Neglected Monteggia fracture dislocation in children: The impact of step cut osteotomy on ulna consolidation and radial head reduction. A case report

Aymen Ben Fredj; Hedi Rbai; Farouk Chatbouri; Abderrahmen Daadoucha

doi:10.1016/j.jorep.2023.100186

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Case Report

2023

:2;

100186

doi:

10.1016/j.jorep.2023.100186

Neglected Monteggia fracture dislocation in children: The impact of step cut osteotomy on ulna consolidation and radial head reduction. A case report

Aymen Ben Fredj^a,, Hedi Rbai^a, Farouk Chatbouri^a, Abderrahmen Daadoucha^b

a Orthopaedics Department, Ibn El Jazzar Hospital, Université de Sousse Faculté de Médecine de Sousse, Sousse, Tunisia

b Radiology Department, Ibn El Jazzar Hospital, Université de Sousse Faculté de Médecine de Sousse, Sousse, Tunisia

∗Corresponding author: Aymen Ben Fredj. aymen.ben.fredj@gmail.com

Received: 2023-5-23, Accepted: 2023-6-14, Published: 2023-6-19

The Author(s)

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Monteggia fracture is identified as ulna fracture combined with radial head dislocation. If not diagnosed at an early stage, it leads to elbow impairment including: cubitus valgus, elbow instability and deformity, decreased supination-pronation arc and late neuropathy resulting in significant restriction of daily activities.

A 10-year-old boy with a two months old Monteggia fracture dislocation labelled Bado Type 1 was evaluated. Open reduction of radial head, annular ligament repair and step cut osteotomy of the ulna were performed. Eight months after operation, the osteotomy site was fully and uneventfully consolidated and the radial head kept its stable reduction. The elbow has regained normal mobility.

Neglected Monteggia fracture dislocation requires specific surgical management to avoid further complications. Step cut osteotomy in neglected Monteggia fracture has several advantages over other techniques. It allows the osteotomy site to be lengthened and angled forward while maintaining a large bone-to-bone contact surface which avoids the use of bone grafting. Maximizing the contact surface at the osteotomy leads to a good consolidation rate and also results in increased stability.

Keywords

Missed Monteggia fracture

Children

Ulna osteotomy

Open reduction

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1 Introduction

Once neglected, Monteggia fracture, particularly in children, causes elbow deformity, decreases elbow range of motion and may even compromise the neurological status of the upper limb. 33% of Monteggia injuries are miss diagnosed at initial consultation, and up to 20% loss of reduction has been noted later in follow-up of patients treated with closed reduction.¹ Patients with neglected Monteggia fracture often seek treatment weeks or even months after the initial trauma. Difficulty is that, beyond 4 weeks, treatment become challenging due to callus already formed in the ulna.²

Different treatment methods are described in the literature aiming to ensure optimal management of neglected Monteggia fracture. There are no guidelines regarding the type of ulna osteotomy, methods of fixation and the necessity of annular ligament reconstruction. Through this clinical case we highlight the interest of step cut osteotomy of the ulna associated with annular ligament repair as a surgical technique that offers superior benefit for a good outcome.

1.1

1.1 Case report

A 10-year-old boy was admitted in our orthopaedic department with a dating back two months Monteggia fracture dislocation labelled Bado type 1 that was mistreated with a brachio-antebrachial cast (Fig. 1).

(a) Initial lateral x-ray of the elbow showing a Monteggia Bado type 1 fracture treated with a long arm cast. (b) Lateral x-ray of the elbow at 2 months with consolidation of the ulna but persistence of the anterior dislocation of the radial head.

He presented with reduced elbow range of motion. The radial head was palpable anteriorly and there was no neurovascular deficit. Surgical procedure consisted of an ulna osteotomy, an open reduction of radial head, and annular ligament repair through Boyd's posterior approach. The step cut osteotomy has a sagittally oriented Z shape, with one longitudinal and two horizontal cuts performed at the identified site on the ulna and fixed with five-hole plate (Fig. 2).

(a) Intraoperative aspect of the Step-cut osteotomy of ulna with a longitudinal cut and two horizontal cuts. (b) Intraoperative aspect of internal fixation. (c) Intraoperative lateral x-ray of the elbow showing reduction of the radial head.

Typically, lengthening the osteotomy site, angulating it anteriorly and direct pressure is a triple combination allowing the dislocated radial head to pull back to a stable reduction position. However, despite these manoeuvres, the radial head was not reduced due to the filling of the joint with fibrous tissue. Excision of this tissue eventually allowed stable reduction of the radial head and, before closing the incision, the annular ligament was repaired. At 8 months follow-up, the osteotomy site was fully and uneventfully consolidated and the radial head kept its stable reduction. At 8 months follow-up, the osteotomy site was fully and uneventfully consolidated and the radial head retained its stable reduction (Figs. 3 and 4).

Clinical photograph of the patient at 18 months postoperative showing good range of motion in: extension (a, d), flexion (b, c), protonation and supination (e, f, g).

Lateral (a) and anteroposterior (b) radiographs of healed ulnar osteotomy and good radial head reduction.

1.2

1.2 Discussion

Neglected Monteggia fracture in children leads to elbow impairment including: cubitus valgus, elbow instability and deformity, chronic pain, subluxation of the distal radioulnar joint, decreased supination-pronation arc and late neuropathy. Over time, progressive dysplastic changes are observed in the patient's radio-capitellar joint.³ The interosseous membrane loses its tension during the anterior migration of the radial head. Therefore, it allows its re-dislocation even after a closed reduction attempt.² To regain its tension, the interosseous membrane needs to be distracted by means of lengthening the ulna. Proximal ulna osteotomy helps to restore joint congruence even years after initial trauma.⁴ The remodelling potential as well as the flexibility of the soft tissues are the key elements to obtain an excellent result. However, dysplastic changes appearing after the initial trauma can change the outcome of surgery. The surgical technique that we recommend consists of step cut osteotomy along with angulation and distraction of the ulna. The reduction is achieved by distraction, while the overcorrection created by the angulation maintains the radial head reduction.

Once stable reduction of the radial head is achieved, the osteotomy site is internally fixed at the desired length and angle. Another advantage of this type of osteotomy is the increased contact surface between the two edges of the bone which guarantees both a good consolidation rate and good stability. Regarding the annular ligament, there is still controversy over the benefit of reconstruction comparing to only repair.

Bhaskar argued that an intraoperative decision should be made based on the stability of the reduction.⁵ However, it should be kept in mind that the additional dissection required for the annular ligament reconstruction may lead to elbow stiffness, heterotrophic ossification, avascular necrosis of radial head or radio-ulnar synostosis.⁶^,⁷

It is for these complications that some authors recommend avoiding reconstruction of the annular ligament except in cases of residual rotational instability of the radial head.⁸

Our case lends support and strength to the step-cut osteotomy technique as a reproducible and simple surgical technique with many advantages over other techniques. It fastens consolidation by increasing the bone–bone contact surface, it increases the stability by giving a larger contact area and finally there will no need for a bone graft.

Funding

This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from the participant included in the study.

Consent to publish

The participant gave their informed consent for the publication of all the figures and data.

Data availability statement

Not applicable.

Author contributions

Aymen Ben Fredj: Conceptualization, Investigation, Resources, writing- original draft, Hedi Rbai: Supervision, Resources, conceptualization, writing-review, and editing, Farouk Chatbouri and Abderrahmen Daadoucha: Supervision, writing-review, and editing.

References

Bae D.S., . Successful strategies for managing Monteggia injuries. J Pediatr Orthop. 2016;36:S67-S70.
[Google Scholar]
Zhang R., Wang X., Xu J., Kang Q., Hamdy R.C., . Neglected Monteggia fracture: a review. EFORT Open Rev. 2022;7(4):287-294.
[Google Scholar]
Zivanovic D., Marjanovic Z., Bojovic N., Djordjevic I., Zecevic M., Budic I., . Neglected Monteggia fractures in children-A retrospective study. Children. 2022;9(8):1100.
[Google Scholar]
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):237-242.
[Google Scholar]
Bhaskar A., . Missed Monteggia fracture in children: is annular ligament reconstruction always required? Indian J Orthop. 2009;43(4):389-395.
[Google Scholar]
Canton G., Hoxhaj B., Fattori R., Murena L., . Annular ligament reconstruction in chronic Monteggia fracture-dislocations in the adult population: indications and surgical technique. Musculoskelet Surg. 2018;102:93-102.
[Google Scholar]
Chen H.Y., Wu K.W., Dong Z.R., Huang S.C., N Kuo K., Wang T.M., . The treatment of chronic radial head dislocation in Monteggia fracture without annular ligament reconstruction. Int Orthop. 2018;42(9):2165-2172.
[Google Scholar]
Stragier B., De Smet L., Degreef I., . Long-term follow-up of corrective ulnar osteotomy for missed Monteggia fractures in children. J Shoulder Elbow Surg. 2018;27(11):e337-e343.
[Google Scholar]