Monteggia Lesion Research Articles

Management of Neglected Pediatric Monteggia Fracture-Dislocation: A Case Report and Literature Review

Background: Missed or neglected Monteggia lesions are defined as classical fracture-dislocation presenting at least four weeks after injury. This injury in children is often challenging to treat and requires complex methods to achieve optimal results. Case Report: We report a 6-year-old girl with a 2-month-old neglected Bado type-I Monteggia fracture-dislocation. Our patient underwent ulnar osteotomy, bone grafting, and fixation with a semi-tubular plate along with open radial head reduction. Although the patient experienced wound complications at the bone graft harvest site, she achieved an excellent outcome with restored functionality and range of motion (ROM). Conclusion: Neglected Monteggia injuries in pediatric patients demand multifaceted treatment approaches due to their complexity and potential for long-term functional impairment. The absence of a consensus on definitive treatment underscores the importance of early diagnosis and open reduction to enhance long-term outcomes. This case report highlights the effectiveness of ulnar osteotomy, plate fixation, and open radial head reduction in achieving favorable results.

An unusual pediatric monteggia equivalent lesion: a rare case report

Abstract: Monteggia lesion is a rare fracture in which ulna shaft fracture and radial head dislocation occur together. Monteggia equivalent is the lesion associated with ulna shaft fracture and radius head and/or neck fracture. We offer a case of Monteggia equivalent in a 9-years-old boy. In the surgery of the patient, anatomical plating was performed for ulna shaft fracture and intramedullary nail was applied for radius neck fracture. When we look at the literature, such case reports are very rare.
 Conclusion: In the 1-year follow-up of the patient, there was no loss in flexion, extension, supination and pronation range of motion.

Bado III Monteggia in children - treatment options and outcome: an ultrasound control study.

The Bado III Monteggia lesion is an uncommon fracture in children. Radial head dislocation can occur due to intra- or extra-articular fractures of the olecranon. In extra-articular ulnar fractures, heterogeneous operative methods are proposed in different case reports. The objective of this study is to determine if closed reduction of the ulnar fracture, either without osteosynthesis or by using TEN, is a safe treatment option. In a multicenter study, we retrospectively analyzed 26 children who were treated for an extra-articular proximal metaphyseal ulnar fracture with dislocation of the radial head. These patients underwent a follow-up examination after an average of four years. The investigation included a physical examination, visualization of the elbow anatomy, and specifically, the radial head retention in the joint by ultrasound. Of the 26 patients, 18 were treated by closed reduction and intramedullary osteosynthesis (TEN), 7 were treated by closed reduction and cast immobilization without osteosynthesis, and 1 child was treated by open reduction of the ulna and plate osteosynthesis. In the follow-up examination, 25 children showed an excellent outcome, as well as inapparent sonography. Although this is a retrospective study with different types of treatment, closed reduction of the ulna with or without osteosynthesis appears to be effective. We believe that the correct primary reduction is the key to an excellent long-term outcome. Regarding the invasiveness of the treatment, reduction without or with TEN osteosynthesis should be the preferred approach in extra-articular pediatric Bado III fractures.

SURGICAL OUTCOME OF PERCUTANEOUS PIN FIXATION OF PROXIMAL THIRD FRACTURE OF ULNA IN MONTEGGIA FRACTURE DISLOCATION IN CHILDREN

Introduction: Monteggia fracture dislocation is a rare and severe injury of both paediatric and adult forearm and elbow.It was described for the rst time by GIOVANNI BATTISTA MONTEGGIA in 1840,who reported two cases of fracture of the proximal third of ulna with conjoint ventral dislocation of the proximal radius. In 1967 JOSE LUIS BADO published a classication scheme of monteggia lesion based on the direction of the dislocation of radial head,this anatomical classication was suitable for both adults and children .Monteggia fracture dislocations constitute about 1% – 2% of all forearm fractures . Monteggia fractures remain challenging paediatric injuries because of difculties in diagnosis , propensity for instability and complexity of late reconstruction. More than 50% of these fracture dislocation are misdiagnosed in children and leads to dysfunction of elbow joint. The xation and stabilization of ulna fracture will automatically reduce the radial head dislocation. The aim of this study is to evaluate a group of paediatric patients with Monteggia lesion and its equivalents treated by percutaneous xation of proximal third ulna fracture with k wire after reduction of fracture ulna and dislocated radio capitular joint under c-arm guidance. Materials and methods We treated 18 children of age ranging between 6 to 12 years with Monteggia fracture dislocation of the forearm with percutaneous xation of the proximal third fracture of ulna with k wires after reduction of fracture and dislocated radio-capitular joint under C-arm control.The elbow is immobilized in exion with plaster of paris slab and bandage for a period of four weeks and mobilization of elbow is started after four weeks. By the end of 8 weeks K-wire removed. All fractures are xed with in twenty four hours. The results Results : are good, there is no incidents of any stiffness. Range of movements of elbow and forearm are well preserved.The function of elbow and forearm are satisfactory.Conclusion:A good outcome after Monteggia injury in a child requires early diagnosis and prompt stable anatomical reduction of the ulna fracture and this can be achieved through stabilization of ulna by percutaneous intramedullary k wires

Radial head volume measurements using quantitative three-dimensional computed tomography images for radial head deformation following missed Monteggia lesions

<h2>Abstract</h2><h3>Introduction</h3> In chronic radial head dislocation, the radial head may enlarge and become dome-shaped. To date there is no validated tool to quantify radial head deformation and predict its influence on surgical outcome. This study assesses the potential value of volume and surface calculations obtained by quantitative three dimensional CT scanning (Q3DCT) in the workup for corrective surgery in pediatric patients with missed Monteggia lesions. <h3>Material and methods</h3> Ten consecutive pediatric patients with a missed Monteggia lesion were included (2012-2020). The volume and the articular surface size of the radial head were calculated using Q3DCT and a three dimensional reconstruction of the articular surface relief was depicted in a heat map. The head/neck ratio was calculated and compared to Q3DCT data of missed Monteggia patients and their age/sex matched controls. <h3>Results</h3> The radial head volume and radial articular surface size did not differ significantly between patients with missed Monteggia lesions and age/sex matched controls (volume 1487 mm³ versus 1163 mm³, p=0,32; articular surface size 282 mm³ versus 236 mm³ ,p=0,33). Optically, heat maps of the articular surface of missed Monteggia patients did not differ notably from control heat maps.. A higher head/neck ratio correlated to a larger radial head volume (Pearson r=0,73; p=0,02). <h3>Discussion and conclusion</h3> Q3DCT may be an interesting tool in the preoperative workup of pediatric missed Monteggia lesions. Prospective research with larger cohort sizes and data that compares the affected side to the contralateral elbow is needed to assess its true clinical potential.

Chronic Monteggia in pediatric population: A narrative literature review.

Monteggia lesion is a traumatic condition that affects the forearm and is characterized by the association of an ulna fracture with a dislocation of the radius capitellar and proximal radius ulnar joints in the majority of cases. Although several authors have contributed to the understanding of this pathology over the years, it remains a challenge for orthopedists, and if not recognized and treated properly, it can have serious consequences. In these cases, a chronic injury develops, which is even more difficult to manage in terms of timing and treatment options. A narrative review of the literature on missed elbow injuries in children was conducted, and chronic Monteggia was the most frequently encountered injury. The analysis of the articles attempts to clarify some points and draw general conclusions on which to reflect.

Missed Monteggia fractures in children treated by open reduction of the radial head and corrective osteotomy of the ulna

Missed Monteggia fractures in children may cause pain, deformity, decreased range of motion, neurological symptoms, and late arthritis of the elbow. Numerous surgical techniques have been advocated to reconstruct missed Monteggia lesions. The purpose of the present study were first to evaluate the clinical and radiographic outcomes after open reduction of the radial head and corrective osteotomy of the ulna, second to identify the factors associated with the preoperative radial notch/head appearance and the postoperative radiographic results. This study investigated the preoperative MRI presentation and the treatment of 29 patients who were diagnosed missed Monteggia fracture. Radiologic and clinical results of these patients were evaluated retrospectively, and the patient’s and surgical factors related to preoperative radial notch/head appearance and the postoperative radiographic results were analyzed. Of the 29 patients, the average Kim elbow performance score at the last follow-up was 93.6, with 25 excellent, three good, one fair, and no poor results. 19 children had reduced radial heads, 8 had a subluxated radial head and 2 had dislocated radial heads at the last follow-up. The patient’s gender and age had no significant influence on the appearance of radial notch/head and final radiographic results. However, the appearance of radial notch/head can significantly affect the final radiographic result (P < 0.001). The interval time was an important factor which related with the appearance of radial notch/head and final radiographic results (P < 0.001). Treating a missed Monteggia fracture by open reduction of the radial head and corrective osteotomy of the ulna is generally successful and preoperative MRI is meaningful for evaluation of the condition of the radial head and the radial notch which is related with the final radiographic result. The interval time from injury to operation exceeds 6 months, the risk of radial notch/head abnormality and radial head subluxation/re-dislocation after operation significantly increase.

Monteggia lesions and equivalent lesions in children

Missed Monteggia lesions results in chronic luxation and deficits in the range of motion. The overall therapeutic goal is aquick and stable anatomical repositioning of the lesion. The prognosis of Monteggia lesions in comparison to its equivalents is better, especially with early diagnosis. Comparison of the types of lesion, treatment modalities, hospitalization, immobilization, movement deficits, perioperative complications and outcome. Retrospective study of 62patients treated with acute Monteggia lesions and its equivalents during the period of 2009-2020. 2patients were treated with cast immobilization only, 11with repositioning under general anesthesia, 39with intramedullary nailing and 10with screw osteosynthesis. The average observation period was 4.1months. Patients with cast immobilization needed only ashort hospitalization (2days), patients with repositioning or osteosynthesis had longer hospitalization (3.4 or 4.3days, respectively). Deficits of the range of motion did not appear in simple cast immobilization or intramedullary nailing without reduction; however, patients with closed reduction or screw osteosynthesis showed some degree of deficits (9% and 40%, respectively). Monteggia lesions needed shorter hospitalization than their equivalents (3.7 vs. 4.5days) and had less deficits in the range of motion (7% vs. 21%). Most patients were treated with osteosynthesis (79%). Patients with Monteggia lesions had abetter outcome than patients with equivalent lesions.

Ultrasound imaging in diagnostics of Monteggia lesion in children.

Purpose:The aim of the study is to evaluate the use of ultrasound imaging in diagnostics of Monteggia lesion in children where conventional radiographs and the use of the radiocapitellar line fail to provide an accurate diagnosis.Methods:Prospective diagnostic study of 70 patients treated between May 2018 and July 2021 in a pediatric level 1 trauma center. In 20 patients with the confirmed radiographic diagnosis of Monteggia lesion, an ultrasound of the humeroradial joint was performed to determine signs of both normal and dislocated elbow joint. In 36 patients with suspected humeroradial dislocation on plain radiographs, ultrasound imaging was performed to determine the definitive diagnosis. Overall, 14 patients with elbow joint injury other than humeroradial dislocation were excluded from the study.Results:The “double-hump sign” and the “congruency sign” were determined as normal findings on ultrasound of the humeroradial joint. These signs were applied to patients with unclear findings on radiographs. In three patients, the dislocation of the humeroradial joint was confirmed by ultrasound. In two patients, “defect in congruency sign” was seen during reduction despite normal radiographs, which required re-reduction. In 31 patients, dislocation of the humeroradial joint was refuted. In 34 out of the 36 patients, the diagnosis determined by ultrasound was confirmed in follow-up. Two patients did not attend the follow-up examination.Conclusion:Ultrasound imaging is an accessible, non-invasive, and dynamic point-of-care method that can be applied in children suffering from suspected humeroradial dislocation and/or subluxation.Level of evidence:Level III—diagnostic study.

Repair of an Isolated Traumatic Cranial Luxation of the Radial Head Using a TightRope System in a Cat

AbstractA 4.4 kg, a 6-year-old Domestic Shorthair male neutered outdoor cat was diagnosed with an isolated traumatic cranial luxation of the left radial head. Surgical stabilization was achieved using a mini TightRope system (Arthrex Vet Systems, Naples, Florida, United States) to hold the radial head to the ulna without attempting to reconstruct the annular ligament. A range of motion within the normal range was achieved after reduction. At 7-week follow-up after surgery, the cat was walking without lameness; at follow-up by telephone 3 years postoperatively, the owner described the overall quality of life as excellent with good mobility in everyday activities such as jumping, running, and playing. Many publications in veterinary medicine detail congenital radial head luxation, Monteggia lesions, or complete elbow luxation, but traumatic radial head luxation is barely cited as the occurrence is rare. To our knowledge, this is the first reported case of a feline isolated traumatic radial head luxation managed with this technique.

Risk factors for redislocation of chronic Monteggia fracture-dislocation in children after reconstruction surgery.

Monteggia fracture-dislocation refers to traumatic ulnar fractures and dislocation of the radial head, which is one of the most frequently missed injuries, especially in children. The most widespread attitude towards chronic Monteggia lesion is the open reduction of the radial head associated with ulnar osteotomy with or without annular ligament reconstruction. Our study aimed to analyze the risk factors for redislocation after surgical management of chronic Monteggia lesion and the benefits of annular ligament reconstruction and radiocapitellar pinning in paediatric. We retrospectively reviewed patients treated with reconstruction surgery for chronic Monteggia fracture-dislocation in our department between 2005 and 2017, with a minimum two years' follow-up. The reconstruction surgery included ulnar osteotomy performed in all patients, annular ligament repair or reconstruction or fixation of radiocapitellar joint, or radial osteotomy in some patients. We collected the related clinical data and evaluated the risk factors of redislocation using logistic regression analyses and a two-piecewise linear regression model with a smoothing function, after reconstruction. Throughout a mean six years' follow-up (range, 2-14years), 62 patients (42 males, 20 females; average age 6.49years range, 2-13years) were reviewed. Of the radiocapitellar joints, 16.1% was noted to have redislocation. Univariate risk analysis showed age, time from injury to surgery, and radial osteotomy were risk factors for a recurrent radiocapitellar redislocation. Time from injury to surgery was found to be independent predictor of redislocation in multivariate analysis. However, there were significant nonlinear associations between time from injury to surgery and redislocation in multivariate logistic regression analysis after multivariate adjustment (p for nonlinear = 0.023). Every one month increase was associated with a 1.37-fold increase in redislocation, in participants within oneyear after injury. In conclusion, the surgery of chronic Monteggia fracture-dislocation should be done as quickly as possible within oneyear after injury. Associated annular ligament reconstruction or fixation of radiocapitellar joint does not seem to be helpful.

Type II Monteggia Lesion with Complete Elbow Dislocation in a Cat

AbstractA 2-year-old neutered male cat was presented for right forelimb non-weight-bearing lameness. A fracture of the proximal third of the ulna (associated with a caudal radio-humeral and humero-ulnar dislocations and a radio-ulnar dislocation) was radiographically identified, leading to a diagnosis of type II Monteggia lesion with complete elbow joint dislocation. The ulnar fracture was reduced and stabilized using an intramedullary pin. During surgery, the lateral collateral ligament and the annular ligament appeared disrupted. The radio-ulnar dislocation was reduced and stabilized, using a double-loop suture prosthesis passing through the metaphysis of the ulna and around the radial head. The radio-humeral dislocation was reduced and stabilized using a lateral collateral suture prosthesis. No postoperative complications were observed and the patient regained good elbow joint range of motion, with no significant lameness at 8 postoperative months.

Monteggia lesions: tips &amp; tricks in acute management and 2-years follow-up

Objective. This report aims to offer a practical protocol and indications on the acute management of Monteggia lesions in the adult population. Methods. We retrospectively analysed all patients with radius and ulna lesions treated over 5 years. Inclusion criteria were: patient with Monteggia injuries, age 18-100; exclusion criteria: Monteggia-like injury, peadiatric patient. Acute management consists of immediate close reduction of the radial head dislocation. All patients received ORIF with 3.5 mm LCP applied to the dorsal surface of the proximal ulna in compression mode. Elbow stability was always evaluated under anaesthesia. Results. Of a total of 3652 patients, 30 (0.82%) met inclusion criteria, and were classified as follow: 2 Bado I; 18 Bado II (4 2a;4 2b;7 2c;3 2d); 6 Bado 3; 4 Bado 4. Heterotopic periarticular ossifications formed in 2 patients. At 24 months, the follow-up VAS score was 1 and the Mayo elbow performance score was 85. Conclusions. The immediate management of radius head dislocation, preservation of the length of the radial column and a stable anatomic synthesis of the ulnar fracture are the key treatment principles in Monteggia lesions. To minimise the risk of arthrofibrosis and stiffness and promote bone healing, indomethacin, muscle relaxants and vitamin D are administered. It is important to inform the patient that restitutio ad integrum after this type of injury is almost impossible.

Surgical Treatment With Titanium Elastic Nail (TEN) for Failed Conservative Treatment of Acute Monteggia Lesions in Children.

This study evaluated the results of intramedullary osteosynthesis with titanium elastic nail (TEN) in the surgical treatment of Monteggia lesions in children aged 12 and under. Patients who underwent surgery with the TEN method between 2013 and 2019 were screened retrospectively. The inclusion criteria were patients who failed conservative treatment, a history of acute trauma (<14 d after injury), age 12 years and under, patients who underwent intramedullary osteosynthesis with TEN when surgical treatment is required, a follow-up period of over 12 months, absence of congenital upper extremity and bone anomalies, and no history of trauma to the ipsilateral elbow. For functional classification, the Grace and Eversmann Criteria were used to evaluate union, pronation, and supination, while the Mayo Elbow Performance Score was used to assess overall elbow function and limitations. Thirty-eight patients (26 male/12 female) were included in the study. The median age was 8.0 (6 to 10) years old and follow-up period was 26.0 (16 to 39) months. The mean value of the Mayo Elbow Performance Score was 97.1, 32 cases were excellent and 6 cases had good results. While the average age was 9.4 years in patients with mobility limitations, it was 7.1 years in patients without mobility limitations. Statistically, less movement restriction was observed in patients of younger age. Length unstable ulnar fracture pattern for Monteggia lesions and those with secondary loss of reduction, intramedullary stabilization of the ulna fracture with TEN helps to achieve good functional and radiologic outcomes. Level III.

Early to midterm radiographic loosening of the press fit radial head prosthesis

BackgroundRadiographic loosening is frequently seen around the radial head (RH) implant. The hypothesis of this study was that radiographic loosening will be more frequent in patients in which the RH prosthesis was implanted due to elbow trauma leading to instability that required lateral collateral ligament repair (LCL). Materials and methodsA retrospective review of the patients who had RH implantation between 2012 and 2019 was performed. Evaluation included evidence of radiographic loosening, stress shielding, formation of heterotopic ossification, and rate of removal of the implant. Range of motion of the elbow at the latest follow up was also recorded. ResultsAt a mean follow up of 18 months (range 1.4 – 80) eight out of 25 patients had radiographic loosening around the implant. The radial head implant was removed in 8 patients (in 3 due to painful radiographic loosening, in 4 due pain without radiographic loosening and in 1 due to infection). Radiographic loosening around the RH implant had no association with LCL repair (p=0.18) or future removal of implant (p=0.18) or the diagnosis of Monteggia lesion (p=0.68). In addition, removal of the RH implant had no association with prior LCL repair (p=0.60) or the diagnosis of Monteggia lesion (p=0.15). Stress shielding was seen in 5 patients and was of no clinical significance. Heterotopic ossification was seen in 12 patients and was classified as Class I in 3, IIA in 3, IIC in 6, according to the Hastings Classification. The average flexion-extension arc was 23° to 130°, and average pronation-supination was 76° to 69°. ConclusionOne third of the patients had radiographic loosening around the RH implant at a mean follow up of 18 months. Pain with or without radiographic loosening were the main reasons for removal of the implant. No associations were found between the development of radiographic loosening and LCL repair at the time of RH replacement. Limitations of this study are: (a) the retrospective design (b). the small sample size and the possibility of a type II statistical error.

Trash Lesions Around the Elbow: A Review of Approach to Diagnosis and Management.

TRASH lesions are a group of special injuries around the elbow resulting from high energy trauma that are routinely missed at initial presentation because of seemingly normal X-rays. These are a group of osteochondral injuries having a high propensity for surgical intervention and usually have poor outcomes if not treated adequately. Prompt diagnosis warrants a high index of suspicion even when a radiograph appears to be normal with a disproportionately swollen elbow in a child. TRASH lesions include radial head osteochondral fractures, medial condylar fractures in unossified elbow, transphyseal separations of the distal humerus, monteggia lesions, entrapped incarcerated medial epicondylar fractures, capitellar shear fractures, lateral condylar fractures extending to the cartilage. This article attempts to review in brief, the approach to early diagnosis and management with literature review and case examples.

Reconstruction of the annular ligament in neglected Monteggia lesions: a case report

Neglected monteggia is a rare lesion. We describe the observation of a young patient who presented this lesion and the surgical treatment has consisted in a reconstruction of the annular ligament with a good anatomical and functional results.

Monteggia-fractures and Monteggia-like Lesions

Monteggia lesions and Monteggia-like lesions involve ulna and radius injuries, which can not be successfully treated using the surgical principles of isolated fractures. Proximal ulnar fracture, radio-humeral dislocation, and additional dislocation in the proximal radioulnar joint result in the disintegration of the functional unit, and there is a complex injury across the elbow to the forearm, resulting in poor clinical outcomes. Thus, addressing all osteo-ligamentous injuries is essential for the long-term course.

A New Single Volar Approach for Both-Bone Fractures of the Forearm: The Mediolateral Windows Approach Extended.

Fractures of the forearm are common injuries in adults. Particularly, both-bone fractures of the radius and ulna are frequently encountered by orthopedic surgeons. To date, these fractures are typically treated with open reduction and internal fixation, because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. We propose a modification of the classic double approach for both-bone fractures of the distal radius and ulna. Indeed, we described a minimal and anatomic approach to prevent complications such as the heterotopic ossification of the interosseus membrane and vascular-nervous lesions. By a single anterior incision, we utilize 2 windows to expose the medial and lateral compartments of the forearm. In this way, we avoid the handling of the interosseous membrane, and we protect the ulnar, median, and radial nerves from the surgical approach. This technique is indicated for complex distal radius and ulna fractures. We exclude open fractures, and Monteggia, Galeazzi, or Essex-Lopresti lesions. In this report, we describe the surgical anatomy, surgical approach, and complications regarding this approach.

Surgical Reconstruction of Missed Monteggia Lesions in Children.

Chronic Monteggia lesions in children may cause pain, deformity, decreased range of motion, and neurological symptoms. Numerous surgical techniques have been advocated to reconstruct long-standing Monteggia injures in efforts to maximize long-term upper limb function. The purpose of this investigation was to assess the clinical and radiographic results of a modified surgical technique for missed Monteggia fracture-dislocations. A retrospective evaluation of 52 patients who underwent surgical reconstruction of missed Monteggia fracture-dislocations at a tertiary pediatric hospital was performed. The median patient age at the time of surgery was 6.8 years, and the median time from injury to surgery was 12.9 weeks. Electronic medical records, including clinic notes, radiographic images, and operative reports, were reviewed for study analysis. Median clinical and radiographic follow-up was 19.1 months. The median elbow range of motion improved from 108 degrees of flexion and 5 degrees short of full extension preoperatively to 140 degrees of flexion (P<0.001) and full extension (P=0.10) postoperatively. Forearm range of motion also improved from a median of 80 degrees of pronation and 58 degrees of supination preoperatively to 80 degrees of pronation (P=0.54) and 80 degrees of supination (P<0.001) postoperatively. Congruent radiocapitellar alignment was maintained in 39 patients (75%). Nine patients (17%) had redislocation of the radiocapitellar joint, and 4 patients (8%) had radiographic resubluxation. Six of the 9 patients who experienced redislocation underwent early revision and achieved uncomplicated longer term results. Patients who received repair of the native annular ligament were more likely to achieve lasting radiocapitellar joint stability (P=0.03) when compared with patients who received annular ligament reconstruction or if the annular ligament was not addressed. Meaningful improvements in elbow motion and radiocapitellar stability can be safely achieved in the majority of children following surgical reconstruction of missed Monteggia lesions. Level IV-retrospective case series.