The Role of Closed Reduction in the Treatment of Pediatric Monteggia Fractures

Introduction: Previous ulnar-based treatment algorithms for pediatric Monteggia fractures advocate for treating incomplete ulnar fractures with closed reduction and casting (CRC) while treating complete fractures surgically. However, recent evidence has suggested that these algorithms may result in overtreatment. This study aimed to evaluate the outcomes of CRC treatment across all ulnar fracture patterns and identify factors associated with CRC failure. Methods: A retrospective study was conducted of patients treated for Monteggia fractures at a single institution from 2002 to 2022. Inclusion criteria were patients younger than 18 at the time of injury, with complete radiographic follow-up from preintervention until the time of bony union. Patients treated surgically without a trial of CRC due to an open fracture or delayed presentation for treatment were excluded. Patient demographics, radiographs, and relevant surgical records were analyzed. Results: Eighty patients, 34 (42.5%) males, were included. Sixty-seven (83.8%) had complete ulnar fractures. The average age at injury was 5.7 years (range: 2 to 17), and the average follow-up was 5.6 months (range: 1 to 71). Fifty-eight (72.5%) patients were successfully treated with CRC. Of the 22 (27.5%) failures, all but 1 required surgery. Older age at injury was a risk factor for CRC failure (P=0.002). Failure occurred in 50% of patients older than 6 and 17.9% of patients ages 6 or younger (P=0.003). Other ulna-related criteria, including Bado classification, fracture pattern, and ulnar displacement, were not significant risk factors. Conclusion: This study's results support an emerging body of evidence suggesting that ulnar-based algorithms may overpredict CRC failure in pediatric Monteggia fractures. A trial of CRC in these fractures, regardless of ulnar fracture pattern, may prevent unnecessary surgical intervention. In this study, 26.3% of patients ultimately required surgery following an initial trial of CRC, whereas previous algorithms would have recommended surgery in 83.8% of patients. However, patients older than 6 may be less likely to retain reduction with CRC, as our study showed that 50% required surgical treatment. Level of Evidence: Level III - Therapeutic studies - investigating the results of treatment.