Concerning ‘Type III Monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child’
James Huntley, University of Glasgow
17 April 2014
Dear Sir
Introduction
I enjoyed the recent case report of Williams et al. [1]: Type III Monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report, but believe there is considerable material to discuss.
Discussion
Consideration of the Monteggia fracture-dislocation presented by Williams et al. Figure 2 of this report shows an approximate Anteroposterior (AP) view of the elbow, in which there is marked proximal apex-radial (varus) plastic deformation of the ulna. The six month follow-up views (Figure 6) show a malunion of the ulna at the same site, which is likely to be indicative of an incomplete reduction at the index procedure. An incomplete reduction might well be the reason for the subsequent ‘radial head relocation’ being ‘unstable’. There is a comment that ‘The ulna fracture was well aligned and therefore was treated non-operatively’ but no correlative post-operative view is given i.e. there is no AP view of the elbow between the fracture (Figure 2) and the six month follow-up (Figure 6)).
Consideration of normal and abnormal ulna anatomy. A recent publication [2] informs us of the radiological anatomy of the paediatric ulna, including an index of normal proximal ulnar varus angulation: the ulnar proximal angle (APPA), this being 13.6o ± 2.8;6o-21o [mean ± SD; range]. This value is less than the mean normal adult value of ̴ 17.6o. Cravino et al. state that ‘Anatomic reduction and stable fixation of ulnar fractures, especially in Monteggia variants, are essential to ensure an accurate reduction of the radial head… …knowing the parameters that define the normal ulna may help the treating surgeon in managing these pathologies.’ Measuring the APPA of the ulna in Figure 6 of Williams et al. [1] yields a value in excess of 30o, indicative of a residual apex-radial bow.
Techniques for reduction of proximal ulna deformity in the type III Monteggia fracture. Proximal deformity of the ulna due to fracture may be difficult to reduce, especially if there is a plastic component. In a previous publication [3], I have alluded to such a difficulty, with the accepted manipulative method involving elbow extension (locking the olecranon in its humeral fossa), to provide an anatomical fulcrum against which to lever [3,4]. In the context of an incomplete reduction after manipulation, the technique of transapophyseal intramedullary stacked nailing of the ulna can be useful for both reduction and stabilisation [3]. ‘Nesting of wires’ within the medullary canal was also alluded to by De la Garza [4].
Radiocapitellar wiring. Radiocapitellar wiring is an accepted technique for temporary joint stabilisation [5,6], albeit usually in the context of the delayed (rather than acute) Monteggia fracture-dislocation. Even for the delayed indication, authorities are mindful of the risk of wire breakage [4,7] – as a technique, it would therefore seem to fall into a category of “sometimes necessary, but of higher risk”.
Conclusion. If an adequate reduction of the ulna had been obtained and maintained – eg by stacked intramedullary nailing of the ulna, it might be that the comparatively fraught radiocapitellar wire could have been avoided.
Faithfully,
James S Huntley
List of abbreviations
AP, anteroposterior
APPA, the ulnar proximal angle
Acknowledgements
None.
Author’s contributions
JSH is the sole and independent author.
Competing interests
The author declares that he has no competing interests.
References
1. Williams HLM, Madhusudhan TR, Sinha A: Type III Monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report. BMC Res Notes 2014, 7:156
2. Cravino M, Oni JK, Sala DA, Chu A: A radiographic study of pediatric ulnar anatomy. J Pediatr Ortho 2014 (in press)
3. Lim J, Huntley JS: Use of intramedullary stacked nailing in the reduction of proximal plastic deformity in a paediatric Monteggia fracture: a case report. J Med Case Reports 2011, 5:153
4. De la Garza JF: Monteggia fracture-dislocation in children. In Rockwood and Wilkins’ Fractures in Children. 6th edition. Edited by: Beaty JH, Kasser JR. Philadelphia: Lippincott Williams 2006:491-541Letts M, Locht R, Wiens J: Monteggia fracture-dislocations in children. J Bone Joint Surg Br 1985, 67:724-727
5. David-West KS, Wilson NIL, Sherlock DA, Bennet GC: Missed Monteggia injuries. Injury 2005, 36:1206-1209
6. Bae DS, Waters PM: Surgical Treatment of acute and chronic Monteggia fracture-dislocations. Oper Tech Orthop 2005, 15:308-314
7. Letts M, Locht R, Wiens J: Monteggia fracture-dislocation in children. J Bone Joint Surg (Br) 1985, 67B:724-727
Concerning ‘Type III Monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child’
17 April 2014
Dear Sir
Introduction
I enjoyed the recent case report of Williams et al. [1]: Type III Monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report, but believe there is considerable material to discuss.
Discussion
Consideration of the Monteggia fracture-dislocation presented by Williams et al. Figure 2 of this report shows an approximate Anteroposterior (AP) view of the elbow, in which there is marked proximal apex-radial (varus) plastic deformation of the ulna. The six month follow-up views (Figure 6) show a malunion of the ulna at the same site, which is likely to be indicative of an incomplete reduction at the index procedure. An incomplete reduction might well be the reason for the subsequent ‘radial head relocation’ being ‘unstable’. There is a comment that ‘The ulna fracture was well aligned and therefore was treated non-operatively’ but no correlative post-operative view is given i.e. there is no AP view of the elbow between the fracture (Figure 2) and the six month follow-up (Figure 6)).
Consideration of normal and abnormal ulna anatomy. A recent publication [2] informs us of the radiological anatomy of the paediatric ulna, including an index of normal proximal ulnar varus angulation: the ulnar proximal angle (APPA), this being 13.6o ± 2.8; 6o-21o [mean ± SD; range]. This value is less than the mean normal adult value of ̴ 17.6o. Cravino et al. state that ‘Anatomic reduction and stable fixation of ulnar fractures, especially in Monteggia variants, are essential to ensure an accurate reduction of the radial head… …knowing the parameters that define the normal ulna may help the treating surgeon in managing these pathologies.’ Measuring the APPA of the ulna in Figure 6 of Williams et al. [1] yields a value in excess of 30o, indicative of a residual apex-radial bow.
Techniques for reduction of proximal ulna deformity in the type III Monteggia fracture. Proximal deformity of the ulna due to fracture may be difficult to reduce, especially if there is a plastic component. In a previous publication [3], I have alluded to such a difficulty, with the accepted manipulative method involving elbow extension (locking the olecranon in its humeral fossa), to provide an anatomical fulcrum against which to lever [3,4]. In the context of an incomplete reduction after manipulation, the technique of transapophyseal intramedullary stacked nailing of the ulna can be useful for both reduction and stabilisation [3]. ‘Nesting of wires’ within the medullary canal was also alluded to by De la Garza [4].
Radiocapitellar wiring. Radiocapitellar wiring is an accepted technique for temporary joint stabilisation [5,6], albeit usually in the context of the delayed (rather than acute) Monteggia fracture-dislocation. Even for the delayed indication, authorities are mindful of the risk of wire breakage [4,7] – as a technique, it would therefore seem to fall into a category of “sometimes necessary, but of higher risk”.
Conclusion. If an adequate reduction of the ulna had been obtained and maintained – eg by stacked intramedullary nailing of the ulna, it might be that the comparatively fraught radiocapitellar wire could have been avoided.
Faithfully,
James S Huntley
List of abbreviations
AP, anteroposterior
APPA, the ulnar proximal angle
Acknowledgements
None.
Author’s contributions
JSH is the sole and independent author.
Competing interests
The author declares that he has no competing interests.
References
1. Williams HLM, Madhusudhan TR, Sinha A: Type III Monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report. BMC Res Notes 2014, 7:156
2. Cravino M, Oni JK, Sala DA, Chu A: A radiographic study of pediatric ulnar anatomy. J Pediatr Ortho 2014 (in press)
3. Lim J, Huntley JS: Use of intramedullary stacked nailing in the reduction of proximal plastic deformity in a paediatric Monteggia fracture: a case report. J Med Case Reports 2011, 5:153
4. De la Garza JF: Monteggia fracture-dislocation in children. In Rockwood and Wilkins’ Fractures in Children. 6th edition. Edited by: Beaty JH, Kasser JR. Philadelphia: Lippincott Williams 2006:491-541Letts M, Locht R, Wiens J: Monteggia fracture-dislocations in children. J Bone Joint Surg Br 1985, 67:724-727
5. David-West KS, Wilson NIL, Sherlock DA, Bennet GC: Missed Monteggia injuries. Injury 2005, 36:1206-1209
6. Bae DS, Waters PM: Surgical Treatment of acute and chronic Monteggia fracture-dislocations. Oper Tech Orthop 2005, 15:308-314
7. Letts M, Locht R, Wiens J: Monteggia fracture-dislocation in children. J Bone Joint Surg (Br) 1985, 67B:724-727
Competing interests
None.