximum pronation. We also evaluated whether this technique could damage the ulnar nerve or the posterior interosseous nerve by dissecting them and whether it could limit the range of rotation of the forearm.

RESULTS

Our ligamentoplasty enables to restore PRUJ stability equivalent to the intact ligament condition. The palmaris longus was inconstant (13/15) and too short to allow concomitant reconstruction of the LCUL (except in one case). No nerve damage was found during the dissection, and the range of rotation of the forearm was not limited by the ligamentoplasty. We also report a clinical case with an excellent result and without complications.

CONCLUSION

This ligamentoplasty we have described makes it possible to stabilize the radial head with respect to the radial notch of the ulna and with respect to the capitellum of the humerus. The gracilis tendon is more suitable than the palmaris longus because of its constant presence and length. A clinical series is now necessary to better evaluate this technique.

Four different management strategies in missed Monteggia lesions in children

Objectives

Management of missed Monteggia lesions presents a challenging clinical scenario for pediatric orthopaedic surgeons as the patient may be exposed to possible morbidities and increased complications. There are several evidenced surgical strategies described. We aimed to present 18 patients diagnosed within 4 months of injury who were treated using 4 of the identified many surgical strategies.

Methods

Eighteen consecutive cases of missed Monteggia lesions were treated in our institution between 2011 and 2014. The mean delay from injury to surgery was 8.3 weeks (range 4-16). Bilateral preoperative and postoperative radiographs, Oxford Elbow Score, the direction of radial head dislocation, Bado classification, ulnar pathology (plastic deformation or fracture), carrying angle, head-neck ratio, any abnormal bony architecture, and any related condition.

Results

There were no major complications to surgery. All patients had regained painless range of motion of the forearm and elbow, and reduced radiocapitellar joint. Ligament reconstruction or transcapitellar k-wire fixation did not influence the radiographic or clinical outcome.

Conclusions

Because conservative treatment of this injury may cause high morbidity, surgical management should be preferred in the foreground. The ulnar deformity is a key point in the reduction of the radiocapitellar joint. The preferred treatment strategy has no significant effect on the results as long as it provides radial head reduction.