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American Association for Hand Surgery

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Missed Monteggia Fracture-Dislocation in Children: Pearls and Pitfalls of Open Reduction and Ulnar Osteotomy with Annular Ligament Reconstruction using Forearm Fascia
Ramy El-Nakeeb, MD, El Hadara university Hospitals, Alexandria, Egypt

Background: Missed radiocapitellar dislocation is a complication of Monteggia fracture. Children usually present with a swelling on the anterior aspect of the elbow. If left untreated they may present with limited elbow flexion and forearm rotation, progressive cubitus valgus, and pain. Surgical treatment is recommended to avoid such complications and to improve long-term function.
Patients and Methods: Ten children with chronic Monteggia lesions were treated with open reduction, annular ligament reconstruction with the fascia of the forearm, and ulnar osteotomy. The left elbow was involved in 6 patients, the right in 4 patients. Mean age at presentation was 6 years (range 3 years 7 months to 10 years), six cases were classified as Bado type I, four cases as Bado type III lesion. The interval between injury and surgery ranged from 3 months to 2 years (mean 8.5 months). Mean follow-up was 2 years 8 months.Pearls, pitfalls, and functional results of open reduction and ulnar osteotomy with annular ligament reconstruction using forearm fascia are presented.
Results: The range of flexion was not affected in any case, range of extension improved in 2 cases and decreased by 15 degrees in one case who had postoperative radial head subluxation and was revised and corrected. Both pronation and supination were affected in 2 patients, they lost 10 and 20 degrees of pronation and 15 and 25 degrees of supination respectively. One patient had 15 degrees of supination loss with full pronation and 2 patients lost 10 and 20 degrees of supination with full pronation. All osteotomies united within 6 to 8 weeks. At the final follow-up, the radiocapitellar joint was reduced in all cases.
Conclusion: Operative intervention is the treatment of choice in cases of missed Monteggia fracture-dislocation as cases treated conservatively, with late radial head excision has a high complication rate. Meticulous execution of open reduction, ulnar osteotomy with annular ligament reconstruction using forearm fascia with avoidance of pitfalls yields good results with a functional range of motion.


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