Missed Monteggia fractures in children – the current state of the problem: A systematic review

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Abstract

BACKGROUNG: A situation in which despite an obvious ulnar fracture, radial head dislocation is not diagnosed, resulting in a missed Monteggia fracture is not uncommon. Unsatisfactory results of the treatment of this pathology have prompted several researchers to search for an optimal treatment strategy.

AIM: This study aimed to conduct a systematic review of literature data on missed Monteggia fractures and dislocations in children by studying the main therapeutic and tactical approaches to this problem.

MATERIALS AND METHODS: A literature search was conducted in the Cochrane Database, Science Direct, Google Scholar, PubMed, and eLibrary information bases, and the search depth was 10 years. Moreover, 46 sources were selected based on the criteria. The main characteristics revealing the problem were identified, divided into four semantic groups, according to which the literature was analyzed: initial data on the condition of patients at the time of seeking medical help, status before and after treatment, and treatment methods.

RESULTS: The average age of the children was 8.4 years. The average interval from injury to the surgical treatment of missed Monteggia fracture was 15.3 months, and 883 clinical cases presented in sources with known treatment techniques were analyzed. Thus, open reduction of the radial head in combination with the restoration or reconstruction of the annular ligament and ulnar osteotomy is one of the most common methods (n = 482, 54.6%). The second most frequent application was the above-described approach, but without manipulations on the annular ligament (n = 273, 30.9%). Bone osteosynthesis and external fixation apparatus were the most widely used stabilization methods in 350 (67.8%) and 149 (28.9%), respectively. The most common complications were associated with the deterioration of the functional status after surgery.

CONCLUSIONS: Accurate diagnosis of injury and early correction of existing disorders is the key to reducing the frequency of missed Monteggia fractures. Surgical treatment is the main method of treating children with this injury, in which the restoration of the ulnar anatomy and the ratios in the brachial and proximal radiocarpal joints are the most important, providing a more physiological development of the segment with the growth of the child.

About the authors

Aigul R. Gubaeva

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: little1ashley3@yandex.ru
ORCID iD: 0000-0002-7056-4923

MD, Resident

Russian Federation, Saint Petersburg

Vyacheslav I. Zorin

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery; North-Western State Medical University named after I.I. Mechnikov

Author for correspondence.
Email: zoringlu@yandex.ru
ORCID iD: 0000-0002-9712-5509
SPIN-code: 4651-8232

MD, PhD, Cand. Sci. (Med.), Assistant Professor

Russian Federation, Saint Petersburg; Saint Petersburg

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Supplementary files

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2. Fig. 1. Classification of Monteggia damage according to Bado: and type I, anterior radial head dislocation with associated ulnar shaft fracture and an anterior angle of inclination; type II, posterior radial head dislocation with an associated ulnar fracture with posterior angulation; type III, lateral or anterolateral radial bone head dislocation associated with an ulnar metaphyseal fracture; type IV, anterior radial head dislocation with radial and the ulnar bone fractures within the proximal third at the same level

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3. Fig. 2. Pediatric classification of Monteggia fracture dislocation according to Letts: type A, radial bone head dislocation with plastic deformity of the ulnar bone shaft; type B, anterior radial bone head dislocation with a fracture of the ulnar bone shaft; type C, complete fracture of the ulnar bone shaft and anterior radial bone head dislocation; type D, posterior radial head dislocation with associated fracture of the ulnar shaft with posterior angulation; type E, lateral, or anterolateral radial bone head dislocation associated with a fracture of the ulnar bone metaphysis

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4. Fig. 3. Study design

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5. Fig. 4. Structure of patients by types of Monteggia injuries according to the Bado classification

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6. Fig. 5. Structure and frequency of implementation of the surgical approach (%). CR, closed reduction of the radial bone head; OR, open reduction of the radial bone head; UO, ulnar bone osteotomy; RO, radial bone osteotomy; TF, transcapitellar fixation; AL, restoration/reconstruction/excision of the annular ligament; EFD, external fixation device

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7. Fig. 6. Approach in relation to the annular ligament in the surgical treatment of neglected Monteggia injuries

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8. Fig. 7. The structure of complications of the surgical treatment of neglected Monteggia injuries

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Copyright (c) 2023 Gubaeva A.R., Zorin V.I.

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