A Very Rare Presentation of Type 1 Monteggia Equivalent Fracture with Ipsilateral Fracture of Distal Forearm-approach with Outcome: Case Report

Abstract

Introduction: We report a case of Type 1 Monteggia equivalent injury with intact radio-capitellar congruity, associated with epiphyseal fracture of distal radius and distal ulna shaft in an 11-year-old boy. There are only a few cases of Monteggia or Monteggia equivalent injury with ipsilateral forearm fractures in children, and injury pattern being reported by us is not only rare but also the only case reported thus far to the best of our knowledge, Sood et al. described Type 1 equivalent with epiphyseal injuries of both radius and ulna Osada et al. also described injury pattern same as Sood et al. with epiphyseal separation in both distal radius and ulna. Our case was slightly different than above two in that distally, there was ulna shaft fracture with Salter Harris Type 2 epiphyseal separation in the radius.

Case report: An 11-year-old, right-hand dominant boy presented in casualty with a history of fall one day back with pain, swelling and deformity in the left forearm with bleeding from left forearm and loss of movement of fingers and thumb of the left hand. On examination, there was a wound of size one centimeter on mid-forearm over the ulnar aspect. Extension of fingers and thumb at metacarpophalangeal joints was lost with intact sensations suggestive of posterior interosseus nerve involvement. No vascular was deficit was present. X-rays were performed which suggested type two epiphyseal separation proximal radius with fracture shaft ulna with lateral angulation in elbow and proximal forearm. Radiocapitellar joint congruity was maintained in the views performed. X-rays of wrist suggested fracture both bones distal forearm epiphysis in distal radius and distal shaft in ulna. The patient was operated with toileting, debridement, and open reduction of proximal ulnar fracture with K-wire. Proximal radius epiphyseal separation was approached by Kocher approach and fixed with two K-wires, while for distal radius epiphyseal separation open reduction and internal fixation was performed. Follow-up of the patient showed posterior interosseus nerve recovery and subsequent union of all fractures with good functional outcome.

Conclusion: This type of lesion is rare in children probably because the annular ligament is relatively lax and the radial head dislocates more easily anteriorly, rather than occurrence of fracture as seen in our case, and associated fracture of distal forearm is a very rare injury.

Keywords: Monteggia equivalent; children; ipsilateral forearm fractures.

Figure 1

Pre-operative clinical picture.

Figure 2

Pre-operative X-rays elbow.

Figure 3

Pre-operative whole forearm X-rays.

Figure 4

Wounds on first wound inspection showing separate incisions and drains.

Figure 5

Post-operative elbow X-rays.

Figure 6

Post-operative wrist X-rays.

Figure 7

X-rays at removal of radius K-wires.

Figure 8

Final follow-up X-rays.

Figure 9

Final follow-up clinical pictures showing full flexion and extension.

Figure 10

Clinical picture showing nearly full pronation and supination.