Neglected Monteggia Fractures in Kids: Pathology and Management Strategies

Abstract

Monteggia fractures are rare injuries in children, and they account for less than 2% of forearm fractures. The condition occurs by fracture of the ulna with the dislocation of the radial head. If left untreated for more than three weeks, they are termed as neglected Monteggia fractures. While ulna fractures in children are generally diagnosed quickly, radial head dislocation is often overlooked and leads to complications that require open reduction and pose an increased risk for further trauma. This review aims to explore the pathological characteristics of neglected Monteggia fractures based on key anatomical changes, including the length ratio of the ulna and radius, relative positions of the proximal ends of the ulna and radius, the integrity of the annular ligament, and pathological changes in the proximal radioulnar joint. Understanding these characteristics is crucial for guiding clinical decision-making and improving treatment outcomes in neglected Monteggia fractures.

Introduction

Monteggia fractures, first described by Giovanni Battista Monteggia in 1814, are defined by a fracture of the ulna associated with dislocation of the radial head. These injuries are rare in pediatric patients but require timely intervention to prevent long-term complications. In many cases, the ulna fracture is promptly diagnosed, while the radial head dislocation is overlooked, leading to delayed treatment and the development of neglected Monteggia fractures. This is one of the more challenging conditions in pediatric orthopedics, thus requiring a full understanding of the underlying pathology for optimal management.

Neglected Monteggia fractures may result in deformities, joint instability, and functional impairment. Failure to restore proper anatomical alignment may lead to progressive radial head subluxation or complete dislocation, contributing to chronic pain and restricted forearm motion. This review will provide an in-depth analysis of the pathological characteristics of neglected Monteggia fractures, offering insights into their pathogenesis, diagnosis, and treatment approaches.

Pathological Characteristics of Neglected Monteggia Fractures

1. Altered Length Ratio of the Ulna and Radius

In neglected Monteggia fractures, the disrupted alignment of the ulna affects the biomechanics of the forearm. The normal length ratio between the ulna and radius is altered due to malunion or inadequate remodeling, leading to an abnormal articulation of the proximal radioulnar joint. The shortened or angulated ulna can create a mechanical block, preventing the spontaneous reduction of the radial head. Furthermore, progressive deformity may result in additional stress on the radial head, leading to secondary degenerative changes over time.

2. Displacement of the Proximal Ulna and Radius

The radial head stays dislocated in neglected Monteggia fractures due to the continued proximal ulna deformity. The relative positioning of these bones is essential for elbow stability. Loss of congruence between the radial head and the capitellum may result in limited pronation and supination of the forearm. In longstanding cases, compensatory remodeling may occur, which complicates surgical intervention. Chronic dislocation can lead to increased strain in adjacent soft tissues, including joint capsule and musculature about the joint. This may accelerate functional limitations.

3. Integrity of the Annular Ligament

The annular ligament plays a vital role in stabilizing the radial head within the radial notch of the ulna. In neglected Monteggia fractures, the annular ligament often becomes disrupted or interposed within the radiocapitellar joint, preventing successful closed reduction. Additionally, fibrosis and scarring around the ligament may necessitate reconstruction during surgical management. The degree of ligament disruption varies among patients, with some cases demonstrating complete ligamentous deficiency requiring advanced reconstructive techniques, such as tendon grafting or synthetic ligament replacement.

4. Pathological Changes in the Proximal Radioulnar Joint

Chronic dislocation of the radial head leads to degenerative changes in the proximal radioulnar joint. These changes include synovial thickening, osteophyte formation, and articular cartilage erosion, contributing to joint stiffness and pain. Understanding these pathological alterations is crucial for determining the feasibility of joint preservation versus salvage procedures in late-presenting cases. In addition, chronic instability may lead to adaptive bony changes that alter the joint mechanics, making reduction more complex and necessitating more extensive surgical intervention.

Clinical Presentation and Diagnosis

Children with neglected Monteggia fractures often present with persistent elbow deformity, limited range of motion, and discomfort. Physical examination may reveal:

• Prominent radial head palpable anteriorly or laterally

• Limited forearm pronation and supination

• Functional impairment in daily activities requiring wrist and elbow mobility

Imaging studies play a critical role in diagnosing neglected Monteggia fractures. Radiographs should include:

• AP and lateral views of the forearm and elbow to assess alignment

• Stress views to evaluate the stability of the radial head

• Computed tomography (CT) or magnetic resonance imaging (MRI) in complex cases to visualize soft tissue structures and annular ligament status

Advanced imaging techniques, including 3D reconstruction CT scans, can provide a more detailed understanding of the bony deformities and assist in preoperative planning.

Management Strategies

1. Non-Surgical Approach

In cases where the radial head remains functional despite dislocation, conservative management may be considered. However, this is typically reserved for asymptomatic patients or those with minimal functional limitations. Physiotherapy and activity modification may help optimize function in select cases. Patients undergoing conservative management require long-term follow-up to monitor for progressive deformity or functional deterioration.

2. Surgical Treatment Options

a) Open Reduction and Internal Fixation (ORIF)

• • Indicated for cases where the ulna malunion requires correction to restore the proper length and alignment

  • Involves ulnar osteotomy to facilitate radial head reduction

  • Annular ligament repair or reconstruction may be necessary to maintain stability

  • Postoperative immobilization followed by gradual rehabilitation is essential for optimal outcomes

b) Radial Head Excision

• • Considered in older children or adolescents with severe joint degeneration

  • May relieve pain but at the cost of reduced forearm stability

  • Potential for long-term complications, including proximal migration of the radius and secondary instability

c) Salvage Procedures

• • For cases with severe deformity and persistent instability, salvage techniques such as radial head reconstruction or joint fusion may be required

  • Considered as a last resort for patients with advanced degenerative changes

Postoperative Rehabilitation and Prognosis

Following surgical correction, a structured rehabilitation program is essential to optimize functional recovery. Early mobilization with controlled range-of-motion exercises helps prevent stiffness. Serial radiographs should be obtained to monitor healing and joint stability. The prognosis depends on factors such as:

• The duration of neglect

• The degree of ulna malunion

• The success of annular ligament reconstruction

With appropriate intervention, many children can achieve significant improvement in elbow function. However, long-term follow-up is necessary to monitor for late complications such as radial head subluxation, growth disturbances, and post-traumatic arthritis. Some patients may require additional procedures to address recurrent instability or progressive deformity.

Future Directions and Research Implications

Advancements in surgical techniques and imaging modalities continue to refine the management of neglected Monteggia fractures. Research into:

• Biological augmentation techniques for annular ligament repair

• 3D printing technology for preoperative planning

• Long-term outcomes of various surgical interventions

Could provide valuable insights for improving patient care. Emerging technologies, such as patient-specific implants and robotic-assisted surgery, may further enhance the precision and effectiveness of corrective procedures.

Conclusion

Neglected Monteggia fractures in children are a significant challenge because of their complex pathology and functional implications. Understanding the changes in ulna and radius alignment, the integrity of the annular ligament, and changes in the proximal radioulnar joint are essential for optimizing the outcome of treatment. Early recognition, timely surgical intervention, and comprehensive rehabilitation are essential to restore elbow stability and function. Ongoing research and advances in orthopedic techniques are likely to continue improving the prognosis for such challenging injuries.

Read more such content on @ Hidoc Dr | Medical Learning App for Doctors