A Case Series on Management of Neglected Monteggia Fractures

Introduction: Neglected Monteggia fracture-dislocations in children remain challenging due to adaptive deformities of the ulna, chronic radial head dislocation, and soft tissue contractures. While early recognition ensures excellent outcomes, delayed cases often require complex reconstructive surgery. This study presents the clinical and radiological outcomes of a case series involving corrective oblique ulnar osteotomy in neglected Monteggia fractures (NMF), open reduction of the radial head, temporary transcapitellar fixation, and annular ligament reconstruction (ALR). Materials and Methods: Eight children (5 males and 3 females; mean age 9.9 years) with NMF presenting >4 weeks after trauma were retrospectively reviewed over a 3-year period. The mean delay from injury to surgery was 11.6 months. All underwent oblique flexion osteotomy of the ulna with plate fixation, open reduction of the radial head, temporary Kirschner wire stabilization, and ALR using an extensor carpi radialis fascial sling. Clinical outcomes were assessed by range of motion and the Mayo Elbow Performance Index (MEPI), while radiological outcomes were graded as good, fair, or poor. Mean follow-up was 30.1 months. Results: At final follow-up, mean flexion improved from 110.6° to 133.1° and mean extension from 9.4° to 3.1°. Forearm supination and pronation averaged 81.9° and 66.3°, respectively. The mean MEPI score increased from 77.6 preoperatively to 91.3 postoperatively, indicating significant functional improvement. Stable reduction of the radial head was maintained in six patients, while one showed subluxation and one developed arthritic changes. Complications included heterotopic ossification in one case and delayed union requiring revision in another. Conclusion: Corrective ulnar osteotomy combined with open reduction, temporary fixation, and ALR provides reliable functional recovery and stable reduction in neglected pediatric Monteggia fractures. Despite delayed presentation, favorable outcomes can be achieved with this comprehensive surgical approach. Keywords: Neglected Monteggia, extensor carpi radialis, Mayo elbow performance index, ulnar osteotomy, radial head.