Missed Pediatric Monteggia Fractures

Abstract

* Careful scrutiny of radiographs is important in the assessment of pediatric elbow injuries. Disruption of the radiocapitellar line and an increased bow of the posterior ulnar border are sometimes subtle signs of a Monteggia injury.* An attempt at closed reduction up to 4 weeks after injury has been cited in the literature as successfully treating some missed injuries.* Operative reduction of chronic radial-head dislocation provides good to excellent range of motion and functional outcome in the setting of irreducible chronic radial-head dislocation.* Ulnar osteotomy and correction of the ulnar deformity component of the missed Monteggia injury are the key to indirect anatomic reduction of the radiocapitellar joint.* Supplemental procedures aimed at increasing the stability of the radiocapitellar joint (e.g., annular ligament reconstruction, radiocapitellar Kirschner wire fixation, radioulnar Kirschner wire fixation) should be directed by a thorough assessment of radiocapitellar stability following ulnar osteotomy and correction of the ulnar deformity.

Neglected Monteggia fracture: a review

“…Though Monteggia fracture is well defined as radial head dislocation combined with proximal ulna fracture, the exact time point to consider a chronic phase Monteggia fracture is ambiguous. Recent studies recommended over 4 weeks after injury as the dividing line for NMF, as malunion of the ulna had already formed (1,2,3,6,8,11,50).…”

“…A rate of misdiagnosis of up to 28% makes the recognition of Monteggia fracture challenging, especially in pediatric patients (3,6,8). Chin et al (33) proposed several possible causes that could make acute pediatric Monteggia fracture a neglected one.…”

“…Monteggia fracture, characterized by proximal 1/3 ulnar shaft fracture combined with radial head dislocation, was first described by Monteggia et al in 1814, while recent studies included fracture of the olecranon (1,2,3,4,5,6). With an incidence of less than 2% of forearm injuries in children and adults, this rare combination injury could eventually lead to forearm deformities and dysfunction if not diagnosed at an early stage, resulting in neglected Monteggia fracture (NMF) (1,4,7,8).…”

Two-stage strategy for neglected Monteggia fracture in children

“…[ 1 ] Around 25% to 50% of these injuries may be missed by the health care providers at first encounter, depending on their expertise and experience. [ 2 ]…”

“…A neglected Monteggia fracture is defined as the fracture of the proximal ulna associated with radial head dislocation (RHD) without undergoing any treatment for 4 weeks or more following injury. [ 2 , 3 , 7 ] Ulnar corrective osteotomy to restore the normal length of the ulna, and the relationship between radius and ulna was reported. [ 8 ] But, in certain patients, UO alone is not able to reduce RHD and maintain the reduction afterward.…”