Bado Type Research Articles

Corrective Ulnar Osteotomy and Annular ligament reconstruction by fascia lata in Neglected Monteggia Fracture Dislocation in Children

Background: Neglected Monteggia fracture dislocation in children constitutes significant disability in respect to pain, stiffness, deformity, neurological compromise and restriction of activities of daily living. Many surgical technique have been described to manage neglected Monteggia fracture dislocation and common technique is the ulnar osteotomy for restoration of the ulnar length and reduction of the radial head with annular ligament reconstruction for restoration of the elbow biomechanics for this difficult problem. Materials and methods: In a prospective study 13 patients with mean age of 7 years and 7 months, who presented with neglected Monteggia fracture dislocation, were studied. The time interval between injury and presentation mean 7.2 months and ranged from 2 months to 25 months. Nine patients were classified as Bado type I, three as BadotypeII and one as Bado type III. All children underwent open reduction of the radiocapitellar joint, Ulnar osteotomy with angulation distraction and annular ligament reconstruction by fascia lata. We used Kim’s scorethe for evaluation of our results. Results: The mean follow-up period was 40.8 months. One of them without ulnar osteotomies healed uneventfully. The mean of pronation was 75°, supination was 88.9°. Elbow flexion-extension range improved postoperative 13.4%. There were two patients with cubitus valgus The elbow score was excellent in ten cases, good in two cases, and fair in one cases. Conclusion: Late open reduction for chronically dislocated radial heads in children produces good to excellent results. Surgery for reduction should be attempted unless dysmorphism of the radial head restricts it. Open reduction with ulnar osteotomy with annular ligament reduction is the most commonly performed procedure and is expected to result in reduced pain and elbow deformity.Statistically

Epidemiological characteristics of Monteggia fractures in the east and west areas in China from 2010 to 2011

Objective To analyze and compare the epidemiological features of Monteggia fractures between the east and west areas in China from 2010 to 2011. Methods The data of Monteggia fractures treated from January 2010 through December 2011 in 63 hospitals in the east and west China were collected through the PACS system and case reports checking system. The data from the 35 east hospitals were classified as group A while those from the 28 west hospitals as group B. The analytic items included general situation, gender, age, and Bado classification. Results A total of 593 Monteggia fractures were included, including 428 males and 165 females, with a male to female ratio of 2.59∶1. The constituent ratios of Bado classification, from high to low, were type Ⅰ (42.50%), type Ⅲ (33.22%), type Ⅱ (14.00%) and type Ⅳ (10.29%). There were 376 patients in group A including 263 (69.95%) males and 113 (30.05%) females while 217 patients in group B including 165 (76.04%) males and 52 (23.96%) females. The median age in group B was 31 years (from 2 to 75 years), significantly older than that in group A [18 years (from 1 to 83 years)] (Z=2.877, P=0.000). The differences in constituent ratios of age and Bado classification were statistically significant between the 2 groups (P< 0.05). The Monteggia fractures predominated in the age range of 0 to 10 years in group A while in the age range of 31 to 40 years in group B. The high risk fracture type was Bado type Ⅰ in group A and Bado type Ⅲ in group B. The Monteggia fractures accounted for 1.15% of the forearm fractures and 0.19% of the systemic fractures. Conclusions More males suffered from Monteggia fracture than females. In the east China, the high risk age range was from 0 to 10 years and the high risk type Bado type Ⅰ; in the west China, the high risk age range was from 31 to 40 years and the high risk type Bado type Ⅲ. The proportion of Bado type Ⅳ in the west China was significantly higher than in the east China. Key words: Forearm injuries; Fractures, bone; Epidemiology

V-Shaped Corrective Ulnar Osteotomy in Neglected Monteggia Fracture Dislocation in Children

Background: Neglected Monteggia fracture dislocation in children constitutes significant disability in respect to pain, stiffness, deformity, neurological compromise and restriction of activities of daily living. Many treatment strategies have been described to manage neglected Monteggia fracture dislocation and one of these strategies is the ulnar osteotomy for restoration of the ulnar length and reduction of the radial head with annular ligament reconstruction for restoration of the elbow biomechanics for this difficult problem. Aim: Evaluation of the results of a new V-shaped corrective ulnar osteotomy without bone grafting with annular ligament reconstruction in management of neglected Monteggia fracture dislocation in children. Materials and methods: In a prospective study 16 patients with mean age of 7 years and 3 months, who presented with neglected Monteggia fractures dislocation, were studied. The time interval between injury and presentation ranged from 3 months to 20 months (mean 11.2 months). Eleven patients were classified as Bado type I and three as Bado II and two as Bado type III. All children underwent open reduction of the radiocapitellar joint with V-shaped angulation-distraction osteotomy of ulna and annular ligament reconstruction. We used the Mayo elbow performance score for evaluation of our results. Results: The mean follow-up period was 19.5 months. All ulnar osteotomies healed uneventfully. The mean loss of pronation was 4°. Elbow flexion-extension range improved postoperative by 3° and no child complained of pain, deformity or restriction of activity. The elbow score was excellent in eight cases, good in five cases, and fair in three cases. Conclusion: V-shaped corrective ulnar osteotomy technique without bone grafting is a technically simple procedure, which achieves lengthening and angulation of the ulna simultaneously in the sagittal plane and reduces the radial head and with annular ligament reconstruction will suffices in most cases of missed monteggia fractures dislocations.

Unusual presentation of a type 1 Monteggia equivalent lesion

The authors describe a case of simultaneous anterior dislocation of the radial head with plastic deformation of the ulna and an ipsilateral medial humeral condyle fracture in a 6-year-old boy after a fall on an outstretched hand. This rare combination of injuries has not been described previously in the literature. Closed reduction of the dislocated radial head and percutaneous K-wire fixation of the medial humeral condyle fracture achieved an excellent result with full function. This rare combination of injuries is considered to be an unusual subtype of the Bado type I Monteggia equivalent lesion. The case emphasizes that when a fracture is detected around an elbow, other injuries in the region should be suspected.

Medial radial head dislocation associated with a proximal olecranon fracture: a bado type v?

The Monteggia fracture is relatively rare. We present an unreported configuration of a traumatic olecranon fracture with a concomitant medial radial head dislocation in a 3-year-old male. This injury was initially missed and required a subsequent operative intervention. Following surgery, there was evident fracture union, articular congruency, and a full functional recovery. Medial radial head dislocation is not accounted for in the Bado (1967) classification of the Monteggia lesion and hence we propose the addition of a Bado V category.

Evaluation of outcome of corrective ulnar osteotomy with bone grafting and annular ligament reconstruction in neglected monteggia fracture dislocation in children.

Neglected Monteggia fracture dislocation in the paediatric age group constitutes significant disability in respect to pain, stiffness, deformity, neurological compromise and restriction of activities of daily living. A longitudinal prospective study was done on 21 children with old Monteggia fracture-dislocation which included 18 cases of Bado type I and 3 cases of Bado type III at the department of orthopaedics, IPGME&R,SSKM hospital, Kolkata, India between 2007 and 2012. All were treated by modified Hirayama corrective osteotomy of ulna with wedge bone grafting along with restoration of its length and reconstruction of annular ligament using Bell Tawse method and fixation of radial head with transcapitellar Kirschner wire. Average follow up period was 5.5 years. Results were evaluated on the basis of 100 point Mayo Elbow Performance Index, radiology and questionnaire. The mean postoperative increase in Mayo Elbow Performance Index score was 30 with average increase in the range of movement by 30o. In three cases, there was subluxation of radial head and in addition one had transient palsy of posterior interosseous nerve. Three cases showed distortion of the radial head which were insignificant functionally. Results of improvement in mean MEPI were analysed by chi-square test and was significant at 0 .01 level of significance. Study showed good results with modified Hirayama osteotomy with annular ligament reconstruction using Bell Tawse procedure which is a more biological option for restoration of elbow biomechanics.

Radiocapitellar impingement due to residual deformities after a Bado type III Monteggia fracture-dislocation in a pediatric patient: a case report

Fracture of the proximal ulna in children is often associated with a lateral dislocation of the radial head, which is classified as a Bado type III Monteggia fracture-dislocation. Although the aim of treatment for this type of injury is to restore anatomic reduction, residual deformity of the ulna, as well as a subluxation of the radial head, occasionally remains. Clinical features of this chronic type III lesion have seldom been reported separately from a type I lesion, and there have only been 5 cases described in the literature to our knowledge.

Case Report: A Rare Variety of Type 4 Monteggia Fracture Dislocation in A 28 Years Old Man

A Monteggia fracture is a fracture of the proximal ulna coupled with a radial head dislocation. Numerous classification systems have been developed to characterize these fractures. Bado classification is most commonly used. Bado type 1 Monteggia fractures are most common while type 3 & 4 are rare entities. In our case, after confirming the diagnosis as type 4 Bado Monteggia fracture dislocation, patient was posted for open reduction and internal fixation. The ulnar and radial fractures were rigidly fixed with 3.5 compression plate and ulnar length restored. However, the radial head was still found to be dislocated anteriorly on fluoroscopy. An attempt of closed reduction of the radial head failed. Open reduction of the radial head was performed under image intensifier and fixed with a Kirschner’s wire followed by immobilization in hyperflexion for 2 weeks. The patient followed up at the end of 2 weeks, 4 weeks and 6 weeks following injury and gradual mobilisation of the elbow joint was made. Further follow up at 6 months and 1 year showed complete return of routine function. As soon as the ulnar length is restored by rigid internal fixation, radial head is itself reduced in majority of Monteggia fracture dislocation where only ulnar fracture is involved. However, in cases of both bone forearm fracture with radial head dislocation, even after restoring the length of ulna and radius, operative reduction of radial head is essential.

Long-term outcome after ulnar osteotomy for missed Monteggia fracture dislocation in children

Missed Monteggia fracture dislocation in children is a serious condition. The treatment of this rare condition is controversial and reports on the long-term outcome are sparse. We present a series of patients treated with open reduction and ulnar osteotomy with a mean long-term follow-up of 8years (range 3-17). All 16 patients had Bado type 1 (anterior radial head) dislocation. The mean delay from injury to surgery was 17months (range 1-83). Bilateral radiographs, Oxford Elbow Score, strength measurements, and range of motion were obtained in all patients. There were no major complications to surgery. The radiographic results showed ten patients with reduction of the radial head and with no arthrosis, four patients with arthrosis or subluxation, and two patients with a dislocated radial head. We found a significant correlation between radiographic outcome and delay to ulnar osteotomy (P=0.03). Typical clinical findings were a small but significant extension deficit and mean loss of supination of 10° (range 0-90, P<0.01). Ligament reconstruction or transfixation of the radial head did not influence the radiographic or clinical outcome. Case reports of similar patients treated conservatively demonstrate high morbidity, and, therefore, open reduction and ulnar osteotomy seemed justified. However, this study underlines the importance of minimizing the delay between injury and ulnar osteotomy. If surgery is performed within 40months after injury, good to fair long-term radiographic results can be obtained. Open reduction and ulnar osteotomy were performed because patients treated conservatively demonstrate high morbidity.

Type III Monteggia fracture with ipsilateral epiphyseal injury of the distal radius

Ipsilateral elbow and wrist injuries are uncommon in children. We present a case of Bado type III Monteggia fracture dislocation with ipsilateral Salter Harris type I epiphyseal injury of distal radius in a 10-year-old boy. A good result was achieved with early closed reduction and percutaneous K wire fixation. This case emphasizes that whenever a fracture is detected around wrist and elbow in children, early anatomical reduction is required for good functional outcome.

Failure of Internal Fixation of a Humerus Fracture Resulting From Longitudinal Fissuring: A Case Report

We present the case of failure of internal fixation of a humerus fracture resulting from longitudinal fissuring of the far cortex from linearly placed screws. Our case involves a 60-year-old right hand-dominant male who underwent open reduction and internal fixation of a left midshaft humerus fracture (Orthopaedic Trauma Association Type 12-B2) with an ipsilateral Bado Type I Monteggia fracture after being struck by a motor vehicle while crossing the street. Our patient's fixation subsequently failed, which was found intraoperatively to be caused by a stress riser along the far cortex from linearly place screws.

Long-Term Evaluation of Surgically Treated Anterior Monteggia Fractures in Skeletally Mature Patients

The purpose of this retrospective study was to evaluate the functional and radiological long-term outcome of open reduction and internal fixation of skeletally mature patients with a Bado type 1 Monteggia fracture. We identified 11 consecutive skeletally mature patients who had surgical treatment of an anterior (Bado type 1) Monteggia fracture. Long-term evaluation at a median of 20 years after injury (range, 7-34 years) was compared with an early evaluation at a median of 13 months after injury (range, 11-32 months). The early and long-term results were evaluated radiographically and according to the system of Broberg and Morrey. The long-term result was also evaluated according to the Mayo Elbow Performance Index, the American Shoulder and Elbow Surgeons, and the Disabilities of the Arm Should and Hand scores. Two patients had subsequent surgery to address a nonunion and 3 elbows had radiographic signs of arthrosis. The mean arc of elbow flexion increased from 110 degrees (range, 35 degrees to 140 degrees) at early follow-up to 120 degrees (range, 40 degrees to 150 degrees) at late follow-up. The mean arc of forearm rotation increased from 145 degrees (range, 90 degrees to 180 degrees) to 149 degrees (range, 90 degrees to 180 degrees). The mean Broberg and Morrey score increased from 89 points (range, 62-100 points) to 94 points (range, 76-100 points). The median DASH score was 7 points (range, 0-34 points) at long-term follow-up. There was no statistical difference between early and late range of motion or Broberg and Morrey score. The results of open reduction and internal fixation of anterior Monteggia fractures in skeletally mature patients are maintained over long-term follow-up. Therapeutic IV.

Treatment of Neglected Monteggia Fracture-Dislocation in Children

Purpose: Our purpose is to evaluate the results of the operative treatment in neglected Monteggia fracture-dislocation in children. Materials and Methods: We retrospectively analyzed 10 elbows in 10 patients who underwent surgery. All patients were classified as Bado type I, except one with type III. The mean duration of follow up was 2 years and 5 months. The mean age at the time of operation was 10 years and the mean time from injury to operation was 7 months. All 10 patients underwent open reduction of the radial head and reconstruction of annular ligament. Ulnar osteotomy was performed in 9 cases. Clinical assessment was done by Bruce et al.'s rating system. Results: All 10 patients gained a mean of of extension-flexion arc, however lost a mean of of pronation-supination arc. And there were three complications, including dislocation of radial head in two patients and breakage of transarticular K-wire in one patient. According to Bruce et al.'s rating system, there were 4 excellent, 1 good, 3 fair, and 2 poor results. Conclusion: We found that the effect of the operative treatment of neglected Monteggia fracturedislocation in children was limited in majority of the patients. Particularly, the loss of pronation-supination arc was noticed postoperatively in most patients.

Radial head dislocation with ulnar plastic deformation in children: An osteotomy within the middle third of the ulna

This retrospective study includes 6 patients (average age, 8.7 years) with a dislocation of the radial head and ulnar plastic deformation. All were Monteggia fractures, Bado type I equivalents. The maximum ulnar bow was near the midulna. Five patients underwent an ulnar osteotomy, with elongation and reduction of the angulation within the middle third of the ulna, and open reduction of the radial head. One patient underwent an ulnar osteotomy with only elongation. The osteotomy sites were stabilized by a plate and screws or Kirschner wires. Mean follow-up was 3.4 years. Postoperatively, the average elbow range of motion was extension to 0 degrees, flexion to 138 degrees, forearm supination to 90 degrees, and forearm pronation to 88 degrees. Results in all patients were rated as excellent. One nonunion occurred. An osteotomy performed within the middle third of the ulna, combined with open reduction of the radial head, resulted in excellent clinical outcomes.

The results of treatment in pediatric Monteggia equivalent lesions

We evaluated the results of conservative and surgical treatment of pediatric Monteggia equivalent lesions. The study included 13 children (3 females, 10 males; mean age 8 years; range 4 to 13 years) who underwent treatment for Monteggia equivalent lesions. Seven patients (53.9%) had Bado type 1 and six patients (46.2%) had type 3 equivalent lesions. Two patients with type 3 equivalent lesions also had a lateral humeral condyle fracture. On presentation, one patient (7.7%) had radial nerve palsy. Primarily, closed reduction was attempted in all the patients except for one patient who underwent urgent debridement and irrigation for an open fracture-dislocation. Reduction was successful in eight patients (61.5%). Upon failure of closed reduction, four patients (30.8%) underwent surgery within the first 24 hours of injury. Functional assessment was made according to the Reckling's criteria. The mean follow-up period was 4.1 years (range 2 to 7 years). None of the patients had nonunion. Conservative treatment did not result in loss of reduction of the radius head or limitation in the range of motion of the elbow joint. Except for the patient with an open fracture-dislocation leading to a poor functional result, the results were good in all the patients receiving conservative or surgical treatment. One patient (7.7%) treated conservatively developed cubitus varus (5 degrees ) and posterior angulation (20 degrees ) of the ulnar fracture line. One patient treated surgically had limitation of supination (10 degrees ) without limitation of flexion or extension of the elbow joint. Accompanying radial nerve palsy in this patient disappeared in the postoperative third month. Closed reduction is the first choice of treatment in pediatric Monteggia equivalent lesions. Surgical treatment becomes necessary if closed reduction fails.

Monteggia fractures in adults

The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery. Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.

Ipsilateral Monteggia fracture dislocation with volar lunate dislocation of wrist: a case report

We present a previously undescribed case of ipsilateral Bado type II Monteggia fracture with volar lunate dislocation. The dislocation was reduced with repair of the volar capsule; ulna was plated and the comminuted radial head was excised. This case is reported for its rarity and its management. Complete diagnostic evaluation is imperative to avoid missed injuries and achieve satisfactory outcome.

Monteggia Fractures and Variants: Review of Distribution and Nine Irreducible Radial Head Dislocations

One hundred and twenty one cases of Monteggia fractures (68) and Monteggia fracture equivalent variant transolecranon fracture dislocations (53) in adults were reviewed to determine the frequency of Bado types and the occurrences of irreducible radial head dislocations. The distribution of Monteggia fractures was 53 Bado type I, two Bado type II, eight Bado type III, and five Bado type IV. Nine (13%) irreducible radial head dislocations were encountered (8 in Bado type I fractures and one in Bado type IV), including an unreported occurrence of biceps tendon interposition. The distribution in the Monteggia variants was 35 Bado type I, 14 Bado type II, one Bado type III, and two Bado type IV, without any irreducible radial heads. The present study demonstrates a greater preponderance of Bado type I than any other type among adult Monteggia fractures.

Late Missed Monteggia Lesions—Reconstruction of the Humeroradial Joint

Reconstruction of the humeroradial joint resulting in immediate functional stability. Missed traumatic dislocation of the radial head. Congenital dislocation of the radial head. Secondary dislocation of the radial head in instances of dysplasia or aplasia of the capitellum. Relative: deformation of the radial head in adults. Open reduction of the radial head without reconstruction of the annular ligament. Osteotomy of the shaft of the proximal ulna and installation of an external fixator with open clamps. Three-dimensional correction of the ulna under visual control of the humeroradial joint until the radial head is relocated in its anatomic position. Between 01/1998 and 05/2001, we performed an osteotomy of the proximal ulna, external fixation, and open reduction of the radial head in 14 patients presenting with a late missed Monteggia lesion (Bado type I). The average age of the seven girls and seven boys at the time of reconstruction was 9 (5–15) years, the mean interval between index trauma and reconstruction amounted to 21 months (2 weeks to 7 years). Removal of the external fixator after an average of 12 (7–16) weeks. In twelve patients the reduction was maintained, and in two patients the radial head redislocated postoperatively. In one of these patients a closed reduction was successful, whereas in the other patient an open reduction was done and the external fixation modified. In both patients the joint position was maintained. Preoperatively seven out of 14 patients showed a decreased range of motion; it improved postoperatively in most. A clinical and radiologic follow-up averaging 14 (3–44) months was possible in 13 patients. No complications were recorded.

Does a Monteggia Variant Lesion Result in a Poor Functional Outcome?

We retrospectively reviewed the clinical and functional outcomes after operative fixation of ipsilateral fractures of the proximal ulna, radial head or neck, and radial head dislocation (Monteggia variant). Twenty of 25 patients who sustained this injury returned for followup at a mean of 2.3 years and were evaluated by an independent examiner. Radiographically, 17 of 20 fractures united after the index surgery. The three patients who had nonunions develop had Bado Type 2 fracture patterns. The fractures of two patients united after revision internal fixation, and bone grafting. Seven patients had heterotopic ossification develop and 14 of 20 patients had arthritic changes develop. The mean Broberg and Morrey score was 79.1 (range, 32.5-100) and the mean disability of the arm, shoulder and hand score was 64.1 (worse outcome than the general population). Eight of 20 patients required revision surgery (three for recurrent instability, three for nonunion of the ulna, one for radial head excision and hardware removal, and one for hardware removal alone). Nine of 20 patients had fair or poor outcomes according to the Broberg and Morrey scale. Physicians should counsel patients that functional impairment is common after these complex high-energy injuries. Prognostic study, Level IV (case series). See the Guideline for Authors for a complete description of levels of evidence.