The Three Step Approach to the management of acute pediatric Monteggia lesions

Abstract

Background: The literature places the occurrence of paediatric Monteggia lesions between 1.5% and 3% of all childhood elbow injuries. There are circumstances, which may make early correct diagnosis difficult. Failure to make an early correct diagnosis may have catastrophic consequences on joint range of motion in the chronic stage. The goal of this paper is to describe our three-step approach to the treatment of acute Monteggia lesions based on the stability and radiological appearance of the fracture dislocation, to give an overview of possible pitfalls and clinical and radiological signs that aid the diagnostic process. Methods: Retrospective analysis of 23 patients treated for this type of injury at our Department over a period of 6 years was performed. Treatment options were 1. Closed reduction under image intensifier followed by immobilization in over the elbow cast, 2. Open reduction and intramedullary nailing with ESIN, or 3. Open reduction and plate osteosynthesis. Average follow-up was 37 months. In our Department we aim for definitive treatment of fracture-dislocations in children within the acute setting. In the 23 acute cases, the selected procedure-reduction + casting/reduction + ESIN/reduction + plating-was performed within 2 to 16 h of arrival. 10 patients were treated with reduction + casting, 10 with reduction + ESIN and 3 with reduction + plating. Results: 21 patients were available for long-term follow-up. No nerve or tendon injuries or infections were observed in these cases. By managing the patients with the Three Step Method retaining the reduction was successful in all but one of our acute cases in the study period. Excellent range of motion was observed in all three groups. Conclusions: The Three Step Method allows for primary definitive treatment of these lesions with low complication rates and good range of motion result. Implementing the three step method in the acute phase helps avoid catastrophic consequences on joint range of motion in the chronic stage.

Management of acute length-unstable Monteggia fractures in children: A case report

“…Leonidou et al [ 14 ], in a retrospective study of 40 paediatric Monteggia fractures, asserts that although conservative management has been shown to correlate with good results, unstable fractures of the ulna need to be treated with plate fixation to ensure good reduction of the radial head and to avoid the possibility of prolonged immobilization leading to elbow stiffness in children[ 14 ]. Moreover, Hetthéssy et al [ 3 ] in a retrospective analysis of 23 acute pediatric Monteggia fractures, affirms that if the dislocation of the radial head is accompanied by an unstable fracture of the ulna, a more stable osteosynthesis plate is required.…”

“…The mechanism of injury is caused by direct trauma and hyperpronation as well as hyperextension[ 3 ]. The occurrence of paediatric Monteggia fractures covers between 1.…”

“…The occurrence of paediatric Monteggia fractures covers between 1. Of 5% and 3% of all childhood elbow injuries[ 3 , 4 ]. Monteggia fractures remain a challenge for paediatric orthopaedic surgeons because of the difficulty involved in diagnosis and in the treatment of missed radial head dislocation and late instability.…”

Fractures-luxations de Monteggia chez l´enfant: étude rétrospective de 40 cas dans le Département d´Orthopédie, Centre Hôpital Universitaire Habib Bourguiba de Sfax, Tunisie

“…La fracture de Monteggia n´est pas une lésion fréquente en milieu de traumatologie infantile, seulement 2 à 6,5% des fractures luxation du coude [ 2 ]. Elle est d´une incidence annuelle moyenne de 2,6 cas par an [ 7 , 8 ]. Cette fracture est plutôt l´apanage des enfants de tranche d´âge entre 4 et 10 ans [ 2 , 7 , 9 ].…”

Retrograde Intramedullary Nailing for Proximal Monteggia Fractures in Children

“…Monteggia fractures [1] are de ned as fractures of the ulna's proximal third with associated dislocation of the radial head and were further described and classi ed by Bado [2]. They are very rare in adults and even rare in children reaching an incidence of 1.5-3% of all pediatric forearm fractures [3]. The treatment's primary goal is the anatomical reduction of the ulnar fracture, and with that, the following indirect anatomic reduction of the radial head.…”