Case Report
 

By Dr. Nasir Muzaffar , Dr. Sukhjeet Singh , Dr. Naveed Bashir , Dr. Tariq Malik , Dr. Rouf Malik , Dr. Arifa Hafeez
Corresponding Author Dr. Nasir Muzaffar
Bone & Joint Surgery Hospital, - India 190005
Submitting Author Dr. Nasir Muzaffar
Other Authors Dr. Sukhjeet Singh
Bone & Joint Surgery Hospital, - India

Dr. Naveed Bashir
Bone & Joint Surgery Hospital, - India

Dr. Tariq Malik
Bone & Joint Surgery Hospital, - India

Dr. Rouf Malik
Bone & Joint Surgery Hospital, - India

Dr. Arifa Hafeez
Bone & Joint Surgery Hospital, - India

ORTHOPAEDICS

Fracture, Ulna, Lateral Humeral Condyle, Monteggia

Muzaffar N, Singh S, Bashir N, Malik T, Malik R, Hafeez A. Concomitant Ulnar Shaft and Humeral Condylar Fracture in a 6 Year Old Child. WebmedCentral ORTHOPAEDICS 2011;2(3):WMC001762
doi: 10.9754/journal.wmc.2011.001762
No
Submitted on: 15 Mar 2011 03:47:20 PM GMT
Published on: 16 Mar 2011 10:22:00 PM GMT

Abstract


We present a case of a 6 year old child with a history of mild trauma to the elbow which turned out to have ipsilateral undisplaced ulnar shaft and humeral condylar mass fractures. The fractures were managed conservatively and the patient recovered without any residual deficit. This is a rare injury with only 5 similar cases reported in literature. It may be considered a Monteggia variant.

Case Report(s)


A 6 year old female child reported to the casualty department with a history of fall from a chair on her extended arm with mild swelling and bruising of the elbow, tenderness of the forearm and joint laterally and no neurovascular deficit. Radiographs revealed undisplaced fractures of the ulnar shaft and lateral humeral condylar mass (Fig 1, 2). The patient was managed by an above elbow backslab for 3 weeks with the elbow in flexion. The slab was removed at 3 weeks and active range of motion exercises were instituted. The patient made an uneventful recovery.

Discussion


Monteggia fracture-dislocation is an elbow trauma that constitutes less than 5% of upper extremity fractures, which is described as a radio-humeral dislocation associated with diaphyseal ulnar fracture. While it is seen more commonly in children compared to the adults, it may be seen in every age. This pathology, which has been first described by Monteggia in 1814, was classified into 4 main types and 2 equivalent lesions by Bado [1]. The scope of the description of equivalent lesions by Bado has been widened by Reckling [2] and various fracture variations have been described in many manuscripts. [3–11]. Fractures of the lateral humeral condyle make up 17% of all elbow fractures in children and mostly occur between 2 and 14 years [12]. Milch classified these fractures into type I where the fracture line courses laterally to the trochlea through and into the capitellar-trochlear groove. These injuries are rare but usually stable. In type II injuries the fracture line extends into the area of the trochlea and produces inherent instability of the elbow [13]. The injury is an intra-articular transepiphyseal fracture classified as Salter Harris IV [14]. The mechanism of injury is usually a fall on the outstretched hand with forced varus angulation of the elbow in supination and extension. Diagnosing the injury radiologically may be difficult since the region is largely cartilaginous and not visible on plain radiography. These injuries are associated with several complications including non-union with subsequent cubitis valgus, mal- union including varus deformity, avascular necrosis of the fragment and tardy ulnar neuropathy [15, 16]. Treatment of lateral condyle fracture has traditionally been divided between closed treatment with casting for minimally displaced fractures and open reduction and internal fixation for displaced fractures [14]. In children, similar to Monteggia fracture dislocation, it is not possible to fully outline the trauma mechanism in equivalent lesions, as well. However, during the initial presentation of the patient; position of the forearm, and the position of the distal portion of fracture and the inclination of the radial head dislocation in radiographs, may provide useful data. Another mechanism held responsible is, known to be traumas having a direct effect on ulnar diaphysis. Greenstick fracture was reported to occur as a result of this [4]. Tompkins [17] proposed over traction of biceps muscle as the reason of radial head dislocation due to falling with an open hand. Bado Type 3 fracture-dislocations are seen due to varus stress on elbow during falling with an open hand while elbow is extended [18]. The mechanism of lateral humeral condylar fractures and Bado Type 3 fracture-dislocations are similar [7]. As a result of this mechanism, lateral dislocation in radiocapitellar joint and subsequent rupture in the lateral condyle may occur. If adequate treatment is not applied, similar to Monteggia fracture-dislocation, equivalent lesions may lead to poor clinical and radiographic results. There is no standard treatment protocol for equivalent lesions, for which results are obtained through case reports except several case series. Whereas early closed reduction provides good and excellent results in Monteggia fracture dislocations, the results in the literature for equivalent lesions are known to be different [2, 19]. In children, Monteggia fracture-dislocations may occur in various forms and as uncommon fracture variations. In order to avoid the complications by establishing an early diagnosis and treatment, a good understanding of the fracture patterns and accurate diagnose of the lesions are required. Currently, as for the Monteggia fracture-dislocations, closed reduction is the first choice of treatment for equivalent lesions. Following conservative treatment, reduction of radial head should be controlled by a series of radiographs. If adequate reduction cannot be achieved after closed reduction of radial head dislocation or associated fractures, surgery should be considered. In the present study, conservative treatment was preferred with good results. Requirement of surgery has been associated with failure of reduction in radial head dislocation or fracture, annular ligament interposition or tear, displaced olecranon or metaphyseal ulnar fracture and lateral humeral condylar fracture especially in patients with Type 3 equivalent lesions. We aim to highlight a rare injury which maybe missed on cursory examination but is actually a Monteggia variant.

References


1. Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967; (50):71-86.
2. Reckling FW. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg [Am] 1982; 64:857-63.
3. Olney BW, Menelaus MB. Monteggia and equivalent lesions in childhood. J Pediatr Orthop 1989;9:219-23.
4. Givon U, Pritsch M, Levy O, Yosepovich A, Amit Y, Horoszowski H. Monteggia and equivalent lesions. A study of 41 cases. Clin Orthop Relat Res 1997; (337):208-15.
5. Ruchelsman DE, Klugman JA, Madan SS, Chorney GS. Anterior dislocation of the radial head with fractures of the olecranon and radial neck in a young child: a Monteggia equivalent fracture-dislocation variant. J Orthop Trauma 2005; 19:428-31.
6. Eglseder WA, Zadnik M. Monteggia fractures and variants: review of distribution and nine irreducible radial head dislocations. South Med J 2006; 99:723-7.
7. Ravessoud FA. Lateral condylar fracture and ipsilateral ulnar shaft fracture: Monteggia equivalent lesions? J Pediatr Orthop 1985; 5:364-6.
8. Faundez AA, Ceroni D, Kaelin A. An unusual Monteggia type-I equivalent fracture in a child. J Bone Joint Surg [Br] 2003; 85:584-6.
9. Hung SC, Huang CK, Chiang CC, Chen TH, Chen WM, Lo WH. Monteggia type I equivalent lesion: diaphyseal ulna and radius fractures with a posterior elbow dislocation in an adult. Arch Orthop Trauma Surg 2003; 123:311-3.
10. Bhandari N, Jindal P. Monteggia lesion in a child: variant of a Bado type-IV lesion. A case report. J Bone Joint Surg [Am] 1996;78:1252-5.
11. Mullick S. The lateral Monteggia fracture. J Bone Joint Surg [Am] 1977; 59:543-5.
12. Grantham SA, Kiernan HA. Displaced olecranon fractures in children. J Trauma 1975; 15(3):197—204.
13. Milch H. Fractures and fracture dislocations of the humeral condyles. J Trauma 1964; 4:592—607.
14. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone and Joint Surg 1963; 45(A):587—93.
15. Beaty JH, Fractures. dislocations about the elbow in children. AAOS Instruct Cours Lect 1992;41:373—84.
16. Horn BD, HermanMJ, Crisci K, Pizzutillo PD,MacEven GD. Fracture of the lateral humeral condyle: role of the cartilaginous hinge in fracture stability. J Paediatr Orthop 2002; 22(1):8—11.
17. Tompkins DG. The anterior Monteggia fracture: observations on etiology and treatment. J Bone Joint Surg [Am] 1971; 53:1109-14.
18. Papavasiliou VA, Nenopoulos SP. Monteggia-type elbow fractures in childhood. Clin Orthop Relat Res 1988; (233):230-3.
19. Letts M, Locht R, Wiens J. Monteggia fracture-dislocations in children. J Bone Joint Surg [Br] 1985; 67:724-7.

Source(s) of Funding


none

Competing Interests


none

Disclaimer


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

Reviews
2 reviews posted so far

Thank you for the review. I have gone through the suggested references.... View more
Responded by Dr. Nasir Muzaffar on 19 May 2011 12:37:24 PM GMT

Comments
0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.

 

Author Comments
0 comments posted so far

 

What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
Where
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)