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Modified surgical technique for missed Monteggia lesions

Monteggia fractures are fairly common in children between 4 and 10 years old, but signs of the initial injury are often missed on x-ray. Misdiagnosis leads to continued pain and limited range of motion. In the longer term, the patient may develop elbow instability, neurological problems, and deformity.

Numerous surgical techniques have been advocated to reconstruct long-standing Monteggia injures in order to maximize long-term upper limb function. Surgeons in the Boston Children’s Hospital Hand and Orthopedic Upper Extremity Program, led by Donald S. Bae, MD, recently reported results of a modified surgical technique for missed Monteggia fracture-dislocations.

The modified technique, described in detail in a study published in the Journal of Pediatric Orthopaedics, includes careful identification and protection of the radial nerve to reduce the risk of nerve injury. If ulna correction is required, rigid fixation helps prevent recurrent displacement of the radial head. Another element, annular ligament repair or reconstruction, further maximizes the chance of long-term elbow stability and function.

Following the procedure, patients demonstrated improved elbow flexion and range of motion in the elbow and forearm. The study reported significant improvements in elbow flexion and forearm supination. Congruent radiocapitellar alignment was maintained in 75 percent of the patients studied.

The importance of early detection and treatment

While this study demonstrated that the vast majority of patients do well after reconstruction, timely and accurate diagnosis of acute Monteggia fractures remains the best way to restore upper arm function. To this end, a high index of suspicion and a careful, systematic approach to radiographic evaluation is encouraged anytime a patient presents with a proximal ulnar fracture, particularly if the patient is a young child.

When treating chronic Monteggia lesions, surgeons should be aware of the possibility that the shape of a dislocated radial head could change as the child grows. Therefore, even if the patient’s symptoms are mild, there may be a finite window of opportunity to reconstruct a missed Monteggia lesion and prevent long-term disability.

Article referenced

ET Zheng, PM Waters, CB Vuillermin, K Williams, DS Bae, Surgical Reconstruction of Missed Monteggia Lesions in Children. Journal of Pediatric Orthopaedics, Nov/Dec 2020;40(10).