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

BACKGROUND Monteggia 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 SUMMARY A 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 lengthunstable 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.CONCLUSION Intramedullary fixation of unstable Monteggia fractures results in excellent outcomes,provides reliable reduction and causes fewer complications.

An unusual Monteggia equivalent type 1 lesion： Diaphyseal ulna and radius fractures with a posterior elbow dislocation in a child

In this report, we describe an extremely unusual Monteggia equivalent type 1 lesion in a 10-year-old boy following a fall from a height of I m. On the plain radiographs, our patient had a particular Monteggia equivalent type 1 injury associating a posterior elbow dislocation with diaphyseal radius and ulna fractures. The patient was treated by closed reduction technique. At six months of follow-up, the frac- tures were consolidated and the elbow was stable. To our knowledge, only 8 adult cases and one pae- diatric observation with similar lesions had been reported through medical literature. Therefore, the aim of our case report is to remind this rare entity and also to provide a comprehensive review of the literature related to this uncommon lesion.

Clinical effect of manual reduction of humeroradial joint in the treatment of typeⅠ-Ⅲfresh Monteggia fracture in children

Purpose:To evaluate the efficacy of closed reduction on the humeroradial joint in the treatment of Bado typeⅠ,ⅡandⅢfresh Monteggia fractures in children and investigate the effect of clinical factors,including Bado classification,age and time of treatment on the success rate of closed reduction.Methods:We retrospectively studied the data of children<10 years old with fresh Monteggia fractures(injury within two weeks)treated by manual reduction with plaster immobilization from January 2014 to April 2019.All patients were followed up in the outpatient department every two weeks for 4-6 weeks until plaster removal and then 3,6 and 12 months.Online or telephone interview was provided for some inconvenient patients after 6 months.Mackay criteria were used to evaluate the clinical effect.Radiographic data were collected and reviewed to assess the reduction of the humeroradial joint.Function of the elbow joint and forearm was evaluated and risk factors related to the failure of reduction were assessed.The successful manual reduction was analyzed from three aspects,respectively Bado fracture type(Ⅰ,Ⅱ,Ⅲ),patient age(<3 year,3-6 years,>6 years)and time interval from injury to treatment(group A,<1 day;group B,1-3 days;group C,>3 days).Results:Altogether 88 patients were employed in this study,including 58 males(65.9%)and 30 females(34.1%)aged from 1 to 10 years.There were 29 cases(33.0%)of Bado typeⅠMonteggia fractures,16(18.2%)typeⅡand 43(48.7%)typeⅢ.Successful manual reduction was achieved in 79 children(89.8%)at the last follow-up.The failed 9 patients received open surgery.Mackay criteria showed 100%goodexcellent rate for all the patients.The success rate of manual reduction was 89.7%,87.5%and 90.7%in Bado typeⅠ,ⅡandⅢcases,respectively,revealing no significant differences among different Bado types(x2=0.131,p=0.937).Successful closed reduction was achieved in 13 toddlers(13/13,100%),38 preschool children(28/42,90.5%)and 28 school-age children(28/33,84.8%),suggesting no significant difference either(x2=2.375,p=0.305).However time interval from injury to treatment showed that patients treated within 3 days had a much higher rate of successful manual reduction:67 cases(67/71,94.4%)in group A,10 cases(10/11,90.9%)in group B,and 2 cases(2/6,33.3%)in group C(x2=22.464,p<0.001).Fisher's test further showed significant differences between groups A and C(p=0.001)and groups B and C(p=0.028).Conclusion:Closed reduction is a safe and effective method for treating fresh Monteggia fractures in children.The reduction should be conducted as soon as possible once the diagnosis has been made.

A rare combination injury of type III Monteggia fracture dislocation and ipsilateral epiphyseal fracture of distal radius in children. Is there a probability of missing the Monteggia component？

Combined type III Monteggia fracture dislocation and ipsilateral distal radial epiphyseal fracture is a very rare injury. Because of difficulty in performing the proper clinical evaluation of a child in an acute injury state, one of the components of this combined injury may be missed. We report a ten- year-old male child with this kind of injury where the Monteggia lesion was initially missed at the emergency department. Later we found the combined epiphyseal fracture of distal radius and Monteggia lesion in the ipsilateral side of the same limb which was managed by closed reduction and K-wire fixation. Bony union as well as wrist and elbow motion was complete 3 months after surgical intervention.

Monteggia fracture dislocation equivalents analysis of eighteen cases treated by open reduction and internal fixation

Objective： Monteggia fracture disloca- tion equivalent, though already described by Bado, is still an unclassified entity. We aimed to retrospectively analyze 18 cases of Monteggia variants and discuss the injury mechanisms, management, and outcome along with a re- view of the literature. Methods： A retrospective record of Monteggia frac- ture dislocation （2003-2008） was reviewed from medical record department of our institute. Classic Monteggia frac- ture dislocation, children below 12 years or adults over 50 years, as well as open grade iI ＆ Ill cases were excluded from this study. Monteggia variant inclusion criteria in- cluded fracture of the proximal ulna together with a fracture of the radial head or neck and skeletal maturity. Totally 26 patients were identified with Monteggia variants and 18 were available for follow-up, including 11 males and 7 fe- males with the mean age of 35 years. The ulna fracture was treated by compression plating along with tension band wiring. Radial head/neck was reconstructed in 12 patients while excised in 6 patients. Results： Follow-up ranged from 1-4 years, mean 2.6 years. Patients were assessed clinicoradiologically. MayoElbow Performance Score outcomes. At final follow-up, was employed to assess the the results were excellent in 10 patients, good in 4, fair in 2 and poor in 2. Mean range of motion of the elbow was 20°, 116°, 50° and 55° for extension, flexion, pronation and supination, respectively. Two patients had complications in the form of heterotopic ossification and stiffness of the elbow. One nonunion ulna, primarily treated by tension band wiring, was managed by refixation with locking reconstruction plate and bone grafting. Bone grafting was only required in this patient for nonunion. Another patient had implants removed on his request. The results in our series closely correlated with extent of intraarticular damage, coronoid fracture and comminuted fractures. Conclusions： Monteggia fracture dislocation equiva- lents are rare injuries and pre-surgery recognition by radio- graphs and 3-D CT helps make optimal plan. The poor results usually relate to intraarticular damage, coronoid fractures and comminution of the ulna and radial head fractures.