- Email: [email protected]
Unusual Monteggia lesions in children
Injury, 12, 399404
Printedin Great Britain
Unusual Monteggia
399
lesions in children
N. R. M. Fahmy Orthopaedic Department,
Wrightington Hospital, Wigan
Summary Two cases of fracture of the ulna with fractureseparation of the radial neck in children are presented. In one case there was no displacement of the radial epiphysis and in the other it was subluxated. The mechanism of injury is essentially a valgus strain on’ the extended elbow caused by a fall onto the outstretched hand. Reduction of this fracture is difftcult to attain by closed manipulation and may displace an undisplaced radial head. Open reduction is advisable and, as the lesion is unstable, some form of fixation may be required; check radiographs of good quality are essential during the first 3 weeks. If reduction cannot be achieved and mal-union or cross-union is expected, it is preferable to put the hand in a neutral or a pronated position as it will be more useful than a hand fixed in supination.
CASE
REPORTS u
Case 1 A girl, aged 5 years, fell off a swing and injured her left elbow. Radiographs showed an oblique fracture of the middle third of the ulna and a fracture-separation of the radial neck without dislocation or subluxation of the proximal radial epiphysis, but with marked displacement of the distal radial fragment (Fig. 1). No attempt at closed manipulation was undertaken but open reduction was performed, fixing the ulnar fracture with a 3-hole plate through an incision over the fracture. Through a separate, small posterolateral incision the proximal part of the radius was exposed, but neither the fracture of the radial neck nor the radial head could be seen as the periosteum and the annular ligament were intact posterolaterally. The periosteum was incised longitudinally and the fracture was found to be almost reduced; only slight adjustment was needed to achieve a perfect position. The wound was dressed and a collar and cuff applied with the elbow at a right angle. Check radiographs showed a satisfactory reduction (Fig 2).
b
Fig. la and b, Case 1. Note the anterior displacement of the distal radial fragment and that the radial epiphysis is not displaced and maintains its anatomical relation to the capitellum. At 3 weeks gentle movements were permitted inside a sling and by 5 weeks the patient had regained a normal range of movement of the elbow and of rotation of the forearm. Radiographs now showed callus at both fractures and maintenance of a satisfactory position (Fig. 3). The plate was removed two months later, without alteration in function (Fig. 4).
Case 2
A 2-year-old boy fell off a fence backwards, injuring his left forearm. Radiography showed a fracture of the middle third of the ulna and possibly anterior subluxation of the radial head, but it was difficult to be certain of this because of the poor quality of the film (Fig. 5).
400
Fig. 2. Case 1. Radiograph appearance.
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
showing postoperative
Fig. 3. Case 1. Five weeks after operation, with callus at both fracture sites.
Fig. 4. Case1. The plate removed 2 months later.
Fig. 5. Case 2. The position uncertain.
Manipulation under anaesthesia was performed and an above-elbow plaster back-slab was applied, with the elbow at a right angle and the forearm in supination. Radiographs showed reduction of the ulnar fracture but there was fracture-separation of the radial head, the position of which could not be ascertained because of the thickness and corrugation of the plaster slab (Fig. 6). After one week radiographs did not clarify the
position. The back-slab was removed and new radiographs showed the position as in Fig. I. Open reduction was carried out, the radial head was brought into alignment with the capitellum but it was impossible to reduce the shaft under the head of the radius. An above-elbow plaster was applied with the forearm in supination and the position shown in Fig. 8 was accepted.
of the radial head is
Fahmy: Unusual Monteggia Lesions
Fig. 6. Case 2. Atter manipulation, the position of the
radial head uncertain.
The plaster was removed after 5 weeks and fit11 flexion and extension movements of the elbow were regained but pronation was reduced by 50 per cent. Three years later the range of rotation was virtually unaltered (Fig. 9).
Fig. 7. Case 2. Position after removal of the back-slab. The radial epiphysis is tilted and there is marked displacement of the distal radial fragment. The forearm is supinated.
DISCUSSION
A Monteggia lesion in a child is an uncommon injury with an incidence varying between 0.1 and 1.7 per cent of fractures. The result of closed reduction is usually satisfactory and operation unnecessary. However, a fracture of the ulnar diaphysis associated with fracture-separation of the proximal radial epiphysis does not lead to such a favourable outcome. The reason for this is the inability to obtain a satisfactory reduction. Five similar cases are described in the literature (see Table Z ). Considering that the lesion occurs in children, the results are far from satisfactory. In 1967, Bado stated that the mechanism of injury of the fracture under discussion is the same as that of a type I Monteggia lesion, i.e. hyperpronation strain of the forearm, and he classified it as one of the equivalents of the type I lesion. I believe that fracture of the ulna with fracture-separation of the radial neck is due to a fall onto the outstretched hand with the forearm in any position of rotation, associated with a valgus strain at the elbow which creates a compression force that fractures the radius at the neck or near the epiphyseal line. These are
relatively weak sites, which explain the solitary fractures of the neck of the radius. As the deforming forces continue, they may result either in an ulnar fracture or a traction lesion on the medial side ofthe elbow. During valgus stress, the radial head is fnmly secured against the radial notch of the ulna and the capitellum, which makes its dislocation ditEcult, but the pull of the biceps tendon displaces the distal radial fragment anteriorly. The radial head may be left undisturbed and the annular ligament intact. However, it can cause the radial head to dislocate or subluxate because the posterior edge of the distal radial fragment strikes the anterior edge of the radial epiphysis at the fracture site. In treating type I Monteggia lesions in children, the usual method is closed manipuIation, supinating the forearm and, if this fails to achieve reduction, then open reduction is undertaken. Internal fixation with a Kirschner wire to stabilize an unstable radial head is needed only occasionally. In the case of fracture of the ulna with fracture of the radial neck, attempts at closed reduction
402
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
a Fig. 8a and b, Case 2. After open reduction.
radial shaft is displaced anteriomedially.
The radial epiphysis is in alignment with the capitellum while the The forearm is fully supinated.
b Fig. 9u and b, Case 2. Three years after the accident. No moulding of the radial shaft with a projection where the
shaft used to be, impeding rotation. Note thinning of the ulna.
(1967)
14 Bado
Wright (1963)
Evans (1949) Wright (1963)
Author
Fahmy (1980)
Fahmy (1980)
1
2
Case Kamali report (1974)
Fig.
5
4
10
Case
Fracture of middle third of ulna with anterior angulation and valgus deformity and fracture separation of the radial neck without dislocation of radial head Fracture of middle third of ulna with anterior angulation and fracture-separation of the neck of the radius with subluxation of the radial epiphysis
5
2
5
Fracture of the ulnar shaft with anterior angulation and fracture of the neck of the radius with anterior displacement Fracture of proximal part of the ulna with displacement and fracture neck of radius without separation
Same as the case above plus separation of epiphysis of medial humeral epicondyle
Fracture-separation upper radial epiphysis and anterior dislocation of superior radio-ulnar joint Greenstick fracture of upper end of ulna with valgus deformity and fracture-separation of upper radial epiphysis
1 esion
Fall from a fence backwards
Fall from a swing
Fall from a chair
?
Not known
Sleeve caught in machine Fall down a flight of steps
Mechanism
Result
Closed reduction, led to separation and displacement radial head; then open reduction with K-wire to radial head Open with plate fixation of ulnar fracture Closed reduction then open reduction of displaced radial head
of
Limitation of pronation (half the normal range)
Full recovery
Slight limitation of supination
No pronation, Open reduction in full supination supination 50’ Fusion of superior Open reduction of radio-ulnar joint radial epiphysis and loss of pronation and manipulation of and supination ulnar fracture 30” loss of extension, Closed, plaster 40’ loss of flexion, for 3 weeks pronation 20’, supination 70” ? Suggested to be by supination
Reduction
of the radial neck associated with fracture of the ulna in children (our 2 cases included)
?
13
10
10
(yr)
Age
Tab/e/ Analysis of 7 cases of fracture-separation
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
404
may dislocate an undislocated radial head or make the position worse, as the manipulations are usually performed with the forearm in supination, as in the case presented by Kamali (1974). Therefore, to attain reduction it is important to regain full ulnar length and as much length as possible in the space occupied by the radius. This can be achieved by traction and a varus stress; while the traction is maintained, the forearm is rotated in alternate pronation/ supination movements and the displaced radial fragment is reduced by direct pressure. If closed reduction is found to be impossible, which is usually the case, then open reduction should be carried out immediately and the ulnar fracture should be reduced first. As in treating fractures of both forearm bones, this not only makes reduction of the radial fracture easier but also restores the anatomy nearly to normal, thus reducing the risk of damaging the posterior interosseous nerve. If the ulnar fracture is unstable it may be fixed with a small plate. It is advisable to perform the open reduction via two separate, small incisions, rather than a single large one, thus avoiding the communication between the haematomas and the risk of crossunion. The plate should be removed as soon as union of the fracture is evident. If reduction is possible but unstable, a Kirschner wire should be passed through the capitellum, radial head and shaft. If reduction is found to be impossible after all attempts, it is better to put the forearm in pronation, because a hand fixed in pronation is more useful than one fixed in supination. Acknowledgements I am greatly indebted to Mr D. G. Wray for allowing me to present his two cases, and 1 would like to thank Mr K. L. Barnes, for his guidance and assistance. My thanks also to Mrs C. Statter for typing the paper.
Requests
BIBLIOGRAPHY
Bado J. L. (1967) The Monteggia lesion. Cfin. Orthop. 50,71. Bruce H. E., Harvey J. P. and Wilson J. C. jun. (1974) Monte&a fracture. J. Bone Joint Surg. 56A, 1563. Eady J. L. (1975) Acute Monteggia lesions in children J. SC Med. Assoc. 71, 107. Evans E. M. (1949) Pronation injuries of the forearm. J. Bone Joint Surg. 31B, 578. Guistra P. E. (1974) The missed Monteggia fracture. Diagn. Radiol. 110,45. Hume A. C. (1975) Anterior dislocation of the head of the radius associated with undisplaced fracture of the olecranon in children. J. Bone Joint Surg. 39B, 508. Jeffery C. C. (1972) Fracture of the neck of the radius in children: mechanism of causation. J. Bone Joint Surg. S4B, 7 17. Jones E. R. and Esah M. (197 1) Displaced fractures of the neck of the radius. J. Bone Joint Surg. 53B, 429. Kamali M. (1974) Monteggia fracture: presentation of an unusual case. J. Bone Joint Surg. 56A, 841. Mullick S. (1977) The lateral Monteggia fracture. J. Bone Joint Surg._S9A, 543. Naylor A. (1942) Monteggia fractures. Br. J. Surg. 29, 323. Peiro A., Andres F. and Femandez-Esteve F. (1977) Acute Monteggia lesions in children. J. Bone Joint Surg. 59A, 92. Theodoru S. D. (1969) Dislocation of the head of the radius associated with fracture of the upper end of the ulna in children. J. Bone Joint Surg. SlB, 700. Tompkins D. G. (1971) The anterior Monteggia fracture, observations on etiology and treatment. J. Bone Joint Surg. 53A, 1109. Watson-Jones R. (1976) Fractures and Joint Injuries. Edinburgh, Churchill Livingstone, 5th ed., Vol. 2, p. 692. Wright P. R. (1963) Greenstick fracture of the upper end of the ulna with dislocation of the radiohumeral joint or displacement of the superior radial epiphysis. J. Bone Joint Surg. 45B, 727.
forreprints should be addressed to: Mr N. R. M. Fahmy, Orthopaedic Department,
Salford 6.
Hope Hospital, Eccles Old Road,
Printedin Great Britain
Unusual Monteggia
399
lesions in children
N. R. M. Fahmy Orthopaedic Department,
Wrightington Hospital, Wigan
Summary Two cases of fracture of the ulna with fractureseparation of the radial neck in children are presented. In one case there was no displacement of the radial epiphysis and in the other it was subluxated. The mechanism of injury is essentially a valgus strain on’ the extended elbow caused by a fall onto the outstretched hand. Reduction of this fracture is difftcult to attain by closed manipulation and may displace an undisplaced radial head. Open reduction is advisable and, as the lesion is unstable, some form of fixation may be required; check radiographs of good quality are essential during the first 3 weeks. If reduction cannot be achieved and mal-union or cross-union is expected, it is preferable to put the hand in a neutral or a pronated position as it will be more useful than a hand fixed in supination.
CASE
REPORTS u
Case 1 A girl, aged 5 years, fell off a swing and injured her left elbow. Radiographs showed an oblique fracture of the middle third of the ulna and a fracture-separation of the radial neck without dislocation or subluxation of the proximal radial epiphysis, but with marked displacement of the distal radial fragment (Fig. 1). No attempt at closed manipulation was undertaken but open reduction was performed, fixing the ulnar fracture with a 3-hole plate through an incision over the fracture. Through a separate, small posterolateral incision the proximal part of the radius was exposed, but neither the fracture of the radial neck nor the radial head could be seen as the periosteum and the annular ligament were intact posterolaterally. The periosteum was incised longitudinally and the fracture was found to be almost reduced; only slight adjustment was needed to achieve a perfect position. The wound was dressed and a collar and cuff applied with the elbow at a right angle. Check radiographs showed a satisfactory reduction (Fig 2).
b
Fig. la and b, Case 1. Note the anterior displacement of the distal radial fragment and that the radial epiphysis is not displaced and maintains its anatomical relation to the capitellum. At 3 weeks gentle movements were permitted inside a sling and by 5 weeks the patient had regained a normal range of movement of the elbow and of rotation of the forearm. Radiographs now showed callus at both fractures and maintenance of a satisfactory position (Fig. 3). The plate was removed two months later, without alteration in function (Fig. 4).
Case 2
A 2-year-old boy fell off a fence backwards, injuring his left forearm. Radiography showed a fracture of the middle third of the ulna and possibly anterior subluxation of the radial head, but it was difficult to be certain of this because of the poor quality of the film (Fig. 5).
400
Fig. 2. Case 1. Radiograph appearance.
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
showing postoperative
Fig. 3. Case 1. Five weeks after operation, with callus at both fracture sites.
Fig. 4. Case1. The plate removed 2 months later.
Fig. 5. Case 2. The position uncertain.
Manipulation under anaesthesia was performed and an above-elbow plaster back-slab was applied, with the elbow at a right angle and the forearm in supination. Radiographs showed reduction of the ulnar fracture but there was fracture-separation of the radial head, the position of which could not be ascertained because of the thickness and corrugation of the plaster slab (Fig. 6). After one week radiographs did not clarify the
position. The back-slab was removed and new radiographs showed the position as in Fig. I. Open reduction was carried out, the radial head was brought into alignment with the capitellum but it was impossible to reduce the shaft under the head of the radius. An above-elbow plaster was applied with the forearm in supination and the position shown in Fig. 8 was accepted.
of the radial head is
Fahmy: Unusual Monteggia Lesions
Fig. 6. Case 2. Atter manipulation, the position of the
radial head uncertain.
The plaster was removed after 5 weeks and fit11 flexion and extension movements of the elbow were regained but pronation was reduced by 50 per cent. Three years later the range of rotation was virtually unaltered (Fig. 9).
Fig. 7. Case 2. Position after removal of the back-slab. The radial epiphysis is tilted and there is marked displacement of the distal radial fragment. The forearm is supinated.
DISCUSSION
A Monteggia lesion in a child is an uncommon injury with an incidence varying between 0.1 and 1.7 per cent of fractures. The result of closed reduction is usually satisfactory and operation unnecessary. However, a fracture of the ulnar diaphysis associated with fracture-separation of the proximal radial epiphysis does not lead to such a favourable outcome. The reason for this is the inability to obtain a satisfactory reduction. Five similar cases are described in the literature (see Table Z ). Considering that the lesion occurs in children, the results are far from satisfactory. In 1967, Bado stated that the mechanism of injury of the fracture under discussion is the same as that of a type I Monteggia lesion, i.e. hyperpronation strain of the forearm, and he classified it as one of the equivalents of the type I lesion. I believe that fracture of the ulna with fracture-separation of the radial neck is due to a fall onto the outstretched hand with the forearm in any position of rotation, associated with a valgus strain at the elbow which creates a compression force that fractures the radius at the neck or near the epiphyseal line. These are
relatively weak sites, which explain the solitary fractures of the neck of the radius. As the deforming forces continue, they may result either in an ulnar fracture or a traction lesion on the medial side ofthe elbow. During valgus stress, the radial head is fnmly secured against the radial notch of the ulna and the capitellum, which makes its dislocation ditEcult, but the pull of the biceps tendon displaces the distal radial fragment anteriorly. The radial head may be left undisturbed and the annular ligament intact. However, it can cause the radial head to dislocate or subluxate because the posterior edge of the distal radial fragment strikes the anterior edge of the radial epiphysis at the fracture site. In treating type I Monteggia lesions in children, the usual method is closed manipuIation, supinating the forearm and, if this fails to achieve reduction, then open reduction is undertaken. Internal fixation with a Kirschner wire to stabilize an unstable radial head is needed only occasionally. In the case of fracture of the ulna with fracture of the radial neck, attempts at closed reduction
402
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
a Fig. 8a and b, Case 2. After open reduction.
radial shaft is displaced anteriomedially.
The radial epiphysis is in alignment with the capitellum while the The forearm is fully supinated.
b Fig. 9u and b, Case 2. Three years after the accident. No moulding of the radial shaft with a projection where the
shaft used to be, impeding rotation. Note thinning of the ulna.
(1967)
14 Bado
Wright (1963)
Evans (1949) Wright (1963)
Author
Fahmy (1980)
Fahmy (1980)
1
2
Case Kamali report (1974)
Fig.
5
4
10
Case
Fracture of middle third of ulna with anterior angulation and valgus deformity and fracture separation of the radial neck without dislocation of radial head Fracture of middle third of ulna with anterior angulation and fracture-separation of the neck of the radius with subluxation of the radial epiphysis
5
2
5
Fracture of the ulnar shaft with anterior angulation and fracture of the neck of the radius with anterior displacement Fracture of proximal part of the ulna with displacement and fracture neck of radius without separation
Same as the case above plus separation of epiphysis of medial humeral epicondyle
Fracture-separation upper radial epiphysis and anterior dislocation of superior radio-ulnar joint Greenstick fracture of upper end of ulna with valgus deformity and fracture-separation of upper radial epiphysis
1 esion
Fall from a fence backwards
Fall from a swing
Fall from a chair
?
Not known
Sleeve caught in machine Fall down a flight of steps
Mechanism
Result
Closed reduction, led to separation and displacement radial head; then open reduction with K-wire to radial head Open with plate fixation of ulnar fracture Closed reduction then open reduction of displaced radial head
of
Limitation of pronation (half the normal range)
Full recovery
Slight limitation of supination
No pronation, Open reduction in full supination supination 50’ Fusion of superior Open reduction of radio-ulnar joint radial epiphysis and loss of pronation and manipulation of and supination ulnar fracture 30” loss of extension, Closed, plaster 40’ loss of flexion, for 3 weeks pronation 20’, supination 70” ? Suggested to be by supination
Reduction
of the radial neck associated with fracture of the ulna in children (our 2 cases included)
?
13
10
10
(yr)
Age
Tab/e/ Analysis of 7 cases of fracture-separation
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
404
may dislocate an undislocated radial head or make the position worse, as the manipulations are usually performed with the forearm in supination, as in the case presented by Kamali (1974). Therefore, to attain reduction it is important to regain full ulnar length and as much length as possible in the space occupied by the radius. This can be achieved by traction and a varus stress; while the traction is maintained, the forearm is rotated in alternate pronation/ supination movements and the displaced radial fragment is reduced by direct pressure. If closed reduction is found to be impossible, which is usually the case, then open reduction should be carried out immediately and the ulnar fracture should be reduced first. As in treating fractures of both forearm bones, this not only makes reduction of the radial fracture easier but also restores the anatomy nearly to normal, thus reducing the risk of damaging the posterior interosseous nerve. If the ulnar fracture is unstable it may be fixed with a small plate. It is advisable to perform the open reduction via two separate, small incisions, rather than a single large one, thus avoiding the communication between the haematomas and the risk of crossunion. The plate should be removed as soon as union of the fracture is evident. If reduction is possible but unstable, a Kirschner wire should be passed through the capitellum, radial head and shaft. If reduction is found to be impossible after all attempts, it is better to put the forearm in pronation, because a hand fixed in pronation is more useful than one fixed in supination. Acknowledgements I am greatly indebted to Mr D. G. Wray for allowing me to present his two cases, and 1 would like to thank Mr K. L. Barnes, for his guidance and assistance. My thanks also to Mrs C. Statter for typing the paper.
Requests
BIBLIOGRAPHY
Bado J. L. (1967) The Monteggia lesion. Cfin. Orthop. 50,71. Bruce H. E., Harvey J. P. and Wilson J. C. jun. (1974) Monte&a fracture. J. Bone Joint Surg. 56A, 1563. Eady J. L. (1975) Acute Monteggia lesions in children J. SC Med. Assoc. 71, 107. Evans E. M. (1949) Pronation injuries of the forearm. J. Bone Joint Surg. 31B, 578. Guistra P. E. (1974) The missed Monteggia fracture. Diagn. Radiol. 110,45. Hume A. C. (1975) Anterior dislocation of the head of the radius associated with undisplaced fracture of the olecranon in children. J. Bone Joint Surg. 39B, 508. Jeffery C. C. (1972) Fracture of the neck of the radius in children: mechanism of causation. J. Bone Joint Surg. S4B, 7 17. Jones E. R. and Esah M. (197 1) Displaced fractures of the neck of the radius. J. Bone Joint Surg. 53B, 429. Kamali M. (1974) Monteggia fracture: presentation of an unusual case. J. Bone Joint Surg. 56A, 841. Mullick S. (1977) The lateral Monteggia fracture. J. Bone Joint Surg._S9A, 543. Naylor A. (1942) Monteggia fractures. Br. J. Surg. 29, 323. Peiro A., Andres F. and Femandez-Esteve F. (1977) Acute Monteggia lesions in children. J. Bone Joint Surg. 59A, 92. Theodoru S. D. (1969) Dislocation of the head of the radius associated with fracture of the upper end of the ulna in children. J. Bone Joint Surg. SlB, 700. Tompkins D. G. (1971) The anterior Monteggia fracture, observations on etiology and treatment. J. Bone Joint Surg. 53A, 1109. Watson-Jones R. (1976) Fractures and Joint Injuries. Edinburgh, Churchill Livingstone, 5th ed., Vol. 2, p. 692. Wright P. R. (1963) Greenstick fracture of the upper end of the ulna with dislocation of the radiohumeral joint or displacement of the superior radial epiphysis. J. Bone Joint Surg. 45B, 727.
forreprints should be addressed to: Mr N. R. M. Fahmy, Orthopaedic Department,
Salford 6.
Hope Hospital, Eccles Old Road,