168
Case report
Severe forearm deformity and instability after Monteggia fracture-dislocation: a case report Junko Otsuka, Emiko Horii, Shukuki Koh and Yuji Hayashi A 16-year-old boy presented with a painful deformity of the forearm. At the age of 11 years, he had sustained a Monteggia fracture-dislocation. Radiographs indicated nonunion of the ulna, radial head dislocation, and degenerative changes of the radiocapitellar joint. The longstanding nonunion of the ulna had caused very severe growth disturbance. Despite severe deformity, the patient had had relatively good motion. To regain forearm stability with maintaining motion, we corrected the deformity and stabilized the ulna with a vascularized fibular graft. Two years after surgery, the patient had a good range of motion without pain and grip strength was
c 2014 Wolters increased. J Pediatr Orthop B 23:168–171 Kluwer Health | Lippincott Williams & Wilkins.
Introduction
Grip strength was 72%, elbow flexor muscle strength was 43%, and elbow extensor muscle strength was 50% of the contralateral side. The Quick DASH score was 9.1 points.
Since the original description of Monteggia in 1814, numerous reports have been published on the diagnosis and treatment of acute Monteggia fracture-dislocations in children. Immediate recognition of this injury, followed by reduction of the radial head and stable and anatomical fixation of the ulna usually results in a positive prognosis [1,2]. Missed diagnosis leads to a chronic radial head dislocation in association with a malunion of the ulna. An ulnar corrective osteotomy and an open reduction of the radial head are the mainstay for this condition [3,4]. We encountered a rare case of a chronic Monteggia fracture-dislocation, in which inappropriate postoperative management led to a nonunion and an undergrowth of the ulna with a redislocation of the radial head. Eventually, the forearm became unstable, with degenerative change of the radial head.
Journal of Pediatric Orthopaedics B 2014, 23:168–171 Keywords: children, forearm instability, free vascularized fibular graft, Monteggia fracture-dislocation, nonunion, trauma Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan Correspondence to Junko Otsuka, MD, Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, 3-35 Michishita-cho, Nakamura-ku, Nagoya 453-8511, Japan Tel: + 81 52 481 5111; fax: + 81 52 482 7733; e-mail: [email protected]
Fig. 1
Case report A 16-year-old, right-handed boy was referred to us for a varus deformity and impaired growth on his right forearm (Fig. 1). He sustained a Bado type 1 Monteggia fracturedislocation 5 years ago (Fig. 2a) and underwent closed reduction of the radial head and an intramedullary K-wire fixation of the ulna (Fig. 2b). A cast was applied for several weeks, but then the K-wire seemed to be removed 12 weeks postoperatively despite the absent of bone union (Fig. 2c). He had been symptom free for a while but gradually began to feel motion pain in his forearm during daily activities, and visited a local doctor. His forearm was grossly unstable with an axial load. The flexion–extension motion of his right elbow was 25–1301, and of the forearm, full supination to 401 of pronation. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Preoperative appearance of the patient’s forearms. His right forearm showed varus deformity with the apex at the proximal forearm and was obviously hypoplastic. DOI: 10.1097/BPB.0000000000000005
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Instability after Monteggia fracture Otsuka et al.
169
Fig. 2
Radiographs taken before the referral. (a) At initial injury, oblique views of the forearm showed an anterior dislocation of the radial head and a displaced ulnar shaft fracture. (b) Anteroposterior and lateral views of the forearm showed that the radial head had been reduced and the ulna had been fixed with an intramedullary K-wire. (c) Anteroposterior and lateral views of the forearm at 12 weeks after injury. The K-wire was removed immediately after for an unknown reason. Note that fracture union was not achieved.
Fig. 3
Radiographs taken 5 years after the initial injury when the patient presented initially. (a) Anteroposterior and lateral views of the forearm showed atrophic ulna with nonunion of the shaft fracture. The ulna had a 301 radial angulation with accompanying bowing of the radius. The radial head was anteriorly dislocated and deformed. (b) Anteroposterior view of the forearm was corrected manually and the aim was to correct the deformity during the operation.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
170 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 2
Fig. 4
restriction of 551 pronation was unchanged. Grip strength was improved to 88%, elbow flexor strength was 71%, and elbow extension strength was 80% of the unaffected side. The Quick DASH score improved from 9.1 to 0 points. Plain radiographs at the final follow-up showed a union of the ulna with a 201 of radial angulation. The ulna was still 2 cm shorter than the unaffected side. The patient was satisfied with the improved forearm appearance (Fig. 5a and b).
Discussion Approximately 80% of the load applied to the wrist is borne by the radius, but transmitted to the ulna in the forearm through the interosseous membrane [5]. In this case, the longstanding nonunion of the ulna in a growing child disturbed the normal force transmission, resulting in a severe atrophy of the ulna. Shortened ulna led to recurrence of the radial head subluxation because of the length discrepancy of both bones. Then, overload and incongruity of the radiocapitellar joint eventually led to gross radial head deformity with arthritic changes. To regain forearm stability, we chose a vascularized fibular graft for the reconstruction of the ulna. For more than 6 cm of the bone defect, a vascularized bone graft is recommended [6,7], and the defect of the ulna was 13.5 cm in this case. Another option might be a one-bone forearm procedure, but bone union would not be easy to achieve because of the impaired vascularity of the ulna. Furthermore, his forearm range of motion was too good to be sacrificed. Postoperative radiographs of the forearm. Anteroposterior and lateral views. Atrophic part of the ulna was replaced by a vascularized fibular graft and the deformed radial head was not reduced.
Plain radiographs at referral indicated a nonunion of the ulna with a 401 radial angulation. The ulna was very thin and 3 cm shorter than the unaffected side and bone adjacent to the nonunion site was sclerotic, suggesting impaired vascularity. The radial head was anteriorly dislocated and grossly deformed, and degenerative change in radiocapitellar joint was already evident (Fig. 3a). Stress view indicated the instability of the nonunion site of the ulna (Fig. 3b). To restore the stability of the forearm, the ulna was explored and 13.5 cm of the sclerotic segment was excised. Varus deformity of the forearm was corrected manually and a free vascularized fibula was grafted and fixed with plates and screws at both ends (Fig. 4). An above-elbow cast was applied for 4 weeks and bone union was achieved in 24 weeks without any complications. The radial head was not reduced because of the deformity and the degenerative change. At 2 years postoperatively, the patient had no pain, full range of elbow flexion–extension motion, and supination, but
Despite the deformity, the disability of the patient was moderate at referral. We aimed not to disturb forearm motion; therefore, we did not correct the varus deformity completely. As for the chronic radial head dislocation, good surgical results have been reported for late reduction in patients younger than 12 years old and/or if performed within 2 years after the injury [3]. In this case, the patient was 16 years old, and underwent the surgery 5 years after the initial injury. Also, the radial head deformity was already evident. We were concerned that the reduction might cause elbow pain and limitation of motions. At the short follow-up, the patient was satisfied with the surgical outcomes. However, the dislocated and deformed radial head might lead to early painful arthritis; therefore, careful long-term follow-up is essential.
Conclusion
Nonunion and growth disturbance of an ulna after a maltreated Monteggia fracture-dislocation was reconstructed by a free vascularized fibula. Forearm stability was regained without compromising the function of the elbow and forearm.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Instability after Monteggia fracture Otsuka et al. 171
Fig. 5
(a) Anteroposterior and lateral views 2 years after the fibular graft. Both ends of the grafted fibula achieved solid union; however, bowing of the radius remained. (b) Postoperative appearance of the patient’s forearms.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2
3
Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J Am Acad Orthop Surg 1998; 6:215–224. Stanley E, Garza JF. Monteggia fracture-dislocation in children. In: Rockwood CA, Wilkins KE, Beaty JH, editors. Fracture in children. Philadelphia, PA: Lippincott-Raven; 1996. pp. p548–p586. Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term clinical and radiographic outcomes after open reduction for missed
4
5
6 7
Monteggia fracture-dislocation in children. J Bone Joint Surg Am 2009; 91:1394–1404. Rodgers WB, Waters PM, Hall JE. Chronic Monteggia lesions in children. Complications and results of reconstruction. J Bone Joint Surg Am 1996; 78:1322–1329. Poitevin LA. Anatomy and biomechanics of the interosseous membrane: its importance in the longitudinal stability of the forearm. Hand Clin 2001; 17:97–110. Kloen P, Wiggers JK, Buijze GA. Treatment of diaphyseal non-unions of the ulna and radius. Arch Orthop Traumas Surg 2010; 130:1439–1445. Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004; 86:2440–2445.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Case report
Severe forearm deformity and instability after Monteggia fracture-dislocation: a case report Junko Otsuka, Emiko Horii, Shukuki Koh and Yuji Hayashi A 16-year-old boy presented with a painful deformity of the forearm. At the age of 11 years, he had sustained a Monteggia fracture-dislocation. Radiographs indicated nonunion of the ulna, radial head dislocation, and degenerative changes of the radiocapitellar joint. The longstanding nonunion of the ulna had caused very severe growth disturbance. Despite severe deformity, the patient had had relatively good motion. To regain forearm stability with maintaining motion, we corrected the deformity and stabilized the ulna with a vascularized fibular graft. Two years after surgery, the patient had a good range of motion without pain and grip strength was
c 2014 Wolters increased. J Pediatr Orthop B 23:168–171 Kluwer Health | Lippincott Williams & Wilkins.
Introduction
Grip strength was 72%, elbow flexor muscle strength was 43%, and elbow extensor muscle strength was 50% of the contralateral side. The Quick DASH score was 9.1 points.
Since the original description of Monteggia in 1814, numerous reports have been published on the diagnosis and treatment of acute Monteggia fracture-dislocations in children. Immediate recognition of this injury, followed by reduction of the radial head and stable and anatomical fixation of the ulna usually results in a positive prognosis [1,2]. Missed diagnosis leads to a chronic radial head dislocation in association with a malunion of the ulna. An ulnar corrective osteotomy and an open reduction of the radial head are the mainstay for this condition [3,4]. We encountered a rare case of a chronic Monteggia fracture-dislocation, in which inappropriate postoperative management led to a nonunion and an undergrowth of the ulna with a redislocation of the radial head. Eventually, the forearm became unstable, with degenerative change of the radial head.
Journal of Pediatric Orthopaedics B 2014, 23:168–171 Keywords: children, forearm instability, free vascularized fibular graft, Monteggia fracture-dislocation, nonunion, trauma Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan Correspondence to Junko Otsuka, MD, Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, 3-35 Michishita-cho, Nakamura-ku, Nagoya 453-8511, Japan Tel: + 81 52 481 5111; fax: + 81 52 482 7733; e-mail: [email protected]
Fig. 1
Case report A 16-year-old, right-handed boy was referred to us for a varus deformity and impaired growth on his right forearm (Fig. 1). He sustained a Bado type 1 Monteggia fracturedislocation 5 years ago (Fig. 2a) and underwent closed reduction of the radial head and an intramedullary K-wire fixation of the ulna (Fig. 2b). A cast was applied for several weeks, but then the K-wire seemed to be removed 12 weeks postoperatively despite the absent of bone union (Fig. 2c). He had been symptom free for a while but gradually began to feel motion pain in his forearm during daily activities, and visited a local doctor. His forearm was grossly unstable with an axial load. The flexion–extension motion of his right elbow was 25–1301, and of the forearm, full supination to 401 of pronation. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Preoperative appearance of the patient’s forearms. His right forearm showed varus deformity with the apex at the proximal forearm and was obviously hypoplastic. DOI: 10.1097/BPB.0000000000000005
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Instability after Monteggia fracture Otsuka et al.
169
Fig. 2
Radiographs taken before the referral. (a) At initial injury, oblique views of the forearm showed an anterior dislocation of the radial head and a displaced ulnar shaft fracture. (b) Anteroposterior and lateral views of the forearm showed that the radial head had been reduced and the ulna had been fixed with an intramedullary K-wire. (c) Anteroposterior and lateral views of the forearm at 12 weeks after injury. The K-wire was removed immediately after for an unknown reason. Note that fracture union was not achieved.
Fig. 3
Radiographs taken 5 years after the initial injury when the patient presented initially. (a) Anteroposterior and lateral views of the forearm showed atrophic ulna with nonunion of the shaft fracture. The ulna had a 301 radial angulation with accompanying bowing of the radius. The radial head was anteriorly dislocated and deformed. (b) Anteroposterior view of the forearm was corrected manually and the aim was to correct the deformity during the operation.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
170 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 2
Fig. 4
restriction of 551 pronation was unchanged. Grip strength was improved to 88%, elbow flexor strength was 71%, and elbow extension strength was 80% of the unaffected side. The Quick DASH score improved from 9.1 to 0 points. Plain radiographs at the final follow-up showed a union of the ulna with a 201 of radial angulation. The ulna was still 2 cm shorter than the unaffected side. The patient was satisfied with the improved forearm appearance (Fig. 5a and b).
Discussion Approximately 80% of the load applied to the wrist is borne by the radius, but transmitted to the ulna in the forearm through the interosseous membrane [5]. In this case, the longstanding nonunion of the ulna in a growing child disturbed the normal force transmission, resulting in a severe atrophy of the ulna. Shortened ulna led to recurrence of the radial head subluxation because of the length discrepancy of both bones. Then, overload and incongruity of the radiocapitellar joint eventually led to gross radial head deformity with arthritic changes. To regain forearm stability, we chose a vascularized fibular graft for the reconstruction of the ulna. For more than 6 cm of the bone defect, a vascularized bone graft is recommended [6,7], and the defect of the ulna was 13.5 cm in this case. Another option might be a one-bone forearm procedure, but bone union would not be easy to achieve because of the impaired vascularity of the ulna. Furthermore, his forearm range of motion was too good to be sacrificed. Postoperative radiographs of the forearm. Anteroposterior and lateral views. Atrophic part of the ulna was replaced by a vascularized fibular graft and the deformed radial head was not reduced.
Plain radiographs at referral indicated a nonunion of the ulna with a 401 radial angulation. The ulna was very thin and 3 cm shorter than the unaffected side and bone adjacent to the nonunion site was sclerotic, suggesting impaired vascularity. The radial head was anteriorly dislocated and grossly deformed, and degenerative change in radiocapitellar joint was already evident (Fig. 3a). Stress view indicated the instability of the nonunion site of the ulna (Fig. 3b). To restore the stability of the forearm, the ulna was explored and 13.5 cm of the sclerotic segment was excised. Varus deformity of the forearm was corrected manually and a free vascularized fibula was grafted and fixed with plates and screws at both ends (Fig. 4). An above-elbow cast was applied for 4 weeks and bone union was achieved in 24 weeks without any complications. The radial head was not reduced because of the deformity and the degenerative change. At 2 years postoperatively, the patient had no pain, full range of elbow flexion–extension motion, and supination, but
Despite the deformity, the disability of the patient was moderate at referral. We aimed not to disturb forearm motion; therefore, we did not correct the varus deformity completely. As for the chronic radial head dislocation, good surgical results have been reported for late reduction in patients younger than 12 years old and/or if performed within 2 years after the injury [3]. In this case, the patient was 16 years old, and underwent the surgery 5 years after the initial injury. Also, the radial head deformity was already evident. We were concerned that the reduction might cause elbow pain and limitation of motions. At the short follow-up, the patient was satisfied with the surgical outcomes. However, the dislocated and deformed radial head might lead to early painful arthritis; therefore, careful long-term follow-up is essential.
Conclusion
Nonunion and growth disturbance of an ulna after a maltreated Monteggia fracture-dislocation was reconstructed by a free vascularized fibula. Forearm stability was regained without compromising the function of the elbow and forearm.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Instability after Monteggia fracture Otsuka et al. 171
Fig. 5
(a) Anteroposterior and lateral views 2 years after the fibular graft. Both ends of the grafted fibula achieved solid union; however, bowing of the radius remained. (b) Postoperative appearance of the patient’s forearms.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2
3
Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J Am Acad Orthop Surg 1998; 6:215–224. Stanley E, Garza JF. Monteggia fracture-dislocation in children. In: Rockwood CA, Wilkins KE, Beaty JH, editors. Fracture in children. Philadelphia, PA: Lippincott-Raven; 1996. pp. p548–p586. Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term clinical and radiographic outcomes after open reduction for missed
4
5
6 7
Monteggia fracture-dislocation in children. J Bone Joint Surg Am 2009; 91:1394–1404. Rodgers WB, Waters PM, Hall JE. Chronic Monteggia lesions in children. Complications and results of reconstruction. J Bone Joint Surg Am 1996; 78:1322–1329. Poitevin LA. Anatomy and biomechanics of the interosseous membrane: its importance in the longitudinal stability of the forearm. Hand Clin 2001; 17:97–110. Kloen P, Wiggers JK, Buijze GA. Treatment of diaphyseal non-unions of the ulna and radius. Arch Orthop Traumas Surg 2010; 130:1439–1445. Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004; 86:2440–2445.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
