Functional Outcome of Bell Tawse Procedure for the Management of Chronic Unreduced Monteggia Fracture-Dislocation in Children

Abstract

Aim of Study:Unreduced or missed Monteggia fracture-dislocation after 4 weeks is a common presentation in a tertiary care center. The aim of this study is to study the functional outcome of Bell Tawse procedure for the management of chronic unreduced Monteggia fracture-dislocation in children.Materials and Methods:In this retrospective study with prospective data collection, 17 children were treated with open reduction of the radial head and annular ligament reconstruction (Bell Tawse) combined with ulnar osteotomy. The cases were classified based on Bado's classification. The minimum period of followup was 14 months and maximum followup was 18 months with the mean period of followup of 16.2 months. Preoperative and postoperative Mayo Elbow Performance Index (MEPI) scores were calculated. We also compared the preoperative and postoperative Kim's elbow functional scores.Results:At the final followup, the radial head was maintained in a completely reduced position in 16 children. Mean preoperative MEPI score was 76.76 and mean postoperative score was 91.11, which was statistically significant (P < 0.001). Mean preoperative Kim's score was 76.94 and mean postoperative score was 91.35, which was also statistically significant (P < 0.001). One girl had a mild subluxation of the radial head at 1-year followup. The ulnar osteotomy was united in all 17 children, and none of them required secondary procedures. We have not identified any complications such as compartment syndrome, infection, posterior interosseous nerve palsy, avascular necrosis of the radial head, or loss of range of motion.Conclusion:We recommend ulnar osteotomy, open reduction of the radial head, and annular ligament reconstruction in children with unreduced Monteggia fracture-dislocation before long term complications sets in.

Novel use of close-wedge osteotomy and monorail external fixator in the treatment of chronic Monteggia fracture

“…The Bell-Tawse technique, consisting of osteotomy and immediate correction of the ulna with internal fixation, open reduction of the radial head and ALR with triceps tendon, is one of the proven procedure for one-stage reconstruction of chronic Monteggia fracture. [ 10 ] The most difficult step of this technique is to stably insert the LCP, once the immediate elongation and angulation of the ulna promises simultaneous reduction of the radiocapitellar joint. To avoid mistake fixation and subluxation during these procedures, immediate angulating and distraction of the ulna after osteotomy for radial head reduction with hinged Ilizarov mini-fixator was advocated by Take et al,[ 20 ] and Wang et al[ 12 ] and Dukan et al[ 15 ] introduced novel techniques using monorail external fixator for accurate correction of the osteotomized ulna and stable insertion of the LCP intraoperatively.…”

“…Those who aimed at facilitating the radial head advocated performing the reconstruction in patients with a TSI less than two months. [ 9 , 10 , 12 , 31 ] The repair of the remnant of annular ligament or autograft transplantation, including triceps tendon, palmaris longus and forearm fascia, was performed in these studies, and complication rate of lost ROM of forearm, narrowing of the radial neck and its necrosis is eliminating in recent years. [ 19 , 32 - 36 ]…”

“…Function of the elbow was evaluated with Mayo Elbow Performance Score (MEPS) preoperatively and at the final follow-up. [ 10 ] Satisfaction comparison was measured using the Disabilities of Arm, Shoulder and Hand (DASH) score system preoperatively and at the final follow-up. [ 24 ]…”

“…Chronic Monteggia fracture usually requires surgical intervention to restore the alignment of the injured limb and the function of the elbow and forearm, which includes osteotomy of the ulna, reduction of the radial head, and repair of the annular ligament and trans-capitellar fixation in some cases. [ 1 , 2 , 10 ] While one-stage management through acute elongation and angulation of the ulna and reduction of the radial head has been reported to achieve immediate reconstruction, several complications due to the distraction tension, including delayed union, compartment syndrome and re-dislocation of the radial head, sometimes occur. [ 8 , 11 - 15 ] On the other hand, gradual lengthening with external fixation may be an alternative to provide safe and effective correction of the composite deformities.…”

Two-stage strategy for neglected Monteggia fracture in children

“…Many authors recommend open reduction and repair or reconstruction of the annular ligament. [ 7 , 12 , 23 ] However, in surgical exploration, the remnants of the annular ligament are usually difficult to recognize. In order to facilitate the reduction of the radial head, the fibrous scarring tissue needs to be removed, and ALR might be performed simultaneously.…”