ACTA ORTHOPAEDICA et Author’s translation TRAUMATOLOGICA Acta Orthop Traumatol Turc 2008;42(2):90-96 TURCICA The results of treatment in pediatric Monteggia equivalent lesions Çocuklardaki Monteggia eşdeğer lezyonlarında tedavi sonuçları Melih GUVEN,1 Abdullah EREN,2 Baris KADIOGLU,2 Umut YAVUZ,2 Volkan KILINCOGLU,3 Korhan OZKAN2 1The Hospital of University of Abant Izzet Baysal, Department of Orthopaedics and Traumatology; 2Göztepe Training and Research Hospital, 2nd Orthopaedics and Traumatology Clinic; 3Fatih Sultan Mehmet Training and Research Hospital, Orthopaedics and Traumatology Clinic Amaç: Monteggia eşdeğer lezyonlu çocuklarda konserva- Objectives: We evaluated the results of conservative and sur- tif ve cerrahi tedavi sonuçları değerlendirildi. gical treatment of pediatric Monteggia equivalent lesions. Çalışma planı: Çalışmaya, Monteggia eşdeğer kırıklı- Methods: The study included 13 children (3 females, 10 çıkığı nedeniyle tedavi edilen 13 çocuk hasta (3 kız, 10 er- males; mean age 8 years; range 4 to 13 years) who under- kek; ort. yaş 8; dağılım 4-13) alındı. Yedi hastada (%53.9) went treatment for Monteggia equivalent lesions. Seven pa- Bado tip 1, altı hastada (%46.2) ise tip 3 eşdeğer lezyon tients (53.9%) had Bado type 1 and six patients (46.2%) had vardı. Tip 3 eşdeğer lezyonlu hastaların ikisinde aynı za- type 3 equivalent lesions. Two patients with type 3 equiva- manda humerus lateral kondil kırığı saptandı. Bir hastada lent lesions also had a lateral humeral condyle fracture. On (%7.7) radial sinir felci vardı. Açık kırıklı-çıkık nedeniyle presentation, one patient (7.7%) had radial nerve palsy. Pri- acil debridman ve irigasyon uygulanan bir hasta dışında, marily, closed reduction was attempted in all the patients ex- tüm hastalarda öncelikle kapalı redüksiyon denendi. Sekiz cept for one patient who underwent urgent debridement and hastada (%61.5) konservatif tedaviyle yeterli redüksiyon irrigation for an open fracture-dislocation. Reduction was sağlandı. Dört hastada (%30.8) redüksiyon sağlanamaması successful in eight patients (61.5%). Upon failure of closed nedeniyle, yaralanmadan sonra ilk 24 saat içinde cerrahi reduction, four patients (30.8%) underwent surgery within girişim uygulandı. Fonksiyonel değerlendirme Reckling the first 24 hours of injury. Functional assessment was made evrelemesine göre yapıldı. Ortalama takip süresi 4.1 yıl according to the Reckling’s criteria. The mean follow-up (dağılım 2-7 yıl) idi. period was 4.1 years (range 2 to 7 years). Sonuçlar: Hiçbir olguda kaynamama gözlenmedi. Kon- Results: None of the patients had nonunion. Conservative servatif tedavi gören hastaların hiçbirinde radius başında treatment did not result in loss of reduction of the radius redüksiyon kaybıyla karşılaşılmadı ve dirsek hareketlerin- head or limitation in the range of motion of the elbow de kısıtlılık gözlenmedi. Bir hastada (%7.7) dirsekte 5° ku- joint. Except for the patient with an open fracture-dislo- bitus varus deformitesi, radyografik olarak ise ulnada kı- cation leading to a poor functional result, the results were rık hattında 20° posteriora açılanma saptandı. Konservatif good in all the patients receiving conservative or surgical tedavi gören hastaların hepsinde fonksiyonel sonuçlar iyi treatment. One patient (7.7%) treated conservatively devel- idi. Cerrahi tedavi uygulanan dört hastada fonksiyonel so- oped cubitus varus (5°) and posterior angulation (20°) of nuçlar iyi iken, açık kırıklı-çıkığı olan olguda kötü sonuç the ulnar fracture line. One patient treated surgically had alındı. Bir hastada 10° supinasyon kısıtlılığı vardı. Dirsek limitation of supination (10°) without limitation of flex- eklemi hareket genişliğinde fleksiyon ve ekstansiyon kısıt- ion or extension of the elbow joint. Accompanying radial lılığı yoktu. Başvuru anında radial sinir felci olan bu has- nerve palsy in this patient disappeared in the postoperative tada sinir lezyonu ameliyat sonrası üçüncü ayda düzeldi. third month. Çıkarımlar: Çocuklardaki Monteggia eşdeğer lezyonlar- Conclusion: Closed reduction is the first choice of treat- da öncelikli tedavi kapalı redüksiyondur. Redüksiyon sağ- ment in pediatric Monteggia equivalent lesions. Surgical lanamaması durumunda cerrahi tedavi gündeme gelir. treatment becomes necessary if closed reduction fails. Anahtar sözcükler: Çocuk; çıkık/tedavi; kırık tespiti, internal; Key words: Child; dislocations/therapy; fracture fixation, inter- Monteggia kırığı/tedavi; radius kırığı/tedavi. nal; Monteggia’s fracture/therapy; radius fractures/therapy. Correspondence / Yazışma adresi: Dr. Melih Guven. The Hospital of University of Abant Izzet Baysal, Department of Orthopaedics and Traumatology, 14280 Bolu. Phone: +90374 - 253 46 56 Fax: +09374 - 253 52 36 e-mai: [email protected] Submitted / Başburu tarihi: 27.08.2007 Accepted / Kabul tarihi: 26.02.2008 ©2008 Türk Ortopedi ve Travmatoloji Derneği / ©2008 Turkish Association of Orthopaedics and Traumatology Guven et al. The results of treatment in pediatric Monteggia equivalent lesions 91 Monteggia fracture-dislocation, is an elbow trauma vement, eight (62%) patients showed left side involve- that constitutes less than 5% of upper extremity frac- ment. Trauma had occured due to fall from bicycle in tures, which is described as a radio-humeral dislocati- five patients, fall while running again in five patients, on associated with diaphyseal ulnar fracture. While it and fall from high in three patients. is seen more commonly in children compared to the All the patients were evaluated by antero-posterior adults, it may be seen in every age. This pathology, and lateral elbow radiographs. Accordingly, equiva- which has been first described by Monteggia in 1814, lent pathologies were categorized in three main gro- was classified into 4 main types and 2 equivalent le- ups. Radial neck fracture associated with diaphyseal sions by Bado[1] in 1967 (Table 1). The scope of the ulna or olecranon fracture without radial head dislo- description of equivalent lesions by Bado, has been cation was determined in seven (54%) patients; olec- widened by Reckling[2] and various fracture variations ranon fracture associated with lateral or anterolate- have been described in many manuscripts.[3–11] ral dislocation of radial head was determined in four If adequate treatment is not applied, similar to Mon- (31%) patients; and lateral humeral condylar fracture teggia fracture-dislocation, equivalent lesions may lead and lateral dislocation of radial head associated with to poor clinical and radiographic results. There is no olecranon fracture was determined in one (8%) while standard treatment protocol for equivalent lesions, for the last combination associated with proximal me- which results are obtained through case reports except taphyseal ulna fracture was determined in another several case series. Whereas early closed reduction pro- (8%) (Table 2). The patients in the first group were vides good and excellent results in Monteggia fracture- the cases with Type I equivalent lesions described dislocations, the results in the literature for equivalent by Bado. The patients in the second and third gro- lesions are known to be different.[2, 12, 13] ups were assessed as having Bado Type 3 Monteggia In the present study, we evaluated our conservative equivalent lesions. In the present study, there was no and surgical treatment approaches and their results on patient having Bado Type 2 equivalent lesion asso- 13 pediatric patients with Bado Type I and Type III ciated with elbow posterior dislocation. One of the Monteggia equivalent lesions. patients in the last group had Type 3 B open fracture- dislocation according to Gustilo-Anderson.[14] Material and methods Following the radiographic examination, Twenty-four patients having at least two years irrigation-debridement and surgical intervention in follow-up and who had been hospitalized in our clinic the operating room were performed on the patient between September 1999 – January 2004 due to Mon- with Bado Type 3 equivalent lesion including open teggia fracture-dislocation, were evaluated. Among fracture-dislocation. For the rest of the patients, first, those patients, 13 cases (three female, ten male) in to- closed reduction was attempted in the emergency room tal were included in the present study. The mean age and fixation with long arm splint was applied with of the patients at the moment of trauma was 7.7 years the forearm supinated. Before and after the reduction, (range; 4-13 years). Initial and subsequent treatments presence of neurovascular lesion was controlled. One of all the patients had been carried out in our clinic. (8%) patient had radial nerve palsy before the reduc- While five (38%) patients exhibited right side invol- tion. In eight (62%) patients, adequate reduction was Table 1. Bado[1] classification in Monteggia fracture-dislocations and equivalent lesions. Type Main pathology Equivalent lesion pathology 1 Anterior radial head dislocation, diaphyseal Diaphyseal ulna fracture associated with radial ulna fracture with anterior angulation head or neck fracture without radial head dislo- 2 Posterior or posterolateral radial head dislocation, cation diaphyseal ulna fracture with posterior angulation Posterior elbow dislocation, radial head or neck 3 Lateral or anterolateral radial head dislocation, fracture and diaphyseal ulna fracture with posteri- proximal metaphyseal ulna fracture or angulation 4 Anterior radial head dislocation, proximal 1/3 diaphyseal fracture of radius and