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Missed Pediatric Monteggia Fractures

James Hubbard, MD Abstract
» Careful scrutiny of radiographs is important in the assessment of
Aakash Chauhan, MD, MBA
pediatric elbow injuries. Disruption of the radiocapitellar line and an
Ryan Fitzgerald, MD increased bow of the posterior ulnar border are sometimes subtle
signs of a Monteggia injury.
Reid Abrams, MD
Scott Mubarak, MD » An attempt at closed reduction up to 4 weeks after injury has been
cited in the literature as successfully treating some missed injuries.
Mark Sangimino, MD
» Operative reduction of chronic radial-head dislocation provides good
to excellent range of motion and functional outcome in the setting of
Investigation performed at the Division irreducible chronic radial-head dislocation.
of Hand, Upper Extremity, and
Microvascular Surgery, Department of » Ulnar osteotomy and correction of the ulnar deformity component of
Orthopaedic Surgery, University of the missed Monteggia injury are the key to indirect anatomic
California, San Diego (UCSD), San reduction of the radiocapitellar joint.
Diego, California
» Supplemental procedures aimed at increasing the stability of the
radiocapitellar joint (e.g., annular ligament reconstruction, radiocapitellar
Kirschner wire fixation, radioulnar Kirschner wire fixation) should be
directed by a thorough assessment of radiocapitellar stability following
ulnar osteotomy and correction of the ulnar deformity.

Background and Epidemiology scenario, exposing the patient to potential

F
irst described by Giovanni
Monteggia in 1814, the epony-
mous Monteggia lesion
describes a fracture of the ulna
associated with dislocation of the radio-
capitellar joint and disruption of the prox-
imal radioulnar joint1. These are rare
injuries in children, constituting ,1% of
all pediatric forearm fractures with an
annual incidence of ,1:100,0002. When
the Monteggia lesion is identified in the
acute setting and is treated with stable
anatomic reduction of the ulna and radio-
capitellar joint, long-term outcomes are
generally excellent1,3,4. However, 16% to
50% of these injuries are missed at initial
presentation, with reasons cited being
inadequate radiographs, subtle greenstick
fractures of the ulna, and the complexity of
evaluating the pediatric elbow with its
multiple ossification centers3-6. A missed
diagnosis presents a challenging clinical
morbidity and increasing the complexity of
management for the treating surgeon as early
as 2 weeks after the initial injury. Morbidity
is primarily associated with persistent dislo-
cation of the radioulnar and radiocapitellar
joints and includes restricted elbow motion,
particularly in flexion and pronation7, pro-
gressive valgus deformity and valgus insta-
bility8, pain, degenerative arthritis9, and
tardy ulnar and radial nerve palsies10-12.
Anatomy
The elbow consists of 3 articulations: the
ulnohumeral joint, the radiocapitellar
joint, and the proximal radioulnar joint.
The annular ligament and the quadrate
ligament are the primary static stabilizers of
the proximal radioulnar joint. Other liga-
mentous structures that play an ancillary
role in stability of the proximal radioulnar
joint include the oblique cord (or Weit-
brecht ligament), present in 52.6% of

COPYRIGHT © 2018 BY THE Disclosure: There was no source of external funding for this study. The Disclosure of Potential
JOURNAL OF BONE AND JOINT Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/
SURGERY, INCORPORATED JBJSREV/A344).

JBJS REVIEWS 2018;6(6):e2 · http://dx.doi.org/10.2106/JBJS.RVW.17.00116 1

 | Missed Pediat r ic Monteg g ia Fractures
forearms, which originates just distal to
the radial notch on the ulna and inserts
distal to the bicipital tuberosity on the
radius13, and the interosseous mem-
brane originating on the radial aspect of
the ulna and inserting on the ulnar
aspect of the radius. These structures
are most taut in supination as a function
of the shape of the radial head and the
bow of the radius. The radial head is
elliptical in axial cross-section, with the
long axis of the ellipse perpendicular to
the radial notch of the ulna in supina-
tion14. This functions to maximally
tension the annular ligament as well as
the thick anterior portion of the quad-
rate ligament in supination.
Classification and Mechanism
of Injury
The Bado classification of Monteggia
fracture-dislocations is the most com-
monly used and describes 4 types of
ulnar fracture patterns with the associ-
ated direction of radial-head disloca-
tion4 (Table I). Type-I injuries are the
most common fracture-dislocation pat-
tern seen in children, representing 75%
of acute pediatric Monteggia injuries15.
Accordingly, type-I lesions represent
approximately 85% of pediatric Mon-
teggia lesions in case series describing
chronic missed injuries7,9,11,12,16-35.
Predictably, the mechanism of
injury varies with the direction of frac-
ture and dislocation. There are several
proposed mechanisms by which type-I
lesions are produced, with the most
accepted being the hyperextension
theory proposed by Tompkins36. He
proposed that type-I injuries likely
result from a patient falling with for-
ward momentum onto an outstretched
arm resulting in hyperextension of the
elbow. This hyperextension produces
reflexive contracture of the biceps bra-
chii, resulting in anterior dislocation of
the radial head. The radius normally
bears 80% of the load transmitted
through the carpus to the forearm, and
when the radial head dislocates, the
ulna becomes the primary load-bearing
structure in the forearm. The ulna is not
equipped to bear the full weight of the
2 JUNE 2018
TABLE I The Letts Classification for Pediatric Monteggia Injuries
and the Bado Classification for Monteggia Injuries
Classification Description
Letts classification
Type A* Anterior radial-head dislocation and apex-anterior
plastic ulnar deformation
Type B* Anterior radial-head dislocation and apex-anterior
greenstick ulnar fracture
Type C* Anterior radial-head dislocation and complete ulnar
fracture
Type D† Similar to Bado type II
Type E‡ Lateral radial-head dislocation and greenstick
fracture of ulna
Bado classification
Type I* Anterior radial-head dislocation and apex anterior
ulnar fracture
Type II† Posterior radial-head dislocation and apex posterior
ulnar fracture
Type III‡ Lateral radial-head dislocation and apex lateral
ulnar fracture
Type IV§ Dislocation of radial head in any direction and ulnar
and radial-shaft fractures
*Letts types A, B, and C represent Bado type-I pattern injuries with anterior dis-
location of the radial head and increasing degrees of completeness of the ulnar
fracture. †Letts type-D injuries represent the classical Bado type-II pattern. ‡Letts
type-E lesions represent Bado type-III injuries with a greenstick fracture rather than
a compete fracture of the ulna. §Bado type-IV injuries do not have a corresponding
type in the Letts classification.
falling patient and subsequently fails are resultant of a hyperpronation
anteriorly in tension with the fracture mechanism4.
propagating in shear, resulting in the Letts et al. subsequently adapted the
classical apex-anterior short-oblique Bado classification with a system more
fracture of the ulna seen in Bado type-I specific to pediatric injuries, describing 5
injuries. Type-II injuries are proposed fracture patterns, types A to E37 (Table I).
to be the result of a fall onto an out- Importantly, their classification recog-
stretched hand with the elbow in nizes the tendency of pediatric long bone
approximately 60° of flexion. This injuries to result in plastic deformation
results in longitudinal loading of the rather than complete fracture as seen in
forearm parallel to the long axis of the the adult population and identifies radial-
radius and ulna, and subsequent pos- head dislocation in the absence of a
terior dislocation of the elbow or, if the complete ulnar fracture as representing a
ulna is weaker than the surrounding Monteggia equivalent. It has subse-
capsuloligamentous structures, a Bado quently been recognized that a truly iso-
type-II injury15. Type-III injuries are lated traumatic radial-head dislocation is
thought to result from a forced varus likely an exceedingly rare injury and that,
stress resulting in failure of the proximal on close inspection, one can usually
part of the ulna in varus and lateral or identify an ulnar injury in even the most
anterolateral dislocation of the radial subtle cases38.
head15. Type-IV injuries have little
description of mechanism of injury in Natural History
the literature; however, in Bado’s initial The natural history of Monteggia injuries
description, he hypothesized that they is largely secondary to chronic radial-head
· VOLUME 6, ISSUE 6 · e2
 Missed Pediatr ic Monteg gia Fractures |

dislocation, as the ulnar component of the
fracture will commonly heal and remodel
as the child ages. With the initial disloca-
tion of the radial head, the annular liga-
ment and associated anterior capsular
structures fall posterior to the radial
head and into the radiocapitellar joint,
calcifying over time and providing a
block to anatomic reduction39,40. With
longer durations of radial-head dislo-
cation, the radial head, capitellum, and
radial notch of the ulna have been noted
to undergo dysplastic changes3,39-41.
The dislocated radial head hypertro-
phies and the normally concave artic-
ular surface becomes convex. The
capitellum is also reported to lose its
normal contour, demonstrating a flat-
tened appearance39,40. Kim et al. dem-
onstrated that these dysplastic changes
may present as early as 3 months after
radial-head dislocation39.
With the loss of the radiocapitellar
articulation, the elbow loses approxi-
mately 33% of its valgus stability42, and
patients demonstrate instability and an
increase in the valgus carrying angle of the
elbow39. This has been reported to con-
tribute to late ulnar nerve palsy in rare
cases43. Tardy median and posterior
interosseous nerve palsies have also been
described secondary to tenting of the
nerve over the dislocated radial head10,43.
The loss of the normal anatomic rela-
tionships of the radiocapitellar joint and
proximal radioulnar joint results in the
loss of normal range of motion, the
development of contractures, and
abnormal loading of these joints, ulti-
mately resulting in late osteoarthritis9,12.
Diagnosis
Patients may present with a history of
remote elbow injury, persistent pain,
decreased elbow motion, limited func-
tion, a fullness in the antecubital
space26, and, rarely, progressive cubitus
valgus deformity. An examination of the
full range of motion at the elbow
including flexion, extension, pronation,
and supination should be undertaken as
these patients often present with limited
range of motion15. A full distal neuro-
vascular examination should also be
performed as posterior interosseous,
anterior interosseous, and ulnar nerve
palsies have been reported in cases of
chronic radial-head dislocation10,43.
Standard orthogonal radiographs
of the injured elbow should be obtained
and inspected for radiocapitellar joint

Fig. 1
Figs. 1-A through 1-D Missed Monteggia injury. (Reproduced, with permission, from San Diego Pediatric Orthopedics [SD PedsOrtho].) A 9-year-old,
right-hand-dominant boy fell onto the outstretched left forearm while skateboarding. He was evaluated by an outside facility where he was treated in a long
arm cast for elbow pain for 6 weeks. The long arm cast was discontinued afterwards, and the patient continued to report elbow stiffness and limited motion.
He was treated with activity modifications and physical therapy with no improvement. Fig. 1-A He was then eventually evaluated by another outside
orthopaedic surgeon who recognized a missed Monteggia injury 11 months after the initial injury on a lateral radiograph. Fig. 1-B The patient was then
referred for pediatric orthopaedic surgery evaluation and was evaluated 12 months after the initial injury, again with the radiograph demonstrating an
anterior radial-head dislocation consistent with a missed Monteggia injury. Figs. 1-C and 1-D Full-length lateral radiographs of the bilateral forearms
demonstrate a positive ulnar bow sign (denoted by an asterisk) of the left proximal part of the ulna (Fig. 1-C) compared with the right side (Fig. 1-D). As seen
in Figures 1-A and 1-B, the anterior radial-head dislocation is clearly noted on initial and follow-up injury radiographs as the radiocapitellar line is not colinear.

JUNE 2018 · VOLUME 6, ISSUE 6 · e2 3

 | Missed Pediat r ic Monteg g ia Fractures
congruity. Images should be scrutinized
by a practitioner with experience in
reading pediatric elbow radiographs.
The complexity of the pediatric elbow
with its numerous ossification centers
has been cited as a potential reason for
why Monteggia injuries are not diag-
nosed in the acute setting among emer-
gency room physicians and junior
orthopaedic residents6. Given the vari-
able radiographic appearance of the
pediatric elbow depending on the
patient’s age, images of the contralateral
elbow may be useful in children ,10
years of age as a reference for the child’s
normal anatomy. Radiocapitellar joint
congruity is assessed on a true lateral
radiograph of the elbow (Figs. 1-A and
1-B). A line called the radiocapitellar line
or, eponymously, the Storen line is
drawn from the center of the radial neck,
through the radial head and capitel-
lum44. If the radiocapitellar joint is
congruent, the radiocapitellar line
should bisect the capitellum in all
degrees of flexion and extension of the
elbow15. Elbow radiographs should also
be assessed for radial-head hypertrophy
with loss of its convex articular surface,
as well as dysplastic flattening of the
capitellar articular surface. Radial-head
hypertrophy is assessed via the head-
neck ratio on a lateral radiograph of the
elbow. The diameter of the radial head is
measured at the widest portion of the
metaphysis adjacent to the physis, and
the diameter of the radial neck is mea-
sured at the narrowest portion of the
neck, just proximal to the bicipital
tuberosity. Radial-head hypertrophy is
present if the head-neck ratio is .1.539.
Radiographs of the forearm should
be obtained to assess for plastic deformity
of the ulna. On a true lateral radiograph of
the elbow, the posterior border of the ulnar
diaphysis should be a straight line. In Lin-
coln and Mubarak’s method (the ulnar
bow sign), they drew a line tangential to the
posterior border of the ulna in both healthy
controls and patients with known radial-
head dislocation (Figs. 1-C and 1-D). They
then measured the maximum perpendic-
ular distance of this line from the ulnar
shaft and determined that this distance
4 JUNE 2018
should be ,2 to 3 mm in the uninjured
ulna, and that deviation greater than this in
the setting of radial-head dislocation rep-
resented a likely traumatic etiology and
mild Monteggia equivalent injury38.
Radiographs of the contralateral forearm
provide a useful comparison in attempting
to identify subtle injuries and should also
be obtained.
Treatment
Treatment of the pediatric Monteggia
injury is ideally performed in the acute
setting. The preferred method of treat-
ment in the acute setting is closed
reduction and long arm casting in supi-
nation with a focus on anatomic ulnar
reduction guiding reduction of the ra-
diocapitellar joint. As early as 2 weeks
after injury, attempts at closed reduction
may be met with failure11. However, in
the subacute setting, for patients pre-
senting up to 4 weeks after their initial
injury, closed reduction may be suc-
cessful in maintaining stable reduction
of the radiocapitellar joint7. No defini-
tive interval from initial injury to treat-
ment has been established beyond which
an attempt at closed reduction has been
deemed futile; however, most authors
describe a .4-week delay in treatment
as representing a chronic Monteggia
lesion that is no longer amenable to
closed reduction21,27,28,33,45,46. Opera-
tive treatment has become the gold
standard for the management of these
injuries; myriad techniques and opin-
ions exist in the current literature with
regard to how to best approach the
chronic missed Monteggia injury. We
provide a review of this literature below.
Nonoperative Treatment
Recent literature has described a limited
role for nonoperative management in
the setting of chronic Monteggia lesions.
A review of the literature provides his-
torical context for the evolution of and
rationale for modern surgical manage-
ment. There is often a delay in the pre-
sentation of symptoms, which
previously led some authors to believe
that chronic radial-head dislocation was
largely asymptomatic. Blount advised
no treatment in the setting of radial-head
dislocations that have been present for
.3 months as he believed that the
postoperative loss of elbow function was
a greater hindrance than the instability
associated with a chronically dislocated
radial head47. It has since been noted
that, with increasing functional
demands on the elbow as patients age,
patients can be expected to experience
increasing pain, deformity, and unsat-
isfactory range of motion39.
Operative Treatment
Operative treatment of missed Mon-
teggia lesions has been undertaken in
cases in which the radiocapitellar joint
cannot be maintained in a reduced state
by closed means. Specific indications
include loss of function, progressive
deformity, decreased range of motion,
and increased pain in the affected
elbow24,30,48-50. Several authors have
suggested operative intervention as soon
as the missed lesion has been identified,
as the duration of neglect has corre-
sponded with worse outcomes23,39.
Contraindications to operative reduc-
tion have been described on the basis of
the duration of radial-head dislocation
and patient age at the time of surgical
intervention. The most commonly cited
criteria for surgical intervention are a
duration of radial-head dislocation of
,3 years and patient age of ,12
years12,51. Nakamura et al. evaluated 22
patients undergoing open reduction of
the radial head with ulnar correction
osteotomy and annular ligament recon-
struction with a mean follow-up of 7
years. Interestingly, those patients who
were $12 years old at the time of the
surgical procedure and also had a delay of
treatment of $3 years had an 88% rate
of radial-head subluxation or osteoar-
thritic changes12. Conversely, reduction
of the radial head was maintained, and
osteoarthritic changes were absent at the
time of the final follow-up in all patients
who were within ,3 years of the injury
or who were ,12 years of age at the time
of the surgical procedure12.
In further support of these criteria,
radial-head dislocation of $3 years has
· VOLUME 6, ISSUE 6 · e2

been shown to predict more pro-
nounced dysplastic changes of the radial
head52. However, in the absence of
dysplastic changes, several authors have
demonstrated good results following
reduction up to 10 years after the initial
injury7,21,30,33,45,53. Horii et al. dem-
onstrated that it was possible to obtain
good reduction in patients 18 to 20 years
of age; however, they noted that the
interval from the time of the injury to the
time of the surgical procedure was 2 to 7
months in these patients. They con-
cluded that the radial head can be suc-
cessfully reduced regardless of age if
treated within a year after the initial
injury51. Thus, it might be suggested
that these numbers be used as guidelines
rather than strict criteria and that all
patients should be carefully evaluated for
dysplastic changes to the radial head
prior to attempted surgical reduction of
the radiocapitellar joint.
Many surgical techniques have
been developed to address this complex
clinical problem, yet there remains no
consensus gold-standard treatment at
this time. Further, treatment of these
injuries can vary in difficulty depending
on the chronicity of the injury and may
necessitate adjunct procedures to assist
in maintaining reduction of the radio-
capitellar joint. Broadly, treatment
strategies have aimed to reduce the
radial-head dislocation through recon-
struction of the ligamentous stabilizers
of the radiocapitellar joint and/or via
correction of the associated ulnar
deformity. Therefore, orthopaedic sur-
geons treating these patients should be
aware of the reconstructive options
available for addressing the radial-head
dislocation and have a guided strategy to
address the ulnar deformity.
Annular Ligament Reconstruction
(without Osteotomy)
Open treatment of chronically dis-
located Monteggia lesions was first
described by Bell Tawse in 196554. His
procedure entailed a posterolateral
approach to the elbow with excision of
interposed capsular material from the
radiocapitellar joint, reduction of the
JUNE 2018 · VOLUME 6, ISSUE 6 · e2
Missed Pediatr ic Monteg gia Fractures
dislocated radius, and annular ligament
reconstruction using a turned-down
central slip of triceps tendon passed cir-
cumferentially around the neck of the
radius and inserted into a drill-hole in
the lateral part of the ulna. Patients were
subsequently splinted in full extension
and supination for 6 weeks, with active
range of motion as tolerated to follow. In
his original series of 6 patients, he
described good results using this proce-
dure, with the exception of 1 recurrent
dislocation in a patient in whom the
triceps tendon was of poor quality for
reconstruction54. Many authors have
advocated for annular ligament recon-
struction as a necessary component of
surgical treatment of missed Monteggia
lesions3,5,21,29,37,40,54,55; however, the
methods of reconstruction have varied,
with authors describing procedures uti-
lizing a slip of triceps tendon5,21,29,40,54,
a free fascial loop3,55, a free palmaris
tendon loop40, and a slip of forearm
fascia37. Seel and Peterson recognized
that the original Bell Tawse procedure
and many of its described variations
produced a posterolaterally directed
reducing force on the radial head.
Although they noted that this may be
appropriate for anteromedial disloca-
tions, it may malreduce other injuries
(e.g., anterolateral, lateral, and posterior
radial-head dislocations). To address
this, they developed a 2-drill-hole
annular ligament reconstruction tech-
nique that allows the reconstructed
annular ligament to function in its ana-
tomic role as a U-bolt, producing a more
centrally directed reducing force33. All
options appear to function similarly,
with authors reporting good results in all
case series regardless of the chosen
reconstructive method.
Radiocapitellar Pinning
Lloyd-Roberts and Bucknill modified
the Bell Tawse procedure by securing
their radiocapitellar joint reduction with
a Kirschner wire passed through the
capitellum and proximal part of the
radius with the elbow in flexion40. They
subsequently splinted patients for 6
weeks, at which point they removed the
|
wire and allowed active range of motion.
In their series of 8 patients, 7 underwent
radiocapitellar pinning, and the
1 patient who underwent annular liga-
ment reconstruction without pinning
demonstrated residual radial-head sub-
luxation at the 7-year follow-up.
Therefore, the authors concluded
that radiocapitellar pinning was neces-
sary to maintain reduction. This
became a popular modification as
authors believed that transarticular
immobilization of the radiocapitellar
joint maintained reduction and
protected the healing annular ligament
reconstruction3,29. Letts et al. further
modified this technique, advocating
against the transradiocapitellar pin over
concern for intra-articular pin breakage,
and recommending pinning the proxi-
mal part of the radius to the ulna37.
Radiocapitellar pinning remains con-
troversial, with authors reporting good
outcomes both with and without trans-
fixing the capitellum and radial head.
However, this strategy provides an
option for increasing stability of the
reduced radiocapitellar joint in particu-
larly unstable dislocations9,23,31.
Ulnar Osteotomy
Lloyd-Roberts and Bucknill recognized
early in the evolution of the treatment of
missed Monteggia lesions that, despite
adequate debridement of interposed
capsuloligamentous tissue from the ra-
diocapitellar joint, some radial-head
dislocations required ulnar osteotomy to
achieve full reduction40. Kalamchi was
the first to discuss ulnar osteotomy as a
primary means for obtaining radial-head
reduction in the English-language liter-
ature. He recognized that residual ulnar
deformity may splint the radial head in
an unreduced position via the interos-
seous membrane and that subsequent
correction of the ulnar deformity would
allow for reduction of the radial head. In
his study of 2 patients, he performed an
ulnar osteotomy through a 1-cm inci-
sion using multiple passes of a Kirschner
wire to maintain the structural integrity
of the surrounding periosteum. He then
performed open reduction of the radial
5
 | Missed Pediat r ic Monteg g ia Fractures

Fig. 2
Figs. 2-A through 2-D Annular ligament button-hole and proximal ulnar osteotomy through the Kocher approach. (Reproduced, with permission,
from San Diego Pediatric Orthopedics [SD PedsOrtho].) Fig. 2-A Intraoperative image highlighting an intact annular ligament under the Freer Elevator
(Sklar) (black arrow), which demonstrates a button-hole phenomenon. The radial head was dislocated anteriorly and medial to the annular ligament. The
annular ligament was vented to facilitate reduction of the radial head. However, given the chronicity of the injury, the annular ligament was taken down
and was repaired at the end of the case. Figs. 2-B, 2-C, and 2-D Intraoperative images, highlighting the exposure of the proximal part of the ulna (Fig. 2-B)
followed by a crescentic osteotomy (white arrow) of the proximal part of the ulna (Fig. 2-C), and a corresponding radiographic image with the white arrow
highlighting the ulnar osteotomy site (Fig. 2-D).

head with slight overcorrection of the
ulnar deformity, repairing the remnant
annular ligament around the proximal
part of the radius. Both patients dem-
onstrated maintenance of the radio-
capitellar joint reduction at the 1-year
follow-up and good range of motion at
the 5-year follow-up56.
Numerous case series have subse-
quently reported on ulnar osteotomy in
the treatment of missed Monteggia
lesions, and surgical techniques have
varied to some degree between nearly
every case series. This is largely attrib-
utable to the rarity of this injury.
Described approaches include a
single-incision technique9,12,16,18,19,21-
25,28,30-32,53
and a dual-incision
technique 20,24,56. Most authors
have advocated a single-incision
technique through either a Boyd
approach9,21,23,26,27,57 or a Kocher
approach11,16,24 (Figs. 2-A through
2-D). These approaches are favored
because they afford the surgeon the
ability to perform procedures directed at
both the proximal part of the ulna and
the radiocapitellar joint through a single
incision.
Methods for concentric reduction
of the radiocapitellar joint vary. Some
authors have contended that open
reduction of the radial head is
unnecessary16,18,19,22,24. Lädermann
et al. obtained closed reduction of the
radiocapitellar joint via ulnar osteotomy
with lengthening and correction of the
ulnar angular deformity through the
osteotomy site in 6 patients. All patients
demonstrated normal range of motion
and had excellent clinical outcomes
postoperatively16. Bor et al. described
closed reduction of the radiocapitellar
joint using an Ilizarov technique to
gradually lengthen and correct the
angular deformity of the ulna through
the ulnar osteotomy site via callotasis19.
They obtained serial radiographs at the
clinical follow-up, adjusting the angle
and distraction through the osteotomy
as necessary to obtain concentric radio-
capitellar joint reduction. Reduction
required a mean time of 3.5 months in the
external fixator frame. They obtained
excellent clinical outcomes in all 4
patients in their series. However, the
most commonly employed technique for
radiocapitellar joint reduction is open
reduction, with many authors finding it
necessary to excise interposed capsu-
loligamentous tissue to obtain concentric
reduction of the radiocapitellar
joint7,9,12,20,21,23,25,27,28,30-32,53,56.
Opinions on the necessity and
method of stabilizing the reduced radial
head vary among authors who agree that
open reduction of the radiocapitellar
joint is required. Some authors have
contended that the ulnar osteotomy
facilitates stability of the radial-head
reduction through the interosseous
membrane and advocate against extensive
annular ligament reconstruction23,27,31,53,
and others have advocated for repair20,23,56
or reconstruction7,12,18,21,27,28,30,32 of
the annular ligament to increase the sta-
bility of the joint. Described options for
annular ligament reconstruction include

6 JUNE 2018 · VOLUME 6, ISSUE 6 · e2


techniques utilizing triceps tendon or
fascia7,9,11,17,21,30,32,34, forearm extensor
fascia12,25-28, free palmaris longus ten-
don12, and absorbable suture18. Delpont
et al. provided the only direct comparison
of ulnar osteotomy with annular ligament
reconstruction to ulnar osteotomy with-
out annular ligament reconstruction9. In
this multicenter study, the surgeon’s
standard practice dictated if annular lig-
ament reconstruction was undertaken.
They reviewed 28 cases in which all
patients underwent overcorrection oste-
otomy, with 12 patients undergoing
annular ligament reconstruction in asso-
ciation with open reduction of the ra-
diocapitellar joint, and 16 patients
undergoing open reduction of the radio-
capitellar joint alone. They showed no
significant difference in clinical func-
tional outcomes between groups. Annu-
lar ligament reconstruction did not
guarantee radial-head stability, with 2
patients in the annular ligament recon-
struction group demonstrating recur-
rence of dislocation. They concluded that
annular ligament reconstruction is not
beneficial in conjunction with ulnar
osteotomy in chronic Monteggia lesions
and that, although ulnar osteotomy with
or without annular ligament reconstruc-
tion consistently produced functional
improvement in the setting of Bado type-I
lesions, it may be less effective in treat-
ment of Bado type-III lesions.
The degree of angular correction
through the ulnar osteotomy has been
described as corrective (i.e., restoration
of the posterior cortical line)28,32, over-
corrective (i.e., reversing the original
deformity)16,21,22,27,32,53,56, and
allowing for stable radial-head reduc-
tion to guide the degree of angular
correction9,12,19,23,24,30,31. Inoue and
Shionoya performed the only retro-
spective review directly comparing
patients undergoing corrective ulnar
osteotomy with patients undergoing
overcorrection ulnar osteotomy in the
treatment of Bado type-I injuries. They
demonstrated a significant increase (p #
0.01) in patient functional outcomes in
the overcorrection group, particularly in
pronosupination. They hypothesized
JUNE 2018 · VOLUME 6, ISSUE 6 · e2
Missed Pediatr ic Monteg gia Fractures
that even with osteotomy and anatomic
correction of the ulna, excess scar tissue or
callus at the fracture site may act as a ful-
crum to the radius during pronation and
that this may be a cause for recurrent
anterior radial-head dislocation, or, in the
setting of a firmly stabilized radial head
(e.g., following annular ligament recon-
struction), this may result in a mechanical
block to pronation. Further, they recom-
mended overcorrection at the ulnar
osteotomy as this further tensions the
interosseous membrane against forces that
would lead to recurrent radial-head dis-
location32. All case series from the last
decade recommend a protocol of ulnar
osteotomy with the degree of angular
correction through the osteotomy to be
determined by the position that allows for
a stable reduction of the radial head in all
combinations of flexion, extension, pro-
nation, and supination. Invariably, these
studies demonstrate overcorrection of the
ulnar deformity9,12,16,19,23,27,31.
The location of ulnar osteotomy
has been described at the center of
rotation of angulation (CORA; often
diaphyseal)16,26,28,30,32,56, and at the prox-
imal part of the metaphysis9,12,16,17,19,21-27.
Lädermann et al. performed osteotomies
at both the CORA and the proximal part
of the metaphysis16. One patient who
underwent osteotomy at the CORA
went on to nonunion requiring revision
and bone-grafting. The authors con-
cluded that proximal osteotomy is a better
option because of the better metaphyseal
blood supply precluding an increased risk
of nonunion, and the shorter proximal
bone segment allowing for finer adjust-
ment of the ulnar angulation. Horii et al.
additionally recommended that more
proximal osteotomy also maintains the
stouter distal fibers of the interosseous
membrane intact to the distal portion of
the ulna, better translating ulnar correc-
tion to the intact radius51. None of the
literature is sufficient to demonstrate an
effect on union rate and maintenance of
radial-head reduction; however, the most
obvious benefit of an ulnar metaphyseal
osteotomy is that the radiocapitellar joint
may be addressed directly through the
same incision.
|
Fig. 3
Figs. 3-A and 3-B Reduction of the radial
head and ulnar osteotomy fixation. (Re-
produced, with permission, from San Diego
Pediatric Orthopedics [SD PedsOrtho].)
Anteroposterior (Fig. 3-A) and lateral
(Fig. 3-B) radiographs demonstrating
reduction of the radial head after proximal
ulnar osteotomy and subsequent fixation
using a 2.7-mm limited contact
dynamic compression plate bent with
apex-dorsal angulation to correct the ulnar
deformity.
Fixation constructs for the ulnar
osteotomy have varied from reports of
no fixation at all56, relying on the peri-
osteum for stability, to fixation with an
elastic nail16, Kirschner wire7,11,23,28,32,33,
plate and screws9,11,12,16,17,20,21,23,25-
27,30,32,34,53
, and, more recently, external
fixation18,19,22,24,27,31. Proponents of
leaving the osteotomy unfixed have
argued that this approach allows for natural
remodeling of the ulna over time58. How-
ever, this approach necessitates prolonged
immobilization, which has been cited as a
cause for elbow contracture and limited
range of motion following radial-head
reduction8,34,46. Kirschner wire and elastic
nail fixation provide more stability than
periosteum alone; these constructs only
provide relative stability, which may be
inadequate for maintenance of angular
correction of the ulna, leading to recurrent
radial-head dislocation51. Rigid fixation of
the osteotomy site with a plate-and-screw
construct provides absolute stability
7
 | Missed Pediat r ic Monteg g ia Fractures

TABLE II Demographic Data of Outcome Studies for Missed Pediatric Monteggia Fractures*

No. of Age at Time of Interval from Injury

Study Patients Sex† Surgery‡ (yr) to Treatment‡ Bado Classification†
54
Bell Tawse (1965) 7 M (2), F (5) 7.1 (4.5 to 10) 14.1 mo (1 to 34 mo) I (7)
Lloyd-Roberts40 (1977) 8 NR 5.5 (3 to 8) 17.8 mo (4 to 36 mo) I (5), II (1),
uncategorized radial-
head dislocation (2)
Hurst29 (1983) 1 M (1) 12 2 yr I (1)
Fowles3 (1983) 5 M (2), F (3) 7.2 (3 to 9) 9.1 mo (1.5 to 24 mo) I (5)
Kalamchi56 (1986) 2 F (2) 5 (2.5 to 7.5) 5 mo (3.5 to 6.5 mo) I (2)
Hirayama53 (1987) 9 M (5), F (4) NR (2 to 12) NR (2 to 36 mo) I (5), III (4)
21
Stoll (1992) 8 NR 8.5 (4.3 to 15.5) 3.3 yr (1 to 9.5 yr) I (6), II (1), unknown (1)
Oner49 (1993) 7 M (1), F (6) 5.7 (4 to 9) 8.75 mo (1.25 to 16 mo) I (5), III (2)
Best30 (1994) 6 NR 9.8 (2.75 to 12) 27.4 mo (7 to 67 mo) I (6)
Tajima20 (1995) 23 NR NR NR I (10), II (2), III (9), IV (2)
Rodgers11 (1996) 7 M (3), F (4) 6.75 (1 to 12) 13.7 mo (1 to 39 mo) I (6), IV (1)
Devnani46 (1997) 3 M (2), F (1) 4.4 (2 to 5.66) 7.33 wk (6 to 8 wk) I (3)
Cappellino34 (1998) 3 F (3) 4 (1.4 to 6) 10 wk (NR) I (3)
Inoue32 (1998) 12 M (7), F (5) 7 (3 to 11) 16 mo (2 to 60 mo) I (12)
Seel33 (1999) 7 F (7) 5.8 (3.25 to 9) 30 mo (3 to 84 mo) NR
De Boeck35 (2000) 4 M (3), F (1) 7.1 (4 to 8.5) 10.5 mo (5 to 21 mo) I (4)
Exner22 (2001) 2 M (1), F (1) 7.13 (2.25 to 12) 2.6 yr (0.25 to 5 yr) I (2)
Horii51 (2002) 22 M (9), F (13) 10.1 (4 to 20) 10 mo (2 to 62 mo) NR
Kim39 (2002) 12 NR 7.4 (3 to 11) 30.3 mo (3 to 144 mo) I (11), II (1)
25
Degreef (2004) 6 M (4), F (2) 5 (2 to 6) 17 wk (5 to 59 wk) I (6)
David-West7 (2005) 8 M (5), F (3) 6.3 (4 to 8) 33.5 wk (2 to 192 wk) I (8)
Hasler24 (2005) 15 M (6), F (9) 9.5 (5 to 15) 22 mo (2 to 84 mo) I (15)
Hui28 (2005) 15 M (10), F (5) 8.25 (3 to 16) 3 mo (1.5 to 24 mo) I (14), III (1)
Koslowsky18 (2006) 3 F (3) 6.33 (6 to 7) 4 mo (1 to 7 mo) I (1), II (1), IV (1)
Wang26 (2006) 13 M (11), F (2) 8.3 (4 to 13) 7.8 yr (1 to 16.9 yr) I (13)
Belangero59 (2007) 8 M (2), F (6) 5.2 (2.7 to 10) 9.5 mo (1 to 18 mo) I (8)
Lädermann16 (2007) 6 M (3), F (3) 6.5 (4 to 8) 17 mo (1 to 49 mo) I (5), II (1)
Nakamura12 (2009) 22 M (14), F (8) 10 (4 to 16) NR I (19), III (1), IV (2)
23
Rahbek (2011) 16 M (11), F (5) 7.5 (3 to 13) 21 mo (1 to 83 mo) I (16)
Stitgen17 (2012) 1 M (1) 2.66 7 yr I (1)
Song27 (2012) 10 M (8), F (2) 7.5 (6 to 10) 1.7 yr (0.1 to 5 yr) I (6), III (4)
Lu31 (2013) 33 M (23), F (10) 7 (3 to 13) 15 mo (1.5 to 84 mo) NR
9
Delpont (2014) 28 M (12), F (16) 7 (4 to 12) 9.5 mo (3 to 44 mo) I (25), III (3)
Bor19 (2015) 4 M (2), F (2) 9.75 (9 to 11) 24 mo (3 to 54 mo) I (4)

*NR 5 not reported. †The number of patients is given in parentheses. ‡The values are given as the mean, with or without the range in parentheses.

allowing for early postoperative range of
motion, minimizing contracture51 (Figs.
3-A and 3-B).
Outcomes
Tables II, III, and IV show a thorough
summary of the literature and outcomes.
There is a paucity of long-term outcome
data in the literature with regard to the
surgical treatment of chronic Monteggia
lesions, and comparisons across studies
are made difficult by heterogeneity in
outcome measures. Most case series have
provided only short-term outcome data,
with only 4 case series reporting final
results at a mean time of 7 years after
treatment or longer12,23,26,27. Across
these 4 studies, the majority of patients
achieved good to excellent outcomes,
with a mean redislocation rate of 6.6%.
Nakamura et al. reported on long-
term outcomes of open reduction of
the radial head in combination with
posterior-bending elongation ulnar

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 Missed Pediatr ic Monteg gia Fractures |

TABLE III Surgical Information for Outcome Studies for Missed Pediatric Monteggia Fractures*
Approach for Ulnar Type of Ulnar Annular Ligament
Radial-Head Osteotomy Osteotomy Transradiocapitellar Reconstruction
Study Operative Treatment† Reduction Site† Fixation† Wire† Graft†
54
Bell Tawse Open reduction of radial head and Boyd NA NA No Triceps (6)
(1965) annular ligament reconstruction (6);
attempted closed reduction (1)
Lloyd- Open reduction of radial head and Boyd NA Plate and screws Yes (7) Palmaris (2),
Roberts40 annular ligament reconstruction (5); (1) triceps (6)
(1977) ulnar osteotomy, open reduction of
radial head, and annular ligament
reconstruction (1)
Hurst29 (1983) Open reduction of radial head and Boyd None NA Yes (6) Triceps (1)
annular ligament reconstruction (1)
Fowles3 (1983) Ulnar osteotomy (1); ulnar NR NR Plate and screws Yes (5) Remnant annular
osteotomy and annular ligament (2) ligament (4)
reconstruction (1); annular ligament
reconstruction (3)
Kalamchi56 Ulnar osteotomy and annular Kocher Site of original Molded cast (no No Remnant annular
(1986) ligament reconstruction (2) fracture (2) internal fixation) ligament (2)
Hirayama53 Ulnar osteotomy (9) Boyd Proximal part of Plate and screws No NA
(1987) metaphysis (9) (9)
Stoll21 (1992) Closed reduction (1); open Boyd Proximal part of Plate and screws Yes (3) Triceps tendon (5)
reduction of radial head, ulnar metaphysis (5) (5)
osteotomy, radial osteotomy, and
late radial-head excision (1); open
reduction of radial head and
annular ligament reconstruction (1);
radial-head excision (1); open
reduction of radial head, ulnar
osteotomy, and annular ligament
reconstruction (4)
Oner49 (1993) Open reduction of radial head and Boyd NA NA Yes (7) Triceps tendon (7)
annular ligament reconstruction (7)
Best30 (1994) Ulnar osteotomy and open Kocher CORA (7) None (5), plate Yes (7) Triceps tendon
reduction of radial head (1); ulnar and screws (2) (5), remnant
osteotomy, open reduction of radial annular ligament
head, and annular ligament (1)
reconstruction (6; note: 1 repeat
operation for late loss of reduction)
Tajima20 (1995) Isolated ulnar osteotomy (13); NR NR NR No NA
isolated radial shaft osteotomy (3);
combined radial and ulnar
osteotomies (2); radial-head
resection (5)
Rodgers11 Closed reduction of radial head and Kocher NR Kirschner wire (1), Yes (1) Triceps, ulnar
(1996) ulnar osteotomy (1); open reduction plate and screws periosteum,
of radial head and annular ligament (2), Rush rod (1), repair
reconstruction (2); open reduction and none (1)
of radial head, annular ligament
reconstruction, and ulnar
osteotomy (4)
Devnani46 Ulnar osteotomy and open Anterolateral Site of original 1.6-mm Kirschner Yes (3) NA
(1997) reduction of radial head (2); open fracture (2) wire
reduction of radial head (1)
Cappellino34 Open reduction of radial head and Boyd NR Plate and screws Yes (2) Triceps (3)
(1998) annular ligament reconstruction (2); (1)
open reduction of radial head,
annular ligament reconstruction,
ulnar osteotomy (1)
Inoue32 (1998) Ulnar osteotomy and open Posterolateral CORA (12) Plate and screws Yes (8) Triceps fascia (4)
reduction of radial head (8); ulnar (NR); Kirschner
osteotomy, open reduction of radial wires (NR);
head, annular ligament combination plate
reconstruction (4) and screws or
Kirschnerwires(NR)
continued

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 | Missed Pediat r ic Monteg g ia Fractures

TABLE III (continued )

Approach for Ulnar Type of Ulnar Annular Ligament
Radial-Head Osteotomy Osteotomy Transradiocapitellar Reconstruction
Study Operative Treatment† Reduction Site† Fixation† Wire† Graft†
33
Seel (1999) Open reduction of radial head, Kocher NR Steinmann pin (1) Yes (4) Remnant annular
annular ligament reconstruction, ligament (5),
ulnar osteotomy (1); open reduction triceps (2)
of radial head and annular ligament
reconstruction (6)
De Boeck35 Open reduction of radial head Kocher NA NA Yes (4) NA
(2000)
Exner22 (2001) Ulnar osteotomy and external NA Proximal part of External fixation No NA
fixation (2) metaphysis (2) (2)
Horii51 (2002) Ulnar osteotomy (10); ulnar Kocher Proximal part of Plate and screws No Triceps fascia (11)
osteotomy and annular ligament metaphysis (NR);
reconstruction (6); ulnar osteotomy, (NR), ulnar shaft intramedullary
radial osteotomy, and annular (NR) Kirschner wire
ligament reconstruction (2); annular (NR)
ligament reconstruction (3); and
radial osteotomy (1)
Kim39 (2002) Open reduction of radial head and Posterior CORA (6) Plate and screws Yes (4) Triceps (11)
annular ligament reconstruction (2); (6)
ulnar osteotomy, open reduction of
radial head, and annular ligament
reconstruction (6); ulnar osteotomy,
radial shortening osteotomy, open
reduction of radial head, and
annular ligament reconstruction (1);
open reduction of radial head,
annular ligament reconstruction,
radial osteotomy, radial-head
arthroplasty, proximal radioulnar
joint notchplasty (2); open
reduction of radial head, annular
ligament reconstruction, radial
osteotomy (1)
Degreef25 Ulnar osteotomy and open Kaplan Proximal part of Plate and screws Yes (6) Forearm fascia (1),
(2004) reduction of radial head (4); ulnar metaphysis (6) (6) remnant annular
osteotomy, open reduction of radial ligament (1)
head, annular ligament
reconstruction (2)
David-West7 Ulnar osteotomy, open reduction of Boyd NR Intramedullary Yes (6) Triceps (6)
(2005) radial head, annular ligament Kirschner wire (6)
reconstruction (6); and closed
reduction (2)
Hasler24 (2005) Ulnar osteotomy, open reduction of Kocher Proximal part of External fixation No NA
radial head, and external fixation metaphysis (15) (15)
(NR); ulnar osteotomy, closed
reduction of radial head, and
external fixation (NR)
Hui28 (2005) Ulnar osteotomy, open reduction Modified Boyd Diaphyseal (12) Kirschner wires No Forearm fascia
of radial head, annular ligament (12) (15)
reconstruction (11); open
reduction of radial head and
annular ligament reconstruction
(3); ulnar osteotomy, radial
osteotomy, open reduction of
radial head, annular ligament
reconstruction (1)
Koslowsky18 Ulnar osteotomy, closed reduction NR NR External fixation Yes (1) Absorbable
(2006) of radial head, and external fixation (3) suture (2)
(1); ulnar osteotomy, open
reduction of radial head, annular
ligament reconstruction, and
external fixation (2)
Wang26 (2006) Ulnar osteotomy, open reduction of Boyd CORA (11), Plate and screws No Forearm fascia
radial head, annular ligament proximal part of (13) (13)
reconstruction (13) metaphysis (2)
continued

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 Missed Pediatr ic Monteg gia Fractures |

TABLE III (continued )

Approach for Ulnar Type of Ulnar Annular Ligament
Radial-Head Osteotomy Osteotomy Transradiocapitellar Reconstruction
Study Operative Treatment† Reduction Site† Fixation† Wire† Graft†
59
Belangero Ulnar osteotomy and open Boyd (2), Proximal part of Plate and screws Yes (8) NA
(2007) reduction of radial head (8) Kocher (6) metaphysis (8) (8)
Lädermann16 Ulnar osteotomy (6) NA Proximal part of Plate and screws No NA
(2007) metaphysis (4), (5), and elastic nail
CORA (2) (1)
Nakamura12 Ulnar osteotomy, open reduction of Kocher Proximal part of Plate and screws No Forearm fascia
(2009) radial head, and annular ligament metaphysis (22) (22) (NR); remnant
reconstruction (22) annular ligament
augmented with
palmaris longus
(NR)
Rahbek23 Ulnar osteotomy, open reduction of Boyd Proximal part of Steinmann pin (9), Yes (7; if deemed Remnant annular
(2011) radial head, and annular ligament metaphysis (16) and plate and unstable ligament (10)
reconstruction (16) screws (7) intraoperatively)
Stitgen17 (2012) Ulnar osteotomy, open reduction of NR Proximal part of Plate and screws No Triceps (1)
radial head, and annular ligament metaphysis (1) (1)
reconstruction (1)
Song27 (2012) Ulnar osteotomy and closed Boyd Proximal part of Plate and screws No Forearm fascia (2)
reduction of radial head (8); ulnar metaphysis (10) (6),
osteotomy, open reduction of radial intramedullary
head, annular ligament nail (2), external
reconstruction (2) fixation (1), and
cast (1)
Lu31 (2013) Ulnar osteotomy, open reduction of Henry Proximal part of External fixation Yes (1) Remnant annular
radial head, external fixation (NR); metaphysis (33) (33) ligament (NR)
ulnar osteotomy, open reduction of
radial head, external fixation,
annular ligament reconstruction
(NR)
Delpont9 Ulnar osteotomy and open Boyd Proximal part of Plate and screws Yes (5) Triceps (12)
(2014) reduction of radial head (16); ulnar metaphysis (28) (28)
osteotomy, open reduction of radial
head, annular ligament
reconstruction (12)
Bor19 (2015) Ulnar osteotomy and external NA Proximal part of External fixation No NA
fixation metaphysis (4) (4)

*NA 5 not applicable, NR 5 not reported, and CORA 5 center of rotation of angulation. †The values in parentheses are given as the number of patients.

osteotomy and annular ligament recon-
struction in 22 children with a mean final
follow-up of 7 years12. The mean Mayo
Elbow Performance Index (MEPI) and
motion improved at the time of the final
follow-up. Radiographic outcomes were
good (maintained radial-head reduction,
no osteoarthritic changes) in 15 patients
and fair (radial-head subluxation or oste-
oarthritic changes) in 7 patients. Notably,
all patients who underwent the surgical
procedure at the age of ,12 years or who
had an interval from the date of the injury
to the date of the surgical procedure of
,3 years had good radiographic and
clinical outcomes. Thus, the authors
concluded that open reduction for missed
Monteggia lesions could be expected to
produce good long-term clinical and
radiographic outcomes in patients who
underwent the surgical procedure at the
age of ,12 years or within 3 years from
the date of the injury12.
Rahbek et al. reported on long-term
outcomes of open reduction of the radial
head with posterior-bending elongation
ulnar osteotomy in 16 children performed
by 1 of 2 surgeons at a mean final follow-
up of 8 years. Cases varied in terms of
annular ligament reconstruction com-
pared with annular ligament resection as
well as plate compared with Steinmann
pin fixation of the ulnar osteotomy. Ra-
diocapitellar pinning was also utilized if
there was residual radial-head instability
following ulnar osteotomy. They also
demonstrated a negative correlation
between patient age and interval from
injury to open reduction with radio-
graphic outcomes. In their series, annular
ligament reconstruction and trans-
radiocapitellar Kirschner wire fixation did
not affect radiographic outcomes or
patient pain scores when compared with
procedures in which they were not per-
formed. They did not recommend for or
against annular ligament reconstruction as
their study was likely underpowered to
detect an effect on outcomes. However,
they emphasized that it is possible to
achieve a radial-head reduction that is
dynamically stable and provides good
radiographic and clinical outcomes at a
long-term follow-up through posterior-

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 | Missed Pediat r ic Monteg g ia Fractures

TABLE IV Outcomes for Missed Pediatric Monteggia Fracture Studies*

Flexion and Extension at Final Pronation and Supination at
Study Follow-up† Follow-up† (deg) Final Follow-up† (deg) Complications‡
54
Bell Tawse (1965) 2.1 yr (1 to 5.5 yr) NR (100 to “full”) and NR (240 to “full”) NR (“Loss of pronation” to “full”) Recurrent radial-head
and NR (“full”) dislocation (1)
Lloyd-Roberts40 (1977) 5.39 yr (0.5 to 18 yr) NR (100 to “full”) and NR (220 to “full”) NR (45 to “full”) and NR (45 to Radial-head subluxation (2)
“full”)
Hurst29 (1983) NR NR NR NR
Fowles3 (1983) 4.6 yr (1 to 8 yr) 157 (125 to 180) and 26 (225 to 0) 76 (60 to 90) and 88 (80 and 90) Loss of rotation (3); residual
valgus carrying angle (2);
radiocapitellar dysplasia (2);
radial-head subluxation (1)
Kalamchi56 (1986) 3 yr (1 to 5 yr) “Full” and “full” 60 and 90 None
Hirayama53 (1987) 3 yr (1.5 to 7 yr) NR NR Loss of pronation (4); persistent
radial nerve palsy (2); plate
fracture (2)
Stoll21 (1992) 3.25 yr (0.5 to 8 yr) 142.1 (130 to 155) and 8.1 (0 to 15) 56.9 (45 to 80) and 51.9 (0 to 80) Loss of radial-head reduction (1;
initially treated without
transcapitellar Kirschner wire
and converted to Kirschner
wire); loss of radial-head
reduction with pain and cubitus
valgus necessitating radial-
head resection (1)
Oner49 (1993) 3.3 yr (1 to 7 yr) NR NR Radioulnar synostosis (1);
radial-neck notching (2); radial-
head subluxation (2)
Best30 (1994) 21.8 mo (11 to 53 mo) “Full” and 21.2 (25 to “full”) 81.7 (60 to 90) and 83.3 (70 to Residual varus (1); loss of radial-
90) head reduction necessitating
reoperation (1)
Tajima20 (1995) NA NR NR Proximal radial migration with
subsequent positive ulnar
variance distally following
radial-head resection (5)
Rodgers11 (1996) 4.5 yr (2 to 11.25 yr) NR 49 (5 to 85) and 64 (35 to 90) Ulnar nerve palsy (2); loss of
fixation of ulnar osteotomy (2);
nonunion of ulnar osteotomy (1);
loss of radial-head reduction (3)
Devnani46 (1997) 3.66 yr (1 to 5 yr) 127.5 (125 to 130) and 25 (220 to 10) 16.66 (10 to 20) and “full” Loss of pronation (3)
Cappellino34 (1998) 25.7 (12 to 44) NR NR None
Inoue32 (1998) 5 yr (1 to 12 yr) 138 (130 to 150) and 20.5 (25 to 0) 55 (30 to 90) and 73 (30 to 100) Persistent radial-head
dislocation (3); unstable valgus
deformity of the elbow (1);
radiohumeral osteoarthritis
Seel33 (1999) 47.7 mo (12 to 96 mo) 132.7 (95 to 145) and 211 (240 to 0) 63.6 (5 to 90) and 81.4 (60 to 90) Recurrent radial-head
subluxation (2)
De Boeck35 (2000) 4.3 (2 to 8.6) 131.25 (120 to 140) and 26.25 (210 to 0) 77.5 (70 to 90) and 85 (80 to 90) None
Exner22 (2001) 5 yr (1 to 9 yr) 142.5 (140 to 145) and 10 (NR) 80 and 90 None
Horii51 (2002) 3 yr (0.66 to 12 yr) 134.2 (NR) and 3 (NR) 56.5 (NR) and 76.5 (NR) Radial-head subluxation (4),
radial-head redislocation (7;
prior to changing to ulnar
angulation osteotomy)
Kim39 (2002) 43.5 mo (12 to 105 mo) Mean flexion-extension arc, 125.0 (NR) 57.9 (45 to 75) and 74.6 (40 to Loss of pronation (7); loss of
85) pronation, supination, flexion,
and extension (1); radial-neck
notching (3); heterotopic
ossification (2); superficial
infection (1); radioulnar
synostosis (1)
Degreef25 (2004) 18 mo (4 to 36 mo) “Full” and “full” “Full” and “full” None
David-West7 (2005) 2.5 yr (1 to 5 yr) 108.8 (100 to 120) and 3.1 (0 to 10) 43.1 (30 to 60) and 61.3 (30 to Loss of radial-head reduction (2;
85) initially treated without
transcapitellar Kirschner wire
and converted to Kirschner wire)
continued

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 Missed Pediatr ic Monteg gia Fractures |

TABLE IV (continued )
Flexion and Extension at Final Pronation and Supination at
Study Follow-up† Follow-up† (deg) Final Follow-up† (deg) Complications‡
24
Hasler (2005) 20 mo (6 to 60 mo) 136 (110 to 150) and 0 (220 to 10) 75.4 (40 to 90) and 80 (20 to 90) Delayed union of ulnar
osteotomy (2); superficial pin-
track infections (2)
Hui28 (2005) 4.25 yr (1 to 6 yr) 138.7 (90 to 150) and 2 (0 to 10) 76 (30 to 90) and 84 (60 to 90) Delayed union of ulnar
osteotomy (1); transient radial
nerve palsy (1), redislocation (1);
persistent radiocapitellar
subluxation (1)
Koslowsky18 (2006) 27.33 (26 to 30) 136.7 (130 to 140) and 16.7 (10 to 20) 90 and 90 None
Wang26 (2006) 7.8 yr (1 to 16.9 yr) 133 (110 to 145) and 1 (0 to 10) 67 (30 to 90) and 79 (30 to 90) Delayed union of ulnar
osteotomy (1); transient
posterior interosseous nerve
palsy (1); redislocation (1)
Belangero59 (2007) 4.5 (2 to 12) 135 and 0 76.25 (60 to 90) and 88.75 (80 to None
90)
Lädermann16 (2007) 3 yr (1.5 to 4.3 yr) 132.5 (120 to 140) and 4.2 (0 to 15) 85 (70 to 90) and 90 Nonunion (1)
Nakamura12 (2009) 7 yr (2 to 17 yr) 137.5 (130 to 145) and 2.3 (220 to 20) 66.8 (40 to 90) and 89.5 (70 to Delayed union ulnar osteotomy
95) (2); elbow contracture requiring
soft-tissue release (2)
Rahbek23 (2011) 8 yr (3 to 17 yr) NR NR Arthrosis or radial-head
subluxation (4); late dislocated
radial head (2)
Stitgen17 (2012) 5 mo “Full” and “full” 10 and “full” None
Song27 (2012) 10 yr (3 to 20 yr) NR NR Redislocation (3)
Lu31 (2013) 38 mo (12 to 86 mo) 130 (115 to 140) and 5 (5 to 10) 80 (70 to 90) and 80 (65 to 90) Redislocation (3; within 1 week),
delayed union ulnar osteotomy
(2; treatment with iliac crest
bone graft)
Delpont9 (2014) 6 yr (2 to 34 yr) 127 (110 to 140) and 24 (225 to 0) 66 (0 to 90) and 77 (20 to 90) Recurrent dislocation of the
radial head despite annular
ligament reconstruction (2);
osteoarthritis (3; 2 with
radiocapitellar pin); recurrent
subluxation of radial head (5;
every radiocapitellar pin)
Bor19 (2015) 3.75 yr (2 to 6 yr) 150 and 0 90 and 85 (70 to 90) Pin-track infection (1)

*NR 5 not recorded. †The values are given as the mean, with or without the range in parentheses. The values in parentheses are the number of patients.

bending elongation osteotomy of the ulna
alone. Finally, they did not demonstrate
an effect of transradiocapitellar fixation
with a Kirschner wire on radiographic or
clinical outcomes, but recommended
against it if a stable radial-head reduction
could be obtained without it23.
Song et al. reported on outcomes in
10 patients undergoing ulnar osteotomy
with correction of ulnar deformity with a
mean final follow-up of 10 years27. Nine
patients reported excellent functional
outcomes, and 1 patient reported a good
functional outcome. All osteotomies
healed at 6 weeks without the use of
bone-grafting. Two patients underwent
annular ligament reconstruction and
the remaining 8 patients were treated
with osteotomy and correction of the
ulnar deformity alone. Three patients
who did not undergo annular ligament
reconstruction needed a revision pro-
cedure for early redislocation of the
radial head and underwent revision of
the ulnar osteotomy without annular
ligament reconstruction because the
original deformity was undercorrected.
One patient had persistent radial-head
dislocation because of an uncorrected
proximal radial deformity not appreci-
ated at initial treatment. Similar to
Rahbek et al.23, these authors con-
cluded that annular ligament recon-
struction is not a necessary component
of maintaining a reduced and stable
radiocapitellar joint.
Wang and Chang reported on a
case series of 13 children treated with a
uniform surgical protocol26. Their
described technique used a single inci-
sion via the Boyd approach with
debridement of the remnant annular
ligament, osteotomy and correction of
the ulnar deformity as dictated by
reduction of the radiocapitellar joint
with plate and screw fixation, and
annular ligament reconstruction using a
strip of forearm fascia. The mean final
follow-up was 7.8 years. Restoration of a
normal flexion-extension arc was noted
to be more predictable than restoration
of full pronosupination. One patient
with a fair outcome and inadequate
motion had a redislocation that was

JUNE 2018 · VOLUME 6, ISSUE 6 · e2 13

 | Missed Pediat r ic Monteg g ia Fractures

TABLE V Preferred Treatment Algorithm for Missed Pediatric Monteggia Injuries

Approach Single-incision, lateral approach through Kocher interval or Boyd approach

Ulnar osteotomy Crescentic osteotomy (to increase surface area for union) with angular correction of the ulnar deformity without
ulnar lengthening. Fixed in place with plate-and-screw fixation.
Radial-head reduction Initially attempt to reduce radial head into intact annular ligament. If this is unsuccessful, pie-crust annular ligament
and attempt second reduction. If this remains unsuccessful, incise annular ligament and repair around radial neck
following reduction.
Assessment of Fluoroscopic examination of radiocapitellar joint through full elbow range of motion. If radiocapitellar joint noted to
radiocapitellar stability be unstable, reassess adequacy of corrective ulnar osteotomy. If further ulnar deformity correction does not yield a
stable radiocapitellar joint, consider reinforcement of annular ligament repair with triceps fascia.
Postoperative Univalved long arm cast with overwrap at 1 week postoperatively. Long arm cast maintained for 6 weeks
management postoperatively, at which point the cast is removed and range of motion is initiated. Progressive increase in weight-
bearing and active range of motion as dictated by clinical and radiographic assessment of osteotomy healing, with
expected full activity without restrictions at 4 to 6 months postoperatively.

attributed to undercorrection of the
ulnar deformity. This patient under-
went revision ulnar osteotomy and
demonstrated a reduced radiocapitellar
joint at the time of the final follow-up.
One patient with an excellent outcome
had a delayed union of the ulna that the
authors attributed to a 2-mm gap in the
osteotomy site following plate-and-
screw fixation and recommended bone-
grafting for gapping of $2 mm. The
authors concluded that their proposed
technique provided excellent functional
outcomes and range of motion at the
long-term follow-up and that forearm
fascia was a suitable alternative annular
ligament reconstruction graft26.
Conclusions
Pediatric Monteggia injuries represent
a rare upper-extremity fracture pat-
tern, and they may be easily missed.
After as little as 2 weeks, a neglected
Monteggia injury can present a serious
clinical challenge, often necessitating
operative intervention. Closed treat-
ment and “skillful neglect,” as
radiocapitellar articulation and annu-
lar ligament reconstruction along with
supplemental radiocapitellar pinning
directed at increasing the stability of
this relationship. Most of the modern
literature has transitioned to a focus on
correction of the ulnar deformity, as
the ulnar deformity has been demon-
strated to splint the radial head in a
dislocated position through the inter-
osseous membrane. Various tech-
niques for osteotomy and fixation are
described, and it is our belief that a
crescentic osteotomy of the ulna
without lengthening minimizes the
risk of osteotomy nonunion. The
degree of ulnar correction is dictated by
the stability of the radiocapitellar joint
on intraoperative fluoroscopic exami-
nation through a full range of motion at
the elbow. Correction of the deformity
is increased until the radiocapitellar
joint is found to be stable in all posi-
tions of flexion, extension, and pro-
nosupination. Various supplemental
techniques directed at increasing the
stability of the radiocapitellar joint are
whom the native annular ligament is
inadequate or in whom reduction of the
radiocapitellar joint necessitates debride-
ment of the interposed annular ligament.
The summary of a preferred technique for
management of these injuries is included
in Table V. Further prospective study is
necessary to determine optimal treatment
of these injuries, with recognition that the
rarity of this injury presents a great chal-
lenge to high-quality study design.
James Hubbard, MD1,2,
Aakash Chauhan, MD, MBA1,
Ryan Fitzgerald, MD3,
Reid Abrams, MD1,
Scott Mubarak, MD2,
Mark Sangimino, MD4
1Division of Hand, Upper Extremity, and
Microvascular Surgery, Department of
Orthopaedic Surgery, University of
California, San Diego (UCSD), San Diego,
California
2Department of Pediatric Orthopaedic
Surgery, Rady Children’s Hospital, San
Diego, California
3Department of Pediatric Orthopaedic

described by Blount47, represent the
earliest management strategy for these
injuries; however, this has largely fallen
out of favor as many authors have rec-
ognized that surgical radiocapitellar
reduction is possible and provides good
functional outcomes prior to onset of
chronic pathologic remodeling of the
radial head and capitellum. Histori-
cally, operative techniques have
focused on direct reduction of the
described and may be used at the discre-
tion of the treating surgeon as dictated by
the perceived stability of the radio-
capitellar joint following ulnar osteotomy
and indirect reduction. Our preferred
method of secondary stabilization is
reduction of the radial head into the
native annular ligament as this ligament is
often intact following radial-head dislo-
cation in the pediatric population.
Reconstruction is reserved for patients in
Surgery, Riley Children’s Hospital,
Indianapolis, Indiana
4Division of Pediatric Orthopaedic
Surgery, Department of Orthopaedic
Surgery, Allegheny General Hospital,
Pittsburgh, Pennsylvania
E-mail address for A. Chauhan: achau-
han1000@gmail.com
ORCID iD for A. Chauhan: 0000-0002-
1195-2491

14 JUNE 2018 · VOLUME 6, ISSUE 6 · e2


References
1. Ring D, Waters PM. Operative fixation of
Monteggia fractures in children. J Bone Joint
Surg Br. 1996 Sep;78(5):734-9.
2. Landin LA. Fracture patterns in children.
Analysis of 8,682 fractures with special reference
to incidence, etiology and secular changes in a
Swedish urban population 1950-1979. Acta
Orthop Scand Suppl. 1983;202:1-109.
3. Fowles JV, Sliman N, Kassab MT. The
Monteggia lesion in children. Fracture of the
ulna and dislocation of the radial head. J Bone
Joint Surg Am. 1983 Dec;65(9):1276-82.
4. Bado JL. The Monteggia lesion. Clin Orthop
Relat Res. 1967 Jan-Feb;50:71-86.
5. Dormans JP, Rang M. The problem of
Monteggia fracture-dislocations in children.
Orthop Clin North Am. 1990 Apr;21(2):251-6.
6. Gleeson AP, Beattie TF. Monteggia fracture-
dislocation in children. J Accid Emerg Med.
1994 Sep;11(3):192-4.
7. David-West KS, Wilson NIL, Sherlock DA,
Bennet GC. Missed Monteggia injuries. Injury.
2005 Oct;36(10):1206-9. Epub 2005 Mar 28.
8. Freedman L, Luk K, Leong JC. Radial head
reduction after a missed Monteggia fracture:
brief report. J Bone Joint Surg Br. 1988 Nov;
70(5):846-7.
9. Delpont M, Jouve JL, Sales de Gauzy J,
Louahem D, Vialle R, Bollini G, Accadbled F,
Cottalorda J. Proximal ulnar osteotomy in the
treatment of neglected childhood Monteggia
lesion. Orthop Traumatol Surg Res. 2014 Nov;
100(7):803-7. Epub 2014 Oct 7.
10. Holst-Nielsen F, Jensen V. Tardy posterior
interosseous nerve palsy as a result of an
unreduced radial head dislocation in
Monteggia fractures: a report of two cases. J
Hand Surg Am. 1984 Jul;9(4):572-5.
11. Rodgers WB, Waters PM, Hall JE. Chronic
Monteggia lesions in children. Complications
and results of reconstruction. J Bone Joint Surg
Am. 1996 Sep;78(9):1322-9.
12. Nakamura K, Hirachi K, Uchiyama S,
Takahara M, Minami A, Imaeda T, Kato H. Long-
term clinical and radiographic outcomes after
open reduction for missed Monteggia fracture-
dislocations in children. J Bone Joint Surg Am.
2009 Jun;91(6):1394-404.
13. Tubbs RS, O’Neil JT Jr, Key CD, Zarzour JG,
Fulghum SB, Kim EJ, Lyerly MJ, Shoja MM,
George Salter E, Jerry Oakes W. The oblique
cord of the forearm in man. Clin Anat. 2007 May;
20(4):411-5.
14. Captier G, Canovas F, Mercier N, Thomas E,
Bonnel F. Biometry of the radial head:
biomechanical implications in pronation and
supination. Surg Radiol Anat. 2002 Dec;24(5):
295-301. Epub 2002 Nov 1.
15. Shah AS, Waters PM. Monteggia fracture-
dislocation in children. In: Flynn JM, Skaggs
DL, Waters PM, editors. Rockwood and
Wilkins’ fractures in children. 8th ed.
Philadelphia: Wolters Kluwer Health; 2014.
p 527-63.
16. L ädermann A, Ceroni D, Lef èvre Y,
De Rosa V, De Coulon G, Kaelin A. Surgical
treatment of missed Monteggia lesions in
children. J Child Orthop. 2007 Oct;1(4):
237-42. Epub 2007 Aug 29.
17. Stitgen A, McCarthy JJ, Nemeth BA, Garrels
K, Noonan KJ. Ulnar fracture with late radial
head dislocation: delayed Monteggia fracture.
Orthopedics. 2012 Mar 7;35(3):e434-7.
JUNE 2018 · VOLUME 6, ISSUE 6 · e2
Missed Pediatr ic Monteg gia Fractures
18. Koslowsky TC, Mader K, Wulke AP,
Gausepohl T, Pennig D. Operative treatment of
chronic Monteggia lesion in younger children: a
report of three cases. J Shoulder Elbow Surg.
2006 Jan-Feb;15(1):119-21.
19. Bor N, Rubin G, Rozen N, Herzenberg JE.
Chronic anterior Monteggia lesions in children:
report of 4 cases treated with closed reduction
by ulnar osteotomy and external fixation. J
Pediatr Orthop. 2015 Jan;35(1):7-10.
20. Tajima T, Yoshizu T. Treatment of long-
standing dislocation of the radial head in ne-
glected Monteggia fractures. J Hand Surg Am.
1995 May;20(3 Pt 2):S91-4.
21. Stoll TM, Willis RB, Paterson DC. Treatment
of the missed Monteggia fracture in the child. J
Bone Joint Surg Br. 1992 May;74(3):436-40.
22. Exner GU. Missed chronic anterior
Monteggia lesion. Closed reduction by gradual
lengthening and angulation of the ulna. J Bone
Joint Surg Br. 2001 May;83(4):547-50.
23. Rahbek O, Deutch SR, Kold S, Søjbjerg JO,
Møller-Madsen B. Long-term outcome after
ulnar osteotomy for missed Monteggia fracture
dislocation in children. J Child Orthop. 2011
Dec;5(6):449-57. Epub 2011 Oct 16.
24. Hasler CC, Von Laer L, Hell AK. Open
reduction, ulnar osteotomy and external
fixation for chronic anterior dislocation of the
head of the radius. J Bone Joint Surg Br. 2005
Jan;87(1):88-94.
25. Degreef I, De Smet L. Missed radial head
dislocations in children associated with ulnar
deformation: treatment by open reduction and
ulnar osteotomy. J Orthop Trauma. 2004 Jul;
18(6):375-8.
26. Wang MN, Chang WN. Chronic
posttraumatic anterior dislocation of the radial
head in children: thirteen cases treated by open
reduction, ulnar osteotomy, and annular
ligament reconstruction through a Boyd
incision. J Orthop Trauma. 2006 Jan;20(1):1-5.
27. Song KS, Ramnani K, Bae KC, Cho CH, Lee KJ,
Son ES. Indirect reduction of the radial head in
children with chronic Monteggia lesions. J
Orthop Trauma. 2012 Oct;26(10):597-601.
28. Hui JHP, Sulaiman AR, Lee HC, Lam KS, Lee
EH. Open reduction and annular ligament
reconstruction with fascia of the forearm in
chronic Monteggia lesions in children. J Pediatr
Orthop. 2005 Jul-Aug;25(4):501-6.
29. Hurst LC, Dubrow EN. Surgical treatment of
symptomatic chronic radial head dislocation: a
neglected Monteggia fracture. J Pediatr
Orthop. 1983 May;3(2):227-30.
30. Best TN. Management of old unreduced
Monteggia fracture dislocations of the elbow in
children. J Pediatr Orthop. 1994 Mar-Apr;14(2):
193-9.
31. Lu X, Kun Wang Y, Zhang J, Zhu Z, Guo Y, Lu
M. Management of missed Monteggia fractures
with ulnar osteotomy, open reduction, and
dual-socket external fixation. J Pediatr Orthop.
2013 Jun;33(4):398-402.
32. Inoue G, Shionoya K. Corrective ulnar
osteotomy for malunited anterior Monteggia
lesions in children. 12 patients followed for 1-12
years. Acta Orthop Scand. 1998 Feb;69(1):73-6.
33. Seel MJ, Peterson HA. Management of
chronic posttraumatic radial head
dislocation in children. J Pediatr Orthop.
1999 May-Jun;19(3):306-12.
34. Cappellino A, Wolfe SW, Marsh JS. Use of
a modified Bell Tawse procedure for chronic
|
acquired dislocation of the radial head. J
Pediatr Orthop. 1998 May-Jun;18(3):410-4.
35. De Boeck H. Treatment of chronic isolated
radial head dislocation in children. Clin Orthop
Relat Res. 2000 Nov;380:215-9.
36. Tompkins DG. The anterior Monteggia
fracture: observations on etiology and
treatment. J Bone Joint Surg Am. 1971 Sep;
53(6):1109-14.
37. Letts M, Locht R, Wiens J. Monteggia
fracture-dislocations in children. J Bone Joint
Surg Br. 1985 Nov;67(5):724-7.
38. Lincoln TL, Mubarak SJ. “Isolated” traumatic
radial-head dislocation. J Pediatr Orthop. 1994
Jul-Aug;14(4):454-7.
39. Kim HT, Conjares JNV, Suh JT, Yoo CI.
Chronic radial head dislocation in children,
part 1: pathologic changes preventing
stable reduction and surgical correction.
J Pediatr Orthop. 2002 Sep-Oct;22(5):
583-90.
40. Lloyd-Roberts GC, Bucknill TM. Anterior
dislocation of the radial head in children:
aetiology, natural history and
management. J Bone Joint Surg Br. 1977
Nov;59-B(4):402-7.
41. Garg R, Fung BKK, Chow SP, Ip WY. Surgical
management of radial head dislocation in
quadriplegic cerebral palsy — a 5 year follow-
up. J Hand Surg Eur Vol. 2007 Dec;32(6):725-6.
Epub 2007 Aug 2.
42. Morrey BF, An KN. Articular and
ligamentous contributions to the stability of the
elbow joint. Am J Sports Med. 1983 Sep-Oct;
11(5):315-9.
43. Chen WS. Late neuropathy in chronic
dislocation of the radial head. Report of two
cases. Acta Orthop Scand. 1992 Jun;63(3):
343-4.
44. Storen G. Traumatic dislocation of the radial
head as an isolated lesion in children; report of
one case with special regard to roentgen
diagnosis. Acta Chir Scand. 1959 Jan 31;116(2):
144-7.
45. Gyr BM, Stevens PM, Smith JT. Chronic
Monteggia fractures in children: outcome after
treatment with the Bell-Tawse procedure. J
Pediatr Orthop B. 2004 Nov;13(6):402-6.
46. Devnani AS. Missed Monteggia fracture
dislocation in children. Injury. 1997 Mar;28(2):
131-3.
47. Blount WP. Fractures in children. Baltimore:
Williams & Wilkins; 1954.
48. Papandrea R, Waters PM. Posttraumatic
reconstruction of the elbow in the pediatric
patient. Clin Orthop Relat Res. 2000 Jan;370:
115-26.
49. Oner FC, Diepstraten AF. Treatment of
chronic post-traumatic dislocation of the radial
head in children. J Bone Joint Surg Br. 1993 Jul;
75(4):577-81.
50. Bhaskar A. Missed Monteggia fracture in
children: is annular ligament reconstruction
always required? Indian J Orthop. 2009 Oct;
43(4):389-95.
51. Horii E, Nakamura R, Koh S, Inagaki H, Yajima
H, Nakao E. Surgical treatment for chronic radial
head dislocation. J Bone Joint Surg Am. 2002
Jul;84(7):1183-8.
52. Oka K, Murase T, Moritomo H, Sugamoto K,
Yoshikawa H. Morphologic evaluation of
chronic radial head dislocation: three-
dimensional and quantitative analyses. Clin
15
 | Missed Pediat r ic Monteg g ia Fractures
Orthop Relat Res. 2010 Sep;468(9):2410-8. Epub
2010 Mar 4.
53. Hirayama T, Takemitsu Y, Yagihara K, Mikita A.
Operation for chronic dislocation of the radial
head in children. Reduction by osteotomy of the
ulna. J Bone Joint Surg Br. 1987 Aug;69(4):639-42.
54. Bell Tawse AJS. The treatment of malunited
anterior Monteggia fractures in children. J Bone
Joint Surg Br. 1965 Nov;47(4):718-23.
16
55. Aufranc OE, Jones WN, Bierbaum BE. Late
traumatic dislocation of the radial head. JAMA.
1969 Jun 30;208(13):2465-7.
56. Kalamchi A. Monteggia fracture-
dislocation in children. Late treatment in two
cases. J Bone Joint Surg Am. 1986 Apr;68(4):
615-9.
57. Boyd HB. Surgical exposure of the ulna
and proximal third of the radius through
one incision. Surg Gynecol Obstet. 1940;71:
86-8.
58. Mehta SD. Flexion osteotomy of ulna for
untreated Monteggia fracture in children. Ind J
Surg. 1985;47:15-9.
59. Belangero WD, Livani B, Zogaib RK.
Treatment of chronic radial head dislocations in
children. Int Orthop. 2007 Apr;31(2):151-4. Epub
2006 Jun 2.
JUNE 2018 · VOLUME 6, ISSUE 6 · e2