One-Bone Forearm Reconstruction Procedure As Salvage Operation After Severe Upper Extremity Trauma: a Case Report Sokratis E

(aspects of trauma)

One-Bone Forearm Reconstruction Procedure as Salvage Operation After Severe Upper Extremity Trauma: A Case Report Sokratis E. Varitimidis, MD, Aaron I. Venouziou, MD, Zoe H. Dailiana, MD, and Konstantinos N. Malizos, MD

Abstract oss of large sections of the Since then, there have been scattered An industrial worker in his early ulna or radius with variable reports of producing a one-bone fore- 20s sustained a severe injury to loss of soft tissue presents arm for diaphyseal radius or ulna the right dominant upper extrem- a significant challenge to defects resulting from tumor resec- ity: fracture, inversion, and com- Lthe reconstructive surgeon. In 1921, tion, civilian trauma, osteomyelitis, plete devascularization of the ulna; Groves1 described a patient for whom and war injuries.4-6 transection of the median nerve, 2 successive bone-grafting proce- In this article, we report a complex the radial artery, and almost all dures failed to bridge a large radial case of a combined skeletal and soft- flexor tendons of the hand and fin- defect. The problem was solved by tissue traumatic lesion of the fore- gers; loss of all extensor muscles; transplanting the ulna into the distal arm. Successful treatment consisted and transection of the biceps and fragment of the radius to produce of early conversion to one-bone fore- brachialis muscles at the elbow. a one-bone forearm. A few years arm and late tendon transfers. Treatment consisted of conver- later, Greenwood2 and then Watson- The authors have obtained the sion to one-bone forearm, immedi- Jones3 reported using the Groves pro- patient’s written informed consent to ate reconstruction of the biceps and brachialis muscles and of all flexor cedure for two separate similar cases. publish his case report. tendons of the hand, repair of the radial artery and median nerve and late tendon transfer for extension of the wrist and fingers. Two and a half years after injury, the patient had full flexion and extension of the elbow, full extension but limited flexion of the wrist, and full flexion and extension of the fingers.

Dr. Varitimidis is Assistant Professor, Dr. Venouziou is Resident, Dr. Dailiana is Assistant Professor, and Dr. Malizos is Professor and Chairman, Department of Orthopaedics, University of Thessalia School of Medicine, Larissa, Greece.

Address correspondence to: Sokratis E. Varitimidis, MD, Department of Orthopaedics, University of Thessalia A B School of Medicine, Mezourlo 41110 Larissa, Greece (tel, 30-2410-682722; Figure 1. (A) Injured arm in emergency department. All extensor muscles fax, 30-2410-670107; e-mail, svaritimi- were detached from middle segment of ulna and lateral condyle of humerus. [email protected]). Extensor tendons were avulsed from their muscles. Brachialis and biceps Am J Orthop. 2009;38(2):90-92. Copyright, muscles were transected. (B) All flexor tendons except flexor profundus of ring Quadrant HealthCom Inc. 2009. All rights finger and flexor profundus of small finger were transected at wrist. Median reserved. nerve and radial artery were transected.

90 The American Journal of Orthopedics® S. E. Varitimidis et al

ing of the median nerve and anas- tomosis of the radial artery were performed under loop magnification with microsurgical technique. The transected flexor tendons and brachialis and biceps muscles were thor- oughly reconstructed. Muscles and tendons of the dorsal compartment were crushed, and the wound was extremely dirty and contaminated. The severe condition of these tis- Figure 2. Emergency room radiograph shows middle segment of ulna inverted sues made their resection necessary. proximal to central. Wounds were closed primarily after careful débridement and copious irri- gation with normal saline. Broad- spectrum intravenous antibiotics were administered for 7 days. The extremity was protected in a long arm cast for 8 weeks after sur- gery, until radiographic and clinical evidence of osseous consolidation was present. Progressive range-of- motion and strengthening exercises commenced for the hand and fingers during splinting. Figure 3. Immediate postoperative radiograph shows fixation of distal radius Seven months after initial treat- to proximal ulna. Distal ulna is retained. ment, tendon transfers were performed to improve hand function Case Report finger, severe loss of all extensor and especially finger extension. The An industrial laborer in his early 20s tendons, and rupture of the biceps stumps of the extensor tendons were caught his arm in a cotton refinery and brachialis muscles at the elbow. dissected at the dorsum of the wrist. press and sustained a severe injury The inverted ulna segment was com- The flexor digitorum superficialis of to the right dominant upper extrem- pletely devitalized because of loss the ring finger was passed to the ity (Figures 1A, 1B). The diagnosis of continuity with the surrounding dorsal compartment and transferred included a type IIIB open forearm healthy soft tissues. to the stump of the extensor carpi

“In our patient’s case, the one-bone forearm reconstructive procedure was selected as a salvage option because of the pattern of the ulna fracture.” fracture with an extended wound The one-bone salvage technique radialis brevis. The flexor digitorum to the brachium. Radiographs con- was used to restore the stability superficialis of the middle finger was firmed a fractured ulna and a dislo- of the forearm. An osteotomy was transferred to the dorsal compart- cated radial head. The ulna fracture performed distal to the radial head, ment and sutured to the stumps of had a unique pattern consisting of and the proximal ulna was fixed to the extensor communis of the index, a large segment (Figure 2) that was the stump of the distal radius shaft. middle, and ring fingers and to the totally inverted, central to periph- Fixation was achieved with plate and stump of the extensor digiti minimi. eral and peripheral to central. The screws (Figure 3) and with use of The flexor carpi radialis was trans- patient was transferred to the operat- autologous bone graft taken from ferred to the stump of the exten- ing room, where surgical exploration the radial head. Attention was given sor pollicis longus. The forearm was revealed rupture of the radial artery to maintaining a neutral position of protected in a back-slab cast for 5 and the median nerve, transection of supination-pronation. For prevention weeks, and then an intense program all flexor tendons except the flexor of wrist instability and for cosmetic of physiotherapy was started. profundus of the ring finger and reasons, the distal stump of the ulna At the latest (30-month) follow-up, the flexor profundus of the small was not resected. End-to-end sutur- the patient had complete flexion-

February 2009 91 One-Bone Forearm Reconstruction Procedure as Salvage Operation

Figure 4. At latest To our knowledge, the literature follow-up, patient includes few reports on primary con- presented with struction of one-bone forearm after (A) complete flex- acute trauma.5,7,8 Peterson and col- ion of the elbow leagues7 noted major complications and extension of in 10 of 19 patients treated with fingers, (B) com- the one-bone forearm reconstruction plete extension procedure. The worst results were of the elbow and found in posttraumatic cases, which flexion of fingers, had a complication rate of 69% and but (C) limited a mean of 5.6 points on the 10-point A C flexion of wrist. grading scale. Our patient had a stable, pain-free, and functional upper extremity and no complications during recovery. His evaluation score was 8 points on the grading scale used by Peterson B and colleagues.7 Resection of all avascular, necrotic, and contaminated extension at the elbow, full extension fracture was segmental, and the free tissues and stable fixation with pro- but limited flexion at the wrist, and middle segment was completely rotated tection until union were the prin- full flexion and extension at the fin- and inverted. The interosseous mem- ciples used to achieve our patient’s gers (Figures 4A–4C). The tenodesis brane of the forearm and the annular satisfactory results. Successful ten- effect was positive. Grip strength ligament between the ulna and proxi- don transfer contributed significantly was 80 pounds, and tip pinch was 14 mal radius were completely destroyed. to the final outcome. pounds. With regard to sensitivity, The defect was too large and totally 2-point discrimination was 15 mm in devascularized. The surrounding soft Authors’ Disclosure the thumb, but there was only protec- tissues were crushed and severely con- Statement tive sensation in the index and long taminated, and the arterial blood supply The authors report no actual or poten- fingers. According to the 10-point of the hand was compromised by the tial conflict of interest in relation to subjective scoring system described rupture of the radial artery. Resection this article. by Peterson and colleagues,7 which of the middle fragment of the ulna was is based on function, pain, and bone inevitable. For these reasons, the option References union, our patient’s score was 8 of interposing a vascularized fibular 1. Groves EW. On Modern Methods of Treating Fractures. Bristol, England: John Wright & points, corresponding to an excel- graft was rejected. Sons; 1921. lent result. There were no soft-tissue The distal part of the ulna was 2. Greenwood HH. Reconstruction of forearm after loss of radius. Br J Surg. 1932;20(77):58-60. infection, osteomyelitis, hardware retained and contributed to the fact 3. Watson-Jones R. Reconstruction of the failure, or refracture during recov- that no carpal impingement symptoms, forearm after loss of the radius. Br J Surg. ery. The patient returned to his job, instability, or cosmetic deformity was 1934;22(85):23-26. 4. Castle ME. One-bone forearm. J Bone Joint but with lighter duties. He expressed observed. During fixation, the forearm Surg Am. 1974;56(6):1223-1227. complete satisfaction with the out- was kept in neutral position, as recom- 5. Haddad RJ Jr, Drez D. Salvage procedures come of treatment given the severity mended by the majority of authors.2,4-6 for defects in the forearm bones. Clin Orthop. 1974;(104):183-190. of his initial injury. Tendon transfers for extension 6. Murray RA. The one-bone forearm. A recon- of the hand and fingers were per- structive procedure. J Bone Joint Surg. 1955;37(2):366-370. Discussion formed 7 months after injury. By that 7. Peterson CA 2nd, Maki S, Wood MB. Clinical In our patient’s case, the one-bone time, the fracture and soft tissues had results of the one-bone forearm. J Hand Surg forearm reconstructive procedure was healed, and the patient had regained Am. 1995;20(4):609-618. 8. Allende C, Allende B. Posttraumatic one-bone selected as a salvage option because very good function of the flexor ten- forearm reconstruction. J Bone Joint Surg of the pattern of the ulna fracture. The dons of the hand. Am. 2004;86(2):364-369.

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