Current concepts in the management of missed Monteggia fracture-dislocation

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Abstract

Missed radiocapitellar dislocation is a feared complication of neglected Monteggia fracture. The duration of missed dislocation is variable, and children usually present with a bump on the anterior aspect of the elbow with some limitation of elbow flexion. Radiography will confirm the radial head dislocation. The ulnar fracture heals uneventfully and sometimes is not even discernible. In long standing cases (over 2 years), the radiocapitellar joint undergoes secondary changes, and reconstructive attempts are ever more challenging. There are several treatment strategies available to correct this deformity. In early cases (within 4–6 weeks) of missed dislocation, simple open reduction of the radiocapitellar joint is sufficient. As the duration of missed dislocation increases, concomitant ulnar osteotomy becomes imperative. An angulation-distraction osteotomy, which causes some lengthening of the bone, is most appropriate. Some authors prefer to reconstruct the annular ligament in every patient but this premise is no longer tenable. Radial head stability can be achieved by osteotomy alone and in some cases with an external fixator without opening the radiocapitellar joint. Functional stability of the elbow is better with radial head reduction, although there are no comparable series of operative and nonoperative groups. Radial head excision at skeletal maturity has been done in isolated cases. Thus, management of missed Monteggia fracture-dislocation continues to evolve with better understanding of the treatment options. Annular ligament reconstruction is not always required provided adequate stability can be achieved by ulnar osteotomy alone.

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