Surgical Management of Neglected Monteggia Fractures in Children.

Abstract

Neglected Monteggia Fractures (NMF) in children typically result from missed diagnoses at initial assessment, and may lead to pain, instability, and functional impairment. The optimal treatment strategy remains controversial. This study evaluates surgical outcomes and prognostic factors in pediatric NMF. A retrospective review was conducted of children under 14 years treated for NMF (>4 weeks postinjury) from 2010 to 2024 at a tertiary pediatric referral center, with a minimum follow-up of 12 months. All patients underwent open reduction of the radial head, with or without ulnar osteotomy, annular ligament reconstruction (ALR), or temporary radiocapitellar fixation (TRCF). Outcomes were assessed using the Mayo Elbow Performance Index (MEPI), and preoperative maximum ulnar bow (MUB) was analyzed as a predictor of osteotomy. Twenty-seven patients (16 boys, 11 girls; median age 6.5 years) were included. The median time to surgery was 73 days (51 to 220.5). Ulnar osteotomy was performed in 14 cases, ALR in 12, and TRCF in 12. The median MUB was -4.5 mm, most commonly located in the proximal third (57.7%). A significant association was found between MUB magnitude and the need for osteotomy (P=0.03), with a predictive threshold of -3.45 mm. Time to surgery was not associated with surgical complexity (P=0.59) or poorer outcomes (P=0.85). MEPI scores were excellent in 22 cases and good in 5, with no poor outcomes. Four complications were reported. Open reduction of the radial head , with selective use of ulnar osteotomy, ALR, or TRCF, is effective for treating pediatric NMF. A preoperative MUB ≥3.45 mm was predictive of the surgeon's decision to perform osteotomy, offering a practical parameter for surgical planning. Delayed intervention did not adversely affect outcomes. Level IV-retrospective case series.