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

Abstract

Introduction: The treatment of chronic radial head dislocations after Monteggia lesions in children can be challenging. This article provides a detailed description of the most frequently performed surgical technique: an ulna osteotomy followed by annular ligament reconstruction. Accordingly, we present the clinical and radiological results of 10 paediatric cases. Material and methods: All paediatric patients that had a corrective osteotomy of the ulna for a missed Monteggia lesion between 2008 and 2014 were evaluated with standard radiographs and clinical examination. A literature search was performed to identify the relevant pearls and pitfalls of surgery. Primary outcome was range of motion. Results: We included 10 patients, with a mean follow-up of 2.5 years. Postoperative range of motion generally improved 30.7. Even in a patient with obvious deformity of the radial head, range of motion improved after surgery, without residual dislocation of the radial head. Conclusion: Corrective proximal ulna osteotomy with rigid plate fixation and annular ligament reconstruction yields good results in patients with chronic radial head dislocation following a Monteggia lesion. Surgery should be considered regardless of patient age or time since trauma. Given substantial arguments in literature, we discourage surgery if a CT scan shows dome-shaped radial head dysmorphic features in work-up to surgery.

Missed post-traumatic radial head dislocation in a three-year-old child: A case report

“…A trans-articular K-wire fixation might be needed to achieve stability after the reduction with or without annular ligament reconstruction. 7 , 8 , 10 Neither situation occurred in the reported Case, which was not a Monteggia or Monteggia-variant fracture. Hence, there was no need for an ulnar osteotomy or lengthening.…”

“… 5 Although most children with missed dislocations are initially asymptomatic, they may develop pain, motion limitation, and secondary degenerative changes that eventually necessitate treatment. 6 , 7 Open reduction of missed RHD is necessary to restore satisfactory functional results. Nevertheless, many complications have been reported after surgical treatment.…”

Heterotopic Ossification of annular ligament: A case report and review of literature

“…Mild restriction in protonation is a common complication among operated cases of neglected monteggia fracture. 16 Author contribution…”

Neglected Monteggia fracture: a review

“…Since expectant treatment of NMF often results in poor outcomes, early surgical intervention is well recommended to decrease complications (5,8,17,22,23,54,63,74). Surgical treatment aims at correcting the angular deformity of the ulnar, stably reducing the radial head and restoring the proper alignment of the radiocapitellar joint (1,2,3,15,19,20,32,40,41,42). Though numerous studies have reported different treatments of NMF, which vary from position to perform osteotomy, options for fixation, and the reconstruction of the annular ligament, there still remains no standard protocol or guidelines (9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,…”

“…Plenty of researchers have reported managements of NMF with different outcomes in recent years (9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49). This review aims at summarizing and discussing the current knowledge of NMF, including its definition, its pathophysiological characteristics, the biomechanics of which the radial head slips, and surgical intervention.…”