- Case Report
- Open Access
Type III monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report
© Williams et al.; licensee BioMed Central Ltd. 2014
- Received: 30 October 2013
- Accepted: 12 March 2014
- Published: 17 March 2014
Although previously reported, ipsilateral Monteggia fracture dislocation and distal radius fracture in a child is still a rare occurrence. A full clinical examination may be difficult but should not be ignored. Full length forearm radiographs are ideal but proper limb positioning may be difficult. The injury pattern can be easily missed.
A five-year- old right hand dominant Caucasian male presented with a history of fall on outstretched hand. Clinical examination was difficult and X - rays confirmed type III Monteggia fracture with an ipsilateral Type II Salter Harris injury of the distal radius and ulna.
This report highlights the need for relevant examination of the wrist and elbow in young children. Appropriate radiographs must also be performed to prevent missing these injuries.
- Monteggia fracture
- Clinical and radiological examination
Monteggia fracture patterns are rare in children and merits appropriate treatment to avoid late disability of the elbow and forearm. The injury pattern is easily missed initially or later if not followed up adequately. Both operative and non operative treatment methods are described and are equally successful. The chosen method will be dictated by the injury pattern, associated skeletal injuries and the stability of reduction achieved intra-operatively. We report this rare injury with associated distal radius and ulna injury in the ipsilateral limb, the importance of a full thorough clinical examination and the need for full length radiographs in order not to miss this injury particularly by the junior doctors in the emergency department.
Giovanni Monteggia, based on cadaveric studies, described the pattern of injury in adults but the peak incidence occurs in the age range of 4–10 and represents 0.4% of all forearm fractures. Due to the infrequent exposure of this type of injury it can be easily missed if not specifically looked into.
Bado later classified the injury into 4 subtypes depending on the direction of radial head dislocation. Several variants have been further described particularly in children. Of these injuries, type 1 (59%) and type-III (26%) are the most common[4, 5]. Our patient sustained a type-III injury with an ipsilateral Type II Salter Harris distal radius and ulna fracture.
It has been estimated that, up to 50% senior house officers in accident and emergency departments and 25% of senior radiologists missed a Monteggia injury. Our patient had a painful forearm coupled with restricted elbow and forearm movements, which heightened the suspicion. A good clinical examination of the elbow and forearm is therefore important to rule out this pattern of injury. This may be difficult in an uncooperative child but should be routinely practised. Appropriate full length radiographs are requested when clinical suspicion is high. This we feel goes a long way in identifying the injury and preventing late complications.
Non operative methods of reduction have been reported with successful outcomes[1, 7–11]. These fractures - whether it be plastic deformation or incomplete fractures – tend to be stable and thus maintain the anatomical reduction in a cast achieving good results[1, 5, 7–11].
Operative intervention should be performed for failed closed reduction and in unstable fracture dislocation patterns with excellent results being achieved[6, 11–15]. In our patient, the radial head was unstable after closed reduction and therefore the option of transcapitellar wiring was contemplated. We feel the instability pattern is more pronounced if there is an ipsilateral radius fracture, necessating operative stabilisation.
Percutaneous radial head pinning ensures maintenance of superior radio-ulnar articulation. Though concerns have been raised about the possibility of capitellar damage and subsequent physeal damage, we did not notice this in our limited period of follow up. However this is a possibility and only a prolonged follow up till skeletal maturity will confirm this occurrence. It is therefore important to communicate this to the parents in the consent process. The ulna fracture was aligned well and therefore it was decided to treat the same in a well moulded plaster cast.
Unstable Monteggia fracture dislocation with ipsilateral distal radius fracture although rare is possible in children. The injury being uncommon can be easily missed particularly by junior doctors in the emergency department. The physician should have a low threshold for suspecting these types of injuries when examining children. A good clinical examination and full length radiographs of the forearm are mandatory in all suspected cases.
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Peter N, Myint S: Type I Monteggia lesion and associated fracture of the distal radius and ulna metaphysis in a child. Can J Emerg Med. 2007, 9 (5): 383-386.Google Scholar
- Bado JL: The Monteggia lesion. Clin Orthop Relat Res. 1967, 50: 71-86.PubMedView ArticleGoogle Scholar
- De la Garza JF: From Monteggia Fracture-Dislocation in children. Rockwood and Wilkins’ fractures in children, Volume 1. Edited by: Beaty JH, Kasser JR. 2006, Philadelphia: Lippincott William and Wilkins, 492-527. 6Google Scholar
- Givon U, Pritisch M, Levy O: Monteggia and equivalent lesions. Clin Orthop Relat Res. 1997, 337: 208-215.PubMedView ArticleGoogle Scholar
- Letts M, Locht R, Wiens J: Monteggia fracture-dislocation in children. J Bone Joint Surg (Br). 1985, 67B: 724-727.Google Scholar
- Gleeson AP, Beattie TF: Monteggia fracture–disclocation in children. J Accid Emerg Med. 1994, 11: 192-194. 10.1136/emj.11.3.192.PubMedPubMed CentralView ArticleGoogle Scholar
- Sen RK, Tripathy SK, Kumar S, Aggarwal S, Tamuk T: Ipsilateral proximal and distal forearm fracture/fracture dislocation in children. J Pediatr Orthop B. 2011, 20 (3): 129-137. 10.1097/BPB.0b013e328341df92.PubMedView ArticleGoogle Scholar
- Shonnard PY, DeCoster TA: Combined Monteggia and Galeazzi fractures in a childs forearm. Orthop Rev. 1994, 23 (9): 755-759.PubMedGoogle Scholar
- Peter VK: Rare presentation of a type I Monteggia fracture. Emerg Med J. 2002, 19: 88-89. 10.1136/emj.19.1.88.PubMedPubMed CentralView ArticleGoogle Scholar
- Biyani A: Ipsilateral Monteggia equivalent injury and distal radial and ulna fracture in a child. J Orthop Trauma. 1994, 8 (5): 431-438. 10.1097/00005131-199410000-00011.PubMedView ArticleGoogle Scholar
- Peiro A, Andres F, Fernandez-Esteve F: Acute Monteggia lesions in children. J Bone Joint Surg Am. 1977, 59 (1): 92-97.PubMedGoogle Scholar
- Kristiansen B, Erikson AF: Simulatneous type II Monteggia lesion and fracture separation of lower radial epiphyse. Injury. 1986, 17: 51-52. 10.1016/0020-1383(86)90019-7.PubMedView ArticleGoogle Scholar
- Deshpande S, O’Doherty D: Type I Monteggia fracture dislocation associated with ipsilateral distal radial epiphyseal injury. J Orthop Trauma. 2001, 15 (5): 373-375. 10.1097/00005131-200106000-00014.PubMedView ArticleGoogle Scholar
- Ring D, Waters PM: Operative fixation of Monteggia fractures in children. J Bone Joint Surg (Br). 1996, 78-B: 734-739.Google Scholar
- Sood A, Khan O, Bagga T: Simultaneous Monteggia type I fracture equivalent with ipsilateral fracture of the distal radius and ulna in a child: a case report. J Med Case Rep. 2008, 2: 190-10.1186/1752-1947-2-190.PubMedPubMed CentralView ArticleGoogle Scholar
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