Comparative Analysis: Operative versus Non-Operative Management of Acute-Pediatric Monteggia Fractures

Background

The management of acute pediatric Monteggia fractures, characterized by a fracture of the ulna with associated radial head dislocation, remains a challenging aspect of pediatric orthopedic care. The primary debate centers around the efficacy of operative versus non-operative treatments. This systematic review aims to provide a comprehensive comparison of these approaches, focusing particularly on the outcomes and effectiveness of intramedullary fixation versus plate fixation within operative treatments.

Methods

A systematic review was conducted following PRISMA guidelines, involving an extensive search of databases including PubMed, Embase, and Cochrane Library up to May 2024. Studies included in the review had to meet specific criteria: they had to involve pediatric patients (age <18 years) with acute Monteggia fractures, compare operative to non-operative management, and report on outcomes such as complication rates, recovery of range of motion (ROM), and need for further interventions. Data extraction covered study characteristics, participant demographics, fracture patterns, intervention details, and outcomes. Quality assessment of the included studies was performed using the MINORS (Methodological Index for Non-Randomized Studies) tool.

Results

A total of 24 studies were included in the qualitative synthesis, with 15 studies providing quantitative data for meta-analysis. The non- operative approach, typically involving closed reduction and casting, was found to be effective for certain fracture patterns but required close monitoring due to the risk of redislocation, especially in Bado Type III and IV fractures. Studies highlighted that non-operative treatment had a comparable outcome to surgical management when careful follow-up was ensured.

In contrast, surgical management showed a higher initial success rate, with intramedullary fixation (IMF) being preferred for its minimally invasive nature and reliable stabilization. IMF was associated with fewer immediate complications, such as infection and nerve injury, and allowed for early mobilization. Plate fixation, while less commonly used, provided superior outcomes in complex fractures, particularly in maintaining reduction and promoting bone healing. This method was noted for its robustness in cases with high angular deformities or comminution.

Key predictors of treatment success included the type and degree of fracture angulation, timing of intervention (with earlier treatment yielding better outcomes), and the presence of associated injuries or comorbidities. The review found that patients undergoing operative treatment had a faster return to full ROM and lower rates of redislocation. However, surgical management also came with risks such as hardware complications and the need for subsequent surgical removal in cases of IMF.