Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems.

BACKGROUND: Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis. MATERIALS AND METHODS: We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II. RESULTS: The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13. DISCUSSION: Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.

Coronoid Fragment Size in Monteggia Fractures Predicts Ultimate Function.

We sought to determine what effect the size of a displaced coronoid fracture fragment in Monteggia injuries has on clinical outcome. Sixty-seven patients presented to an academic medical center for operative fixation of a Monteggia fracture. Radiographs were assessed for length and height of the displaced coronoid fragment using measuring tools in our center's imaging archive system. Data were analyzed using binary logistic or linear regression, as appropriate, controlling for sex, age, and Charlson Comorbidity Index. Outcome measurements included radiographic healing, range of motion, postoperative complications, and reoperation. The cohort had a mean follow-up of 16.7 months. Mean coronoid fragment area was 362.4±155.9 mm2. Elbow range of motion decreased by 3.8° of elbow flexion (P<.001), 3.3° of elbow extension (P<.001), and 3.8° of forearm supination (P=.007) for every 1-cm2 increase in coronoid fragment area. Complications (P=.012) and reoperation (P=.036) were associated with increasing coronoid fragment area. Nonunion rate, nerve injury, and pronation range of motion were not correlated to increasing coronoid fracture fragment area (P=.777, P=.123, and P=.351, respectively). As displaced coronoid fragment size increases in Monteggia fracture patterns, elbow range of motion decreases linearly. Coronoid displacement was also associated with increased rates of postoperative complication and need for reoperation. [Orthopedics. 2024;47(1):15-21.].

Magnetic Resonance Imaging Manifestations of Annular Ligament Injuries in Children With Monteggia Fractures.

BACKGROUND: Magnetic resonance imaging (MRI) is commonly performed in children with elbow injuries to visualize soft tissues such as the annular ligament. Herein, we investigated the MRI manifestations of annular ligament injuries in children with Monteggia fractures following attempted closed reduction. METHODS: The clinical and imaging data of 88 children with acute Monteggia fractures treated at our hospital between 2015 and 2019 were analyzed. Clinically and radiographically, 67 patients achieved radiologic reduction of the radial head at the time of MRI, whereas 21 patients had a failed closed reduction. Annular ligament injury and superior radioulnar joint congruency were analyzed qualitatively, and the maximum superior radioulnar joint gap distance was measured. RESULTS: MRI manifestations of annular ligament injury were primarily characterized as varying degrees of annular ligament displacement, as follows: I degree (10 patients), the annular ligament encircled the radial head without displacement; II degree (5 patients), the annular ligament was partially displaced but visibly encircled the radial head at the level of the radial notch; and III degree (73 patients), the annular ligament was completely displaced. In 15 patients with I and II degrees annular ligament injuries, the annular ligament encircled the radial head (maximum superior radioulnar joint gap distance, 1.2±0.3 mm), showing good congruency of the superior radioulnar joint. In 73 patients with III degree annular ligament injury, the annular ligament was displaced and did not encircle the radial head (maximum superior radioulnar joint gap distance, 3.3±2.7 mm; P <0.05), showing good congruency of the superior radioulnar joint in 25 of 73 patients, and significantly poor congruency in 48 of 73 patients ( P <0.05). CONCLUSIONS: Annular ligament injuries in children with Monteggia fractures exhibit different degrees of displacement of the annular ligament. In I and II degree annular ligament injuries, the annular ligament still encircles the radial head. In III degree annular ligament injuries, the annular ligament is displaced away and is no longer around the radial head. Without the annular ligament restraining the radial head, the superior radioulnar joint is more likely to exhibit poor congruency and increased gap distance. LEVEL OF EVIDENCE: Level II.

Ultrasound, a new adjuvant method for treating acute Monteggia fracture in children.

PURPOSE: This study aims to evaluate the feasibility of using ultrasound-guided Kirschner wire or elastic intramedullary nail for fixation in the treatment of acute Monteggia fracture in children. METHODS: A retrospective analysis was conducted on 31 cases of acute Monteggia fracture in children treated with ultrasound-guided Kirschner wire or elastic intramedullary nail fixation between April 2020 and December 2022, including 14 cases of Kirschner wire fixation and 17 cases of elastic intramedullary nail fixation. During the operation, soft tissue compression and nerve and vascular injuries were explored, fracture reduction was performed under ultrasound guidance, and operation time was recorded. After the operation, X-ray examination was conducted to assess the quality of fracture reduction. At the last follow-up, the flexion, extension, pronation, and supination angles of both affected and unaffected elbow joints were measured, and the Mayo score was used to evaluate elbow joint function. RESULTS: The average duration of surgery was 50.16 ± 19.21 min (ranging from 20 to 100 min). Based on the evaluation criteria for assessing reduction quality, 28 cases were deemed excellent, while 3 cases were considered good. After immobilization with long-arm cast for 4-6 weeks postoperatively, elbow and forearm rotation exercises were performed. Kirschner wires were removed after an average of 6.64 ± 0.93 weeks (ranging from 6 to 9 weeks) postoperatively, and elastic intramedullary nails were removed after an average of 5.12 ± 1.54 months (ranging from 4 to 10 months) postoperatively. The average follow-up time was 19.13 ± 11.22 months (ranging from 4 to 36 months). During the final follow-up, the affected limb's range of motion in flexion, extension, pronation, and supination was (141.16 ± 4.24)°, (4.61 ± 2.81)°, (84.52 ± 3.74)°, and (84.23 ± 3.69)°, respectively. There was no notable variance when compared to the healthy limb, which had a range of motion of (141.81 ± 2.99)°, (4.81 ± 2.50)°, (85.61 ± 3.12)°, and (85.03 ± 2.73)° (P > 0.05). The Mayo Elbow Performance index classified 29 cases as excellent and 2 cases as good. CONCLUSION: Ultrasound-guided Kirschner wire or elastic intramedullary nail fixation can be used for the treatment of acute Monteggia fracture in children, which can explore the surrounding nerves, blood vessels, and soft tissue compression, reduce the difficulty of reduction, and cause minimal trauma. It can greatly reduce the risk of radiation exposure and complications such as vascular and nerve injury during the operation.

Monteggia fracture associated with ipsilateral intercondylar distal humeral fracture with posterior interosseous nerve palsy: case report, medico-legal implications, and methodological assessment analysis.

BACKGROUND: The Monteggia fracture, defined as a fracture of the proximal third of the ulnar shaft associated with an anterior or posterior dislocation of the proximal radial epiphysis, is a serious injury accounting for 0.7% of all elbow fractures and dislocations in adults. For adult patients, good results can only be obtained through early diagnosis and adequate surgical treatment. Monteggia fracture-dislocations associated with distal humeral fracture are extremely rare injuries in adults and there are few cases described in the literature. Medico-legal implications arising from such conditions have a host of complexities that cannot be discounted. CASE REPORT: This case report revolves around a patient affected by a type I Monteggia fracture-dislocation, according to the Bado classification, associated with an ipsilateral intercondylar distal humeral fracture. To our knowledge, this combination of lesions has never been reported before in adult patients. A positive result was obtained due to early diagnosis, achievement of anatomical reduction, and optimal stabilization with internal fixation which made it possible to achieve early functional recovery. CONCLUSIONS: Monteggia fracture-dislocations associated with ipsilateral intercondylar distal humeral fracture are extremely rare in adults. In the case herein reported, a favorable outcome was obtained due to early diagnosis, achievement of anatomical reduction and management with internal fixation with plate and screws, as well as early functional training. Misdiagnosis makes such lesions risky in terms of potentially delayed treatment, increasing the need for surgical interventions and the possibility of high-risk complications and disabling sequelae, with possible medico-legal implications. In the case of unrecognized injuries under urgent circumstances, the injuries may become chronic, making the treatment more complex. The ultimate outcomes of a misdiagnosed Monteggia lesion can lead to very serious functional and aesthetic damage.

Functional outcomes of pediatric true and equivalent Monteggia fractures - Review of the literature.

BACKGROUND: This study aims to describe the functional outcome of true and equivalent Monteggia fracture-dislocations in the pediatric population. We also provided a review of the literature about the treatment options. METHODS: Five surgically and three conservatively treated patients were identified who were treated in 2009-2021. The study pop-ulation consisted of six female and two male patients. The mean age at the time of treatment was 7. The mean follow-up time was 55 months (range, 12-128). The Mayo Elbow Performance Score and the Oxford Elbow Score were used for outcome evaluation. Range of motion and grip strengths were also evaluated. RESULTS: There were two Bado type 1 and six Monteggia equivalent injuries. Closed reduction and casting were utilized for the two Bado type 1 injuries as the initial treatment. However, one had a radial head re-dislocation and had to be treated operatively. This patient had a radial head re-dislocation after the surgery and was followed up conservatively. Three Monteggia equivalent injuries were treated with closed reduction and casting, with no complications. One patient had a radial head anterior dislocation with plastic deformation of the ulna, and this patient was managed with CORA-based corrective ulnar osteotomy. For Monteggia injuries, the main treatment objective is to restore the ulnar length. Bilateral computed tomography imaging with 3D reconstruction can be utilized in preoperative planning of Monteggia fracture-dislocations to customize the treatment. Close observation is essential to detect radial head subluxation, which needs early intervention before irreversible changes occur. CONCLUSION: The true/equivalent Monteggia fractures' main treatment goal is to restore the ulnar length. Conservative treatment, with a close follow-up, is the first option if closed reduction can be achieved. If closed reduction is not possible, careful preop-erative planning and early rehabilitation are key to success for management of Monteggia fractures.

Exposed Intramedullary Fixation Produces Similar Outcomes to Buried Fixation for Acute Pediatric Monteggia Fractures.

BACKGROUND: Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal. METHODS: A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion. RESULTS: Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients. CONCLUSION: Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization. LEVEL OF EVIDENCE: III.

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.

Fracture-Dislocations of the Elbow: A Comparison of Monteggia and Terrible Triad Fracture Patterns.

Fracture-dislocations of the elbow are a spectrum of injuries that have varying outcomes and complications, such as limited range of motion and long-term pain. The Monteggia fracture-dislocation and terrible triad fracture-dislocation are 2 such injury patterns that occur secondary to different mechanisms. This study sought to compare complication profiles and patient outcomes associated with these 2 distinct injury patterns. A retrospective chart review of all adult patients treated by 1 of 3 orthopedic traumatologists at a major academic center for operative fixation for either a Monteggia fracture-dislocation or a terrible triad elbow fracture-dislocation over a 12-year period was performed. Data collected included demographics, surgical data, patient-reported pain and elbow stiffness, elbow range of motion, presence of elbow joint contracture, nerve injuries, healing complications, and need for reoperation. The review included 105 patients, 58 with Monteggia injury and 47 with terrible triad injury, who had complete follow-up and radiographic imaging available. At latest follow-up, the 2 groups had similar rates of pain, reoperation, and ultimate elbow range of motion in flexion, extension, pronation, and supination. Elbow contractures requiring operative release were more commonly associated with terrible triad injury, and the incidence of nonunion was significantly greater in Monteggia fractures. A Monteggia fracture-dislocation portends a higher risk of ulna nonunion, whereas terrible triad injury is associated with elbow contracture. Despite their unique complications, both patterns ultimately have high rates of reoperation as their unique complications are both indications for operative repair. Patients should be appropriately counseled on the complication profile of their unique injury pattern. [Orthopedics. 2023;46(3):158-163.].

Radial head distalisation with an external ring fixator as a therapy option in children with chronic posttraumatic radiocapitellar dislocations.

PURPOSE: Missed monteggia-type injuries in children can result in chronic radial head dislocation with anatomic changes and osteoarticular remodeling of the radial head. In later stages, joint reconstruction is impossible and a functional radial head distalization can be a therapy option in symptomatic patients. METHODS: From 2010 to 2018, 46 patients (18 female and 28 male, mean age 11.8 (4-20)) with chronic radius head dislocation treated in our institution were retrospectively analyzed. A radial head distalization was performed in symptomatic patients at the time of ulna lengthening and angulation by use of an external ring fixator. We analyzed the surgical and radiographic data as well as the clinical outcome of the patients measured by DASH and Mayo Elbow score. RESULTS: 16 patients (6 female, 10 male) fulfilled the criteria for functional radial head distalization. Main reason was Monteggia injury in 11 cases, and radial head fracture in 5 cases. Average follow-up was 5.1 years (range 1-9, SD 2.1). Mean time from injury was 4.14 years (range: 4 months to 12 years, SD 3.5 years). Mean duration of external fixation was 106 days (range 56-182, SD 31.2), lengthening was 21.3 mm (range 12-42, SD 8.8). Average degree of sagittal angulation 14.8° (0-32°, SD 10.7°), coronal angulation 4.4° (0-25°, SD 7.3°). DASH score showed a good result with 2.4, and the MAYO Elbow Score was excellent (95/100). No secondary luxation of the radius head was detected. CONCLUSION: Radial head distalization with external ring fixator can be a therapy option for chronic radius head dislocations in symptomatic patients without losing stability of the elbow joint in contrast to radial head resection.

[Monteggia lesions and equivalent lesions in children]. / Monteggia-Läsionen und Monteggia-Äquivalent-Läsionen im Kindesalter.

BACKGROUND: Missed Monteggia lesions results in chronic luxation and deficits in the range of motion. The overall therapeutic goal is a quick and stable anatomical repositioning of the lesion. The prognosis of Monteggia lesions in comparison to its equivalents is better, especially with early diagnosis. OBJECTIVE: Comparison of the types of lesion, treatment modalities, hospitalization, immobilization, movement deficits, perioperative complications and outcome. MATERIAL AND METHODS: Retrospective study of 62 patients treated with acute Monteggia lesions and its equivalents during the period of 2009-2020. RESULTS: 2 patients were treated with cast immobilization only, 11 with repositioning under general anesthesia, 39 with intramedullary nailing and 10 with screw osteosynthesis. The average observation period was 4.1 months. Patients with cast immobilization needed only a short hospitalization (2 days), patients with repositioning or osteosynthesis had longer hospitalization (3.4 or 4.3 days, respectively). Deficits of the range of motion did not appear in simple cast immobilization or intramedullary nailing without reduction; however, patients with closed reduction or screw osteosynthesis showed some degree of deficits (9% and 40%, respectively). Monteggia lesions needed shorter hospitalization than their equivalents (3.7 vs. 4.5 days) and had less deficits in the range of motion (7% vs. 21%). CONCLUSION: Most patients were treated with osteosynthesis (79%). Patients with Monteggia lesions had a better outcome than patients with equivalent lesions.

Monteggia fractures and Monteggia-like-lesions: a systematic review.

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

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.

Missed Monteggia fractures in children treated by open reduction of the radial head and corrective osteotomy of the ulna.

Missed Monteggia fractures in children may cause pain, deformity, decreased range of motion, neurological symptoms, and late arthritis of the elbow. Numerous surgical techniques have been advocated to reconstruct missed Monteggia lesions. The purpose of the present study were first to evaluate the clinical and radiographic outcomes after open reduction of the radial head and corrective osteotomy of the ulna, second to identify the factors associated with the preoperative radial notch/head appearance and the postoperative radiographic results. This study investigated the preoperative MRI presentation and the treatment of 29 patients who were diagnosed missed Monteggia fracture. Radiologic and clinical results of these patients were evaluated retrospectively, and the patient's and surgical factors related to preoperative radial notch/head appearance and the postoperative radiographic results were analyzed. Of the 29 patients, the average Kim elbow performance score at the last follow-up was 93.6, with 25 excellent, three good, one fair, and no poor results. 19 children had reduced radial heads, 8 had a subluxated radial head and 2 had dislocated radial heads at the last follow-up. The patient's gender and age had no significant influence on the appearance of radial notch/head and final radiographic results. However, the appearance of radial notch/head can significantly affect the final radiographic result (P < 0.001). The interval time was an important factor which related with the appearance of radial notch/head and final radiographic results (P < 0.001). Treating a missed Monteggia fracture by open reduction of the radial head and corrective osteotomy of the ulna is generally successful and preoperative MRI is meaningful for evaluation of the condition of the radial head and the radial notch which is related with the final radiographic result. The interval time from injury to operation exceeds 6 months, the risk of radial notch/head abnormality and radial head subluxation/re-dislocation after operation significantly increase.

Comparison of the midterm result between locking plate and elastic intramedullary nail treating oblique ulnar fracture Bado type I acute monteggia fracture in pediatric patients.

BACKGROUND: Acute Monteggia fracture (AMF) is defined as a fracture of the proximal ulna combined with a dislocation of the radial head, with less than 1 percent prevalence in pediatric patients with an elbow injury. This retrospective study aimed to compare the efficacy of two treatment methods for oblique ulnar fracture AMF Bado type I in children. METHODS: In this retrospective study, 28 children with oblique ulnar fracture acute Monteggia injury Bado I were included. Patients was divided into two groups: In the EIN group 16 patients were fixed with elastic intramedullary nail after reduction, and in the LCP group 12 patients were fixed with locking compression plate after reduction. Operation time and blood loss were recorded and the patients were assessed clinically by the Mayo Elbow Performance Score (MEPS), range of movement(ROM) and range of rotation(ROR). RESULTS: Twenty-eight patients were accessible for durable follow-up, with a mean age of 7.7 ± 1.3 years, follow up by 33.7 ± 5.1 months. The average operation time was 48.1 ± 9.2 min for the EIN group and 67.1 ± 7.2 min for the LCP group. The average blood loss was 8.2 ± 2.3 ml for the EIN group and 18.8 ± 3.8 ml for the LCP group. The average operation time and average blood loss in the EIN group are significant less than the LCP group. Mean MEPS, ROM, ROR in both group improved significantly before sugery to three months after surgery, and maintained very good results at last follow up. There is no significant difference between the EIN group and the LCP group in MEPS, ROM and ROR. CONCLUSIONS: Oblique ulnar fracture Bado type I acute monteggia fracture in pediatric patients fixed by EIN and LCP can both get good mid-term results measured by MEPS, ROM and ROR, Fixed by EIN have shorter operation time and less blood loss than fixed by LCP.

Novel use of close-wedge osteotomy and monorail external fixator in the treatment of chronic Monteggia fracture.

OBJECTIVES: This study aims to evaluate the efficacy of close-wedge osteotomy and monorail external fixator in the treatment of chronic Monteggia fracture. PATIENTS AND METHODS: Between January 2014 and December 2021, data of a total of 22 patients (14 males, 8 females; mean age: 15.6±5.1 years; range, 6 to 25 years) who suffered from chronic Monteggia fractures were retrospectively reviewed. All the patients were treated for acute angulation of the ulna after osteotomy and gradual angulation for radial head reduction. Range of motion of the elbow and forearm, the angle between the longitudinal axis of proximal radius and the hypothesized Storen's line (RSA), Visual Analog Scale (VAS), and Mayo Elbow Performance Score (MEPS), as well as Disabilities of Arm, Shoulder and Hand (DASH) score were recorded preoperatively and at the final follow-up. RESULTS: Objective parameters were all significantly improved in the aspects of range of motions of the elbow and forearm, and RSA (21.4±4.5° preoperatively and 2.0±1.4° at the final follow-up, t=18.20, p<0.05). The level of pain due to the chronic injury was eliminated, as the mean VAS was significantly lower at the final follow-up compared to preoperative scoring (2.8±2.0 preoperatively and 0.5±0.9 at the final follow-up, t=4.86, p<0.05). The function of the elbow and upper limb was restored, which was indicated by improved MEPS (73.2±12.5 preoperatively and 96.6±6.4 at the final follow-up, t=7.70, p<0.05) and DASH (28.3±6.0 preoperatively and 4.1±2.0 at the final follow-up, t=19.35, p<0.05). No complication was observed. CONCLUSION: Close-wedge osteotomy and gradual lengthening with monorail external fixator in the treatment of chronic Monteggia fracture showed great efficacy. We also provided a specified osteotomy site aiming at PRUJ reconstruction.

Reoperations and Radiographic Outcomes of Monteggia Variant Facture Repair Through a Trans-Olecranon Approach.

BACKGROUND: Adult Monteggia fracture variants are rare but potentially devastating injuries to the elbow generally requiring surgical treatment. Monteggia injuries with co- existing fractures of the radial head and coronoid present a surgical challenge due to the need to adequately expose all components of the injury for internal fixation or arthroplasty. In this study, we evaluated the clinical outcomes following surgical treatment of adult Monteggia fracture variants in which a coexisting radial head or coronoid fracture was ad- dressed through a single extensile posterior trans-olecranon approach. METHODS: A retrospective review of all adult patients who underwent fixation of Monteggia variant fractures with coexisting radial head and coronoid fractures through a trans-olecranon approach by a single surgeon from January 1, 2012, to January 1, 2021, was performed. Patient records were reviewed for demographic information, radiographic outcomes, and postoperative complications leading to re- operation. RESULTS: A total of 13 patients met the inclusion criteria for the study, three males and 10 females. The average age of the patients was 64 years old, and patients were followed for an average of 9.9 months postoperatively. Six patients underwent re-operation: one for flap coverage due to wound necrosis, two for revision fixation due to early loss of fixation, two for removal of painful hardware, and one for arthroscopic capsulectomy to treat a flexion contracture. Twelve patients achieved radiographic union and one patient had not achieved union by 1.3 months postoperatively and thereafter did not undergo further radiographic follow-up. No cases of heterotopic ossification, capitellar erosions, overstuffing of a radial head implant, or residual elbow subluxation were seen. There were two cases of lucency around a prosthetic radial head implant stem but without migration of the implant.

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.

Monteggia fractures: analysis of patient-reported outcome measurements in correlation with ulnar fracture localization.

BACKGROUND: Monteggia fractures and Monteggia-like lesions result after severe trauma and have high complication rates. Preliminary biomechanical studies suggested a correlation between ulnar fracture localization and clinical result. OBJECTIVES: Key objective was to evaluate whether the site of the ulnar fracture can be correlated to clinical outcome after open reduction and internal stabilization. METHODS: In a retrospective, monocentric study 35 patients who underwent surgical treatment after suffering a Monteggia injury or Monteggia-like lesion were included. Fractures were classified according to Bado and Jupiter, the site of the fracture location at the proximal ulna and regarding the potential accompanying ligamentary injury. In a follow-up examination validated patient-reported outcome measures and functional parameters were evaluated. Furthermore, treatment strategy and complications were analysed. RESULTS: Mean patient age was 51.9 years (± 18.0). 69% were females (n = 24). Follow-up took place after 50.5 months (± 22.1). Fractures were classified according to Bado (I:2, II:27, III:4, IV:2). Bado II-fractures were further classified according to Jupiter (A:7, B:16, C:3, D:1). Cases were divided into subgroups depending upon the distance of the ulnar fracture site in respect to its distal endpoint (A: < 7 cm and B: > 7 cm). Average overall MEPS was 84.1 (± 19.0). Oxford elbow score and DASH were 37.2 (± 10.5) and 20.4 (± 20.5). Average extension capability reached - 7° (± 7.5). Mean flexion was 134.8° (± 19.7). Average pain according to visual analogue scale was 1.6 (± 1.9). We found no differences between the subgroups regarding the PROMs. Subgroup A displayed a worse extension capability (p = 0.027) and patients were significantly older (p < 0.01). Comparing patients with and without fracture of the radial head, we observed no differences. Patients with an accompanying injury of the coronoid process displayed higher pain levels (p = 0.011), a worse functionality (p = 0.027) and overall lower scoring in PROM. CONCLUSION: The presented results suggest that in Monteggia fractures and Monteggia-like lesions, the localization of the ulna fracture can give a hint for its postoperative outcome. However, we could not confirm the hypothesis of an increasing instability in ulnar fractures located further distally (high severity of the potential ligamentous injury). Intraarticular fractures or injuries with a close relation to the joint have a worse prognosis, especially if the coronoid process is injured. Trial registration Registration was done with ClinicalTrials.gov under NCT05325268.