Yonsei Med J.  2017 Jul;58(4):829-836. 10.3349/ymj.2017.58.4.829.

Impact of Open Reduction on Surgical Strategies for Missed Monteggia Fracture in Children

• Park H
• Park KW
• Park KB
• Kim HW
• Eom NK
• Lee DH

• KMID: 2419091
• DOI: http://doi.org/10.3349/ymj.2017.58.4.829

Abstract

PURPOSE
The aims of this study were to review our cases of missed Monteggia fracture treated by open reduction of the radial head with or without ulnar osteotomy and to investigate the indications for open reduction alone in surgical treatment of missed Monteggia fracture.
MATERIALS AND METHODS
We retrospectively reviewed 22 patients who presented with missed Monteggia fracture. The patients' mean age at the time of surgery was 7.6 years. The mean interval from injury to surgery was 16.1 months. The surgical procedure consisted of open reduction of the radiocapitellar joint followed by ulnar osteotomy without reconstruction of the annular ligament. The mean period of follow-up was 3.8 years. Radiographic assessment was performed for the maximum ulnar bow (MUB) and the location of the MUB. Clinical results were evaluated with the Mayo Elbow Performance Index and Kim's scores.
RESULTS
Five patients underwent open reduction alone, and 17 patients underwent open reduction and ulnar osteotomy. When the MUB was less than 4 mm and the location of the MUB was in the distal 40% of the ulna, we could achieve reduction of the radial head without ulnar osteotomy. The radial head was maintained in a completely reduced position in 21 patients and was dislocated in one patient at final follow-up.
CONCLUSION
Open reduction alone can be an attractive surgical option in select patients with missed Monteggia fracture with minimal bowing of the distal ulna. However, ulnar osteotomy should be considered in patients with a definite ulnar deformity.

Keyword

Missed Monteggia fracture; open reduction; ulnar osteotomy; ulnar bow

MeSH Terms

Adolescent
Child
Child, Preschool
Elbow Joint/diagnostic imaging/physiopathology/surgery
Female
Humans
Male
Monteggia's Fracture/diagnostic imaging/physiopathology/*surgery
*Open Fracture Reduction
Postoperative Care
Preoperative Care
Radius/diagnostic imaging/surgery
Range of Motion, Articular
Retrospective Studies
Ulna/physiopathology/surgery

Figure

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  Fig. 1 Schematic drawing showing measurement of the maximum ulnar bow (MUB) and the location of MUB. A straight line is drawn along the dorsal border of the ulna from the level of the olecranon to the distal ulnar growth plate. MUB is the maximum perpendicular distance from this straight line. Distance A is the length of straight line; the distance B is the length from the distal ulnar growth plate to the point of MUB of straight line. The location of MUB represents as a percentage of B/A.

• 

  Fig. 2 The radial head is surrounded with dense fibrous scar tissue preventing reduction.

• 

  Fig. 3 The annular ligament was dislocated to the radiocapitellar joint but intact without rupture.

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  Fig. 4 A 4-year-old girl with a missed Monteggia fracture after a 2-month interval with loss of full flexion. (A) Radiograph showing isolated anterior dislocation of the radial head. (B) Immediate postoperative radiograph demonstrating the reduced radial head with open reduction alone. (C) A 5-year follow-up radiograph showing normal alignment of the proximal radius with the capitellum. (D) Full range of motion of the elbow and forearm is demonstrated.

• 

  Fig. 5 A 6-year-old boy presented 6 months after injury of his left elbow with pain and an extension deficit. (A) Radiograph shows anterior dislocation of the radial head with calcification of annular ligament remnants. (B) He was treated with open reduction and ulnar osteotomy, because the radial head was unstable with open reduction alone. (C) Radiograph obtained 2 years later showing an anatomical position of the radial head.

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  Fig. 6 Scatterplot shows the relationships between the method of surgical treatment, maximum ulnar bow (MUB), and the distance of the MUB from the distal end of the ulna. Open reduction alone was successful in four cases (solid circle) in which the MUB was less than 4 mm and the MUB was in the distal 40% of the ulna. Additionally, one case with isolated radial head dislocation was successfully treated with open reduction alone.

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