Segmental Radius and Ulna Fractures with Scaphocapitate Fractures and Bilateral Multiple Epiphyseal Fractures

(aspects of trauma • a case report)

Segmental Radius and Ulna Fractures With Scaphocapitate Fractures and Bilateral Multiple Epiphyseal Fractures

Mohammed Naveed Yasin, MB BCh, MRCSEd, Sumedh Chittaranjan Talwalkar, MB BS, MRCSEd, John James Henderson, MB ChB, FRCSEd, and Stephen Peter Hodgson, MB ChB, FRCS, MD

Abstract 30% of all long bone injuries.2 Distal fractures in children,14 fractures of Segmental forearm fractures are rare radius fractures in children are more the radial neck,15 multiple epiphy- in children, and management is con- likely to involve the radiocarpal or seal fractures,16 and scaphocapitate troversial. Epiphyseal injuries further radioulnar joints than those in the fracture syndrome.10 However, to our complicate matters. We report the elderly.3 However, the vast majority knowledge, our patient’s pattern of case of a 15-year-old boy who had of pediatric distal forearm fractures injuries was not previously reported segmental radius and ulna fractures can be treated by closed reduction in a child or adult. We evaluate our with a coronal split of a metaphyseal and immobilization in a plaster cast.4 management of such complex frac- fragment, along with bilateral epiphy- In adults, segmental fractures of the ture patterns and assess the outcome seal fractures of the distal radius and forearm are treated with open reduc- at 12 months. ulna as well as ipsilateral scaphocapi- tion and internal fixation (ORIF).5 In tate fractures with perilunate disloca- children, these fractures are extreme- Case Report tion. There was also a contralateral ly rare, and correct management is A 15-year-old boy fell from a height fracture through the radial neck. The the subject of debate.6 ORIF with of approximately 60 feet in an abseil- patient underwent immediate internal plates and screws, intramedullary ing (rappelling) accident. The patient fixation of the forearm fractures and elastic nails, and intramedullary and sustained multiple injuries, including delayed fixation of the scaphocapi- percutaneous Steinmann pins have been a fractured frontal bone with a frontal tate fractures. Results at 12 months used in children, with no increased risk contusion, fractures of the zygoma showed excellent functional outcome. for complications over using pins and and petrous apex, and an undisplaced plaster cast for unstable pediatric fracture of the left patella. He also orearm fractures are com- forearm fractures.7,8 Further contro- sustained complex fractures of both mon in children.1-4 The versy exists about how many bones arms. He had an open injury to the usual site of injury is the should be fixed in unstable pediatric distal radius.4 In children, forearm fractures.9 Fgrowth plate fractures account for Scaphocapitate fracture syndrome is another rare injury in young patients.10 Each case can have sev- Dr. Yasin is Senior House Officer, and eral injury patterns, including oblique Dr. Talwalkar is Specialist Registrar, capitate fractures,11 fractures through Department of Orthopaedics, and the coronal plane,12 and concurrent Dr. Henderson and Dr. Hodgson are 13 Consultant Orthopaedic Surgeons, Royal dislocations. Bolton Hospital, Farnworth, Bolton, We describe the case of a young United Kingdom. patient with compound segmental fractures of the ipsilateral radius and Address correspondence to: Mohammed ulna with distal epiphyseal fractures Naveed Yasin, 13 Hampton Rd, Bolton, Greater Manchester, BL3 2DX, United of both bones as well as ipsilateral Kingdom (tel, 01204-450805; fax, 01204- scaphocapitate fractures with perilu- 450805; e-mail, naveedyasin@doctors. nate dislocation. The patient also had org.uk). epiphyseal fractures of both distal Figure 1. Preoperative anteroposterior and lateral x-rays of left forearm show ulna and radius with a fracture of the Am J Orthop. 2008;37(4):214-217. segmental radial and ulna fractures with Copyright Quadrant HealthCom Inc. radial neck in the opposite arm. There epiphyseal injuries as well as fractures 2008. All rights reserved. are case reports of segmental forearm of the scaphoid and capitate.

214 The American Journal of Orthopedics® M. N. Yasin et al

Figure 2. Preoperative anteroposterior and Figure 4. Postoperative anteroposterior Figure 6. Anteroposterior and lateral lateral x-rays of right forearm show distal and lateral x-rays of right forearm. x-rays of right forearm 12 months after radius and ulna epiphyseal injuries and an surgery. undisplaced fracture of the radial head.

Figure 7. X-rays show capitate and scaphoid fixation 12 months after surgery.

radial fractures was done through an anterior Henry approach. The shaft Figure 3. Postoperative anteroposterior Figure 5. Anteroposterior and lateral and lateral x-rays of left forearm show x-rays of left forearm 12 months after of the radius was reduced and fixed reduction and various fixations used. surgery. with an AO (Arbeitsgemeinschaft für Osteosynthesefragen) plate. The dis- left forearm with 2 small compound of the distal and middle third. In tal metaphyseal fragment was split wounds less than 1 cm on the volar addition to these injuries, there were in the coronal plane with a separate surface over the radial side and 1 fractures of the scaphoid and capitate volar segment. This deformity was small puncture mark, again less than with a perilunate dislocation (Figure corrected, and the coronal split held 1 cm over the ulna side. Initial x-rays 1). The right forearm had no open with an interfragmentary screw. The showed a segmental injury of both injuries. X-rays showed Salter-Harris radial epiphysis was then reduced the ulna and radius on the left side II epiphyseal injuries to both distal onto the shaft and the reduction main- with multiple epiphyseal injuries. radius and ulna as well as an undis- tained with 2 smooth Kirschner wires There were Salter-Harris II fractures placed fracture of the radial head (K-wires). A volar buttress plate was of both the distal radius and the ulna. (Figure 2). then used to hold the metaphyse- There was a transverse midshaft radi- The patient was taken to the emer- al fragment in place. Sutures were us fracture as well as a comminuted gency department for immediate passed through the distal periosteum fracture at the radial metaphysis with attention to both forearm fractures. on the epiphysis to tie down to the the distal fragment angulated around On the left side, the perilunate dislo- plate. The ulna was exposed through to almost 160° on the lateral view. cation was reduced. The open wounds its subcutaneous border, and the com- The ulna had a second fracture with to the left arm were cleaned and minuted fracture was reduced. This a butterfly fragment at its junction edges excised. Open reduction of the was fixed with a dynamic compres-

April 2008 215 Segmental Radius and Ulna Fractures

radiologic union in a satisfactory position. However, all the growth plates had fused slightly prematurely (Figures 5–7). There was a slight dorsal tilt of the left distal radius articular surface. Figure 8. Wrists in neutral at 12 months (right forearm on left). Clinically, the patient had excellent results, no visible deformity, and well-healed scars. Dorsiflexion of the left wrist was slightly reduced to 60°. There was no forearm-length discrepancy. Palmar flexion, pronation, supination, and radial and ulnar deviation were normal and symmetrical on both sides (Figures 8–11). The carpus was stable, demonstrating no subluxation or shift. The distal radioulnar joints Figure 9. Wrists in full active palmar-flexion at 12 months (right forearm on left). also seemed stable on both sides. The patient worked in a physically demanding job. He did not have any residual pain or restriction in daily activities from his forearm and wrist injuries. At 12 months, there was no appreciable weakness in grip strength.

Discussion Figure 10. Wrists in full active dorsiflexion at 12 months (right forearm on left). Management of such an array of complex segmental fractures is tech- nically demanding. We opted for internal fixation with dynamic compression plates and a buttress plate for the segmental fractures with percutaneous K-wires to maintain the reduction of the epiphyseal fractures. Figure 11. Full supination and pronation at 12 months. Other methods (eg, intramedullary K-wires,17 intramedullary elastic sion plate. The ulnar epiphysis was Subsequently, the patient re- nails,18 pins and plaster casts8) are then reduced and fixed with a sin- mained in intensive care. Further also available. At time of surgery, gle K-wire. The ulnar wound was wound inspections were performed, however, it was felt that this form of closed, but the volar incision could but attempts at closure failed. The fixation would offer more stability, not be closed and was left open to act scaphoid and capitate fractures especially since several fragments as a prophylactic fasciotomy. After were addressed 18 days later, after required open reduction. appropriate dressings, the arm was detailed imaging, by the upper With regard to scaphocapitate frac- placed into an above-elbow plaster limb team. The carpus was opened tures, we ensured that the perilunate cast, ensuring that the alignment of through a Berger approach. The dislocation was reduced and initially the carpus was satisfactory (Figure capitate and scaphoid fractures were treated in a plaster cast so that the 3). A closed reduction of the radial reduced and fixed by mini-Acutrak other, more life-threatening injuries epiphysis was performed on the right fixation screws. The patient went could be addressed first. In the mean- side. This was held in position with 2 on to require split skin grafting to time, further imaging was performed smooth K-wires. Closed reduction of the left forearm. K-wires in both to determine the exact fracture pat- the ulna failed, and thus open reduc- arms were removed after 6 weeks. tern. Arrangements were made for the tion through a small incision was per- The patient was then referred for upper limb team to perform the fixa- formed. The ulnar epiphysis was held physiotherapy. Functional outcome tion electively after the swelling had in place with 2 additional smooth was evaluated after 1 year. X-rays resolved and the patient’s condition K-wires (Figure 4). The wound was obtained at 12 months showed the stabilized. In other case reports of closed and the forearm placed into an metal plates to be in situ in the left similar injuries to the wrist, the same above-elbow plaster cast. forearm. The fractures all showed good results were not achieved.10

216 The American Journal of Orthopedics® M. N. Yasin et al

We acknowledge that the distal References 10. Kumar A, Thomas AP. Scapho-capitate frac- 1. Landin LA. Fracture patterns in children: anal- ture syndrome. A case report. Acta Orthop epiphysis fused slightly prematurely, ysis of 8,682 fractures with special reference Belg. 2001;67(2):185-189. but the patient was not left with any incidence, etiology and secular changes in a 11. Freeland AE, Pesut TA. Oblique capitate frac- Swedish urban population 1950-1979. Acta ture of the wrist. Orthopedics. 2004;27(3):287- significant limb-length discrepancy Orthop Scand Suppl. 1983;202:1-109. 290. or loss of function. Similar results 2. Mann DC, Rajmaira S. Distribution of phy- 12. Robison JE, Kaye JJ. Simultaneous frac- seal and nonphyseal fractures in 2,650 long- tures of the capitate and hamate in the with regard to early growth plate bone fractures in children aged 0-16 years. coronal plane: case report. J Hand Surg Am. fusion were reported by Osada and J Pediatr Orthop. 1990;10(6):713-716. 2005;30(6):1153-1155. 16 3. Lindau TR, Aspenberg P, Arner M, Redlundh- 13. Osti M, Zinnecker R, Benedetto KP. Scaphoid colleagues, who used K-wires to fix Johnell I, Hagberg L. Fractures of the distal and capitate fracture with concurrent 3 epiphyseal fractures. forearm in young adults. An epidemiologic scapholunate dissociation. J Hand Surg Br. description of 341 patients. Acta Orthop 2006;31(1):76-78. The patient seemed to have excel- Scand. 1999;70(2):124-128. 14. Grainger J, Oliva F. Maffulli N. Segmental radius lent function at 12 months and 4. Cheng JC, Shen WY. Limb fracture pattern in and ulna fracture with epiphyseal involvement. different pediatric age groups: a study of 3,350 Bull Hosp Joint Dis. 2005;62(3-4):131-133. returned to his full-time, manually children. J Orthop Trauma. 1993;7(1):15-22. 15. Ikram MA, Ibrahim MR. A displaced fracture of demanding job soon after undergo- 5. Anderson LD, Sisk D, Tooms RE, Park WI III. the neck of the radius with diaphyseal fracture Compression-plate fixation in acute diaphy- of ipsilateral radius and ulna in a child. Injury. ing fixation of these fractures. We seal fractures of the radius and ulna. J Bone 2004;35(8):831-833. conclude that ORIF using a combina- Joint Surg Am. 1975;57(3):287. 16. Osada D, Tamai K, Kuramochi T, Saotome 6. Cheng JC, Ng BK, Lam PK. A 10-year study K. Three epiphyseal fractures (distal radius tion of plates, screws, and K-wires is of the changes in the pattern and treat- and ulna and proximal radius) and a diaphy- a valid method of treatment for such ment of 6,493 fractures. J Pediatr Orthop. seal ulnar fracture in a seven-year-old child’s 1999;19(3):344-350. forearm. J Orthop Trauma. 2001;15(5):375- complex segmented forearm fractures 7. Ortega R, Loder RT, Louis DS. Open reduction 377. and multiple epiphyseal fractures. and internal fixation of forearm fractures in chil- 17. Yung SH, Lam CY, Choi KY, Ng KW, Maffulli dren. J Pediatr Orthop. 1996;16(5):651-654. N, Cheng JC. Percutaneous intramedullary 8. Voto SJ, Weiner DS, Leighley B. Use of pins Kirschner wiring for displaced diaphyseal fore- Authors’ Disclosure and plaster in the treatment of unstable arm fractures in children. J Bone Joint Surg pediatric forearm fractures. J Pediatr Orthop. Br. 1998;80(1):91-94. Statement 1990;10(1):85-89. 18. Lascombes P, Prevot J, Ligier JN, Metaizeau The authors report no actual or poten- 9. Bhaskar AR, Roberts JA. Treatment of unsta- JP, Poncelet T. Elastic stable intramedullary ble fractures of the forearm in children. Is plat- nailing in forearm shaft fractures in children: tial conflict of interest in relation to ing of a single bone adequate? J Bone Joint 85 cases. J Pediatr Orthop. 1990;10(2):167- this article. Surg Br. 2001;83(2):253-258. 171.

This paper will be judged for the Resident Writer’s Award.

Guest Editorial (Continued from page 187) A. J. Aboulafia

bone tumors tend to be symptomatic. or abscess. Similarly, soft-tissue sar- about potential malignancy, referral All too often, asymptomatic soft-tis- comas are generally well defined on to an orthopedic oncologist may be sue masses are thought to be benign magnetic resonance imaging (MRI). warranted.The cases that are not easy solely on the basis of the lack of Again, this is contrary to the impres- to diagnose or that foil expectations symptoms. Unfortunately, while it sions of many orthpedic surgeons and should remind us of the importance may seem counterintuitive, soft-tissue radiologists. Frequently, an MRI scan of being thoughtful and humble. The sarcomas are generally asymptomatic. is read as a benign soft-tissue mass obvious diagnosis is not always the Since they share this clinical presen- because the lesion is well defined. correct one. n tation with benign soft-tissue masses, The orthopedic surgeon relying on clinical symptoms may not be help- the reading of a radiologist in such Reference ful. Symptomatic soft-tissue masses cases can become an unsuspecting 1. Parker SL, Tong T, Bolden S, Wingo PA. may suggest a diagnosis of angio- accomplice to delays in treatment or Cancer statistics, 1996. CA Cancer J Clin. lipoma, hemangioma, schwannoma, misdiagnosis. If one has a concern 1996;46(1): 5-27.

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