Aims. To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically. Methods. A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples t-test, chi-squared test, and logistic regression analysis were used to identify the risk factors associated with unsuccessful RHR. Results. Redislocation occurred during surgery in 48 patients (23%), and during follow-up in 44 (21.1%). The mean follow-up of patients with successful RHR was 13.25 months (6 to 78). According to the univariable analysis, time from injury to surgery (p = 0.002) and preoperative dislocation distance (p = 0.042) were identified as potential risk factors for unsuccessful RHR. However, only time from injury to surgery (p = 0.007) was confirmed as a risk factor by logistic regression analysis. Receiver operating characteristic curve analysis and chi-squared test confirmed that a time from injury to surgery greater than 1.75 months increased the rate of unsuccessful RHR above the cutoff (p = 0.002). Conclusion. Time from injury to surgery is the primary independent risk factor for unsuccessful RHR in surgically treated children with CMFs, particularly in those with a time from injury to surgery of more than 1.75 months. No other factors were found to influence the incidence of unsuccessful RHR. Surgical reduction of paediatric CMFs should be performed within the first two months of injury whenever possible. Cite this article: Bone Jt Open 2024;5(7):581–591

Introduction. Chronic aquired anterior dislocation of the radial head, Bado type I Monteggia equivalent lesion is a uncommen occurence in children. We present our results of sixteen childrn treated with an angular corrective osteotomy. Material and methods. Sixteen children, mean age at the time of injury was six years and eight years at the time of surgery. Time from dislocation to diagnosis was median 30 weeks. Preoperatively decreased range of motion was detected. All children underwent angular ulnar osteotomy using Boyd-Thompson approach. The osteotomy was fixed using a single Steinmann pin. Long arm cast was applied until radiographic healing was detected. Results. Follow-up showed all but one had successful reduction. Non-union was not detected. All children were pain free at follow up. The total flexion-extension arc of motion measured median 135 degrees. Total rotation of forearm measured median 145 degrees. Conclusion. Correct treatment of Monteggia equivalent lesionsare demanding. Both in relation to obtaining the correct diagnosis without delay as well as the best treatment procedure. Full antebrachium X-rays are recommended in order to get exact diagnosis initially. Corrective angular ulnar osteotomy is recommened as soft tissue procedures alone is insufficient for alignment of the elbow

Introduction. Bisphosphonates are among the most commonly prescribed drugs in Osteoporotic Patients. Their mode of action is anti-resorptive. Since remodeling is a key step in fracture healing, there has been concern regarding the effect of bisphosphonates on fracture healing. Objectives. To assess the effect of alendronate on fracture healing in the rabbit ulna osteotomy model. Materials and methods. 16 New Zealand white rabbits were divided into 2 equal groups. Bilateral ulnar osteotomies were performed in the first week. Group 1 was the control group and group 2 was gavaged with alendronate solution (human equivalent dose). 2 rabbits were euthanised at 3 and 6 weeks and the remaining 4 rabbits were euthanised at 8 weeks. Fracture healing was assessed radiologically, with mechanical testing using the Instron 4302 materials testing machine and histologically, in that order. Results. The fractures healed satisfactorily in all the control group animals. However, in the alendronate treated group, there was an abundance of woven bone and little lamellar bone in the callus. However there was no significant difference in mechanical testing. In addition we did not find any evidence of Osteonecrosis in the Bisphosphonate treated group. Conclusion. Bone remodelling in the alendronate treated group is slower but a larger amount of bone callus is formed around the fracture, thus giving the fracture callus a higher ultimate load to failure at an earlier stage

Ten cases of missed Monteggia lesions were reviewed following treatment. Four cases were treated with an ulnar osteotomy, open reduction of radial head and annular ligament reconstruction (Group A). In six cases only an open reduction of the radial head was performed with an ulnar osteotomy (Group B). No annular ligament reconstruction was done in Group B. The mean age seven in both groups (range 4-12 years). The children presented three months to 24 months after the initial injury. Nine patients were classified as Bado type I, and one with Bado type III injury. The mean follow-up was 20 months (8-26 months) after surgery. In both groups the ulnar osteotomy healed uneventfully. In group A, there was one superficial infection, the mean loss of pronation was 12 degrees and in one case the radial head re-subluxed. In group B, the mean loss of pronation was 10 degrees. Elbow flexion was comparable to Group A. No radial head subluxation was seen in this group. No child in either group had any functional limitation in activities. Thus, in chronic Monteggia lesion, annular ligament reconstruction is not always required to restore radio-capitellar alignment. Open reduction of radial head with an ulnar osteotomy and stable fixation will suffice. Ligament reconstruction will not stabilise an inadequately reduced radial head

Introduction. Chronic radial head dislocation in children after trauma is a serious condition. Often the dislocation is overseen initially and is a part of the Monteggia fracture complex with anterior bowing of the ulna. Typical complaints are pain, decreased ROM and cubitus valgus. Radial head dysplasia often occurs. The treatment of this condition is debated. Only few series of patients treated with open reduction and ulnar osteotomy exists with long-term follow up. We present a group of rare patients with long-time follow-up treated by only two surgeons through a period of 16 years. Materials and Methods. All 16 patients had anterior radial head dislocation (Bado type 1). Mean age at the time of traumatic dislocation was 6 years ranging from 2 to 9. We found a mean delay of 17 (range 1–83) months before open reduction and ulnar open wedge osteotomy. In 8 cases reconstruction of the annular ligament was performed and in 6 patients temporary transarticular fixation of the radial head with a k-wire was performed. Follow-up time was 8 (range 3–17) years postoperatively. Patients were investigated with bilateral x-ray, arthrosis status, congruency of the radiocapitellar joint, Oxford Elbow Score, force measurements and range of motion. Results. There were no major complications to surgery such as infection, nerve palsies or pseudarthrosis. Radiological results showed 9/16 with reduction of the radial head and with no arthrosis, 4/16 with arthrosis or subluxation, and 2/16 with a dislocated radial head. We found a significant correlation between radiological outcome and delay to ulnar osteotomy (p = 0.03). At follow up the mean Function score was 92 (SD 9), Social/psychological score 83 (SD 14) and Pain score was 88 (SD 15). None of the patients with fully reduced radial head had progressed in increased valgus deformity. In contrast, one of two patients with postoperative secondary dislocation of the radial head had an increase in carrying angle on 25 degrees. Typical clinical findings were a small but significant extension deficit and median loss of supination on 10 grades ranging from 0–90 (p = 0.008). Five patients had subsequent surgery, of which one had an excision of the radial head 8 years after primary surgery. Ligament reconstruction or transfixation of the radial head did not influence the radiological or clinical outcome. Discussion and Conclusion. Case reports of similar patients treated conservatively demonstrate high morbidity and therefore open reduction and ulnar osteotomy is justified given the good clinical longterm outcome in the present study. However, this study underlines the importance of minimising the delay between trauma and open reduction. If surgery is performed before 40 months after trauma good to fair longterm radiological results can be obtained. After 40 months there is a high risk of recurrent luxation of the radial head

Background: Healing of segmental diaphyseal bone defects in animals can be enhanced by covering the defects with resorbable polylactide membranes. Based on the results of bone healing in defects 10 mm long in the rabbit radii, it was suggested that the membrane prevents muscle and soft tissue from invading the defect and maintains osteogenic cells and osteogenic substances within the space covered with membrane, thus promoting new bone formation. However, for bone defects larger than a critical size, bone healing did not occur when covered with polylactide membrane. Objectives: To investigate and compare bone regeneration with resorbable polylactide membrane and polylactide sponge in a 20 mm bone defect in rabbit radii. The material used was polylactide (L/DL) 80/20/1. To determine and compare the biomechanical strength of the bone fixation construct with reinforcement by membrane and sponge of such bone defect which were rendered unstable by ulnar osteotomy. Material & method: 20 mm long diaphyseal segmental defects were made in the left radii of adult New Zealand rabbits. Transverse ulnar osteotomies were made at mid-shaft to make the forearm unstable. The rabbits were divided into 4 groups. In group 1, no fixation of the bone were performed and the limbs were immobilized in a plaster for 8 weeks. In group 2, the bone defects were fixed with 1.5 AO miniplate, with 2 screws on each side of the defect. In group 3, the bone defects were fixed similarly and polylactide membranes were used to cover up the bony defect. In group 4, the bone defects were fixed similarly to group 2 and the defects were bridged by sponge of 20 mm long, 3.5 mm in diameter. In group 5, the bone defects were bridged by sponge similar to group 4 and were also covered by polylactide membrane and similar internal fixation were performed. Results: In group 1, there was bone healing bridging the bone ends. However, there was marked shortening of the limbs and all the limbs were deformed. In group 2, there were bone formation at the ends of both proximal bone stumps and distal bone stumps. There was no bone bridging the defect. In group 3,4, there were bone formation across the defect. There was more bone formation in group 4, i.e. the defects were bridged by sponge. Conclusion: Polylactide membrane and sponge promote bone regeneration in 20 mm both defects in the rabbit radii model. There was more bone formation when sponged were employed

Purpose of Study. We report the outcome of five cases of chronic paediatric Monteggia lesion treated with a modified Bell-Tawse procedure. Methods. Five patients with a chronic Monteggia lesion were treated over an eight-year period (2004–2012) at our institution. All underwent a modified Bell-Tawse procedure. The patient medical records were retrospectively analysed. We report the outcome in five patients. Results. Four girls and one boy were treated for a chronic Monteggia lesion in the period studied. The mean age at time of surgery was 8 years old (range 4–14 years). The mechanism of injury was post-traumatic in four of the five cases, while in one case the mechanism was uncertain. All children underwent modified Bell-Tawse procedure. All children ultimately required ulnar osteotomy, while two also required radial osteotomy. At a mean follow-up of 22 months (range 16–38 months), four children had experienced complications. Symptomatic metalwork was removed in one case, two children re-dislocated the affected joint, and one child required revision Bell-Tawse procedure. No nerve palsies were noted on follow-up. Conclusion. Paediatric elbow trauma necessitates early, senior management. We report a series of five patients who underwent modified Bell-Tawse procedure for chronic Monteggia lesion. Four of the five children experienced complications. All required shortening osteotomies. The chronic Monteggia lesion is an unusual but troublesome presentation in the paediatric population. Further research in the area is necessary

Introduction. Amino acids like arginine and lysine have been suggested to hasten the process of fracture healing by improving the local blood supply, supplementing growth factors, and improving collagen synthesis. We studied the role of lysine and arginine in the fracture repair process with regard to the rate of healing, probable mechanisms involved in the process, and mutual synergism between these agents. Materials and methods. In an experimental study, 40 rabbits were subjected to ulnar osteotomy. They were distributed in control (14) and test groups (26). Twenty-six animals in the test group were fed with a diet rich in lysine and arginine. Both the groups were followed radiologically and histologically till union. Results. Ten weeks postoperatively, there was difference evident radiologically between those supplemented with lysine and arginine, indicating that these components enhance the healing in the later part of bone remodeling, canal restoration, and medullary as well as cortical continuity and repair. X-rays obtained at weeks 9, 10, and 12 in both the groups showed statistical significance. These findings showed that healing is better in the test group in terms of increased vascularity in the early part of healing, i.e., at approx. 2–3 weeks and in terms of bone matrix, Haversian system formation, and cortical repair in the later part of healing, i.e., at approx. 9–12 weeks between the two groups. There was better healing of osteotomy in terms of better vascularization, callus formation, and mineralization in the test group. The time of healing in the test group was reduced by a period of 2 weeks. Discussion. NO is expressed during fracture healing in rats and humans, as after fracture, mRNA, protein, and enzymatic activity iNOS have been identified at the fracture callus with maximum activity at day 15. Thus, the initial better healing, by 3 weeks, in the test group rabbits can be explained by the fact that the iNOS activity mediates an increased vascularity at the fracture site. The mRNA activity for eNOS and bNOS was induced slightly later than that for iNOS, which was consistent with a temporal increase in the calcium-dependent NOS activity that gradually increased up to day 30. All calcium-dependent processes like collagen recruitment for Haversian system formation, better bone matrix, and cortical repair were significantly better at any point of time, in the rabbits that were supplemented with arginine; however, lysine has also an important role in these processes. Arginine may influence bone formation by enhancing local IGF-I production. Nitric oxide (NO), an EC mediator, has been reported to be antigenic as well as proangiogenic in different models of in vivo angiogenesis. Arginine being nitric oxide donor increases angiogenesis. Summary. Amino acids like arginine and lysine may hasten fracture healing. Adjuvant amino acid treatment is having inherent advantage in being nontoxic, inexpensive, and a simple oral therapy

The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1). Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients. Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy. Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures

Aims: Osteotomy of ulna with fractional distraction maintains ulnar length and reduced position of radial head via interrosseous membrane. Methods: We reviewed 9patients, 5:M, 4:F, aged 2Ð14years. Interval between injury and surgery ranged 2–36months. All had elbow deformity with radial head prominence. Restricted movement in 6patients. 3 had pain on movements. 2x2mm k-wires each, proximal and distal to ulnar osteotomy. Distal k-wires transþxed in radius in supination (during distraction of ulna, radius is pulled down). ÔZñ/ÔTransverseñ osteotomy performed subperiosteally Ulna lengthened by fractional distraction. Axial k-wire in ulna in selected patients to prevent angular deformity, developing at osteotomy site during distraction. Latency period: 7days, Distraction rate: 0.8mm/day. Radial head position monitored by weekly x-rays. Static þxator time: 2x(distraction time), for consolidation of new-bone. Total þxator time: 6weeks followed by þxator removal. Brace for 2weeks with elbow-joint physiotherapy. Results: Distraction corrected ulnar deformity, restored ulnar length and radial head in anatomical position. Average ulnar length gain: 14mm. Duration of distraction: 17days. Average follow-up: 2years (1.5 Ð 4years). We achieved full, painless, stable elbow ßexion, extension, pronation and supination movements in eight but one patient. Pronosupination movement did not deteriorate over four years of study. No patient developed myositis ossiþcans or neurodeþcit. 2patients had minor pin-tract infection, subsided on treatment. Conclusion: Safe, effective and fully controlled method. This technique may be considered before open procedures for radial head

Purpose: Ulnolunate disorders secondary to fracture of the radius generally result from inversion of the distal radioulnal index due to the relative shortening of the radius creating a conflict between the head of the ulna and the proximal anterior articular surface of the semilunate and cartilage impingement. Arthroscopy can often provide the diagnosis and minimally invasive treatment. Material and methods: We reviewed a series of 32 patients, 15 men and 17 women, mean age 66 years (45–82). All presented sequelae of a fracture of the lower quarter of the radius with axial impaction. The ulnar variance was 2.7 mm (2–5). Time from initial fracture to arthroscopic resection was nine months (2–26). All patients presented pain, which was moderate and permanent in 19 and disabling in 13. Overall muscle force was reduced by 50% compared with the healthy side. Motion was limited due to the callus often associated with healing of these fractures. Patients underwent arthroscopy in an outpatient setting under locoregional anaesthesia. The arthroscope was introduced via a 3–4 radiocarpal portal allowing exploration of the joint space. Surgical treatment consisted in milling for partial distal resection of the ulnar head (6R radiocarpal portal). Wrist motion was restored in all cases. Results: Mean follow-up was 39 months (18–54). Wrist motion was restored immediately in all cases. Pain at the radioulnar joint persisted in two patients. For 26 patients, the preoperative pain disappeared immediately. Muscle force improved compared with the preoperative level but did not reach the level of the healthy side. Discussion: Arthroscopic treatment of ulnolunate impingement has proven efficacy and safety. It should however be reserved for cases with an inverted distal radioulnar index measuring less than 5 mm. If the ulnar variance is larger, we prefer ulnar osteotomy to shorten the bone. Other techniques are reserved for cases where the distal radioulnar joint is damaged

Introduction: The variety of operative procedures for neglected Monteggia lesions reflect the difficulty to securely keep the radial head relocated. The amount and direction of angulation in case of an ulnar oste-otomy can only be defined intraoperatively by empirically searching for the appropriate position since the primary ulnar deformity has already partially or completely remodelled with growth in most cases. Material and Methods: Retrospective study. From Janu-ary 1998 to May 2001 14 patients with late missed Mon-teggia lesions (Bado type I) underwent an osteotomy and external fixation (Hoffmann II compact, Howmed-ica) of the ulna combined with an open reduction of the radial head but without reconstruction of the anular ligament. The average age of 7 girls and 7 boys at the time of reconstruction was 9 years (5 to 15 years), the mean interval between the primary trauma and the reconstructive procedure 21 months (2 weeks to 7 years). Removal of the external fixator:12 weeks (7 – 16 weeks). Results: In 12 patients the radial head remained located, in 2 patients it re-dislocated postoperatively. After early postoperative closed reduction in one patient and open relocation of the radial head in the other patient with modification of the external fixation, the radial head remained located. Preoperatively 7 of the 14 patients showed a decreased range of motion which improved postoperatively in most cases. Thirteen of the 14 patients had a clinical and radiological follow-up 14 months (3 – 44 months) after the reconstructive procedure. There were no complications. Conclusions: Ulnar osteotomy, external fixation and open reduction of the radial head without ligament reconstruction or transarticular wire fixation proved to be a technically simple and safe procedure. It allows early functional after treatment without plaster. In case of posttraumatic overlength of the radius, it can be combined with acute or gradual lengthening of the ulna. Radio-humeral joint reconstruction in case of incongruency of the radial head and the capitullum, as well as reconstruction in adults with longstanding dislocation of the radial head are prone to failure

Osteotomy of ulna with fractional distraction maintains ulnar length and reduced position of radial head via interrosseous membrane. We reviewed 9 patients, 5:M, 4:F, aged 2–14 years. Interval between injury and surgery ranged 2–36months but in seven patients the repositioning was performed within 6 months. All had elbow deformity with radial head prominence. 6 patients had restricted movements of elbow. 3 had pain on movements. 2 x 2mm k-wires each, proximal and distal to ulnar osteotomy. Distal k-wires were transfixed in radius in complete supination (during distraction of ulna, radius is pulled down). ‘Z’/‘Transverse’ osteotomy was then performed subperiosteally. Ulna lengthened by fractional distraction. Axial k-wire in ulna was used in selected patients to prevent any angular deformity from developing at osteotomy site during distraction. Latency period was 7 days, Distraction rate was 0.8mm/day. Radial head position was monitored by weekly x-rays. Static fixator time was 2 x (distraction time) so as to allow time for consolidation of new-bone. Total fixator time was 6weeks followed by fixator removal and brace for 2weeks with elbow-joint physiotherapy. Distraction corrected ulnar deformity, restored ulnar length and repositioned radial head in anatomical position. Average ulnar length gained was 14mm. Duration of distraction was 17 days. Average follow-up was 2 years (1.5 – 4years). We achieved full, painless, stable elbow flexion, extension, pronation and supination movements in eight but one patient. Pronosupination movement did not deteriorate over four years of our study. No patient developed myositis ossificans or neurodeficit. 2 patients had minor pin-tract infection, which responded to basic treatment. Safe, effective and fully controlled method. This technique may be considered before open procedures for radial head is undertaken

Clinical assessment of elbow deformity in children at present is mainly based on physical examination and plain X-ray images, which may be inaccurate if the elbow is not in fully supination; furthermore, the rotational deformity is even harder to be determined by such methods. Morrey suggested that the axis of rotation of the elbow joint can be simplified to a single axis. Based on such assumption, we are proposing a method to assess elbow deformity using rotational axis of the joint, and an optimized calculation algorithm is presented. The rotation axis of elbow in respective to the upper arm can be obtained from the motion tract of markers placed at the forearm. Cadaver study was done, in which three skeletal motion trackers were placed over both the anterior aspect of humerus, as well as distal ulna. Osteotomy was created at the supracondylar region of humerus through lateral approach, and the bone fragments were stabilized with a set of external skeletal fixator, leaving the soft tissue intact. The amount of deformity was created manually by adjusting the position of the distal fragment via skeletal fixator. Ultrasound 3D motion tracking system from Zebris® was used in this study, and the program was developed under the Matlab environment. Cycles of passive elbow flexion/extension motion were carried out for each set of deformity. The data were initially transformed to humerus coordinate, and since the upper arm was not absolutely stationary, its influence on the measured position of ulna was adjusted. With this adjusted data, a best fit plane that would include most of the ulna positions (MU) within a minimal distance was obtained. The rotation axis was calculated as the normal vector to this plane, and the carrying angle could subsequently be assessed according to the relationship between this axis and the x-axis on the xy-plane as well as on the xz-plane. Fresh frozen cadaver study was conducted in the Medical Simulation Center at Tzu-Chi University. After adjustment of the raw data to eliminate the influence of humerus motion, the ulna motion could be narrowed down from a band of 10mm to 3mm, with a significant smaller standard deviation. The rotation axis was obtained by the normal vector to the best fit plane. Two different approaches were attempted to find the plane. In the first method, the plane was obtained via least square method from the adjusted ulna positions, and the second method found the plane via RANSAC method. Calculations were repeated several times for each method, and the results showed a variation of 5 degrees in the first method and about 2 degrees in the second method. Rotational axis can be used to define the 3-dimensional deformity of elbow joint; however, it is difficult to obtain such axis accurately due to hypermobility and multi-directional motion of the shoulder joint. In this study, we have developed another method to assess the elbow deformity using motion analysis system instead of the conventional image studies, and this may be applicable clinically if the facility becomes more accessible in the future. (This research was supported by the project TCRD-TPE-99-30 granted by the Buddhist Tzu-Chi General Hospital, Taipei Branch)

After a fracture of the distal radius, the bone segments may heal in a suboptimal position. This condition may lead to a reduced hand function, pain and finally osteoarthritis, sometimes requiring corrective surgery. The contralateral unaffected radius is often used as a reference in planning of a corrective osteotomy procedure of a malunited distal radius. In the conventional procedure, radiographs of both the affected radius and the contralateral radius have been used for planning. The 2D nature of radiographs renders them sub-optimal for planning due to overprojection of anatomical structures. Therefore, computer-assisted 3D planning techniques have been developed recently based on CT images of both forearms. The accuracy of using the contralateral forearm for CT based 3D planning the surgery of the affected arm and the optimal strategy for planning have not been studied thoroughly. To estimate the accuracy of the planned repositioning using the contralateral forearm we investigated bilateral symmetry of corresponding radii and ulnae using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography scan of both forearms. The left radius and ulna were segmented to create virtual 3 dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored CT-image of the contralateral side. This allowed estimation of the accuracy by calculation of relative displacements (Δx, Δy, Δz) and rotations (Δψx, Δψy, Δψz) required to align the left bone with the right bone segments as a reference. We also investigated the relationship between longitudinal length differences in radius and ulna and utilised this relationship to arrive at an optimal planning of the length of the affected radius after surgery. Relative differences in displacement and orientation parameters after planning based on the contralateral radius were (Δx, Δy, Δz): −0.81±1.22 mm, −0.01±0.64 mm, and 2.63±2.03 mm; and (Δψx, Δψy, Δψz): 0.13°±1.00°, −0.60°±1.35°, and 0.53°±5.00°. The same parameters for the ulna were (Δx,Δy, Δz): −0.22±0.82 mm, 0.52±0.99 mm, 2.08±2.33 mm; and (Δψx, Δψy, Δψz): −0.56°±0.96°, −0.71°±1.51°, and −2.61°±5.58°. The results also point out that there is a strong linear relationship between absolute length differences (Δz) of the radius and ulna among the individuals. Since we observed substantial length difference of the longitudinal bone axes of both forearms in healthy individuals, including the length difference of the adjacent forearm bones in the planning turned out to be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies. The improved planning markedly reduces length positioning variability, (from 2.9± 2.1 mm to 1.5 ± 0.6 mm). We expect this approach to be valuable for 3-D planning of a corrective distal radius osteotomy. Awareness of the level of bilateral symmetry is important in reconstructive surgery procedures when the contralateral unaffected side is used as a reference for planning and evaluation. Bilateral asymmetry may introduce length errors into this type of preoperative planning that can be reduced by taking into account the concomitant ulnae asymmetry

Five patients with isolated Madelung’s deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas average age at follow-up was 53 years. The deformity was bilateral in 4 patients and unilateral in 1. At diagnosis deformity, pain and limitations of the range of motion were present in all the wrists except 2, which were painless but presented marked functional impairment. In all the patients the typical radial deviation of the hand, was observed, with dorsal prominence of the distal end of the ulna. The x-rays showed, in anteroposterior view, the V-shaped arrangement of the first carpal row, with the lunate at the apex of the V and the marked obliquity of the articular surface of the radius toward the ulnar side. In the lateral view, the articular surface of the radius was markedly angulated anteriorly, the ulna was subluxated posteriorly and carpal bones were translated anteriorly. In no patient did we observe growth disturbance of the other bones or deformities typical of osteochondrodysplasias. In some cases the deformity progressed rapidly, whereas in the others the progression was slow. Surgical correction was sought by both the family and the patients mainly for functional reasons, although cosmetic improvement was also expected. The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At the operation all the patients had passed the adolescence growth spurt, although in 5 out of the 9 wrists growth plates were still open. At follow- up, all the patients were satisfied with the results of the operations and the range of motion of the wrists was improved. Some residual radiographic abnormalities were present in 4 wrists, but all patients were mostly pleased with the absence of pain and improvement of wrist cosmesis. No radiographic osteoarthritis was present in any of the operated wrists, although 4 of the 5 patients were over 55 years of age. Conclusions: An association of distal radial wedge-closing osteotomy and either distal ulnar hand resection or shortening distal ulnar osteotomy to correct Madelung’s deformity gave very good results in line with other reports. The limited number of our cases may be compensated by the very lengthy long-term follow-up of our series that showed how the results of these corrective operations do not deteriorate in time; moreover no radiographic osteoarthritis was present even almost 50 years after the operation

Number one in frequency of all fractures in children is the distal forearm fracture. The most common green-stick fracture with minor or no dislocation is treated by short or long arm cast. Depending on the age 4 or six weeks of immobilization is sufficient. Displaced fractures of the distal radius and ulna are treated by closed reduction under general anaesthesia or lighter forms of analgesia. Reduction is followed by fixation in the “Schede position” (flexion, ulnar abduction) with obligatory change of cast after 10–14 days. Healing can be expected after 6 weeks. As an alternative percutaneous pinning of the reduced fracture allows immobilization in a short arm cast and without the the unpleasant flexion and ulnar abduction (. Voto et al 1990. , . Mani et al 1993. , . Gibbons et al 1994. , Choi et al 1959). There is currently a prospective randomised study running organized by Mr Clarke from Southampton, to the advantages and disadvantages after use of pins or abstaining from them apparent risks. For midshaft forearm fractures closed reduction and long arm cast immobilisation had been treatment of choice in the past. Remanipulation under anaesthesia because of lack of retention of both bone fractures have been common. Concerns came up mainly in the age group above 10 years with a high rate of unsatisfactory results (. Kay et al 1986. ). Plate fixation of both bones is a difficult procedure and causes damage to the interosseous membrane and can enhance rotatory deficits. In addition ugly scars are not unusual. Intramedullary nails seemed advantageous. (. Amit et al 1985. ). J.L. Morote and the Spanish school of Sevilla were the first to use a minimal invasive method of reduction and K-wire fixation of midshaft and proximal forearm fractures. (Perez-Sicilia et al 1977). The French group in Nancy and Metz had the some years later and developed their elastic stable intramedullary system for forearm fractures . Metaizeau 1988. , . Lascombes et al. 1990. ). A high rate of excellent outcomes and hardly any complications were observed. Intramedullary fixation with elastic stable nails even permits immediate motion (. Verstreken et al 1988. ). The surgical technique of Morote using blunt-ended 1,6 to 1,8 mm K-wires is described in “Operative Technique in Orthopaedics and Trauma” (. Parsch 1990. ) The results were confirmed by Kaye Wilkins (1996), . Luhmann et al 1998. , and . Richter et al 1998. An unacceptable high rate of complications was seen in groups, who used pins, which were not buried, who removed pins to early and before consolidation or who had fixed only one bone (. Cullen et al 1998. , . Shoemaker et al 1999. ). We recommend the intramedullary system for all displaced forearm fractures of children above 6 years until closure of the growth plate.(. Parsch 1990. ). The learning curve is short, the time of surgery an average of 40 minutes. The radiation exposure can be limited by the use of short impulse image intensifier. There is virtually no blood loss. With the learning curve more than 80 % can be fixed by closed means. Open reduction might be necessary in adolescents, or in delayed fracture care. Postoperative immobilisation is a plaster shell or brace is used for 2 weeks, this is not obligatory. Postoperative infections have not been observed after this minimal invasive method. Skin irritations can be avoided by complete bending of the K-wire ends. In unacceptable malunion after conservative treatment closed or open realignment of the fractures followed by intramedullary Morote pinning is the treatment of choice. Refractures may happen with wires in place shortly or a long time after removal of the hardware. They are not associated to the system, but rather to the fact that some children are subject to repeated falls, liable to break an arm. Acute Monteggia fractures have the radial head reduced conservatively, usually under general anaesthesia. (. Bado 1967. ). The ulnar fracture is reduced and than fixed by intramedullary K-wires (. Fowles et al 1983. ). In late reconstruction of Monteggia lesions we prefer plate fixation of ulna osteotomy