Advertisement

Chronic Monteggia Injuries

  • Francisco Soldado
  • Scott H. KozinEmail author
Chapter
  • 589 Downloads

Abstract

Traumatic radiocapitellar dislocations that remain unreduced for more than 4 weeks are usually irreducible by closed means and are considered chronic Monteggia injuries (Fig. 14.1) [1]. The term “Monteggia fracture-dislocation” refers to all fractures of the ulna, irrespective of their location, that are associated with dislocation of the radial head. Monteggia fracture-dislocations are uncommon injuries that only account for about 1% of all pediatric forearm fractures [2, 3]. Despite its overall rarity, this injury is one of the most frequently missed injuries in children. Misdiagnosis is because the radial head dislocation is often overlooked and associated with plastic deformation of the ulna [1, 4]. An estimated 33% of acute Monteggia injuries are missed, making it the most common cause of chronic radial head subluxation [1, 5]. Another source of chronic injury is the loss of reduction following closed treatment, which can be seen in up to 20% of cases, especially when the ulnar fracture is oblique [1, 5–7].

Supplementary material

Video 14.1

Elbow and forearm anatomy specimen. An ulnar fracture was performed. To obtain a radial head dislocation, section of the annular and quadrangular ligament was necessary. Section of the proximal interosseous membrane was not necessary to obtain a Monteggia-like injury. Depending on the spatial angulation of the ulna, different types of Monteggia injuries can be obtained. https://vimeo.com/183622020 (MP4 7305 kb)

Video 14.2

Patient B. 6-year-old chronic Bado and Letts Type-1 Monteggia (see Fig. 14.2). Although elbow and forearm range of motion is grossly preserved, there is a progressive forearm valgus deformity and medial elbow laxity. Over time, an elbow arthritis might be developed. https://vimeo.com/183622022 (MOV 2476 kb)

Video 14.3

Patient A. Intraoperative video. The radial head has been reduced but is unstable with forearm rotation. https://vimeo.com/183622023 (MOV 23544 kb)

Video 14.4

Patient A. Intraoperative video. Ulnar flexion allows proximal radius (radial head) realignment. https://vimeo.com/183622024 (MOV 10257 kb)

Video 14.5

Patient A. The ulnar osteotomy has been prefixated with a KW. The amount of ulnar flexion and distraction is estimated depending on the stability of the radial head tested by performing forearm rotation. https://vimeo.com/183622025 (MOV 20916 kb)

References

  1. 1.
    Dormans JP, Rang M. The problem of Monteggia fracture-dislocations in children. Orthop Clin North Am. 1990;21(2):251–6.PubMedGoogle Scholar
  2. 2.
    Ring D, Waters PM. Operative fixation of Monteggia fractures in children. J Bone Joint Surg Br. 1996;78(5):734–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Tan JW, MZ M, Liao GJ, Li JM. Pathology of the annular ligament in paediatric Monteggia fractures. Injury. 2008;39(4):451–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Chin K, Kozin SH, Herman M, et al. Pediatric Monteggia fracture-dislocations: avoiding problems and managing complications. Instr Course Lect. 2016;65:399–407.Google Scholar
  5. 5.
    Fowles JV, Sliman N, Kassab MT. The Monteggia lesion in children. Fracture of the ulna and dislocation of the radial head. J Bone Joint Surg Am. 1983;65(9):1276–82.CrossRefPubMedGoogle Scholar
  6. 6.
    Bae DS. Successful strategies for managing Monteggia injuries. J Pediatr Orthop. 2016;36(Suppl 1):S67–70.CrossRefPubMedGoogle Scholar
  7. 7.
    Ramski DE, Hennrikus WP, Bae DS, et al. Pediatric Monteggia fractures: a multicenter examination of treatment strategy and early clinical and radiographic results. J Pediatr Orthop. 2015;35(2):115–20.CrossRefPubMedGoogle Scholar
  8. 8.
    Speed JS, Boyd HB. Treatment of fractures of ulna with dislocation of head of radius: (Monteggia fracture). JAMA. 1940;115(20):1699–705.CrossRefGoogle Scholar
  9. 9.
    Goyal T, Arora SS, Banerjee S, Kandwal P. Neglected Monteggia fracture dislocations in children: a systematic review. J Pediatr Orthop B. 2015;24(3):191–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Blount WP. Fractures in children. Baltimore: Williams and Wilkins Co; 1954. p. 57.Google Scholar
  11. 11.
    Stelling FH, Cote RH. Traumatic dislocation of head of radius in children. JAMA. 1956;160(9):732–6.CrossRefGoogle Scholar
  12. 12.
    Bell Tawse AJ. The treatment of malunited anterior Monteggia fractures in children. J Bone Joint Surg Br. 1965;47(4):718–23.CrossRefPubMedGoogle Scholar
  13. 13.
    Chen W-S. Late neuropathy in chronic dislocation of the radial head: report of two cases. Acta Orthop Scand. 1992;63(3):343–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Fabricant PD, Baldwin KD. Missed pediatric Monteggia fracture: a 63-year follow-up. J Pediatr. 2015;167(2):495.CrossRefPubMedGoogle Scholar
  15. 15.
    Kadic MAC, Bloem RM. Traumatic isolated anterior dislocation of the radial head: a case with a 32-year follow-up. Acta Orthop Scand. 1991;62(3):288–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Lloyd-Roberts GC, Bucknill TM. Anterior dislocation of the radial head in children: aetiology, natural history and management. J Bone Joint Surg Br. 1977;59(4):402–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Mehta SD. Missed Monteggia fracture. J Bone Joint Surg Br. 1993;75(2):337.CrossRefPubMedGoogle Scholar
  18. 18.
    Seel MJ, Peterson HA. Management of chronic posttraumatic radial head dislocation in children. J Pediatr Orthop. 1999;19(3):306–12.PubMedGoogle Scholar
  19. 19.
    Sandman E, Canet F, Petit Y, Laflamme GY, Athwal GS, Rouleau DM. Radial head subluxation after malalignment of the proximal ulna: a biomechanical study. J Orthop Trauma. 2014;28(8):464–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Tan J, Mu M, Liao G, Zhao Y, Li J. Biomechanical analysis of the annular ligament in Monteggia fractures using finite element models. J Orthop Surg Res. 2015;10:30.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    An KN, Morrey BE. In: Morrey BF, editor. The elbow and its disorders. 1st ed. Philadelphia: WB Saunders; 1985. p. 57.Google Scholar
  22. 22.
    Kim HT, Conjares JNV, Suh JT, Yoo CI. Chronic radial head dislocation in children, part 1: pathologic changes preventing stable reduction and surgical correction. J Pediatr Orthop. 2002a;22(5):583–90.PubMedGoogle Scholar
  23. 23.
    Kim HT, Park BG, Suh JT, Yoo CI. Chronic radial head dislocation in children, part 2: results of open treatment and factors affecting final outcome. J Pediatr Orthop. 2002b;22(5):591–7.PubMedGoogle Scholar
  24. 24.
    Hasler CC, Von Laer L, Hell AK. Open reduction, ulnar osteotomy and external fixation for chronic anterior dislocation of the head of the radius. J Bone Joint Surg Br. 2005;87(1):88–94.CrossRefPubMedGoogle Scholar
  25. 25.
    Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86.CrossRefPubMedGoogle Scholar
  26. 26.
    Letts M, Locht R, Wiens J. Monteggia fracture-dislocations in children. J Bone Joint Surg Br. 1985;67(5):724–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Garg P, Baid P, Sinha S, Ranjan R, Bandyopadhyay U, Mitra SR. Outcome of radial head preserving operations in missed Monteggia fracture in children. Indian J Orthop. 2011;45(5):404.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Lincoln TL, Mubarak SJ. “Isolated” traumatic radial-head dislocation. J Pediatr Orthop. 1994;14(4):454–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Storen G. Traumatic dislocation of the radial head as an isolated lesion in children; report of one case with special regard to roentgen diagnosis. Acta Chir Scand. 1959;116(2):144–7.PubMedGoogle Scholar
  30. 30.
    Fader LM, Laor T, Eismann EA, Cornwall R, Little KJ. Eccentric capitellar ossification limits the utility of the radiocapitellar line in young children. J Pediatr Orthop. 2016;36(2):161–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Eilert RE. Pediatric orthopedic deformities: basic science, diagnosis, and treatment. J Bone Joint Surg Am. 2003;85(10):2067.CrossRefGoogle Scholar
  32. 32.
    Kosay C, Akcali O, Manisali M, Ozaksoy D, Ozcan C. Congenital anterior dislocation of the radial head: a case with radiographic findings identical to traumatic dislocation. Eur J Radiol. 2002;43(1):57–60.CrossRefPubMedGoogle Scholar
  33. 33.
    Bhaskar A. Current concepts in the management of missed Monteggia fracture-dislocation. Curr Orthop Pract. 2013;24(1):49–52.CrossRefGoogle Scholar
  34. 34.
    Nakamura K, Hirachi K, Uchiyama S, et al. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone Joint Surg Am. 2009;91(6):1394–404.CrossRefPubMedGoogle Scholar
  35. 35.
    Adams JP, Rizzoli HV. Tardy radial and ulnar nerve palsy: case report. J Neurosurg. 1959;16(3):342–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Austin R. Tardy palsy of the radial nerve from a Monteggia fracture. Injury. 1976;7(3):202–4.CrossRefPubMedGoogle Scholar
  37. 37.
    Cho CH, Lee KJ, Min BW. Tardy posterior interosseous nerve palsy resulting from residual dislocation of the radial head in a Monteggia fracture: a case report. J Med Case Reports. 2009;3:9300.CrossRefPubMedCentralGoogle Scholar
  38. 38.
    Holst-Nielsen F, Jensen V. Tardy posterior interosseous nerve palsy as a result of an unreduced radial head dislocation in Monteggia fractures: a report of two cases. J Hand Surg [Am]. 1984;9(4):572–5.CrossRefGoogle Scholar
  39. 39.
    Nishimura M, Itsubo T, Horii E, Hayashi M, Uchiyama S, Kato H. Tardy ulnar nerve palsy caused by chronic radial head dislocation after Monteggia fracture: a report of two cases. J Pediatr Orthop B. 2016;25(5):450–3.CrossRefPubMedGoogle Scholar
  40. 40.
    Ruchelsman DE, Pasqualetto M, Price AE, Grossman JA. Persistent posterior interosseous nerve palsy associated with a chronic type I Monteggia fracture-dislocation in a child: a case report and review of the literature. Hand (N Y). 2009;4(2):167–72.CrossRefGoogle Scholar
  41. 41.
    Tubbs RS, Griessenauer C, Rizk E, et al. Posterior interosseous nerve palsy in a child associated with recurrent dislocation of the head of the radius. J Neurosurg Pediatr. 2013;11(4):389–91.CrossRefPubMedGoogle Scholar
  42. 42.
    Lädermann A, Ceroni D, Lefèvre Y, De Rosa V, De Coulon G, Kaelin A. Surgical treatment of missed Monteggia lesions in children. J Child Orthop. 2007;1(4):237–42.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Lu X, Yan G, Wang Y, Zhu Z, You H, Zhang J, et al. Repositioning of the annular ligament in the management of missed Monteggia fracture. J Pediatr Orthop. 2015;37(1):20–2.CrossRefGoogle Scholar
  44. 44.
    Bor N, Rubin G, Rozen N, Herzenberg JE. Chronic anterior Monteggia lesions in children: report of 4 cases treated with closed reduction by ulnar osteotomy and external fixation. J Pediatr Orthop. 2015;35(1):7–10.CrossRefPubMedGoogle Scholar
  45. 45.
    Hirayama T, Takemitsu Y, Yagihara K, Mikita A. Operation for chronic dislocation of the radial head in children. Reduction by osteotomy of the ulna. J Bone Joint Surg Br. 1987;69(4):639–42.CrossRefPubMedGoogle Scholar
  46. 46.
    Rahbek O, Deutch SR, Kold S, Søjbjerg JO, Møller-Madsen B. Long-term outcome after ulnar osteotomy for missed Monteggia fracture dislocation in children. J Child Orthop. 2011;5(6):449–57.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Lambrinudi C. Proc R Soc Med. 1940;33:1549.Google Scholar
  48. 48.
    Freedman L, Luk K, Leong JC. Radial head reduction after a missed Monteggia fracture: brief report. J Bone Joint Surg Br. 1988;70(5):846–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Stoll TM, Willis RB, Paterson DC. Treatment of the missed Monteggia fracture in the child. J Bone Joint Surg Br. 1992;74(3):436–40.CrossRefPubMedGoogle Scholar
  50. 50.
    Tajima T, Yoshizu T. Treatment of long-standing dislocation of the radial head in neglected Monteggia fractures. J Hand Surg [Am]. 1995;20(3):S91–4.CrossRefGoogle Scholar
  51. 51.
    Boyd HB, Boals JC. The Monteggia lesion. A review of 159 cases. Clin Orthop Relat Res. 1969;66:94–100.CrossRefPubMedGoogle Scholar
  52. 52.
    Huish EG Jr, Trzeciak MA. Versatility through the Boyd approach. Tech Shoulder Elbow Surg. 2016;17(2):63–6.CrossRefGoogle Scholar
  53. 53.
    Degreef I, De Smet L. Missed radial head dislocations in children associated with ulnar deformation: treatment by open reduction and ulnar osteotomy. J Orthop Trauma. 2004;18(6):375–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Bhaskar A. Missed Monteggia fracture in children: Is annular ligament reconstruction always required? Indian J Orthop. 2009;43(4):389.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    De Boeck H. Treatment of chronic isolated radial head dislocation in children. Clin Orthop Relat Res. 2000;380:215–9.CrossRefGoogle Scholar
  56. 56.
    Devnani AS. Missed Monteggia fracture dislocation in children. Injury. 1997;28(2):131–3.CrossRefPubMedGoogle Scholar
  57. 57.
    Lu X, Wang YK, Zhang J, Zhu Z, Guo Y, Lu M. Management of missed Monteggia fractures with ulnar osteotomy, open reduction, and dual-socket external fixation. J Pediatr Orthop. 2013;33(4):398–402.CrossRefPubMedGoogle Scholar
  58. 58.
    Inoue G, Shionoya K. Corrective ulnar osteotomy for malunited anterior Monteggia lesions in children. 12 patients followed for 1-12 years. Acta Orthop Scand. 1998;69(1):73–6.CrossRefPubMedGoogle Scholar
  59. 59.
    Wang MN, Chang W-N. Chronic posttraumatic anterior dislocation of the radial head in children: thirteen cases treated by open reduction, ulnar osteotomy, and annular ligament reconstruction through a Boyd incision. J Orthop Trauma. 2006;20(1):1–5.CrossRefPubMedGoogle Scholar
  60. 60.
    Horii E, Nakamura R, Koh S, Inagaki H, Yajima H, Nakao E. Surgical treatment for chronic radial head dislocation. J Bone Joint Surg Am. 2002;84-A(7):1183–8.CrossRefPubMedGoogle Scholar
  61. 61.
    Kim HT, Ahn TY, Jang JH, Kim KH, Lee SJ, Jung DY. A graphic overlay method for selection of osteotomy site in chronic radial head dislocation: an evaluation of 3d-printed bone models. J Pediatr Orthop. 2015;37(2):e88–95.CrossRefGoogle Scholar
  62. 62.
    Rodgers WB, Waters PM, Hall JE. Chronic Monteggia lesions in children. Complications and results of reconstruction. J Bone Joint Surg Am. 1996;78(9):1322–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Watson-Jones R. Fractures and joint injuries. 3rd ed. Baltimore, MD: Williams & Wilkins; 1943. p. 2.Google Scholar
  64. 64.
    Oner FC, Diepstraten AF. Treatment of chronic post-traumatic dislocation of the radial head in children. J Bone Joint Surg Br. 1993;75(4):577–81.CrossRefPubMedGoogle Scholar
  65. 65.
    Hui JH, Sulaiman AR, Lee H-C, Lam K-S, Lee E-H. Open reduction and annular ligament reconstruction with fascia of the forearm in chronic Monteggia lesions in children. J Pediatr Orthop. 2005;25(4):501–6.CrossRefPubMedGoogle Scholar
  66. 66.
    Hudson DA, De Beer JD. Isolated traumatic dislocation of the radial head in children. J Bone Joint Surg Am. 1986;68(3):378–81.CrossRefGoogle Scholar
  67. 67.
    Exner GU. Missed chronic anterior Monteggia lesion. Closed reduction by gradual lengthening and angulation of the ulna. J Bone Joint Surg Br. 2001;83(4):547–50.CrossRefPubMedGoogle Scholar
  68. 68.
    Gicquel P, De Billy B, Karger C, Maximin MC, Clavert JM. Treatment of neglected Monteggia’s fracture by ulnar lengthening using the ilizarov technique. Rev Chir Orthop Reparatrice Appar Mot. 2000;86(8):844–7.PubMedGoogle Scholar
  69. 69.
    Futami T, Tsukamoto Y, Fujita T. Rotation osteotomy for dislocation of the radial head: 6 cases followed for 7 (3-10) years. Acta Orthop Scand. 1992;63(4):455–6.CrossRefPubMedGoogle Scholar
  70. 70.
    Vinz H. Isolated dislocation of the radius head in childhood. Beitr Orthop Traumatol. 1989;36(4):169–76.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Hospital Sant Joan de DeuBarcelonaSpain
  2. 2.Shriners Hospital for Children—PhiladelphiaPhiladelphiaUSA

Personalised recommendations