Missed Diagnosis and Acute Management of Radial Head Dislocation With Plastic Deformation of Ulna in Children.

BACKGROUND: Radial head dislocation with ulnar bowing (Monteggia type I equivalent injury) is a frequently missed injury. If not recognized acutely, these missed injuries can lead to serious long-term complications. The purpose of this study was to evaluate the rate of missed diagnosis and to report on the characteristics and early management of this specific injury pattern. METHODS: A total of 112 patients with Monteggia fracture-dislocation were identified, of which 18 patients had sustained a Monteggia type I equivalent injury. The total duration between injury, diagnosis, and treatment was noted. Medical records were reviewed to identify cases with the initially missed diagnosis. The radiographic assessment included the direction of radial head dislocation and location/displacement of the apex of the ulnar bow. Clinical outcomes were evaluated using Kim elbow performance score. RESULTS: Thirteen of 18 cases with Monteggia equivalent injury were missed at the initial presentation. The diagnosis was established when the patients followed up in the orthopaedic clinic. Of these 18 patients, 11 were treated by closed reduction/cast and 7 patients required surgery. Significant differences were found between the closed reduction/cast and operative group for the mean time from injury to treatment (3.2±2.6 vs. 12.7±13.6 d). For each day of delay in treatment, the odds for surgical intervention increased by a factor of 1.126 (12.6%). There were no significant differences between the location and magnitude of the apex of the ulnar deformity between the 2 groups. Kim elbow score was excellent in all cases at the latest follow-up. CONCLUSIONS: Clinical suspicion and careful radiographic assessment are of utmost importance for every child with forearm and elbow injury without an apparent fracture, as there is a high rate of missed diagnosis for this specific Monteggia injury pattern. Prompt treatment would allow for successful closed reduction while even minor delays would increase the need for surgical intervention. LEVEL OF EVIDENCE: Therapeutic, level III.

Long-term follow-up of corrective ulnar osteotomy for missed Monteggia fractures in children.

BACKGROUND: Pediatric Monteggia fractures are relatively rare and are commonly missed. Radial head subluxation can persist with long-term consequences if these fractures are left untreated. We evaluated the long-term treatment outcomes after open reduction with ulnar osteotomy for missed Monteggia fractures during childhood. MATERIALS AND METHODS: Fourteen children were included. Our objective was to assess the clinical and radiographic postoperative outcomes. We evaluated satisfaction by questionnaire. Open reduction of the radial head was performed, combined with an opening-wedge ulnar osteotomy. The mean interval between trauma and surgery was 26.9 months (range, 1-145 months). The mean length of follow-up was 132 months (range, 67-206 months). RESULTS: Only patients with a delay of more than 6 months complained of elbow tenderness. Clinical improvement (except for pronation) was obtained postoperatively, with significance found in the flexion-extension arc (P = .011). In addition, pronation loss (P = .044) and the flexion-extension arc (P = .041) improved significantly in patients with a surgical delay under 6 months compared with patients with a surgical delay of more than 6 months. Radiographically, there were 9 good and 5 fair results. We found a negative association between radiographic outcomes and both age at surgery and delay to surgery (P = .036 and P = .039, respectively). CONCLUSIONS: Good results can be obtained after open reduction with opening-wedge ulnar osteotomy. Lesser clinical and radiographic outcomes can be expected after a surgical delay of more than 6 months. Furthermore, the radiographic outcome seems better if the patient is younger than 6 years.

[Type III Monteggia lesion: a rare association, about a case]. / Lésion Monteggia du groupe III association rare, à propos d'un cas.

Type III Monteggia lesion is very rare, usually occurring within a context of violent trauma and often going unnoticed. We report the case of a 11-year old boy presenting to the Emergency Department with blunt trauma of the upper limb. The radiological evaluation showed olecranon fracture and radial epiphyseal separation associated with dislocation of the radial head. The patient underwent orthopedic treatment with good outcome after a mean follow-up of 3 months.

Open reduction combined with CORA-based osteotomy of the ulna in the treatment of missed Bado type I Monteggia injury: A retrospective study of 5 cases.

Open reduction combined with ulnar osteotomy is the most common approach to treating missed Monteggia injuries. The osteotomy is usually performed at the proximal ulna to ensure better healing and fewer complications. The purpose of this study is to present a center of rotation angulation (CORA)-based osteotomy of the ulna for treating Bado type I Monteggia injuries.We retrospectively reviewed the cases of patients who were treated with open reduction combined with a CORA-based ulnar osteotomy between February 2014 and December 2016. Each patient provided his or her internal control, and paired data of the involved and uninvolved sides were analyzed to evaluate forearm rotation function.Five patients (3 male, 2 female) with median age 5.7 years (range, 3.4-6.8 years) were operated on by the senior author in our hospital. The median interval between the original injury and the corrective surgery was 3 months (range, 1-4 months). In a median follow-up of 10 months (range, 6-17 months), all patients obtained stable reduction of the radial head and uneventful healing of the ulnar osteotomy. All patients had pain-free elbows with no neurological or vascular complications and no implant breakage. Patients showed excellent outcomes evaluated using the Broberg and Morrey index.Open reduction with a CORA-based osteotomy of the ulna for the treatment of missed Bado type I Monteggia injury with an obvious ulnar bowing deformity resulted in stable reduction of the radial head and excellent forearm function.

Successful Strategies for Managing Monteggia Injuries.

Monteggia fracture-dislocations refer to traumatic ulnar fractures associated with proximal radioulnar and radiocapitellar joint instability. Careful clinical and radiographic evaluation of the entire limb in the acutely injured child is critical for timely diagnosis and appropriate treatment. Treatment principles include restoring and maintaining both ulnar length and alignment as well as radiocapitellar joint reduction. Recent information suggests that surgical treatment of acute injuries associated with complete ulnar fractures is safe and effective in maintaining bone and joint alignment. In cases of late presentation or missed diagnoses, chronic reconstruction may be considered in symptomatic patients with preserved radiocapitellar morphology. Although challenging, ulnar osteotomy and open joint reduction with or without ligament reconstruction may restore joint congruity in the majority of patients.

[Radial head anterior dislocation and ulna bowing in children: About 3 cases and review of the literature]. / Luxation antérieure de tête radiale et déformation plastique de l'ulna chez l'enfant: A propos de 3 cas et revue de la littérature.

We present three cases of anterior dislocation of the radial head associated with plastic deformation of the ulna in children. It is a Monteggia equivalent lesion type 1 according to the Bado's classification. Radiological diagnosis often goes unnoticed to the untrained eye. The relationship between the radius and the capitulum identifies the dislocated radial head on radiographs AP or lateral. Line Mubarak highlights the bowing of the ulna on radiographs lateral. Evolution is pejorative in the absence of early orthopedic care. Older is the patient and longer is the time between injury and treatment, less good are the clinical and radiological results. The first line treatment is closed reduction of the dislocation of the radial head and the bowing of the ulna. Surgical treatment is indicated in cases of failure of closed reduction. Adequate surgical treatment is that which allows and maintain the reduction. The surgery is the most possible minimally invasive. Open reduction can be associated with various surgical techniques: the annular ligament plasty, the establishment of a transitory pin intra-articular capitulo radiale, the ulna osteotomy, the radial osteotomy. Radial head resection is not indicated in children.

Nous présentons trois cas de luxation antérieure de tête radiale associée à une déformation plastique de l'ulna chez l'enfant. Il s'agit d'une lésion de Monteggia équivalent type 1 selon la classification de Bado. Le diagnostic radiologique passe souvent inaperçu pour un oeil non averti. L'alignement entre le radius et le capitulum permet d'identifier la luxation de tête radiale sur des radiographies de face ou de profil. La ligne de Mubarak met en évidence la déformation plastique de l'ulna sur des radiographies de profil. L'évolution est péjorative en l'absence d'une prise en charge orthopédique précoce. Plus le patient est âgé et plus le délai entre le traumatisme et le traitement est long, moins les résultats clinique et radiologique sont bons. Le traitement de première ligne est la réduction à foyer fermé de la luxation de tête radiale et de la déformation plastique de l'ulna. Le traitement chirurgical est indiqué en cas d'échec de la réduction à foyer fermé. Le traitement chirurgical adéquat est celui qui permet la réduction et le maintien de celle-ci tout en étant le moins invasif possible. La réduction à foyer ouvert simple peut être associée à diverses techniques chirurgicales : la plastie du ligament annulaire, la mise en place d'une broche intra-articulaire capitulo radiale transitoire, l'ostéotomie ulnaire, l'ostéotomie radiale. La résection de tête radiale n'a pas d'indication chez l'enfant.

Recognition and fixation of crista supinatoris fractures in Monteggia injuries.

In Monteggia fracture dislocations of the elbow, the lateral collateral ligament complex is disrupted as the radial head dislocates from the capitellum. A persistently incompetent lateral ulnar collateral ligament (LUCL) predisposes to posterolateral rotary instability of the elbow, thus restoration of the LUCL is essential for recovery. Although LUCL disruptions following elbow dislocations typically occur at the lateral humeral origin, we have identified a series of Monteggia injuries where the LUCL is avulsed from its ulnar insertion along with a fracture fragment containing the crista supinatoris. Failure to recognize and appropriately treat the crista supinatoris fracture in this injury may result in LUCL incompetence and risk symptomatic instability. The following technique describes the recognition and surgical treatment of Monteggia injuries, specifically recognizing the crista supinatoris fracture. Using this technique, patients reliably experience good functional outcomes with normal elbow stability.

The Monteggia fracture: series of 20 cases.

The Monteggia fracture is one of the pitfalls of conventional diagnosis of upper limb trauma. Through a retrospective study of 20 cases diagnosed at the Department of Orthopaedic Surgery and Traumatology, University Hospital Center, Ibn Sina, Mohamed V University, Rabat, Morocco, between 2010 and 2014, we have tried to do an update on the management of Monteggia fractures either at of paraclinical exams or the surgical management. We support the idea that the dislocation of the radial head should be sought systematically to any isolated fracture of the ulna, for not to miss fracture Monteggia authentic. Rehabilitation of the upper limb must be done as soon as possible.

Management of bilateral complex fracture-dislocation of proximal ulna and radius: a case report.

Complex fracture-dislocation of proximal ulna and radius (FDUR) are rare, representing only 2-5 % of elbow injuries. Monteggia-like lesions and transolecranon fractures include various patterns of complex FDUR, which are not well defined. The management of these injuries is considered extremely difficult, and clinical results are often poor. In this report, we present a case of a 66-year-old woman with bilateral complex FDUR. This pattern of injury is very rare and little information is available about its management. Diagnosis, surgical technique, rehabilitation programme and clinical results are reported. The bilaterality of the condition does not appear to influence the treatment and results.

Elbow arthrography in children with an ulnar fracture and occult subluxation of the radial head.

The purpose of this study was to investigate the use of elbow arthrography for detecting an occult subluxation of the radial head and for verifying the quality of reduction in children with ulnar fractures. The study involved 15 children who underwent closed reduction (with or without percutaneous pinning) based on arthrography for minimally displaced fractures with or without radial head subluxation. The mean age of the patient at the time of surgery was 6 years (range, 3-12 years). Initial diagnoses based on conventional radiographs were compared with arthrographically confirmed final diagnoses in groups of children with ulnar fractures of the olecranon, proximal, and diaphysis. Arthrography confirmed initial radiographic diagnoses in 10 and altered diagnoses in five patients. We conclude that arthrography can be useful for detecting an occult subluxation of the radial head and for evaluating adequate reduction in children of less than 6 years with ulnar fractures.

Monteggia fractures in adults.

Over the past fifty years, treatment outcomes of traumatic injuries in the upper limb have improved with the advent of better implants. However, the Monteggia fracture is often still associated with various complications, poor functional outcomes and a relatively high rate of revision surgeries. Rigid anatomic fixation of ulnar fracture is paramount. Open relocation of the radial head and soft tissue procedures are redundant. Monteggia fractures are challenging to treat. Critical analysis with respect to the high rate of complications and unsatisfactory functional outcomes is required. The type of fracture and associated injuries such as coronoid fracture and radial head fracture appear to influence the outcome in most cases. Negative prognostic factors such as prolonged immobilization, associated coronoid and radial head fractures must be minimized and treated appropriately. Prior to surgery the patient should be informed regarding the possible risk of residual functional limitations and the potential need for further revision surgeries.

[Posterior monteggia fracture-dislocations of proximal ulna].

OBJECTIVES: To discuss the diagnosis and differential diagnosis, and to establish an effective protocol to treat the posterior Monteggia fracture-dislocations of proximal ulna in adult according to our experience. METHODS: Between April 2004 and December 2007, 16 patients with posterior Monteggia fracture-dislocations were treated surgically, 13 were followed up at a mean of 28 months (range, 12 - 58 months). All the operations were through the posterior midline approach. The fractures of radial head and coronoid process were reduced and fixed, if possible. The proximal ulna fractures were fixed with a single plate in 7 cases, plate combined with K-wires in 2, plate combined with K-wires tension band in 3, and K-wires tension band combined with screws in 1. RESULTS: No elbow was painful or unstable at the last follow up examination. They had an average of 100 degrees (range, 0 degrees to 145 degrees ) of flexion-extension of elbow. The average motion of forearm rotation was 119 degrees (range, 0 degrees to 170 degrees ). The mean Mayo Elbow Performance Score (MEPS) was 93.1 points (67 - 100 points), excellent and good results were achieved in 92.3%. The mean system of Broberg and Morrey score was 88.8 points (53 - 100 points), excellent and good results were achieved in 76.9%. CONCLUSIONS: Attention should be paid to the diagnosis and differential diagnosis of the posterior Monteggia fracture-dislocation of proximal ulna. Anatomically reduction and stable fixation of proximal ulna is the keystone for the surgical treatment.

[Delayed radial paralysis after Monteggia fracture--a case report]. / Verzögerte Radialisparese nach Monteggia-Fraktur--Ein Fallbericht.

Concomittant lesions of neural structures represent a rare type of complications in Monteggia's fractures. In acute fractures spontaneous neurological remission usually occurs after reduction of the dislocated radial head. In the presented case a 33-year old man experienced a trady palsy of the posterior interosseus nerve 27 years after a Monteggia's fracture with the radial head left dislocated. Following a minimal trauma in badminton a neurological deficiency probably caused by distraction occurred and resulted in impairment of wrist extension and extension of the fingers. Initiated conservative treatment including intensive physiotherapy and electrotherapy for 4 months was unsuccessful. Consecutively the radial nerve was surgically exposed and released from an entrapping and thickened arcade of Frohse. The radial head was left dislocated. Full neurological recovery was obtained 9 months after surgery.

Missed chronic anterior Monteggia lesion. Closed reduction by gradual lengthening and angulation of the ulna.

Two consecutive cases of chronic dislocation of the head of the radius after missed Bado type-I Monteggia lesions are presented. Reduction was successfully achieved in both patients after ulnar corticotomy, gradual lengthening and angulation of the ulna using an external fixator. Open reduction or reconstruction of the radio-ulnar capitellar joint was not undertaken. The age at injury was seven years in the older and two years in the younger patient. The time from injury to treatment was five years in the older and three months in the younger child. At follow-up, nine years after completion of treatment in the older and eight months in the younger patient, both show satisfactory movement, function of the forearm and reduction of the head of the radius. This technique may be considered in missed Monteggia lesions before open procedures on the radio-ulnar capitellar joint are undertaken.

[Old Monteggia lesions in children. Apropos of 14 cases]. / Lésions de Monteggia anciennes chez l'enfant. A propos de 14 observations.

Fourteen patients between the ages of 3.5 years and 11 years, with an old Monteggia lesion were managed in the Orthopaedics department between 1968 and 1997. Dislocation of the radial head was not diagnosed at the time of the initial trauma in 9 out of 14 cases and the diagnosis was made an average of 14 months after the trauma (range: 5 weeks to 84 months). Twelve of the 14 patients underwent surgical reduction of chronic dislocation of the radial head, mostly associated with proximal ulnar osteotomy and/or a procedure on the extensor retinaculum. The mean follow-up is 4 years 9 months. There were 66% excellent and good results, 25% of moderate results and 9% of poor results. Due to the difficulty of surgery of neglected lesions, the authors report their experience and emphasize the importance of the initial diagnosis.

[Complex disorders of radius and ulna in childhood]. / Komplexe Störungen von Radius und Ulna beim Kind.

Treatment of congenital or acquired disturbances of the radius or ulna always requires recognition of the complex biomechanics of the forearm. In particular trauma, seemingly restricted to one of the bones, should caution against concomitant lesions to the other bone. The typical example is unfortunately the often missed dislocation of the capitulum radii in Monteggia-type lesions. Additional examples are deranged growth of the distal epiphysis of the radius after a fracture of the ulna, in association with multiple osteochondromas and of the proximal epiphysis of the radius in presumptively congenital dislocation of the capitum radii. Lesions encountered in children have to be analyzed carefully with respect to dynamics of maldevelopment. Corrections that have implications for neighbouring articulations should be undertaken with the intent to fully exploit the potential for remodelling by forthcoming growth processes.