Challenging Case: A child with a Monteggia fracture

Monteggia fracture X-ray

A six-year-old boy presented to the Orthopedic Center at Boston Children’s Hospital in July 2014 having sustained an injury during a fall that spring. The treating physician did not initially recognize the injury as a Monteggia fracture, a fairly uncommon and often unrecognized injury.

This injury comprises a fracture of the ulna shaft and dislocation of the radial head. Monteggia fractures tend to be misdiagnosed as elbow sprains or isolated ulna fractures (in which case the dislocation of the radius is not recognized). When a Monteggia fracture is missed on initial presentation, it becomes more challenging for the surgeon to restore the bones and joints of the elbow to their pre-fracture state. As such, fractures of the ulna should be carefully inspected for a concomitant dislocation of the radial head.

Surgical reconstruction of a Monteggia fracture involves osteotomizing (re-breaking) the ulna, placing internal fixation and reducing the dislocated radial bone back into joint. The final step is reconstruction of the annular ligament to provide elbow joint stability. Although reconstructive surgery is often successful, it is a challenging operation, and the success rate could be increased with improved surgical planning.

3D printing orthopedic surgery Monteggia fracture
3-D printed model based on scans from an orthopedic patient.

In this case, the surgery was performed in August and went smoothly. The child was casted for six weeks and referred for outpatient physical therapy. He healed and returned to all activities. Approximately one year later, the screws and plate implanted during surgery were removed.

Boston Children’s Simulator Program launched its SIMPeds 3D Print and Prototyping Service shortly after the child’s initially surgery. Now, an orthopedic colleague and I work with the program to print models (based on clinical imagery) of particularly challenging forearm injuries prior to surgery. By using these models as surgical planning tools, our goal is to improve our surgical results and maximize functional outcomes.

Donald Bae orthopedic surgeon Monteggia fractureDonald Bae, MD, is a surgeon with the Orthopedic Center at Boston Children’s Hospital an an assistant professor of orthopedic surgery at Harvard Medical School.