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Monteggia Fractures In Children: An Examination of Treatment Strategy and Outcomes

Saturday, October 20, 2012: 9:28 AM
Melrose (Hilton Riverside)
David E. Ramski, BS, BM1, William P. Hennrikus, BA2, Donald S. Bae, MD2, Keith D. Baldwin, MD, MPH, MSPT1, Neeraj M. Patel, MBS1, Peter M. Waters, MD2 and John M. Flynn, MD, FAAP1, (1)Department of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, (2)Department of Orthopaedics, Children's Hospital Boston, Boston, MA

Purpose: Despite general guidelines regarding the care of Monteggia fractures in children, risks of late instability and suboptimal clinical outcomes persist. The purpose of this study was to test the hypothesis that Monteggia fracture management should be based on the pattern of ulna fracture, using the following strategy: closed reduction and casting for plastic/incomplete and greenstick ulnar fractures, intramedullary wire fixation for transverse/short oblique fractures, and open reduction and internal fixation (ORIF) for long oblique/comminuted fractures.

Methods: 114 consecutive acute Monteggia fracture patients were analyzed from two pediatric level 1 trauma centers from 2003-2011. Ulnar fracture patterns were classified, and patients were sorted for comparison into group A and group B, depending on whether the fracture was or was not fixed according to the treatment strategy, respectively. “Failures” were defined as resubluxation/redislocation of the radial head or nonunion of the ulna; “complications” as compartment syndrome, nerve palsy, or neurapraxia requiring further surgery; “unsatisfactory outcomes” as persistent pain or loss of ROM at last contact. 

Results: During follow-up (average 23.6 weeks), 5 of 57 (8.8%) patients in group A experienced an adverse event (failure, complication or unsatisfactory outcome), compared to 11 of 57 (19.3%) adverse events in group B. Six patients exhibited either resubluxation or instability of the radiocapitellar joint (4 in group B) and 4 patients exhibited re-displacement or nonunion of the ulna (3 in group B). These failures alone revealed a 5.3% event rate in group A and 10.5% in group B. As a group, comminuted, oblique and transverse fracture patterns had a 30% (6 of 20) adverse event rate with initial non-operative treatment; greenstick or plastic deformation had a 12% (3 of 25) adverse event rate with the same treatment strategy. Of all groups, patients with a transverse fracture in group B exhibited the largest incidence of adverse events (40%). 

Conclusion: In this largest series of exclusively acute, pediatric Monteggia injuries in the orthopaedic literature, we found that a treatment strategy based on ulna stability yielded superior outcomes. Failure was twice as high in cases that were not treated according to this strategy. Transverse, short/long oblique, and comminuted ulnar fracture patterns may have a higher risk of failure without initial operative treatment.