[Monteggia lesions in the growing skeleton: principles of therapy]

In this retrospective study we analyse the methods of Monteggia lesion (ML) treatment in children used in our department. Based on the results we propose several general principals for the therapy of this complex injury to the forearm in agrowing skeleton.

The group included patients with the diagnosis of acute ML treated at our department in the 2003-2007 period. No patients in whom therapy was started later than two weeks after injury were included.

We assessed injuries according to the Bado classification system modified by Olney for young age, and also by the system based on ML stability assessment previously published by us.We evaluated the type of ulnar fracture and lesions affecting the radio-humero-ulnar joint, and the therapeutic method used. The treatment outcome was evaluated by the criteria proposed by Letts et al. for the elbow joint in children (minimal follow-up of one year). RESULTS In the five-year period, we treated 36 children with acute ML. The most frequent were patients with Bado type I equivalent lesion (61 %) and those with unstable ML (53 %).We treated 39 % of the patients conservatively and 61% by osteo-synthesis. The ;osteosynthesis of one bone was performed in 30 % (radius, 11 % ulna, 19 %) and of both bones in 31 % of the cases. The outcome assessed by the Letts score was excellent in 80 %, good in 17 % of the patients and poor in only one patient (3 %).

There is general consensus in the literature that childhood ML, if early and correctly diagnosed and correctly treated, has a good prognosis in most of the cases, in contrast to adult ML. However, the views on therapy vary from closed reduction under general anaesthesia to routine surgical exploration of the radio-humero-ulnar joint with open reduction of dislocation of the radial head and temporary radio-humeral arthrodesis. However, a unified therapeutic approach to an immature skeleton has not been proposed yet.

In the treatment of a growing skeleton, the reduction and stabilisation of an ulnar fracture is of primary concern. Only then is the management of injury to the radio-humero-ulnar joint reasonable. Any ML should always be considered on the whole. In most cases, a stable lesion is indicated for conservative treatment and an unstable one for surgical stabilisation. Apotentially unstable lesion should first be managed conservatively and, if this fails, by surgical stabilisation.