Combined ulnar shaft fracture with displaced radial head fracture in the form of an atypical Monteggia-like lesion in children and adolescents

Objectives Combined ulnar shaft fracture and displaced radial head fracture in form of an atypical Monteggia-like lesion occurs very rarely in children and adolescents. Not only its surgical management remains frequently challenging, but also the injury itself happens to be often overlooked and mistreated. The purpose of this study is to evaluate both the radiological and the clinical functional outcomes under our current treatment strategy.

Methods During a period of 12 years between 2008 and 2019, a total of 17 cases of traumatic non-pathological atypical Monteggia-like lesion were treated surgically at our department, where both the ulnar shaft fracture and the displaced radial head fracture (either Judet type III or type IV) underwent closed reduction and intramedullary stabilization with a postoperative immobilization of 10 days through a long arm cast. Radiological exams were performed at cast removal, upon consolidation and before hardware removal while clinical follow-ups carried out until bone maturity.

Results and Conclusion The patients in our study cohort aged between 3.4 and 11.7 (6.5 ± 2.0) years at the time of the initial injury. In three cases that involved small children under four years old, the radial head fracture was not visible in the initial x-rays due to the not yet ossified radial head cartilage at this age and was first detected through an intraoperative arthrography. No neurovascular injury occurred intraoperatively. The consolidation period lasted 5.5 ± 1.4 weeks and the hardware removal took place after 16.6 ± 7.0 weeks. No delayed consolidation or pseudarthrosis was observed. Re-displacement of the radial head occurred in one case, which underwent closed reduction and intramedullary stabilization again. Otherwise no material failure, secondary displacement or correction loss occurred before implant removal. No premature implant removal became necessary due to infection, soft tissue irritation or subjective discomfort. In one other case, proximal radioulnar synostosis developed postoperatively, therefore a surgical resection was performed together with the hardware removal. A very satisfying Mayo Elbow Performance Score (MEPS) of 97.1 ± 5.6 was achieved, where it showed an excellent clinical functional result (MEPS > 90) in 16 cases and a good one (MEPS 75-89) in the other case.

Closed reduction with intramedullary stabilization has been shown as a valid treatment option for atypical Monteggia-like lesions with combined ulnar shaft fractures and displaced radial head fractures. In small children with not yet ossified radial head cartilage, an intraoperative arthrography is mandatory for correct diagnosis. Due to the high risk of radial head re-displacement, a short postoperative immobilization of 10 days with radiological exam at cast removal is strongly recommended. Anatomical reduction and sufficient stabilization generally lead to very promising radiological and clinical functional outcomes. Clinical follow-ups should be continued until bone maturity.

Stichwörter Atypical Monteggia-like lesion; Radial head fracture; Ulnar shaft fracture; Intramedullary stabilization; Children and adolescents

Publication History

Article published online:
15 October 2020