Complications of Pediatric Elbow Dislocations and Monteggia Fracture-Dislocations

Scott H. Kozin, MD Joshua M. Abzug, MD Shannon Saﬁ er, MD Martin J. Herman, MD

Abstract management. This chapter discusses Pediatric elbow dislocations and Monteggia lesions are prone to acute and chronic compli- the acute and chronic complications of cations. A pediatric patient’s cartilaginous and unossifi ed distal humerus contributes to pediatric elbow dislocations and Mon- the risks of inaccurate diagnoses resulting from the misinterpretation of fi ndings on plain teggia fracture-dislocations. radiographs. The debate continues regarding the amount of acceptable displacement for medial epicondyle fractures. In contrast, the radial head should always point directly to Pediatric Elbow Dislocations the capitellum. Chronic complications include instability and arthritis. Instability, which Pediatric elbow dislocations are rel- can be subtle and diffi cult to diagnose, can occur in the medial or the posterolateral direc- atively uncommon; however, the ad- tion, depending on the injured stabilizer. Restoration of stability remains the mainstay vent of extreme sports has resulted in of treatment. Pediatric traumatic arthritis is extremely diffi cult to manage with surgery an increasing number of high-velocity because of the limited number of reliable treatment options. injuries in children. Similar to adults, Instr Course Lect 2015;64:493–498. posterior dislocations are the most common injury pattern.1,2 Children are Pediatric injuries about the elbow are additional imaging is warranted to bet- prone to apophyseal injuries instead common. Treatment requires accurate ter detail the anatomy. This chapter’s of ligamentous tears. After an elbow recognition and prompt management. authors prefer intraoperative arthrog- dislocation, the medial epicondyle with In children, the cartilaginous and un- raphy to delineate pathology and direct its attached collateral ligament is fre- ossifi ed distal humerus can confound treatment. Early treatment of pediatric quently displaced. the injury diagnosis. In equivocal cases, elbow injuries is more reliable than late Acute Complications When assessing radiographs of an el- Dr. Kozin or an immediate family member serves as a paid consultant to or is an employee of Checkpoint Surgical and serves as a board member, owner, offi cer, or committee member of the American Society for Surgery of the Hand. Dr. Abzug or bow dislocation, identifi cation of the an immediate family member serves as a paid consultant to or is an employee of Axogen. Dr. Safi er or an immediate family medial epicondyle is crucial. Specifi - member is a member of a speakers’ bureau or has made paid presentations on behalf of Orthopediatrics and serves as a paid cally, a diligent search is necessary to consultant to or is an employee of Orthopediatrics and Medicrea. Dr. Herman or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons and the Pediatric ensure that the medial epicondyle is Orthopaedic Society of North America. not residing within the ulnohumeral

Figure 1 A, Lateral radiograph of the elbow of a 15-year-old, right hand–dominant adolescent boy with a posterior elbow dislocation and a displaced medial epicondyle fracture. B, A sagittal CT scan conﬁ rms that the medial epicondyle is within the ulnohumeral joint. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.)

(Figure 1, B). Prompt recognition of Chronic Complications the position of the epicondyle allows Chronic complications after elbow urgent surgical removal and fracture dislocations are typically related to in- fi xation. Failure to recognize the instability. Instability can occur in two carcerated medial epicondyle results in different scenarios: valgus instability pain and stiffness (Figure 2). or recurrent elbow dislocations.3,4 Val- When the elbow joint is not reduced, gus instability is related to nonunion secondary calcifi cations with resultant or malunion of the medial epicondyle stiffness in the elbow capsule are com- fracture and associated medial collateral mon. These calcifi cations may be mis- ligament insuffi ciency. The instability interpreted as an additional injury. After often presents years after an injury as the incarcerated medial epicondyle is the child increases his or her activity recognized, urgent removal is indicated. level and valgus stress. The diagnosis Delayed extrication of the medial epi- requires a physical examination and Figure 2 A 12-year-old boy had condyle is diffi cult and often results imaging studies, such as intraoperative persistent stiffness after an elbow in suboptimal fi xation. Intraoperative fl uoroscopy. Examination under anes- dislocation that occurred 3 months earlier. CT scan shows the medial fl uoroscopy is benefi cial in terms of thesia may be necessary to confi rm the epicondyle within the ulnohumeral identifying the fragment and guiding diagnosis. The initial treatments are ac- joint and periarticular calcifi cations. relocation of the epicondyle into the tivity modifi cation and fl exor-pronator (Courtesy of Shriners Hospital for Children, Philadelphia, PA.) optimal position. Fixation can be ac- strengthening. Failure to curtail the in- complished using a cannulated screw stability requires medial collateral liga- system or with tension wire fi xation. ment reconstruction4 (Figure 3). The The choice depends on the size and the procedure is complicated by malposi- joint1 (Figure 1, A). If there is any consistency of the fragment. The goal is tion of the epicondyle and distortion question about the location of the simply to obtain a stable ulnohumeral of the anatomy. Therefore, medial col- medial epicondyle, advanced imaging joint with adequate motion for activities lateral ligament reconstruction requires studies can accurately assess its position of daily living. ingenuity with regard to distal humeral

Figure 3 A 13-year-old adolescent was unable to participate in gymnastics after a right elbow dislocation that occurred 2 years earlier. The elbow examination under anesthesia showed valgus instability. A, Radiograph shows a displaced medial epicondyle at the ulnohumeral joint (arrow). B, Intraoperative photograph of medial collateral ligament reconstruction using autograft tendon. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.)

fi xation in this setting. The fragment undetermined reliability in children.6 consideration of biologic resurfacing may be left alone or excised depending The initial treatment for recurrent el- procedures, such as distraction inter- on its location with reference to the bow dislocation is activity modifi cation position arthroplasty or osteochondral ligament reconstruction. This recon- and fabrication of a hinged elbow brace autograft transplantation mosaicplasty. struction can restore stability and allow that blocks terminal extension and supi- Osteochondral autograft transplanta- a return to normal activity; however, nation. Because the local tissue is usu- tion mosaicplasty is indicated for de- activities requiring a high level of valgus ally inadequate for imbrication, lateral fi ned symptomatic defects, whereas elbow motion, such as gymnastics, may collateral ligament reconstruction is re- interposition arthroplasty is indicated not be possible. quired.7-9 The procedure is complicated for global loss of articular cartilage.10-12 Recurrent elbow dislocation is a by the open physis because docking into Interposition arthroplasty is designed rare problem.3 In contrast to valgus the distal humerus must avoid crossing to resurface the elbow joint to eliminate instability and medial insuffi ciency, re- the growth plate. Reconstruction can pain and enhance motion. In the gin- current dislocation is related to lateral restore stability and prevent further glymus, or elbow hinge joint, it appears collateral ligament defi ciency. The di- dislocations. Return to normal activity more suitable than in multiplanar joints. agnosis requires a physical examination is possible after recovery. Minimal resection of bone, careful re- and possible examination under anes- Osteonecrosis and/or arthritis can pair of the collateral ligaments, and dis- thesia. The posterolateral pivot shift occur after an elbow dislocation and traction of the joint surfaces (distraction test is unreliable in the awake child, and may be more likely in patients with a interposition arthroplasty) improves examination under anesthesia is often delayed diagnosis and open reduction. stability, decreases shear forces, and necessary to confi rm the posterolat- Loss of articular cartilage is a challeng- promotes healing of the graft. A hinged eral instability.5 Other tests, including ing problem in children. Asymptomatic external fi xator is helpful to distract the the chair sign, the fl oor push-up sign, arthritis does not merit extensive inter- articulating surfaces and permits imme- and the table-top relocation test, have vention. Symptomatic arthritis requires diate movement while protecting the

interposition and soft-tissue repairs. ligament(s) and the common extensor Other treatment options include total and/or fl exor origins with transosseous elbow arthroplasty (contraindicated in sutures or bone anchors. Radiographs a young patient), resection arthroplasty, should be checked before leaving the and elbow arthrodesis. Elbow arthro- operating room to confi rm joint reduc- desis provides stability and eliminates tion and correct positioning of external pain; however; there is no optimum fi xation. The olecranon should align position that allows performance of all with the trochlea, and the radial head the activities of daily living.13 should point to the capitellum. Poste- When performing interposition ar- rior subluxation of the radial head infers Figure 4 A 16-year-old adoles- throplasty, a long posterior longitudinal posterolateral instability and must be cent had painful, posttraumatic left incision centered over the olecranon is corrected. elbow arthritis after delayed open preferred.11 The common extensor ori- reduction for an elbow dislocation. Two-ply fascia lata was draped and gin and lateral collateral ligament origin Monteggia Fracture- secured over the distal humerus are elevated from the lateral epicondyle Dislocations before application of an external fi x- and distal humerus. The joint surface Acute Complications ator. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.) is exposed by supinating the forearm Failure to make the diagnosis is the and applying varus stress to the elbow. most common, acute complication of This maneuver rotates the ulna and a Monteggia fracture-dislocation.14 The maximum angulation. The radiocapitel- radial head from the distal humerus. radial head should align with the cap- lar joint is opened, and the radial head After dislocating the joint, the anterior itellum regardless of the radiographic is reduced. Débridement of the radio- and posterior capsules are elevated to view. The diagnosis may be missed be- capitellar joint may be necessary to re- increase motion. The deformed joint cause the ulna fracture may be in the move any debris preventing reduction. surfaces are refashioned to resemble an form of plastic deformation, which is The ulna is then fi xed with a plate and innate humerus. The goal is to re-create diffi cult to appreciate without a full- screw construct, and the stability of the congruency between the trochlea and length forearm radiograph, or the radiocapitellar joint is assessed clinically the olecranon. elbow radiograph may reveal subtle ra- and under fl uoroscopy. Frequently, the The joint is reduced and assessed for dial head subluxation instead of frank radial head is stable, and the remnants satisfactory passive motion. The inter- dislocation.15 Radial head subluxation of the ligament are repaired. Persistent position material of choice is then pro- will progress to dislocation during the instability requires a reassessment of the cured. Allograft or autograft are both ensuing weeks, secondary to the unre- ulnar osteotomy and/or ligament repair. viable options. A two-ply interposition stricted biceps tendon pull on the radial is fashioned that cloaks the distal hu- tuberosity. Chronic Complications merus. The graft is secured to the distal A patient with a delayed diagnosis Chronic complications are related to humerus via transosseous mattress su- requires prompt surgical management. persistent dislocation of the radial head. tures (Figure 4). An external fi xation Closed reduction is usually unsuccess- The radial head is usually dislocated in distraction device is applied, with care ful. Treatment includes correction of an anterior direction and can block taken to avoid injury to the radial nerve, the ulna fracture and radiocapitellar elbow fl exion. In addition, the loss of and the joint is distracted 3 to 4 mm. joint reduction16-18 (Figure 5). An ulnar lateral column bony stability can lead to The crucial step is to ensure the external osteotomy is recommended to relocate valgus instability. Treatment is directed fi xator is aligned at the joint axis to al- the radial head and gain ulnar length. at restoring radiocapitellar alignment low the normal arc of motion. Accurate The apex of the osteotomy should be and reestablishing lateral column sta- axis wire placement is the critical step designed to redirect the radial head to- bility. The procedure follows the same because the fi xator is constructed about ward the capitellum. An extended lat- tenets as those for subacute manage- this wire. Closure is then accomplished, eral Kocher incision is performed. The ment, although the level of diffi culty is with a focus on repair of the collateral ulna is cut with a saw at the point of much greater. Instead of an acute ulnar

References 1. Rasool MN: Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86(7):1050-1058. 2. Carlioz H, Abols Y: Posterior dislocation of the elbow in children. J Pediatr Orthop 1984;4(1):8-12. 3. Osborne G, Cotterill P: Recurrent dislocation of the elbow. J Bone Joint Surg Br 1966;48(2):340-346. 4. Rohrbough JT, Altchek DW, Hyman J, Williams RJ III, Botts JD: Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med 2002;30(4):541-548. 5. O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73(3):440-446. 6. Charalambous CP, Stanley JK: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Br 2008;90(3):272-279. 7. Cohen MS, Hastings H II: Rotatory instability of the elbow: The anatomy and role of the lateral stabilizers. J Bone Joint Surg Am 1997;79(2):225-233. 8. Yadao MA, Savoie FH III, Field Figure 5 A 6-year-old boy had a missed Monteggia fracture-dislocation that LD: Posterolateral rotatory insta- occurred when he fell from a slide 3 months earlier. A, Lateral radiograph with bility of the elbow. Instr Course Lect anterior dislocation of the radial head and healed ulna fracture. B, Intraopera- 2004;53:607-614. tive photograph showing radiocapitellar joint reduction, temporary Steinmann 9. Savoie FH, Field LD, Ramsey JR: Pos- pin fi xation, and ulnar osteotomy. C, Postoperative radiograph shows radio- terolateral rotatory instability of the capitellar joint reduction. (Courtesy of Shriners Hospital for Children, Philadel- elbow: Diagnosis and management. phia, PA.) Oper Tech Sports Med 2006;14:81-85. 10. Kokkalis ZT, Schmidt CC, So- osteotomy, slow distraction osteogene- reconstruction is more anatomic and tereanos DG: Elbow arthritis: sis may be necessary to gain adequate results in better centering of the radial Current concepts. J Hand Surg Am length.19,20 During the consolidation head. 2009;34(4):761-768. phase, open joint reduction is per- 11. Kozin SH, Zlotolow DA: Distraction interposition arthroplasty: Pediatric, formed with adjustment of the fi xator to Summary in Glickel SZ, Bernstein RA, eds: Ar- optimize radiocapitellar alignment. The Elbow dislocations and Monteggia thritis of the Hand and Upper Extremity: surgeon should be prepared to perform fracture-dislocations can result in both A Master Skills Publication. Rosemont, IL, American Society for Surgery of an annular ligament reconstruction to acute and chronic complications. Acute the Hand, 2011, pp 415-428. enhance stability of the radial head. complications center on inaccurate di- 12. Larson AN, Morrey BF: Interposition Options for reconstruction include agnoses and a subsequent delay in treat- arthroplasty with an Achilles tendon the Bell-Tawse procedure using a strip ment. Chronic complications involve allograft as a salvage procedure of triceps tendon16 or the technique instability at the ulnohumeral or radio- for the elbow. J Bone Joint Surg Am 2008;90(12):2714-2723. using tendon graft described by Seel capitellar joints. The management of and Peterson.21 This chapter’s authors chronic complications is more diffi cult, 13. Morrey BF, Askew LJ, Chao EY: A biomechanical study of normal prefer the latter technique because the and outcomes are less predictable.

functional elbow motion. J Bone Joint 17. Hasler CC, Von Laer L, Hell AK: 20. Exner GU: Missed chronic anterior Surg Am 1981;63(6):872-877. Open reduction, ulnar osteotomy and Monteggia lesion: Closed reduction external ﬁ xation for chronic anterior by gradual lengthening and angula- 14. Goh SH: Monteggia ‘fracture’-disloca- dislocation of the head of the radius. J tion of the ulna. J Bone Joint Surg Br tion with bowing of the ulna: A pitfall Bone Joint Surg Br 2005;87(1):88-94. 2001;83(4):547-550. for the unwary emergency physician. Eur J Emerg Med 2008;15(5):281-282. 18. Rodgers WB, Waters PM, Hall JE: 21. Seel MJ, Peterson HA: Management Chronic Monteggia lesions in chil- of chronic posttraumatic radial head 15. Stoll TM, Willis RB, Paterson DC: dren: Complications and results of dislocation in children. J Pediatr Orthop Treatment of the missed Monteggia reconstruction. J Bone Joint Surg Am 1999;19(3):306-312. fracture in the child. J Bone Joint Surg 1996;78(9):1322-1329. Br 1992;74(3):436-440. 19. Bhaskar A: Missed Monteggia fracture 16. Gyr BM, Stevens PM, Smith JT: Video Reference in children: Is annular ligament Chronic Monteggia fractures in chil- reconstruction always required? Indian Kozin SH: Video. Posterolateral Pivot Shift Test. dren: Outcome after treatment with J Orthop 2009;43(4):389-395. Philadelphia, PA, 2014. the Bell-Tawse procedure. J Pediatr Orthop B 2004;13(6):402-406.