Type-I monteggia with ipsilateral fracture of distal radius epiphyseal injury: A rare case report.

Simultaneous Monteggia injuries of the elbow and ipsilateral fracture distal radius with epiphyseal injury both bone are a unique case. A unique case of a Type I Monteggia fracture equivalent with ipsilateral fracture distal radius with epiphyseal injury (Salter-Harris Type II) in a child is reported. We describe the management of this unique fracture and discuss the possible mechanism of injury. We have highlighted a rare combination of injuries. Early recognition and prompt surgical intervention can lead to a satisfactory outcome even in these complex injuries. Résumé Les traumatismes de Monteggia simultanés du coude et le rayon distal de fracture ipsilatérale avec lésion épiphysaire des deux os sont un cas unique. Un cas unique d'une fracture de Monteggia de type I avec un rayon distal de fracture ipsilatérale avec lésion épiphysaire (Salter-Harris Type II) chez un enfant est rapporté. Nous décrivons la gestion de cette fracture unique et discuter du mécanisme possible de la blessure. Nous avons mis en évidence une combinaison rare de blessures. Une reconnaissance précoce et une intervention chirurgicale rapide peuvent conduire à un résultat satisfaisant même dans ces blessures complexes.

Introduction

A Monteggia fracture is a fracture of the proximal ulna coupled with a radial head dislocation. These fractures are an uncommon class of forearm fractures. Numerous classification systems have been developed to characterize these fractures, with the Bado classification being the most common. Elbow radiograph is the primary investigating and diagnostic modalities. A notable difference exists in the prevalence, treatment, and outcome of the Monteggia fractures for pediatric and adult patient populations, with adolescent often achieving a better prognosis. Nonoperative management with closed reduction and cast immobilization often prevails in pediatrics patients, dictated by the pattern of the ulna fracture more so than the direction of the radial head dislocation. The operative management is frequently indicated because angulation and shortening of the ulna often occur after closed reduction. Although the orthopedic community understanding of these fractures has evolved, the fracture themselves remains a challenging clinical phenomenon. Hence, this article present a unique case report of an 11-year-old male child diagnosed as Monteggia fracture (Bado type-01) with ipsilateral fracture distal radius with epiphyseal injury (Salter harries Type-II).

Case Report

A case of the 11-year-old male child came in orthopedics emergency department with a complaint of pain, swelling, deformity and unable to use his left upper limb for 1 day with a history of fall from 5 feet height while playing in school sustaining injury over the left upper limb.

Clinical presentation and physical examination of the left upper limb:

On inspection: Punctured wound of about 1 cm × 1 cm present over volar aspect of forearm with gross swelling and deformity of forearm and wrist. On Palpation: tenderness present in the left forearm and left wrist, radial head palpable in the anticubital fossa, abnormal mobility present in forearm, range of motion (ROM) of elbow and wrist – painful and restricted, no distal neurovascular deficit [Figure 1].

Figure 1

Displaced radial head in anticubital fossa

The management of injury-Immediately universal splint provided for immobilization of upper limb then a standard anteroposterior and lateral radiograph of elbow with forearm with wrist done [Figure 2a preoperatively] then universal splint was replaced by plaster of paris splintage, i.e., above elbow (A/E) slab applied. Limb elevation with an analgesic to reduce swelling and pain. The close reduction is the treatment of choice for Monteggia fracture in children. Close reduction attempted under image intensifier but proper alignment cannot obtain so we proceeded for open reduction.

Figure 2

Pre-op and post op X - rays of elbow and wrist (a) Pre-op X-ray, (b) Immediate post-op X-ray, (c) 2 months post-op X-ray

Under image intensifier proximal and distal radioulnar joint reduction done and internal fixation of ulna shaft done with 2.5 mm recon plating through dorsolateral approach and fracture distal epiphyseal injury fixation done with cross kirschner pinning. A standard postoperatively anteroposterior and lateral radiograph [Figure 2b postoperatively] done. Immobilization of limb done with plaster of paris splintage at 90° of flexion at the elbow for 4 weeks.

After the 3rd postoperative day, the swelling subsided, and patient discharged after complete suture removal, immobilization, analgesic, and active hand and shoulder ROM exercises started. K-wire removal done and A/E slab removed at 4th week postoperative follow-up X-ray in Figure 2c and patient started with wrist and elbow ROM. Now, the patient is in regular follow-up till date 6 months postoperative and having good ROM, i.e., 0°–110° at elbow and wrist dorsiflexion of 30° and palmer flexion of 40°.

Discussion

While fracture of distal forearm is quite common in children but the Monteggia lesion remains uncommon, simultaneously ipsilateral proximal and distal forearm fracture are very rare. Previous such combination reported includes Type III Monteggia injury with ipsilateral distal radius and ulna fractures.[1] Olecranon fracture and distal radial physis.[2] Type II Monteggia injury with fracture separation of the distal radial physis.[3] Type IV Montaggia injury with distal diaphyseal fracture of the radius.[4] 11 cases of Montaggia fracture dislocation with fracture of the ipsilateral radius and ulna.[5] Three epiphyseal fracture (distal radius and ulna and proximal radius) and a diaphyseal ulnar fracture in the same forearm.[6]

Four types of Monteggia fractures, as well as three equivalent types, have been described.[7] These were described according to the direction of the radial head subluxation: the most common (75%) is fracture of the proximal third ulna, anterior angulation of the fracture with anterior dislocation of the radial head; the second most common is fracture of the proximal third of the ulna, lateral angulation of the fracture and lateral dislocation of the radial head; proximal ulna fracture with postdislocation of the radial head; fracture of the proximal radius and ulna with dislocation of the radial head. Three Monteggia equivalent fractures have been described: isolated radial head dislocation; fractures of the proximal ulna with a fracture of the radial neck; proximal one-third fracture of both bones with radial fracture proximal to an ulna fracture. Closed reduction is generally the treatment of choice for Monteggia fractures in children.[38] Quite often in Monteggia equivalent fractures, proper alignment cannot be obtained, and open reduction may be necessary. In this particular instance, we felt that we would be unable to achieve satisfactory closed reduction and proceeded to open reduction.

The mechanism of injury causing two level fractures in the forearm which is not well understood when child has fallen on ground with outstretched hand the forearm is in mid prone position this original injury leads to fracture separation of radial, and ulnar physis and simultaneously the trunk rotates and this leads to longitudinal compression on wrist leads to Monteggia injury. To the best of our knowledge, the combination of Type I Monteggia fracture-dislocation and Salter-Harris Type II distal radial epiphyseal injury only 1 case has been reported in the literature. They also Attempted closed reduction under a general anesthetic but failed hence an open reduction with plating of the ulnar fracture was performed. A further attempt at closed reduction of the radial head also failed, and the radial head was explored through a modified Kocher approach. The radial head had button-holed through the anterior capsule and required open reduction. The distal radial Salter-Harris injury was satisfactorily manipulated to an acceptable position. An above-the-elbow POP was applied with the forearm in full supination and the elbow in 110° of flexion. At 6 months of follow-up, the patient had regained full flexion and extension of the elbow, and supination was restricted in the terminal 20° with nearly full pronation. Both fractures had healed, and the patient had regained full functional use of the upper limb and returned to active sports.

Conclusion

The key to good outcome in Monteggia fracture-dislocation includes early complete diagnosis, stable anatomic reduction of the ulnar fracture, and relocation of radial head. Although in most childhood cases this can be achieved by closed methods, one should not hesitate to use operative fixation if attempts at closed reduction fail as in our patient.

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Conflicts of interest

There are no conflicts of interest.