A rare case of Monteggia fracture dislocation with distal radius epiphyseal injury in a 12-year-old male: case report and review of literature

INTRODUCTION

In the paediatric population, fractures around the elbow and wrist are commonly encountered. However, patients with ipsilateral elbow and wrist joint fractures are rarely seen.¹ Monteggia fracture dislocation was first described by Giovanni Batista Monteggia in 1814. It is an uncommon injury in children comprising only 0.4% of all forearm fractures.^2,3 Bado classified the injury into four types depending upon the direction of radial head dislocation.⁴

Authors present a rare case of Monteggia fracture dislocation Bado’s type I with ipsilateral distal radius physeal injury Salter Harris type II in a twelve years old boy. The purpose of this case report is to illustrate the rarity of this type of injury, as this is the first case we have encountered in our hospital and only few cases have been reported in literature (Table 1). This case also emphasizes that often, if closed reduction fails, one should not hesitate in doing surgical intervention in the paediatric age group.

CASE REPORT

The patient, a 12-year-old male, was admitted to the Orthopaedics ward through the emergency as a case of injury to the left forearm with above elbow pop cast in place. He had a history of fall while playing cricket eight days back leading to pain, swelling and deformity over left elbow and pain over left wrist. He was managed conservatively at a local centre with closed reduction and above elbow pop cast. No previous X-ray was available from the local centre where he had received primary care. The patient continued to complain of pain, which resulted in his referral to our hospital.

In the emergency, X-ray was done, which showed fracture of proximal ulna with anterior dislocation of radial head along with ipsilateral epiphyseal injury of distal radius (Figure 1). Diagnosis was made as Bado Type 1 Monteggia fracture with Type II physeal injury of distal radius. As conservative method had failed, surgery was planned and following appropriate work-up, he was posted for surgery. Authors did open reduction and internal fixation with a 3.5 mm eight-hole semi tubular plate for fracture proximal ulna through dorsolateral approach. Distal radial physeal injury was closely reduced and fixed with percutaneous two K-wires.

Lastly, anteriorly dislocated radial head was reduced, but as it was found to be unstable, a trans-capitellar K-wire was used to fix the radial head. Above elbow POP slab was given at 90 degrees of flexion and kept for 4 weeks. A standard postoperative X-ray was advised (Figure 2).

It was found to be satisfactory. At 4 weeks post-op, a check X-ray was done (Figure 3). K-wires were removed and aggressive physiotherapy with elbow and wrist mobilization was started. At 3 months follow up he had attained good functional range of motion with elbow movement of 0 to 110 degree. There was mild restriction of pronation and supination.

DISCUSSION

Monteggia fracture dislocation is defined as fracture of proximal ulna with disruption of proximal radioulnar joint. Bado classified Monteggia fracture dislocations into four types depending on direction of radial head displacement.⁴ Bado’s type II injuries are the most common variety in the adult population whereas Bado’s type I is common in paediatric population.⁴ This case was Bado’s Type I. Authors reviewed the literature and found that there were ten such cases reported, of which Monteggia Bado type III with distal radius Salter Harris type II were most commonly seen.

Two cases of Bado Type I with salter Harris Type II of distal radius physeal injury have been reported.^5-13 To authors knowledge this is the third case. In majority of cases, proximal ulna fracture was treated with open reduction and distal radius with close manipulation and had full range of motion (ROM). In this case along with open reduction of the fractured ulna we required closed K-wire stabilization of the distal radial physeal injury. This is the first case where we had to fix the radial head with transcapitullar K-wire as it was unstable. The exact mechanism of injury causing this type of forearm fractures is not clearly understood. As these types of injury are very rare, a good clinical examination and full-length forearm radiographs should be taken to avoid missing ipsilateral wrist injuries in cases of elbow injuries.

CONCLUSION

A good functional outcome in Monteggia fracture dislocation includes complete diagnosis of associated injuries, single stage stabilization of fracture and aggressive physiotherapy. A thorough clinical examination and full-length forearm radiographs involving one joint above and one joint below should be taken to avoid missing associated injuries.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Biyani A. Ipsilateral Monteggia equivalent injury and distal radial and ulnar fracture in a child. J Orthopaed Trauma. 1994;8(5):431-3.
2. 2. Waters PM. Monteggia fracture-dislocation in children. children. 1996;97(98):111.
3. 3. Papaioannou I, Repantis T, Baikousis A, Korovessis P. Adult monteggia lesion with ipsilateral distal radius fracture: a case report and review of the literature. J Orthop Case Rep. 2018;8(3):77.
4. 4. Song KS, Bae KC. Type III Monteggia Equivalent Fracture with Ipsilateral Distal Radial Epiphyseal and Ulnar Metaphyseal Fracture in a Child: Case Report. J Korean Orthop Assoc. 2004;39(5):563-5.
5. 5. Sood A, Khan O, Bagga T. Simultaneous monteggia type I fracture equivalent with ipsilateral fracture of the distal radius and ulna in a child: a case report. J Med Case Reports. 2008;2:190.
6. 6. Nataraj AR, Sreenivas T. Type III Monteggia fracture with ipsilateral epiphyseal injury of the distal radius. European J Orthopaed Surg Traumatol. 2011;21(3):185-7.
7. 7. Williams HL, Madhusudhan TR, Sinha A. Type III Monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report. BMC Res Notes. 2014;7:156.
8. 8. Kamudin NAF, M Firdouse, Han CS, M Yusof A. Variants of Monteggia Type Injury: Case Reports. Malaysian Orthopaed J. 2015;9(1):93-5.
9. 9. Kapil Mani KC, Sigdel A, Rayamajhi AJ. A rare combination injury of type III Monteggia fracture dislocation and ipsilateral epiphyseal fracture of distal radius in children. Is there a probability of missing the Monteggia component. Chin J Traumatol. 2015;18(1): 51-3.
10. 10. Singh D, Awasthi B, Padha V, Thakur S. A very rare presentation of type 1 Monteggia equivalent fracture with ipsilateral fracture of distal forearm-approach with Outcome: Case Report. J Orthop Case Rep. 2016;6(4):57-61.
11. 11. Mundada G, Khan SM, Singhania SK, Gupta V, Singh PK, Khan S. Type-I monteggia with ipsilateral fracture of distal radius epiphyseal injury: A rare case report. Ann Afr Med. 2017;16(1):30-2.
12. 12. Yugal karkhur, Anurag Tiwari, Nishit Bhatnagar. Monteggia fracture dislocation with ipsilateral distal radius ulna fracture in a child. J Trauma Orthopaed Surg. 2017;12(2):23-6.
13. 13. Tsuji K, Onda K, Kawaguchi S. Simultaneous ipsilateral Monteggia fracture-dislocation and distal radius fracture: A report of a pediatric case and review of the literature. Trauma Case Rep. 2022;37:100566.