Outcome of radial head preserving operations in missed Monteggia fracture in children

Abstract

Background:The dislocated radial head in missed Monteggia fracture loses its concave articular surface and displays hypertrophic changes and flattened humeral capitellum configuration, thereby limiting the range of motion. We evaluated the results of open reduction in missed Monteggia fractures by various techniques.Materials and Methods:Sixty-three missed Monteggia fractures were included in the analysis. We performed four combinations of operation: Group I: 22 patients treated with modified Hirayama ulnar osteotomy plus annular ligament reconstruction with free Palmaris longus grafting; Group II:18 patients treated with modified Hirayama ulnar osteotomy plus annular ligament reconstruction by the Bell Tawse's procedure; Group III-9: patients treated with only modified Hirayama's osteotomy; and Group IV: 14 patients treated with transverse osteotomy of ulna and annular ligament reconstruction by the Bell Tawse's procedure. During followup these cases were assessed for the following parameters: 1) range of motion and 2) mayo elbow performance index (MEPI). Results were noted on follow ups at 3, 6, 12 months and then on yearly basis. Sixty-three patients were followed up for an average duration of 5.6 years (range 3-8 years).Results:The mean range of motion was increased by 45°, 30°, 45°, 20° for Group I, II, III and IV respectively. The average increase in MEPI scores was also almost on the same lines. There was one case of frank dislocation in group III and six cases of subluxation, two each in Groups II, III, and IV. For Annular ligament reconstruction, amongst two procedures, Groups II and IV (Bell Tawse group), had a significant extension lag contributing to the lower increase in the range of motion as compared to the Palmaris longus reconstruction group (group I).Conclusion:Hirayama's osteotomy is inherently more stable than the simple transverse osteotomy and it should be combined with annular ligament reconstruction. Palmaris longus graft for ligament reconstruction provides more stability as compare to Bell Towse's procedure.

Biomechanical study of isolated radial head dislocation

“…There are several surgical procedures available for the treatment of chronic radial head dislocation, including osteotomy of the ulna [ 19 – 22 ] with or without annular ligament reconstruction [ 16 , 23 – 25 ]. Annular ligament reconstruction according to the Bell Tawse procedure is one popular technique, in which a slip of the triceps tendon is looped around the radial neck to stabilize the radial head.…”

Posterior interosseous nerve palsy associated with neglected pediatric Monteggia fracture-dislocation: A case report

“…They advocate the open reduction of the annular ligament in every case [4] , [13] . In chronic Monteggia lesions, if the annular ligament repair cannot be accomplished, reconstruction should be performed to achieve radiocapitellar joint stability [5] , [10] .…”

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

“…Dysplastic changes of the radiocapitellar joint (RCJ) are identifiable on a CT scan, and the process enables the construction of a 3D model. 14,24 In cases where the patient is a young child with considerable residual growth and potential for remodeling, 15,25 an MRI may be preferable.…”

“…37 Several authors conclude that the risk for postoperative redislocation of the radial head is lower following bending and lengthening ulna osteotomy than in a simple transverse osteotomy of the ulna, intended to only straighten the ulna. 4,25 This slight overcorrection is considered to result in extra tension on the interosseous membrane, facilitating reduction of the radial head. 26,32 Acute ulna lengthening of up to 1 cm has been supported by others despite the risk of delayed union and failure of fixation.…”

“…Most authors state that a transcapitellar K-wire may be considered if persisting instability is suspected after completing ulna osteotomy and ALR. 5,7,15,21,25,26,35,36,39,[42][43][44][47][48][49][50][51] However, we favour radioulnar K-wire fixation, because it has the advantage that no joint surfaces are damaged. In our case series, we did not find any influence of this extra immobilisation on ROM outcome.…”