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Monteggia type IV fracture in a child with radial head dislocation irreducible by closed means: a case report.

Ha T, Grant S, Huntley JS - BMC Res Notes (2014)

Bottom Line: We present the case of a 3-year-old Caucasian boy who attended the emergency department following an un-witnessed fall, resulting in right elbow and forearm pain, swelling and deformity.After failed attempts at closed reduction, open reduction of the radial head was required.The block to reduction was due to a buttonholing of the radial head through the anterior joint capsule, with interposition of the capsule in the radiocapitellar joint.Accurate reduction of the radiocapitellar joint is crucial to prevent significant long-term consequences and failed closed reduction requires open reduction.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, Royal Hospital for Sick Children, Dalnair Street, Yorkhill, Glasgow G3 8SJ, UK. james.huntley@glasgow.ac.uk.

ABSTRACT

Background: Fractures of the proximal third of the ulna and radius with associated anterior radial head dislocation are uncommon in children. Early recognition and appropriate management are essential to prevent long-term consequences of loss of forearm rotation, cubitus valgus, elbow instability and chronic pain.

Case presentation: We present the case of a 3-year-old Caucasian boy who attended the emergency department following an un-witnessed fall, resulting in right elbow and forearm pain, swelling and deformity. Clinical and radiological examination revealed a Monteggia type IV fracture-dislocation.The patient was treated with closed manipulation and percutaneous fixation of both bone forearm fractures with intra-medullary wires. After failed attempts at closed reduction, open reduction of the radial head was required.The block to reduction was due to a buttonholing of the radial head through the anterior joint capsule, with interposition of the capsule in the radiocapitellar joint. Subsequently, alignment was maintained with fracture healing. Follow-up at five months showed a full range of elbow movement with no adverse symptoms.

Conclusion: Monteggia lesions of the paediatric elbow, albeit uncommon, should be considered in all forearm fractures. Accurate reduction of the radiocapitellar joint is crucial to prevent significant long-term consequences and failed closed reduction requires open reduction. Here we have described the management of a rare type IV lesion in which there was buttonholing of the radial head through the anterior capsule, causing the radiocapitellar dislocation to be irreducible (even after fixation of the radial and ulnar fractures).

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8 weeks post-operative radiographs demonstrating union of both radius and ulnar shaft fractures with successful maintenance of radiocapitellar joint reduction.
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Fig4: 8 weeks post-operative radiographs demonstrating union of both radius and ulnar shaft fractures with successful maintenance of radiocapitellar joint reduction.

Mentions: There was deformity of the right forearm with a small abrasion over the proximal ulna. His peripheral pulses and capillary refill time were normal. However, the patient was upset and uncooperative and therefore the neurological status of the affected limb was impossible to assess comprehensively. There was no history of previous fractures, dislocations or any medical conditions.Initial radiographs showed diaphyseal fractures of both radius and ulna (Figure 1). After immobilisation, further radiographs of the elbow revealed a Bado type IV Monteggia lesion – fractures of both radius and ulna with an associated anterior dislocation of the radial head (Figure 2).The following day, the injury was treated with manipulation of the forearm fractures under general anaesthesia (Figure 3a). Closed reduction of the forearm fractures was unsuccessful at reducing the radiocapitellar joint (RCJ) dislocation so a 2 cm radial incision was made over the distal radius and a 2 mm titanium elastic nail (TEN) was inserted under X-ray image intensifier (XRII) guidance across the radial fracture site. Despite successful reduction of the radial fracture, the RCJ remained dislocated (Figure 3b). A 2 mm Kirschner wire (K-wire) was then inserted across the ulnar fracture site via the olecranon apophysis (Figure 3c), but again the RCJ was not reducible. A decision was made to carry out an open reduction of the RCJ. A posterolateral approach revealed a radial head which had buttonholed through the capsule, associated with a ruptured annular ligament. The capsule was also found interposed within the joint and these findings explained the failed attempts at closed reduction.The interposed tissue was freed from the joint, the radial head reduced and the position confirmed using XRII. Reducing the radial head in this case required placement of two McDonald retractors along the radial neck, through the buttonhole in the capsule and then at right angles to each other (one around the radial head in the axial plane and one over the radial head proximally in the sagittal plane). Using these two levers, the radial head was brought back through the buttonhole, clearing the obstructing capsular mass from the articulation. The RCJ reduced and was then stable throughout a full range of movement. The annular ligament was reconstructed and the forearm immobilised in an above elbow cast in flexion and mid-supination (Figure 3d).Follow-up at one week showed no change in alignment of the RCJ and no neurovascular abnormalities. In particular, there was normal posterior interosseous nerve (PIN) function with extension of all fingers at the metacarpo-phalangeal joints. He remained in cast until his six week follow-up where radiographs showed normal radiocapitellar alignment and ongoing fracture healing, at which point he was fitted with a below elbow cast. Follow-up at eight weeks showed satisfactory radiographic union and maintenance of reduction and his cast was removed (Figure 4). He had full range of movement at his right elbow and had wire removal from both radius and ulna under general anaesthesia 12 weeks following the injury. Follow-up at five months demonstrated full range of elbow movement and no adverse symptoms.Figure 1


Monteggia type IV fracture in a child with radial head dislocation irreducible by closed means: a case report.

Ha T, Grant S, Huntley JS - BMC Res Notes (2014)

8 weeks post-operative radiographs demonstrating union of both radius and ulnar shaft fractures with successful maintenance of radiocapitellar joint reduction.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4150939&req=5

Fig4: 8 weeks post-operative radiographs demonstrating union of both radius and ulnar shaft fractures with successful maintenance of radiocapitellar joint reduction.
Mentions: There was deformity of the right forearm with a small abrasion over the proximal ulna. His peripheral pulses and capillary refill time were normal. However, the patient was upset and uncooperative and therefore the neurological status of the affected limb was impossible to assess comprehensively. There was no history of previous fractures, dislocations or any medical conditions.Initial radiographs showed diaphyseal fractures of both radius and ulna (Figure 1). After immobilisation, further radiographs of the elbow revealed a Bado type IV Monteggia lesion – fractures of both radius and ulna with an associated anterior dislocation of the radial head (Figure 2).The following day, the injury was treated with manipulation of the forearm fractures under general anaesthesia (Figure 3a). Closed reduction of the forearm fractures was unsuccessful at reducing the radiocapitellar joint (RCJ) dislocation so a 2 cm radial incision was made over the distal radius and a 2 mm titanium elastic nail (TEN) was inserted under X-ray image intensifier (XRII) guidance across the radial fracture site. Despite successful reduction of the radial fracture, the RCJ remained dislocated (Figure 3b). A 2 mm Kirschner wire (K-wire) was then inserted across the ulnar fracture site via the olecranon apophysis (Figure 3c), but again the RCJ was not reducible. A decision was made to carry out an open reduction of the RCJ. A posterolateral approach revealed a radial head which had buttonholed through the capsule, associated with a ruptured annular ligament. The capsule was also found interposed within the joint and these findings explained the failed attempts at closed reduction.The interposed tissue was freed from the joint, the radial head reduced and the position confirmed using XRII. Reducing the radial head in this case required placement of two McDonald retractors along the radial neck, through the buttonhole in the capsule and then at right angles to each other (one around the radial head in the axial plane and one over the radial head proximally in the sagittal plane). Using these two levers, the radial head was brought back through the buttonhole, clearing the obstructing capsular mass from the articulation. The RCJ reduced and was then stable throughout a full range of movement. The annular ligament was reconstructed and the forearm immobilised in an above elbow cast in flexion and mid-supination (Figure 3d).Follow-up at one week showed no change in alignment of the RCJ and no neurovascular abnormalities. In particular, there was normal posterior interosseous nerve (PIN) function with extension of all fingers at the metacarpo-phalangeal joints. He remained in cast until his six week follow-up where radiographs showed normal radiocapitellar alignment and ongoing fracture healing, at which point he was fitted with a below elbow cast. Follow-up at eight weeks showed satisfactory radiographic union and maintenance of reduction and his cast was removed (Figure 4). He had full range of movement at his right elbow and had wire removal from both radius and ulna under general anaesthesia 12 weeks following the injury. Follow-up at five months demonstrated full range of elbow movement and no adverse symptoms.Figure 1

Bottom Line: We present the case of a 3-year-old Caucasian boy who attended the emergency department following an un-witnessed fall, resulting in right elbow and forearm pain, swelling and deformity.After failed attempts at closed reduction, open reduction of the radial head was required.The block to reduction was due to a buttonholing of the radial head through the anterior joint capsule, with interposition of the capsule in the radiocapitellar joint.Accurate reduction of the radiocapitellar joint is crucial to prevent significant long-term consequences and failed closed reduction requires open reduction.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, Royal Hospital for Sick Children, Dalnair Street, Yorkhill, Glasgow G3 8SJ, UK. james.huntley@glasgow.ac.uk.

ABSTRACT

Background: Fractures of the proximal third of the ulna and radius with associated anterior radial head dislocation are uncommon in children. Early recognition and appropriate management are essential to prevent long-term consequences of loss of forearm rotation, cubitus valgus, elbow instability and chronic pain.

Case presentation: We present the case of a 3-year-old Caucasian boy who attended the emergency department following an un-witnessed fall, resulting in right elbow and forearm pain, swelling and deformity. Clinical and radiological examination revealed a Monteggia type IV fracture-dislocation.The patient was treated with closed manipulation and percutaneous fixation of both bone forearm fractures with intra-medullary wires. After failed attempts at closed reduction, open reduction of the radial head was required.The block to reduction was due to a buttonholing of the radial head through the anterior joint capsule, with interposition of the capsule in the radiocapitellar joint. Subsequently, alignment was maintained with fracture healing. Follow-up at five months showed a full range of elbow movement with no adverse symptoms.

Conclusion: Monteggia lesions of the paediatric elbow, albeit uncommon, should be considered in all forearm fractures. Accurate reduction of the radiocapitellar joint is crucial to prevent significant long-term consequences and failed closed reduction requires open reduction. Here we have described the management of a rare type IV lesion in which there was buttonholing of the radial head through the anterior capsule, causing the radiocapitellar dislocation to be irreducible (even after fixation of the radial and ulnar fractures).

Show MeSH
Related in: MedlinePlus