Response to Comment on Yuan et al: The use of external fixation for the management of acute and chronic Monteggia fractures in children.

Dear Colleagues,

We have appreciated your insightful comments concerning our work,[1] in particular your observation that there may be a distal radio-ulnar joint dislocation. Your comments prompted us to review all cases,[1] and we thank you for that.

Dislocation of the distal radio-ulnar joint is described as when the position of the ulna is volar or dorsal to the radius.[2] After reviewing all cases, we found some patients with chronic Monteggia fracture treated by ulnar osteotomy and lengthening by external fixator that seemed to have dislocation of the distal radio-ulnar joint, on radiographs, at last follow-up visit.[3] However, it is very difficult to make the diagnosis of distal radio-ulnar joint dislocation from radiographs alone as the position of the forearm under radiographic examination may also contribute to this appearance.

We performed posteroanterior and lateral radiographs of the forearm (elbow and wrist included) in patients with chronic Monteggia fracture during follow-up.[4] In order to maintain the forearm in such a position, the wrist may require additional pronation or supination, which will potentially contribute to the radiographic appearance of distal radio-ulnar joint dislocation. In addition, and most importantly, clinical evaluation did not reveal any wrist pain nor limitation of movement in any of the patients.

Moreover, following your remarks, we also did a comparison between radiographs of normal children and age-matched patients with operated chronic Monteggia fracture, and we could not detect any significant difference between the two sets of radiographs (Fig. 1).

Fig. 1.

Radiographs of children with normal distal radio-ulnar joint and age-matched children with chronic Monteggia fracture. A1 and A2 and C1 and C2 show posteroanterior and lateral view of the forearm of a five- and eight-year-old boy with chronic Monteggia fracture, respectively. B1 and B2 show the radiographic appearance of the forearm of an age-matched normal boy; D1 and D2 are the forearm radiograph of the same boy following distal radius fracture, as comparison.

In particular, we paid special attention to the case labelled as ‘Figure 5’ in the original article.[1] We examined the patient again, and clinical evaluation did not reveal any wrist pain or limitation of movement.

We would like to thank our colleagues again for their very interesting remarks, and we confirm the absence of distal radio-ulnar joint dislocation. We are currently following this cohort of patients for the long term, and we will publish our results, with particular attention to both the function and the radiographic appearance of the wrist.

Yours sincerely

The Authors