Surgical treatment in children missed Monteggia lesions at Bhuj, Kutch, Gujarat: a retrospective study

Abstract

<p class="abstract"><strong>Background:</strong> The treatment of an unrecognized Monteggia lesion continues to pose a therapeutic challenge, as evidenced by the variety of surgical techniques described. Moreover, there are high complication and redislocation rates following surgery. This report concerns a surgical technique to reduce a chronic dislocation of the radial head utilizing an ulnar osteotomy and internal fixation<span lang="EN-IN">.</span></p><p class="abstract"><strong>Methods:</strong> Present study was performed at department of orthopedics, Gujarat Adani institute of medical science, Bhuj, Kutch, Gujarat. Ethical clearance was taken from the institutional ethics board and informed consent was obtained from all the participants. Between July 2015 and September 2016 six children presented in a traumatic context with chronic dislocation of the radial head and malunion of the ulna. Patient mean age was 6.5 (range 4–8) years, and the mean interval between injury and surgical procedure was 17 (range 1–49) months. Surgery consisted of an ulnar osteotomy with angulation and lengthening, bone grafting at the osteotomy site, and internal fixation. Open reduction of the radial head, repair or reconstruction of the annular ligament or temporary fixation of the radial head with a transarticular wire was not undertaken. Cast immobilization with the forearm in neutral rotation was maintained for 4-6 weeks.<strong></strong></p><p class="abstract"><strong>Results:</strong> There was one case of nonunion. At an average follow-up of 3 (range 1.5–4.4) years, all patients had regained painless function of the forearm, good range of elbow and forearm motion, and maintenance of the radial head reduction<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> Both angulation and elongation of the ulna are required to allow for reduction of the radial head. We do not see any indication for procedures directed at the radio-capitellar joint<span lang="EN-IN">.</span></p>

Ulnar osteotomy is the only required procedure for chronic monteggia fracture in children.

“…13,14 Also, distraction and angulation at the osteotomy site pushes the radial head down through the interosseous membrane, eliminating for any ligament reconstruction requirement. 15,16 There are two studies in which only ulnar osteotomy is done 17,18 In study of Parkash, angulation and elongation of the ulna by ulnar osteotomy are required for reduction of the radial head and this is same in our study. In study of Park et al, ulnar osteotomy and correction of the ulnar deformity are the key components to achieve reduction and this is also true in our study Another study showed both ulnar ostetomy and annular ligament reconstruction are required.…”

Corrective Ulnar Osteotomy and Annular Ligament Reconstruction by Fascia Lata in Neglected Monteggia Fracture Dislocation in Children.

“…Synostosis was observed in one patient in the series by Oner and Diepstraten [46] , although no ulnar osteotomy was carried out. Dissection during open reduction of the radial head appears to be a greater risk factor for proximal synostosis.…”

Surgical treatment of chronic anterior radial head dislocations in missed Monteggia lesions in children: A rationale for treatment and pearls and pitfalls of surgery

“…3,6,12,22 On the contrary, successful closed radial head repositioning has been documented by some authors. [17][18][19][20]…”

“…Reduction of the radial head can be achieved by an open approach or without opening the joint. [17][18][19][20] No consensus has yet been reached regarding the necessity for the several steps in this surgical procedure. Therefore, work-up to surgery is also still unclear; it is unknown whether dysmorphic features of the radial head are a contraindication for surgery or whether time between trauma and surgery is of influence on surgical outcome.…”