Monteggia Type IV Equivalent Injury

The Three Step Approach to the management of acute pediatric Monteggia lesions

BACKGROUND

The literature places the occurrence of paediatric Monteggia lesions between 1.5% and 3% of all childhood elbow injuries. There are circumstances, which may make early correct diagnosis difficult. Failure to make an early correct diagnosis may have catastrophic consequences on joint range of motion in the chronic stage. The goal of this paper is to describe our three-step approach to the treatment of acute Monteggia lesions based on the stability and radiological appearance of the fracture dislocation, to give an overview of possible pitfalls and clinical and radiological signs that aid the diagnostic process.

METHODS

Retrospective analysis of 23 patients treated for this type of injury at our Department over a period of 6 years was performed. Treatment options were 1. Closed reduction under image intensifier followed by immobilization in over the elbow cast, 2. Open reduction and intramedullary nailing with ESIN, or 3. Open reduction and plate osteosynthesis. Average follow-up was 37 months. In our Department we aim for definitive treatment of fracture-dislocations in children within the acute setting. In the 23 acute cases, the selected procedure-reduction+casting/reduction+ESIN/reduction+plating - was performed within 2 to 16 h of arrival. 10 patients were treated with reduction+casting, 10 with reduction+ESIN and 3 with reduction+plating.

RESULTS

21 patients were available for long-term follow-up. No nerve or tendon injuries or infections were observed in these cases. By managing the patients with the Three Step Method retaining the reduction was successful in all but one of our acute cases in the study period. Excellent range of motion was observed in all three groups.

CONCLUSIONS

The Three Step Method allows for primary definitive treatment of these lesions with low complication rates and good range of motion result. Implementing the three step method in the acute phase helps avoid catastrophic consequences on joint range of motion in the chronic stage.

Segmental forearm bone injuries in children: classification and treatment

Background

Fractures of the forearm bones in children are a very frequent injury, while segmental injuries of the forearm bones are very rare and have not been sufficiently examined. In this retrospective study, segmental injuries involving the radius, the ulna or both in children are classified and treatment outcome is presented.

Materials and methods

Bone injury included any type of fracture or dislocation; segmental bone injury indicated the occurrence of more than one traumatic injury throughout the whole extent of each forearm bone. A total of 17 patients with 22 segmental bone injuries were identified and classified. Of these injuries, 12 involved the radius and 10 the ulna. The mean age at the time of injury was 8.9 years (range 3–13). In all cases, conservative treatment was the first treatment option; in three cases, however, surgical treatment was necessary.

Results

All injuries were classified into five types using the new nomenclature. Patients were evaluated after an average follow-up of 10.4 years. Union was noted in all cases without any complications. The function results were rated as excellent in 15 cases and satisfactory in 2 cases.

Conclusions

An inclusive classification system for segmental injuries of the forearm bones in children is presented. The proposed classification is a practical and utilitarian scheme that classified the patients of this report as well as all case reports previously published in the literature. It revealed that a wide variety of segmental injuries may be diagnosed following forearm injuries in children. This report also provided useful information that may influence the treatment of these complex injuries indicating that conservative treatment may be considered the first treatment option, and that primary surgical treatment is not justified.

Level of evidence

Level V.

A case of an unusual Monteggia equivalent type II with lateral condyle fracture

Monteggia fracture dislocations are uncommon in childhood. Since the term 'Monteggia equivaents' was termed, various equivalents of this entity have been described. However, these fractures with concomitant elbow injuries are exceedingly rare in young children. We present a case of an 18 month-old girl who sustained a fracture of lateral condyle of right distal end of humerus with posterior dislocation of the elbow. We suggest that the fracture pattern can be included under type II Monteggia equivalent on the basis of its characteristics, biomechanics and the mode of injury with supporting literature review for the same.

Unusual presentation of a type 1 Monteggia equivalent lesion: simultaneous medial humeral condyle fracture with ipsilateral anterior dislocation of the radial head and acute plastic bowing of the ulna

The authors describe a case of simultaneous anterior dislocation of the radial head with plastic deformation of the ulna and an ipsilateral medial humeral condyle fracture in a 6-year-old boy after a fall on an outstretched hand. This rare combination of injuries has not been described previously in the literature. Closed reduction of the dislocated radial head and percutaneous K-wire fixation of the medial humeral condyle fracture achieved an excellent result with full function. This rare combination of injuries is considered to be an unusual subtype of the Bado type I Monteggia equivalent lesion. The case emphasizes that when a fracture is detected around an elbow, other injuries in the region should be suspected.