| Background and objective Early in the 19 th century, Monteggia are published for the first time in the proximal end of the ulna third fracture and dislocation of the radial head accompanied by injury. After this, Bado raises the new concept, Monteggia fracture, and this made the concept analysis: any part of the ulna fractures and associated with a dislocation of the radial head, known for Monteggia fracture, and subdivided into four types. With the continuous development of elbow surgery and the damage mechanism and have a more profound understanding of, and the surgical method of old Monteggia fracture in children exist many differences, until today, for the Monteggia fracture mechanisms have different views. Evens’ s view is that in the fracture, the forearm before the symptoms of rotation, so that the effect of the radial head, in the role of leverage, the radial head will be the case of dislocation. In order to verify his claim, he through the cadaver experiments were carried out. The first is in the bones of the body, make ulna excessive pronation and successfully simulated out the occurrence of dislocation of the radial head. Tompkin felt that when people fall, arms stretched forward over caused by the excessive contraction of biceps brachii, such situation makes the radial head excessive forward, resulting in dislocation; at this time, because their bones need to bear a certain weight, andcaused a further fracture. In earlier times, some people hold a different point of view, that the fracture is because of human violence and human violence makes fractures of the ulna and radial head dislocation. In the previous radial head dislocation surgery, especially in subacute few cases found that the bones of the annular ligament is not impaired, can firmly stuck in the gap of the biceps brachii muscle and the radial head; because the arm excessive forward movement, but elastic annular ligament not be transverse opened, so in the composite process of radial head, it is difficult to achieve to make it into the interior of the annular ligament. In the following several times about the situation is very serious, and has instability of the ulna fracture cases, through the ulna closed and the radial head replacement surgery, to understand the damage minimal normal radiohumeral joint check the pictures. But in such a procedure, also found in the ulna was fixed before, the humeroradial joint is very prone to dislocation again. In this case, we have done such a clinical study. Clinical, because the diagnostic process, there is a lack of experience, or in the process of filming, shooting site is not complete, not completely cover the forearm and elbow, ignore the ulna again deformity and radial head dislocation may exist, which delayed the best treatment time. This is called the old Monteggia fracture. Even some patients long-term ignore this situation, the time may be decades, until arm of the forearm and elbow joint activities is limited, the outer side of the elbow joint severely deformed bulges or in valgus elbow, ulnar bone paralysis, elbow joint pain is not normal, will not aware of the situation, then found old fracture and radial head dislocation. Old Monteggia fracture, usually left over from the growth of ulnar shortening and deformity, and radial bone growth caused by excessive bone and joint and the increase of deformation, head of depression will gradually disappear, radius of the femoral neck will be thinner, rotating, brachioradialis and radioulnar joint length asymmetry deformity. Many experts believe that age dissatisfaction at the age of twelve children, in bone fracture to get accurate diagnosis and treatment time less than three years, through surgery, old Monteggia fracture of children’s bone correction, correction of the bones of the forearm deformity. There are a few experts believe that such old fractures do not require surgery, growth to mature inthe process of bone for elbow joint pain for removal of the radial head. On the ulna of osteotomy correction, the ulnar angulation get correction and abnormal parts is improved, the currently used in most of the treatment is radial head replacement and annular ligament reconstruction. In operation, the key step is the ulna osteotomy and ulna of internal fixation, which proper reduction of the radial head lay the foundation. For children with Monteggia fracture, early diagnosis and treatment can increase the therapeutic effect, for function recovery and annular ligament reconstruction have great benefits. For many years the old Monteggia fractures, take appropriate surgery program operation, still can make the reduction of the radial head, and is conducive to the reconstruction of the annular ligament, can achieve satisfactory effect. After a series of analysis of old Monteggia fracture found that old Monteggia fracture in the pathological change guide the surgical methods, to improve the clinical efficacy.Objects and methods Selected 2013 to 2016 3 months in our hospital of Monteggia fracture in children were 34 cases, 18 cases were male, 16 female; aged 2~9(3.7 ±2.9) years old. Among them, Bado type I type 34 cases; 12 cases on the left side, 22 cases on the right side. Combined radial nerve injury in 2 cases,. Elbow joint movement was obviously limited, which extends 0 to 30(13.6 ± 7.7) degrees, flexion 110 to 135(123.7 ± 6.5) degrees, 35 to 70(50.3 ±9.5) before the rotation, after 45 ~ 75(57.9 ± 8.9) degrees; injury to the operation time of 1 ~ 16 months. According to whether the reconstruction or repair the annular ligament, the patients were divided into three groups: group A(ulna oblique osteotomy of bone and steel plate fixed orthopedic + reconstruction of the annular ligament) in 18 cases and group B(osteotomy of the ulna and percutaneous pin fixation of humeral radioulnar joint, no reconstruction of the annular ligament) in 16 cases. Deformity of patients in the two groups were observed and the observation records, in operation process, through observation of patients at the time of the operation, and operation of bleeding, fracture healing time and operation whether complications, including incision ofinternal fixed is loose and fracture, incision healing or healed wound, radial head dislocation again, postoperative joint stiffness, etc.). After the operation, the patients were followed up for 3 and 6 months, and the score of the elbow joint was used to evaluate the curative effect. There was no significant difference between the two groups before surgery(P>0.05). All patients were taken Boyd incision and the ulna upper and humeral head and dislocation of the radial head revealed, then separated from the deep branch of the radial nerve, and protected, isolated radial head joint capsule, group A with exploration of the annular ligament injury, oblique osteotomy of the proximal ulna and corrected for angular deformity, distal forearm traction, finally, the dislocation of the radial head replacement and 4~6 hole plate fixing lengthening of the ulna, finally repair or reconstruction of the annular ligament and rebuild the dorsal forearm deep muscle film or autologous fascia lata or fracture of the annular ligament direct suture and repair. Group B revealed the radiocapitellar joint, clean up the joint scar tissue and residual of the annular ligament and direct adjustment of ulna broken end angle, and to observe the radial head replacement, reduction of radial head with elbow flexion 90 degrees, Kirschner wire fixation of humeral radioulnar joint, bending, shearing pin, tail exposed in the outer and plate fixation of ulnar stump. After the operation is completed, the joint of the operation of the joint is fixed with plaster, and the elbow joint is fixed with 90 degrees, and the joint center of the arm is rotated, which needs to be fixed for 4-6 weeks.Result Using SPSS17.0 statistical software, measurement data as mean standard difference(mean + s), compared with two sets of independent samples t test, set the test standard of 0.05 determined value p, with P values 0.05 said there was significant statistical difference. Elbow score using the chi square test method, produced on the patient’s operation time, the amount of bleeding, fracture healing time, complications and complications appear time. During the operation time and the amount of bleeding during the operation, the A group was greater than the Bgroup(P<0.05). At the time of fracture healing, there were no significant differences between the two groups(P>0.05). In group B, there were 3 cases of radial head dislocation, 1 cases were found in A group, and the incidence of complications was less than that of B group in A group. Six months after the end of surgery, using elbow joint score standard of elbow joint function scores and comparison of obtained data, a group of patients, 12 cases, good in existence in 3 cases, excellent probability is about 83.3%; and in group B, 10 cases, good in 2 cases, the excellent and good rate is 68.8%. Superior rate of elbow joint A group than B group(P<0.05).Conclusion Ulnar shortening the scar contracture deformity, and the radius was relatively long, annular ligament dislocation or scar contracture and interosseous membrane is old Monteggia fracture the basic pathological changes. The surgical method of old Monteggia fracture in children selection should be based on the patients with different pathological changes. In the two groups, although the ring ligament reconstruction or repair surgery is difficult, long time, a large amount of bleeding, but the recovery of elbow function after surgery has a significant effect. |
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