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Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children
Hai Li1, Qi-Xun Cai, Pin-Quan Shen
1Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China.
Insights
Surgical exploration for posterior interosseous nerve (PIN) entrapment is crucial in pediatric Monteggia fracture-dislocation, especially for Type III fractures with irreducible radial heads. Prompt neurolysis ensures complete nerve function recovery.
Area of Science:
- Pediatric Orthopedics
- Pediatric Neurosurgery
- Musculoskeletal Trauma
Background:
- Monteggia fracture-dislocation in children often involves nerve injuries, primarily neurapraxias.
- Posterior interosseous nerve (PIN) entrapment requires surgical consideration, but indications and timing remain debated.
- Understanding PIN injury pathology in this context is vital for optimal treatment strategies.
Purpose of the Study:
- To investigate the pathology of posterior interosseous nerve (PIN) injuries associated with pediatric Monteggia fracture-dislocation.
- To identify specific indications for surgical nerve exploration in these cases.
Main Methods:
- Retrospective review of eight pediatric cases with Monteggia fracture-dislocation and PIN injury managed operatively.
- All patients underwent attempted closed reduction followed by PIN exploration, open/closed reduction, and internal fixation.
- Surgical findings and post-operative nerve function recovery were analyzed.
Main Results:
- Posterior interosseous nerve (PIN) entrapment was observed acutely posterior to the radiocapitellar joint in 4 of 5 Type III Bado's fractures.
- Chronic compressive changes and epineural fibrosis were noted in cases with delayed surgery.
- All patients achieved complete nerve function recovery after microsurgical neurolysis.
Conclusions:
- Type III Monteggia fracture-dislocation with diminished PIN-innervated muscle function and irreducible radial head in children warrants immediate surgical exploration.
- This exploration is essential to rule out and address potential posterior interosseous nerve (PIN) entrapment.
- Early surgical intervention facilitates favorable nerve recovery outcomes.
Objective:
Although most of nerve injuries associated with Monteggia fracture-dislocation in children are neurapraxias and will recover spontaneously after conservative treatment, surgical exploration of the involved nerve is always required in the cases with the entrapment of posterior interosseous nerve (PIN). However, the necessity and time frame for surgical intervention for specific patterns of nerve dysfunction remains controversial. The aim of the report is to observe and understand the pathology of PIN injury associated with Monteggia fracture-dislocation in children, and to propose the possible indication for the exploration of nerve.
Methods:
Eight cases, six boys and two girls, with Monteggia fracture-dislocation complicated by PIN injury, managed operatively at the authors?Hospital from 2007 to 2008 were retrospectively reviewed. All the patients underwent the attempted closed reduction before they received exploration of PIN, with open reduction and internal fixation or successful closed reduction.
Results:
The PIN was found to be trapped acutely posterior to the radiocapitellar joint in 4 out of 5 Type III Bado's Monteggia fractures. In the remaining cases, since there were longer time intervals from injury to operation, chronic compressive changes and epineural fibrosis of radial nerve were visualized. After a microsurgical neurolysis performed, the complete recovery in the nerve function was obtained in all the cases during the follow-up.
Conclusion:
The findings from this study suggest that every case of type III Monteggia fracture-dislocation with decreased or absent function of muscles innervated by PIN and an irreducible radial head in children should be viewed as an indication for immediate surgical exploration of the involved nerve to exclude a potential PIN entrapment.
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