Surgical Management of Neglected Monteggia Fractures in Children
Sergio Martínez-Álvarez1, María Galán-Olleros1, Paula Arias-Martínez2
1Department of Orthopaedic Surgery and Traumatology, Pediatric Orthopaedics Hospital Infantil Universitario Niño Jesús, Madrid, Spain.
Insights
Surgical treatment for neglected pediatric Monteggia fractures (NMF) is effective, with open radial head reduction and selective procedures yielding excellent outcomes. Preoperative ulnar bow measurement predicts the need for osteotomy, aiding surgical planning.
Area of Science:
- Pediatric Orthopedics
- Pediatric Trauma Surgery
- Pediatric Upper Extremity Surgery
Background:
- Neglected Monteggia Fractures (NMF) in children often result from initial misdiagnosis.
- These fractures can lead to persistent pain, joint instability, and impaired function.
- Optimal surgical management strategies for pediatric NMF remain a subject of debate.
Purpose of the Study:
- To evaluate the surgical outcomes of treating pediatric NMF.
- To identify prognostic factors influencing treatment decisions and outcomes in pediatric NMF.
- To assess the effectiveness of open reduction of the radial head with adjunctive procedures.
Main Methods:
- A retrospective review of pediatric patients (<14 years) treated for NMF (>4 weeks postinjury) between 2010 and 2024.
- Surgical interventions included open radial head reduction, with or without ulnar osteotomy, annular ligament reconstruction (ALR), or temporary radiocapitellar fixation (TRCF).
- Outcomes were measured using the Mayo Elbow Performance Index (MEPI); preoperative maximum ulnar bow (MUB) was analyzed as an osteotomy predictor.
Main Results:
- Twenty-seven pediatric patients were included, with a median surgery delay of 73 days.
- Excellent or good MEPI scores were achieved in all patients, with only four reported complications.
- A preoperative MUB magnitude of ≥3.45 mm significantly predicted the need for ulnar osteotomy (P=0.03).
Conclusions:
- Open radial head reduction, with judicious use of ulnar osteotomy, ALR, or TRCF, provides effective treatment for pediatric NMF.
- Preoperative MUB measurement offers a practical tool for surgical planning, predicting osteotomy necessity.
- Delayed surgical intervention did not negatively impact functional outcomes in this cohort.
Introduction:
Neglected Monteggia Fractures (NMF) in children typically result from missed diagnoses at initial assessment, and may lead to pain, instability, and functional impairment. The optimal treatment strategy remains controversial. This study evaluates surgical outcomes and prognostic factors in pediatric NMF.
Method:
A retrospective review was conducted of children under 14 years treated for NMF (>4 weeks postinjury) from 2010 to 2024 at a tertiary pediatric referral center, with a minimum follow-up of 12 months. All patients underwent open reduction of the radial head, with or without ulnar osteotomy, annular ligament reconstruction (ALR), or temporary radiocapitellar fixation (TRCF). Outcomes were assessed using the Mayo Elbow Performance Index (MEPI), and preoperative maximum ulnar bow (MUB) was analyzed as a predictor of osteotomy.
Results:
Twenty-seven patients (16 boys, 11 girls; median age 6.5 years) were included. The median time to surgery was 73 days (51 to 220.5). Ulnar osteotomy was performed in 14 cases, ALR in 12, and TRCF in 12. The median MUB was -4.5 mm, most commonly located in the proximal third (57.7%). A significant association was found between MUB magnitude and the need for osteotomy ( P =0.03), with a predictive threshold of -3.45 mm. Time to surgery was not associated with surgical complexity ( P =0.59) or poorer outcomes ( P =0.85). MEPI scores were excellent in 22 cases and good in 5, with no poor outcomes. Four complications were reported.
Conclusion:
Open reduction of the radial head, with selective use of ulnar osteotomy, ALR, or TRCF, is effective for treating pediatric NMF. A preoperative MUB ≥3.45 mm was predictive of the surgeon's decision to perform osteotomy, offering a practical parameter for surgical planning. Delayed intervention did not adversely affect outcomes.
Level Of Evidence:
Level IV-retrospective case series.
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