- Email: [email protected]
Previously unreported Monteggia type II-equivalent fracture of the olecranon: A proposed modification of the Letts classification
Injury Extra 43 (2012) 151–152
Contents lists available at SciVerse ScienceDirect
Injury Extra journal homepage: www.elsevier.com/locate/inext
Case report
Previously unreported Monteggia type II-equivalent fracture of the olecranon: A proposed modification of the Letts classification Harinder Gakhar *, Naveed Ahmed, Salim Punjabi, Ajay Sharma Prince Charles Hospital, Merthyr Tydfil, UK
1. Introduction Fractures of the proximal ulna accompanied by a radial head dislocation have been eponymously associated with Giovanni Battista Monteggia, after he first described this injury in 1814.6 In 1967, Bado modified the definition, called it a ‘‘Monteggia Lesion,’’ and classified related injuries on the basis of the direction of the radial head dislocation.1 Bado also described a few ‘‘equivalent lesions’’ in his classic paper. Considering the plastic nature of paediatric bones, in 1985 Letts et al. described his paediatric Monteggia classification to take into account plastic deformations and greenstick fractures.5 We report a case of a child who had a rare combination of a Salter Harris type II olecranon fracture with a posterior radial head dislocation and a radial neck fracture. The purpose of this case report is to present this extremely rare injury to raise awareness among clinicians to avoid a wrong diagnosis or a delay in diagnosis. To date, and to the best of our knowledge, physeal injuries of the olecranon have not been included in any paediatric Monteggia classification system. We also propose a modification of the Letts classification of paediatric Monteggia fracture dislocations.
After confirmation of a physeal injury to the proximal ulna (Salter Harris II), the fracture was reduced and held with two K wires and a thick vicryl (Ethicon) tension band suture. The radial head reduced spontaneously and was stable on range-of-motion testing. An above-elbow splint was applied with the forearm at some level of supination. Films at 1 week post-surgery revealed that the radial head was reduced. Wires were removed at 5 weeks and range-of-motion exercises were commenced. At 3 months the fracture was consolidated, the radial head was reduced, and the child had full range-of-flexion/extension and pronation/supination. The child continues to have full range-of-motion and has had no growth problems at 1 year post surgery. 3. Discussion Paediatric elbow injuries remain a difficult diagnosis even in the best of hands, and they are notorious for wrong or missed diagnoses. In his landmark paper, Bado described the different type I Monteggia-equivalent injuries in detail. He suggested that the only type II Monteggia-equivalent injuries were fractures through the radial epiphysis or of the radial neck.1 Letts et al. in 1985 examined 33 paediatric Monteggia cases and proposed his
2. Case report A 3-year-old girl injured her right dominant elbow when she fell off a climbing frame onto her outstretched hand. On physical examination there were no neurovascular deficits or open wounds. Plain radiographs revealed a fracture of the proximal ulna. On the anteroposterior view there was medial displacement of the forearm bones in relation to the humerus. A bony fragment stayed with the capitellum. The radial head was dislocated posteriorly with a radial neck fracture (Figs. 1 and 2). Clinico-radiological diagnosis of either an elbow joint dislocation or olecranon fracture was entertained. Under general anaesthesia all attempts at closed reduction were unsuccessful. The elbow was approached from the posterior aspect and the proximal metaphysis of the ulna had buttonholed through the deep fascia of the forearm (Figs. 3 and 4).
* Corresponding author at: 94 Dorchester Way, Coventry CV2 2LX, UK. E-mail address: [email protected] (H. Gakhar). 1572-3461/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.08.002
Fig. 1. Anteroposterior view showing medially displaced radius and ulna and a bony fragment alongside the capitellum.
152
H. Gakhar et al. / Injury Extra 43 (2012) 151–152
Fig. 2. Lateral view showing posteriorly displaced radial head and radial neck fracture.
Fig. 4. At open reduction radial head reduced completely with no instability after Kwiring.
Fig. 3. Button holed metaphysis of proximal ulna not allowing closed reduction.
classification.5 There was no inclusion of a physeal injury to the proximal ulna within this classification. Wiley et al. in 1985 studied 46 children with Monteggia fractures.8 They mentioned olecranon fractures with radial head dislocation. The majority of the type III injuries had associated olecranon fractures. Wiley et al. even suggested that olecranon fractures with radial head dislocations should be mentioned in the classification of Monteggia lesions. In their review of Monteggia fractures, Bruce et al. excluded cases that had olecranon fractures.2 Onley and Menelaus examined 102 patients with Monteggia and equivalent lesions.7 Among their cases, Table 1 Letts’ proposed paediatric Monteggia classification showing our proposed modification. Description of each group Paediatric Monteggia fracture dislocation Group A Plastic deformity of the ulna with an anterior radial head dislocation Group B Anterior green stick fracture of the ulna with an anterior radial head dislocation Group C Complete fracture of the ulna with an anterior radial head dislocation Group D Complete fracture of the ulna with a posterior dislocation of the radial head Group E Lateral displacement of the radial head with an ulnar fracture Proposed modification Group F Epiphysial injury through the olecranon with a radial head dislocation
they did not come across any type II Monteggia-equivalent lesions. They mentioned fractures of the olecranon but not physeal injuries. Givon et al. did not find a single type II Monteggia-equivalent injury.3 Heinrich and Butler described a case of type II Monteggia-equivalent injury that was a plastic deformation of the ulna with a radial head fracture and posterior radial head dislocation.4 Our case is a rare, previously unreported case of a type II Monteggia-equivalent injury that involves the Salter Harris II fracture of the olecranon with a radial head dislocation and a radial neck fracture. This injury is uncommon and highlights the very basic fact that paediatric elbow injuries can have variable presentations. Our case was relatively easily diagnosed on plain radiographs due to the bony fragment that stayed behind with the cartilaginous olecranon. If this had not been the case, a clinicoradiological diagnosis would have been extremely difficult. We suggest a modification to the Letts classification. Because groups A–E already exist, another group (group F) may be added to include epiphyseal injuries to the proximal ulna (Table 1). References 1. Bado JL. The Monteggia lesion. Clinical Orthopaedics and Related Research 1967;50:71–86. 2. Bruce HE, Harvey JP, Wilson Jr JC. Monteggia fractures. Journal of Bone and Joint Surgery 1974;56:1563–76. 3. Givon U, Pritsch M, Levy O, Yosepovich A, Amit Y, Horoszowski H. Monteggia and equivalent lesions: a study of 41 cases. Clinical Orthopaedics and Related Research 1997;337:208–15. 4. Heinrich SD, Butler RA. Late radial head dislocation with radial head fracture and ulnar plastic deformation. Clinical Orthopaedics and Related Research 2007;460:258–62. 5. Letts M, Locht R, Wiens J. Monteggia fracture dislocation in children. Journal of Bone and Joint Surgery British Volume 1985;67-B:724–7. 6. Maspero GM. Istituzioni Chirurgiche, 2a (ed.), Milan, 1813–1815. 7. Olney BW, Menelaus MB. Monteggia and equivalent lesions in childhood. Journal of Pediatric Orthopedics 1989;9:219–23. 8. Wiley JJ, Galey JP. Monteggia injuries in children. Journal of Bone and Joint Surgery British Volume 1985;67-B:728–31.
Contents lists available at SciVerse ScienceDirect
Injury Extra journal homepage: www.elsevier.com/locate/inext
Case report
Previously unreported Monteggia type II-equivalent fracture of the olecranon: A proposed modification of the Letts classification Harinder Gakhar *, Naveed Ahmed, Salim Punjabi, Ajay Sharma Prince Charles Hospital, Merthyr Tydfil, UK
1. Introduction Fractures of the proximal ulna accompanied by a radial head dislocation have been eponymously associated with Giovanni Battista Monteggia, after he first described this injury in 1814.6 In 1967, Bado modified the definition, called it a ‘‘Monteggia Lesion,’’ and classified related injuries on the basis of the direction of the radial head dislocation.1 Bado also described a few ‘‘equivalent lesions’’ in his classic paper. Considering the plastic nature of paediatric bones, in 1985 Letts et al. described his paediatric Monteggia classification to take into account plastic deformations and greenstick fractures.5 We report a case of a child who had a rare combination of a Salter Harris type II olecranon fracture with a posterior radial head dislocation and a radial neck fracture. The purpose of this case report is to present this extremely rare injury to raise awareness among clinicians to avoid a wrong diagnosis or a delay in diagnosis. To date, and to the best of our knowledge, physeal injuries of the olecranon have not been included in any paediatric Monteggia classification system. We also propose a modification of the Letts classification of paediatric Monteggia fracture dislocations.
After confirmation of a physeal injury to the proximal ulna (Salter Harris II), the fracture was reduced and held with two K wires and a thick vicryl (Ethicon) tension band suture. The radial head reduced spontaneously and was stable on range-of-motion testing. An above-elbow splint was applied with the forearm at some level of supination. Films at 1 week post-surgery revealed that the radial head was reduced. Wires were removed at 5 weeks and range-of-motion exercises were commenced. At 3 months the fracture was consolidated, the radial head was reduced, and the child had full range-of-flexion/extension and pronation/supination. The child continues to have full range-of-motion and has had no growth problems at 1 year post surgery. 3. Discussion Paediatric elbow injuries remain a difficult diagnosis even in the best of hands, and they are notorious for wrong or missed diagnoses. In his landmark paper, Bado described the different type I Monteggia-equivalent injuries in detail. He suggested that the only type II Monteggia-equivalent injuries were fractures through the radial epiphysis or of the radial neck.1 Letts et al. in 1985 examined 33 paediatric Monteggia cases and proposed his
2. Case report A 3-year-old girl injured her right dominant elbow when she fell off a climbing frame onto her outstretched hand. On physical examination there were no neurovascular deficits or open wounds. Plain radiographs revealed a fracture of the proximal ulna. On the anteroposterior view there was medial displacement of the forearm bones in relation to the humerus. A bony fragment stayed with the capitellum. The radial head was dislocated posteriorly with a radial neck fracture (Figs. 1 and 2). Clinico-radiological diagnosis of either an elbow joint dislocation or olecranon fracture was entertained. Under general anaesthesia all attempts at closed reduction were unsuccessful. The elbow was approached from the posterior aspect and the proximal metaphysis of the ulna had buttonholed through the deep fascia of the forearm (Figs. 3 and 4).
* Corresponding author at: 94 Dorchester Way, Coventry CV2 2LX, UK. E-mail address: [email protected] (H. Gakhar). 1572-3461/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.08.002
Fig. 1. Anteroposterior view showing medially displaced radius and ulna and a bony fragment alongside the capitellum.
152
H. Gakhar et al. / Injury Extra 43 (2012) 151–152
Fig. 2. Lateral view showing posteriorly displaced radial head and radial neck fracture.
Fig. 4. At open reduction radial head reduced completely with no instability after Kwiring.
Fig. 3. Button holed metaphysis of proximal ulna not allowing closed reduction.
classification.5 There was no inclusion of a physeal injury to the proximal ulna within this classification. Wiley et al. in 1985 studied 46 children with Monteggia fractures.8 They mentioned olecranon fractures with radial head dislocation. The majority of the type III injuries had associated olecranon fractures. Wiley et al. even suggested that olecranon fractures with radial head dislocations should be mentioned in the classification of Monteggia lesions. In their review of Monteggia fractures, Bruce et al. excluded cases that had olecranon fractures.2 Onley and Menelaus examined 102 patients with Monteggia and equivalent lesions.7 Among their cases, Table 1 Letts’ proposed paediatric Monteggia classification showing our proposed modification. Description of each group Paediatric Monteggia fracture dislocation Group A Plastic deformity of the ulna with an anterior radial head dislocation Group B Anterior green stick fracture of the ulna with an anterior radial head dislocation Group C Complete fracture of the ulna with an anterior radial head dislocation Group D Complete fracture of the ulna with a posterior dislocation of the radial head Group E Lateral displacement of the radial head with an ulnar fracture Proposed modification Group F Epiphysial injury through the olecranon with a radial head dislocation
they did not come across any type II Monteggia-equivalent lesions. They mentioned fractures of the olecranon but not physeal injuries. Givon et al. did not find a single type II Monteggia-equivalent injury.3 Heinrich and Butler described a case of type II Monteggia-equivalent injury that was a plastic deformation of the ulna with a radial head fracture and posterior radial head dislocation.4 Our case is a rare, previously unreported case of a type II Monteggia-equivalent injury that involves the Salter Harris II fracture of the olecranon with a radial head dislocation and a radial neck fracture. This injury is uncommon and highlights the very basic fact that paediatric elbow injuries can have variable presentations. Our case was relatively easily diagnosed on plain radiographs due to the bony fragment that stayed behind with the cartilaginous olecranon. If this had not been the case, a clinicoradiological diagnosis would have been extremely difficult. We suggest a modification to the Letts classification. Because groups A–E already exist, another group (group F) may be added to include epiphyseal injuries to the proximal ulna (Table 1). References 1. Bado JL. The Monteggia lesion. Clinical Orthopaedics and Related Research 1967;50:71–86. 2. Bruce HE, Harvey JP, Wilson Jr JC. Monteggia fractures. Journal of Bone and Joint Surgery 1974;56:1563–76. 3. Givon U, Pritsch M, Levy O, Yosepovich A, Amit Y, Horoszowski H. Monteggia and equivalent lesions: a study of 41 cases. Clinical Orthopaedics and Related Research 1997;337:208–15. 4. Heinrich SD, Butler RA. Late radial head dislocation with radial head fracture and ulnar plastic deformation. Clinical Orthopaedics and Related Research 2007;460:258–62. 5. Letts M, Locht R, Wiens J. Monteggia fracture dislocation in children. Journal of Bone and Joint Surgery British Volume 1985;67-B:724–7. 6. Maspero GM. Istituzioni Chirurgiche, 2a (ed.), Milan, 1813–1815. 7. Olney BW, Menelaus MB. Monteggia and equivalent lesions in childhood. Journal of Pediatric Orthopedics 1989;9:219–23. 8. Wiley JJ, Galey JP. Monteggia injuries in children. Journal of Bone and Joint Surgery British Volume 1985;67-B:728–31.