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[Corrective interventions after elbow para-articular fractures in childhood]
Abstract
Besides supracondylar fracture of the humerus there are several injuries of the elbow joint, which may lead to major disability. In this study 5 cases of corrective procedures are described after elbow fractures. Initially the lesions were overlooked. These were a fracture of the radial condyle, producing a pseudarthrosis, three cases of Monteggia fractures with persisting dislocation of the radial head in young children and a periarticular calcification issuing from an avulsion of the radial epicondyle and the radial capsule in a 13-year-old. All children had marked functional limitation of the elbow joint. The primarily overlooked fractures were corrected early. Various osteosynthesis procedures including movement and distraction extend fixator were employed. Overall, in all patients an almost complete movement of the joint at existing stability could be achieved. Transcondylar and Monteggia fractures should not be overlooked at the initial diagnosis as secondary operations for correction always have a less favorable outcome than the primary one. For the management of ankylosis of the elbow a movement extend fixator after distraction is a useful additional management.
... The outcome was excellent as determined by the mobility of the elbow and maintenance of radial head relocation [15]. However, some studies reported a less favorable outcome with attempted reconstruction of an unreduced radial head161718. Others reported late reconstruction to be complicated and unpredictable [4] and recommend that surgery should be reserved for symptomatic patients [19]. ...
... Others reported late reconstruction to be complicated and unpredictable [4] and recommend that surgery should be reserved for symptomatic patients [19]. Gunther and Wessel [16] emphasized that Monteggia fractures should not be overlooked, as secondary operations always had a less favorable outcome. Rodgers et al. reported their results of reconstruction in 7 patients with chronic Monteggia lesions, in whom they observed 14 complications. ...
The most common cause of chronic radial head dislocations is Monteggia lesions. Although acute, Monteggia fractures in children
are easy to treat; complex reconstruction techniques may be required to reduce and stabilize chronic radial head dislocations.
Early, accurate diagnosis and appropriate treatment remain the key factors for successful results in Monteggia or equivalent
lesions in children.
La cause la plus commune des luxations chroniques de la tête radiale sont les lésions de Monteggia. Bien qu’il soit facile
de traiter les fractures fraîches de Monteggia chez les enfants, des techniques complexes de reconstruction peuvent être exigées
pour réduire et stabiliser des luxations chroniques de la tête radiale. Le diagnostic précoce et précis et le traitement approprié
demeurent les facteurs principaux de succès dans les fractures de Monteggia ou dans les lésions équivalentes chez les enfants.
Der Kern des Capitulum humeri entsteht im 5.–6. Embryonalmonat und ist somit bei Geburt bereits vorhanden. Der Knochenkern des proximalen Radius entwickelt sich um das 2. Lebensjahr. Um das 4. Lebensjahr erscheint der Knochenkern des Epicondylus ulnaris. Die Knochenkerne des Condylus ulnaris entstehen um das 6.–8. Lebensjahr, sie sind häufig unregelmäßig und asymmetrisch zur Gegenseite. Der Knochenkern für das Olekranon entwickelt sich um das 9.–11. Lebensjahr. Zuletzt erscheint der Knochenkern für den Epicondylus radialis um das 12.–14. Lebensjahr.
Die Erstbeschreibung der distalen Radisufraktur in loco typico geht auf den französischen Chirurgen Clause Pouteau (1725–1775) zurück. Typischerweise wird der irische Chirurg und Anatom Abraham Colles (1773–1843), der erst im Jahre 1814 im »Medical Journal « einen Artikel über Frakturen des distalen Radius veröffentlichte, in der Literatur häufiger zitiert, da die französische Literatur – unglücklicherweise für die gesamte Handchirurgie – im deutschen und angloamerikanischen Sprachraum relativ unbekannt ist.
The treatment of fractures in children and adolescents must be based on an adequate knowledge of the physiology of the growing skeleton. Treatment failures usually do not result from technical deficiencies, but rather from a misunderstanding of the special considerations applying to the treatment of fractures in this age group.
We selectively reviewed recent publications on the main types of long bone fracture occurring in the period of skeletal development.
Alleviating pain is the first step in fracture management, and due attention must be paid to any evidence of child abuse. The goals of treatment are to bring about healing of the fracture and to preserve the function of the wounded limb. The growth that has yet to take place over the remaining period of skeletal development also has to be considered. Predicting the growth pattern of fractured bones is a basic task of the pediatric traumatologist. During the period of skeletal development, conservative and surgical treatments are used in complementary fashion. Particular expertise is needed to deal with fractures around the elbow, especially supracondylar humeral fractures, displaced fractures of the radial condyle of the humerus, radial neck fractures, and radial head dislocations (Monteggia lesions). These problems account for a large fraction of the avoidable cases of faulty fracture healing leading to functional impairment in children and adolescents.
The main requirements for the proper treatment of fractures in children and adolescents are the immediate alleviation of pain and the provision of effective treatment (either in the hospital or on an outpatient basis) to ensure the best possible outcome, while the associated costs and effort is kept to a minimum. Further important goals are a rapid recovery of mobility and the avoidance of late complications, such as restriction of the range of motion or growth disorders of the fractured bone. To achieve these goals, the treating physician should have the necessary expertise in all of the applicable conservative and surgical treatment methods and should be able to apply them for the proper indications.
Forearm fractures are some of the most common injuries in childhood. Monteggia fractures and Monteggia equivalents are rare injuries of the proximal forearm, but they are important because of their special biomechanics. Many authors have reported good results with excellent function if the Monteggia injuries are diagnosed primarily and treated by an axial reposition of the ulna and by an exactly repositioned proximal radioulnar joint. In our investigation, some clinical cases of pediatric Monteggia fractures were operated upon using the technique of elastic stable intramedullary nailing (ESIN). In correct indications, ESIN could be used as a minimally invasive therapeutic alternative to plate osteosynthesis for treating pediatric Monteggia injuries.
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