Management of Missed Monteggia Fractures With Ulnar Osteotomy, Open Reduction, and Dual-socket External Fixation

Background: Open reduction of the radial head is usually necessary in the treatment of a missed Monteggia fracture. However, the best way to stabilize the reduction remains controversial. The purpose of this study is to present our experience using the dual-socket external fixator to stabilize the ulna osteotomy and capture the reduction of the radial head. Methods: We reviewed 33 patients with missed Monteggia fracture who underwent open reduction, ulnar osteotomy, and dual-socket external fixation from 2004 to 2010. The average age of this group was 7 years and the average time to surgical treatment after the fracture was 15 months. We treated all patients with open reduction of the radial head, fully releasing the capsular contracture, removing the fibrous scar tissue within the joint, performing ulnar osteotomy, and fixing the osteotomy with dual-socket external fixation. The clinical and radiographic follow-up averaged 38 months. Descriptive statistics utilized the Student test to compare the preoperative and postoperative functional movement of elbow and forearm. Results: All patients had excellent clinical and radiographic outcomes without losing motion of the elbow and forearm, and all patients maintained reduction of the radial head at the final follow-up. There were no significant differences in the motion of the elbow and forearm between preoperative and postoperative examinations. Delayed union of the ulna occurred in 2 cases, both successfully treated with autologous iliac crest bone graft at 7 months after the operation. Three cases had early redislocation of the radial head, and these were treated successfully by changing the position of the ulnar osteotomy and readjusting the external fixators. Conclusions: Dual-socket external fixation has the major advantage of permitting and capturing the optimal position of the ulna osteotomy to achieve the best possible reduction of the radial head. A further advantage is the possibility of easily changing the position of the ulnar osteotomy by adjustment of the fixator should the radial head subluxate or redislocate in the early postoperative period as had occurred in 3 of our cases. We conclude that our procedure of fully releasing the capsular contractures, removing scar tissue, ulnar osteotomy, reduction of the radial head, and fixation of the osteotomy with dual-socket external fixation is a safe and effective way to manage children with a missed Monteggia fracture. Level of Evidence: Therapeutic level IV.