Missed Monteggia fractures in children – the current state of the problem: A systematic review

Abstract

BACKGROUNG: A situation in which despite an obvious ulnar fracture, radial head dislocation is not diagnosed, resulting in a missed Monteggia fracture is not uncommon. Unsatisfactory results of the treatment of this pathology have prompted several researchers to search for an optimal treatment strategy.
 AIM: This study aimed to conduct a systematic review of literature data on missed Monteggia fractures and dislocations in children by studying the main therapeutic and tactical approaches to this problem.
 MATERIALS AND METHODS: A literature search was conducted in the Cochrane Database, Science Direct, Google Scholar, PubMed, and eLibrary information bases, and the search depth was 10 years. Moreover, 46 sources were selected based on the criteria. The main characteristics revealing the problem were identified, divided into four semantic groups, according to which the literature was analyzed: initial data on the condition of patients at the time of seeking medical help, status before and after treatment, and treatment methods.
 RESULTS: The average age of the children was 8.4 years. The average interval from injury to the surgical treatment of missed Monteggia fracture was 15.3 months, and 883 clinical cases presented in sources with known treatment techniques were analyzed. Thus, open reduction of the radial head in combination with the restoration or reconstruction of the annular ligament and ulnar osteotomy is one of the most common methods (n = 482, 54.6%). The second most frequent application was the above-described approach, but without manipulations on the annular ligament (n = 273, 30.9%). Bone osteosynthesis and external fixation apparatus were the most widely used stabilization methods in 350 (67.8%) and 149 (28.9%), respectively. The most common complications were associated with the deterioration of the functional status after surgery.
 CONCLUSIONS: Accurate diagnosis of injury and early correction of existing disorders is the key to reducing the frequency of missed Monteggia fractures. Surgical treatment is the main method of treating children with this injury, in which the restoration of the ulnar anatomy and the ratios in the brachial and proximal radiocarpal joints are the most important, providing a more physiological development of the segment with the growth of the child.