Incidence, Characteristics, and Management of Concomitant Ipsilateral Upper-Extremity Fractures in Pediatric Monteggia Fracture-Dislocations: A 13-Year Single-Institution Case Series.

Abstract

Monteggia fracture-dislocations are uncommon pediatric injuries that often require surgical stabilization. Concomitant ipsilateral upper-extremity fractures are rare, are poorly characterized, and may be missed during initial evaluation. In this study, we aimed to evaluate the incidence, characteristics, and management of acute pediatric Monteggia fracture-dislocations with concomitant ipsilateral upper-extremity fractures. A retrospective review was conducted at a single tertiary academic center from 2011 to 2024. Patients ≤18 years of age with acute Monteggia or Monteggia-equivalent fracture-dislocations were identified and categorized using the Bado classification. Patients with concomitant ipsilateral upper-extremity fractures were identified and reported descriptively. The rates of formal operative reduction and ulnar fracture fixation were compared between patients with and without concomitant fractures. In total, 468 pediatric patients with Monteggia fracture-dislocations (mean age, 6.3 ± 2.5 years; 49% female; 48% White, 39% Hispanic, 8% Asian, 3% Black, and 2% not specified) were included. Of these, 32 (7%) had ≥1 concomitant ipsilateral upper-extremity fracture. Bado I was most common among patients with concomitant fractures (59%). Concomitant fracture types included distal radial fractures in 59%, supracondylar humeral fractures in 34%, distal ulnar fractures in 25%, medial epicondylar fractures of the humerus in 9%, and lateral condylar fractures of the humerus in 6%. The observed fracture combinations, in decreasing order, were Monteggia fracture-dislocation with distal radial fracture (34%), with supracondylar humeral fracture (25%), and with combined distal radial and distal ulnar fractures (16%). Additional patterns included Monteggia fracture-dislocation with combined supracondylar humeral, distal radial, and distal ulnar fractures (9%); with medial epicondylar fracture of the humerus (9%); and with lateral condylar fracture of the humerus (6%). Patients with concomitant fractures more frequently underwent formal operative reduction (78% versus 48%; p = 0.001) and ulnar fracture fixation (66% versus 37%; p = 0.001) compared with those with isolated Monteggia fracture-dislocations. Concomitant ipsilateral upper-extremity fractures were identified in 7% of acute pediatric Monteggia fracture-dislocations, most frequently involving the distal radius (59%) and the supracondylar region of the humerus (34%). Patients with concomitant fractures more commonly underwent formal operative reduction and ulnar fracture fixation compared with those without concomitant fractures. Given the 7% incidence, surgeons should maintain a high index of suspicion for subtle secondary injuries and ensure appropriate imaging during initial evaluation. Further research is needed to guide management and rehabilitation in these complex cases. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.