Ramski David E, Hennrikus William P, Bae Donald S, Baldwin Keith D, Patel Neeraj M, Waters Peter M, Flynn John M
*Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA †Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.
J Pediatr Orthop. 2015 Mar;35(2):115-20. doi: 10.1097/BPO.0000000000000213.
Monteggia fractures remain challenging pediatric injuries because of difficulties in diagnosis, propensity for instability, and complexity of late reconstruction. The objective of this investigation was to assess the efficacy of the following treatment strategy based upon ulnar fracture pattern: closed reduction (CR) for plastic/greenstick fractures, intramedullary (IM) pin fixation for transverse/short oblique fractures, and open reduction and internal fixation for long oblique/comminuted fractures.
A total of 112 acute Monteggia fracture patients were retrospectively analyzed at two level 1 pediatric trauma centers from 2000 to 2011. Mean age was 6.9±2.9 years (range, 0.6 to 16.7 y); 54% were male. Mean clinical follow-up was 19.8 weeks. Fracture patterns were classified and patients were separated into 3 groups: treatment according to the strategy versus more rigorous versus less rigorous intervention. The Fisher exact test was used to compare the rates of failure between the groups. "Failure" was defined as failure to obtain and maintain an anatomic reduction of the radial head and/or loss of ulnar reduction during follow-up.
None of the 57 patients treated according to the strategy experienced failure, nor did any of the 23 patients treated more rigorously. In contrast, 6 of 32 patients (19%) who were treated less rigorously compared with the recommended strategy demonstrated recurrent radiocapitellar instability (n=3), loss of ulnar fracture reduction requiring revision surgery (n=2), or both events together (n=1) (P<0.001). Specifically, all treatment failures occurred in complete fractures treated nonoperatively-there were 6/18 failures (33% failure rate) of complete fractures treated nonoperatively compared with 0/52 failures of complete fractures treated operatively (P<0.001). Other complications were similarly distributed between the treatment groups and consisted of 1 ulnar nonunion, 2 compartment syndromes, and 3 transient nerve palsies/neuropraxias. Comminuted fractures required open reduction of the radiocapitellar joint more than other fracture types (P<0.001).
In this pediatric Monteggia series, recurrent instability only occurred in patients who were not treated according to the ulnar-based strategy. Complete ulnar fracture patterns are at risk of failure without initial operative treatment.
Level III, therapeutic.
孟氏骨折仍是具有挑战性的小儿损伤，原因在于诊断困难、易于出现不稳定以及后期重建的复杂性。本研究的目的是基于尺骨骨折类型评估以下治疗策略的疗效：对于青枝/塑性骨折采用闭合复位（CR），对于横行/短斜形骨折采用髓内（IM）针固定，对于长斜形/粉碎性骨折采用切开复位内固定。
回顾性分析了2000年至2011年在两家一级小儿创伤中心就诊的112例急性孟氏骨折患者。平均年龄为6.9±2.9岁（范围0.6至16.7岁）；54%为男性。平均临床随访时间为19.8周。对骨折类型进行分类，并将患者分为3组：按照该策略治疗组与更严格干预组和较宽松干预组。采用Fisher精确检验比较各组的失败率。“失败”定义为未能获得并维持桡骨头的解剖复位和/或随访期间尺骨复位丢失。
按照该策略治疗的57例患者中无一例失败，采用更严格治疗的23例患者中也无一例失败。相比之下，与推荐策略相比治疗较宽松的32例患者中有6例（19%）出现复发性桡骨头不稳（n = 3）、尺骨骨折复位丢失需要翻修手术（n = 2）或两种情况同时出现（n = 1）（P < 0.001）。具体而言，所有治疗失败均发生在非手术治疗的完全骨折中——非手术治疗的完全骨折中有6/18例失败（失败率33%），而手术治疗的完全骨折中0/52例失败（P < 0.001）。其他并发症在各治疗组中的分布相似，包括1例尺骨不愈合、2例骨筋膜室综合征和3例短暂性神经麻痹/神经失用。粉碎性骨折比其他骨折类型更需要切开复位桡骨头关节（P < 0.001）。
在本小儿孟氏骨折系列研究中，复发性不稳定仅发生在未按照基于尺骨的策略治疗的患者中。尺骨完全骨折类型若不进行初始手术治疗有失败风险。
三级，治疗性。
