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Aim of Study: Unreduced or missed Monteggia fracture-dislocation after 4 weeks is a common presentation in a tertiary care center. The aim of this study is to study the functional outcome of Bell Tawse procedure for the management of chronic unreduced Monteggia fracture-dislocation in children. Materials and Methods: In this retrospective study with prospective data collection, 17 children were treated with open reduction of the radial head and annular ligament reconstruction (Bell Tawse) combined with ulnar osteotomy. The cases were classified based on Bado's classification. The minimum period of followup was 14 months and maximum followup was 18 months with the mean period of followup of 16.2 months. Preoperative and postoperative Mayo Elbow Performance Index (MEPI) scores were calculated. We also compared the preoperative and postoperative Kim's elbow functional scores. Results: At the final followup, the radial head was maintained in a completely reduced position in 16 children. Mean preoperative MEPI score was 76.76 and mean postoperative score was 91.11, which was statistically significant (P < 0.001). Mean preoperative Kim's score was 76.94 and mean postoperative score was 91.35, which was also statistically significant (P < 0.001). One girl had a mild subluxation of the radial head at 1-year followup. The ulnar osteotomy was united in all 17 children, and none of them required secondary procedures. We have not identified any complications such as compartment syndrome, infection, posterior interosseous nerve palsy, avascular necrosis of the radial head, or loss of range of motion. Conclusion: We recommend ulnar osteotomy, open reduction of the radial head, and annular ligament reconstruction in children with unreduced Monteggia fracture-dislocation before long term complications sets in.

The treatment of neglected radial head dislocation after missed Monteggia fracture dislocation in children is a controversial issue. The purpose of this study is to report our clinical experience in the treatment of the condition without annular ligament reconstruction. This is a retrospective review of 20 patients between 2008 and 2014. Procedures included open reduction of the radial head and ulnar lengthening angulation osteotomy. In cases of unstable radial head reduction, a trans-capitellar K wire was applied. The pre- and post-operative radiographs were available for evaluation as well as the Mayo Elbow Performance Index (MEPI). The average pre-operative elbow extension-flexion arc was 99.5° and pronation-supination arc was 151°. At last follow-up, the flexion of elbow had significant improvement (from 110° to 124°), while the average pronation and supination arc decreased, most in pronation (from 75° to 65°). Post-operatively, MEPI scored higher, especially in elbow pain and stability. Patients underwent surgery within one year of injury had better functional outcome than those injured over one year. The patients required trans-capitellar K wire for unstable radial head reduction and were in the older age group. At final follow-up, the reduction of radial head was maintained in all cases except two with mild subluxations of the radial head in radiographs. Two cases required radial shaft shortening to facilitate the reduction because of proximal migration of the radius. For neglected radial head dislocation following Monteggia fracture dislocation, we presented our surgical strategy to reduce the radial head without annual ligament reconstruction. Our patients functionally benefited from the procedure with significant improvement in elbow pain and stability, as well as improved flexion of the elbow with stable radial head reduction. IV

Background A Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach. Methods Eight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane. Results An anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures. Conclusion On the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.

Background Isolated radial head dislocation is a rare injury with an unclear pathomechanism, and the treatment is controversial. The purpose of the present study was to investigate the biomechanical contributions of the annular ligament, quadrate ligament, interosseous membrane, and annular ligament reconstructions to proximal radioulnar joint stability. Methods Five fresh frozen cadaveric upper extremities were amputated above the elbow and solidly fixed on a customized jig. Radial head dislocation was reproduced by sequential sectioning of ligamentous structures and passive mobility testing. Radial head displacement during mobility testing was measured with an electromagnetic tracking device in three forearm rotation positions. The data were compared among different sectioning stages and between two types of simulated ligamentous reconstruction. Results Lateral displacement of the radial head significantly increased in the neutral forearm rotation after annular ligament sectioning (46 ± 10%, p

Background Osteochondroma is the most common benign bone tumor of the upper limbs that occurs during the developmental phase of children. Solitary epiphyseal enchondromas can be usually found in the humeral capitellum, and the proximal ulna of the elbow. Case presentation Herein, we report the case of a 12-year-old boy of Han ethnicity with a developmental radial head dislocation with a progressive radius deformities, caused by a solitary osteochondroma which originated from the proximal metaphysis of the radius. Obvious complaints and limitations were present. After tumor excision was performed, radial head reduction and deformity correction were achieved through a biplanar shortening osteotomy of the radius. Conclusions After a follow-up of 18 months, the child remained asymptomatic and regained a full range of motion. Radiographic study revealed satisfactory reduction of the radial head with no recurrence of the osteochondroma.

In the last 20 years 49 children with gross posttraumatic elbow deformities have been treated in our hospital: 19 patients with an overlooked radial head dislocation, 12 children with a radial condyle deformity and 19 patients with a severe radial head deformity. Secondary treatment: In the majority of cases secondary surgical procedures led to unsatisfying results. Only 4 patients with a pseudarthrosis of the radial condyle were treated secondarily. Surgical fixation led to good functional results but was not able to remove the joint deformity. Overlooked radial head dislocations were treated by ulnar osteotomy in 17 cases. We were able to follow up 13 of these: a redislocation had taken place in 8 of them. Functional impairment was found in 6 redislocated cases and in 2 children with a correct position of the radial head. In patients with gross radial head deformities arthrolysis was performed. The radial head had to be taken out in 7 cases. Functional results of pro- and supination were unsatisfactory. Initial treatment and causes: Persistent dislocations of the radial head had been overlooked initially. In 9 out of 12 cases with a radial condyle deformity a conservatively treated dislocated fracture had led to a pseudarthrosis. In the remaining 2 cases the fracture fragments had been fixated in an incorrect position. Radial head deformities were seen after dislocated radial head fractures which had been treated by open reduction, internal fixation, longterm immobilization (6-8 weeks) and excessive physiotherapy.In 47 out of 49 cases posttraumatic deformities were either caused by delayed an neglected treatment or traumatic and excessive therapy methods. An adequate initial diagnosis and therapy can prevent more than 90 % of severe posttraumatic elbow deformities in children.

We present a case report of a 5-year-old girl who presented with a traumatic isolated anteromedial dislocation of her left radial head, without any associated fractures or dislocations in the ipsilateral limb. This is a rare elbow injury and a condition that is easily missed on initial presentation.

We read with deep interest the “sliding angulation osteotomy” technique for chronic radial head dislocation following missed Monteggia injuries by Rajasekaran and Venkatdass [1]. The distinct advantages of the osteotomy as rightly described are its extra-articular nature and a la carte approach to radial head reduction. We use a similar technique for our patients and would like to enhance the technical details of the technique for the reader’s benefit