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 Table of Contents  
SYMPOSIUM - DISTAL RADIAL FRACTURES
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 61-65

Ipsilateral elbow and distal radial injuries: Experience with management


1 Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Consultant Orthopaedic Surgeon, Raipur CG, India, India
3 Orthopaedics, R D Gardi Medical College, Ujjain, India
4 Orthopaedics, S S Medical College, Rewa, Madhya Pradesh, India

Date of Submission03-Jul-2020
Date of Decision18-Jul-2020
Date of Acceptance25-Jul-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Alok Chandra Agrawal
H-2, Sector 2, Agrasen Nagar, Raipura - 492 013, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_26_20

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  Abstract 


Simultaneous occurrence of injury to ipsilateral distal humerus/elbow and distal radial and/or radioulnar bone at wrist is extremely uncommon. Most of the textbooks do not mention this combination of injury. This fracture combination was studied in 42 children as a multicentric study where the peak age incidence was 10 years (range: 6–15 years); injury was common in males and on the right side in most of the cases. Open fractures were seen in 12 cases where injury resulted due to fall from height on an outstretched hand. Thirty of these injuries were treated conservatively and 12 by surgery. The study discusses the problems in management and complications observed thereof. A flowchart has been recommended based on experience.

Keywords: Distal radius, elbow, fractures, ipsilateral, management protocol


How to cite this article:
Agrawal AC, Mukharjee SK, Vyas G S, Lakhtakia PK, Tiwari V. Ipsilateral elbow and distal radial injuries: Experience with management. J Orthop Dis Traumatol 2020;3:61-5

How to cite this URL:
Agrawal AC, Mukharjee SK, Vyas G S, Lakhtakia PK, Tiwari V. Ipsilateral elbow and distal radial injuries: Experience with management. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Oct 30];3:61-5. Available from: https://www.jodt.org/text.asp?2020/3/2/61/294736




  Introduction Top


Ipsilateral fractures of the distal humerus and forearm bones in a child pose a therapeutic challenge to the orthopedic surgeon. Although supracondylar fractures of the humerus and fractures of the radius and ulna are fairly common in children, a combination of this injury is rare. The incidence of this injury ranges from 3% to 13%.[1],[2],[3],[4],[5],[6],[7]

This is a difficult injury to treat. Even in closed fractures because of the forearm fracture, one cannot treat the supracondylar fracture by closed reduction and plaster immobilization. Similarly, the principle of a cast extending from one joint above to one joint below does not work on forearm fractures due to the elbow injury and related fracture, swelling, compartment syndrome, or nerve injury. Ideally, this injury needs to be treated as an emergency with closed reduction under anesthesia and percutaneous “K” wire fixations of both the fractures, but due to delay in patient presentation, open fractures, and associated acute and other complications, the golden period of management usually passes of and then treatment becomes difficult.[8],[9],[10],[11],[12],[13],[14],[15]

This injury combination is caused by dual forces acting on the bone when a child falls down from a tree on an out stretched hand and extended elbow.

Depending on the force, the injury pattern may be 1. Undisplaced, Partially displaced, Totally displaced, and 2. Closed or Open. Six children presenting to us have came with a severe swelling in the elbow and forearm and an open Salter and Harris epiphyseal displacement Type II where the distal radius is projecting outside on the volar surface and is heavily contaminated with grease, mud, and other organic material. This delays the treatment due to the following problems:

  1. Hampered vascularity of the limb, acute compartmental syndrome, Volkmann's ischemic contracture (VIC), and even gangrene
  2. Risk of infection
  3. Postoperative stiffness of the elbow and hand
  4. Chronic osteomyelitis of the distal radius and ulna
  5. Compartment syndrome
  6. Epiphyseal growth problems, angular deformities, and stiff wrist.[16],[17],[18],[19]


The present study aims to analyze the characteristics of injury complex, mechanism of injury, modalities of treatment, and associated complications.


  Materials and Methods Top


Forty-one children with ipsilateral fractures of the distal humerus/elbow injuries along with fracture separation of the lower radial and/or ulnar epiphysis or their fracture presenting to us form the material of this study. Peak incidence of injury was observed in June. There were 35 male and 7 female cases, ranging from age group of 6 years–15 years (peak age group was 10 years). Injury was common in the right upper limb. Mode of injury was fall from tree in 37 cases, fall from height in 3 cases, and roadside accident in 2 cases. Associated injuries were contralateral fracture separation of lower radial epiphysis in two cases, contralateral posterior dislocation of elbow joint in one case, ipsilateral fracture shaft humerus (extremely rare combination of supracondylar, shaft humerus, and distal radial and ulnar epiphyseal separation) in one case, and cerebral concussion in one case. Twelve cases had open fractures of distal radius and the impact surface were uneven muddy ground in majority of the cases [Table 1]. Duration between injury and admission to the hospital was from 8 h to 1 week. Hospitalization was required from 2 to 40 days. All patients were managed as inpatient basis and follow-up was done as outpatient basis. Management of a case is shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Table 1: Nature of fractures and treatment given

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Figure 1: Clinical photograph of the 10-year-old child with ipsilateral elbow and forearm injury

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Figure 2: Preoperative X-ray of this child showing ipsilateral displaced SC# humerus and distal radius ulna fracture

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Figure 3: Postoperative X-ray showing K wire fixation of both distal humerus and distal radius ulna fractures done in steps

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Figure 4: On follow-up, the child with restriction of elbow movements undergoing physiotherapy

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Treatment

Treatment was planned in four stages:

  • Stage 1: Primary treatment in the form of wound debridement, dressing of wound, above elbow plaster of Paris slab, and elevation. Patient continued in this manner till swelling subsided or was fit for operative management
  • Stage 2: Treatment plan after primary treatment: This was done under the groups shown in [Table 3].
  • Stage 3: Limb was immobilized in a plaster of Paris above elbow posterior slab. Cleaning and dressings of the wound were continued till wound heals
  • Stage 4: Physiotherapy was advised at 6 weeks after removal of slabs/SOS K wire removal.
Table 2: Type of Injury and Treatment Plan

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Table 3: Assessment of results using modified Dodge[3]

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Observations

We managed 42 cases in this multicentric study, and depending on the infrastructure, the management varied from conservative to operative depending on patient presentation, duration since injury, fracture type, and experience of surgeon. The treatment was planned in four stages of primary treatment, actual treatment, postoperative care, and physiotherapy. There were 29 cases with both elbow and wrist fractures closed which were treated by B, C, E, and F method [Table 3].

There were six cases with closed supracondylar fractures and open distal radius/ulna fractures which were treated by B, C, and G method [Table 3].

There were two cases of open supracondylar fractures and closed radius/ulna fractures which were treated by D, E, and F method [Table 3].

Two cases with both open elbow and wrist fractures were treated by D and G method [Table 3].

Two cases with elbow dislocation and open distal radius/ulna fractures were treated by A and G method [Table 3] and one case with elbow dislocation and closed distal radius/ulna fracture was treated by A, E, and F method [Table 2].

We assessed the results at the end of 6 months based on modified Dodge criteria and had excellent results in 4, good results in 10, and unsatisfactory results in 28 cases, but their limbs were saved [Table 3].


  Discussion Top


The mechanism of injury for ipsilateral elbow and wrist fractures has been studied on the basis of fall from height, age group, position of hand (outstretched hand), as well as the season. In our study, it was found that June is summer vacation with mango and black berry fruits bloom, so the chances of a child falling become more.[1]

Prognosis of fracture of long bones and amount of spontaneous correction of angular deformity depends on the age of the child, location of the fractures, and degree of angulation (Blount).

Most of our cases were treated conservatively because:

  1. Good union capacity in pediatrics age group
  2. Good remodeling capacity
  3. No chance of nonunion
  4. Operative interventions in children can lead to tissue trauma and chance of infection of implants, resulting into nonunion, stiffness of joints, delayed union, and growth disturbances
  5. Cost factor
  6. Less hospital stay.


It is a known fact that there are other methods also to treat supracondylar fractures such as olecranon pin traction and below elbow cast application for forearm fractures.[16],[17],[18],[19] Stanitski and Micheli (1980) treated supracondylar fractures by Olecranon pin traction, close reduction and percutaneous pinning and close reduction for forearm fractures and application of above elbow posterior slab was done. We preferred Wilkins techniques in that forearm fractures should be treated at the first stage then closed manipulation of the supracondylar fracture in second stage will be easier.[2],[3],[4],[5]

Male predominance was similar to most of the previous works; right side involvement as observed by us is supported by works of Biyani et al., but left-sided predominance was observed by some workers. The mean age of the cases also coincides with the previous studies. Interestingly, the mean of this combination of injuries is higher than that group which mostly sustained supracondylar fractures alone. This age of 10 years is also less than the usual age observed for forearm diaphyseal fractures or fracture separation.[6],[8],[9],[10]

Complications of cubitus varus have been found to occur in 9%–57% of cases of supracondylar fractures alone. The forearm fractures can be missed on the severity of supracondylar fracture, which usually takes away all the attention from rest of the limb. It is obvious that the possibility of associated fractures in the forearm should be kept in mind when examining the child for supracondylar injuries. The results following injury were affected both by the severity of initial trauma and by the treatment given.[13] All the patients regained an useful range of motion of the elbow. The patient with a closed injury did significantly better than those with an open injury.[11],[12],[14],[15]

Most of these cases come from the income group with injuries in far off villages and so the patients come very late. We have analyzed that more than 70% of our patients reported to us after 1–2 days of the injury when the elbow was totally edematous with blisters and the open distal radial wound had become infected. It is really difficult in these cases to go for immediate surgery, open reduction of the supracondylar fracture with K wire fixation due to the blistered swollen elbow where there will be wound healing problems and usually postoperative infections. Close reduction under C-arm image intensifier is also not feasible because of the gross edematous swelling, which is obscuring all bony landmarks. The compound distal radius ulna with the bony ends projecting out and covered with mud and infection requires urgent debridement, reduction of the fragments with K wire stabilization, and leaving the wound open for permitting the discharge to drain out. In these cases, we usually gave the patient multiple puncture in the forearm to reduce the compartmental pressure, cover the limb with glycerin magsulph dressings, and elevate the limb to reduce edema and compartmental pressure. Once the swelling comes down, supracondylar fracture humerus is dealt with. The treatment plan after primary treatment is given in [Table 3], which formed the basis of treatment; however, one must not forget the possibility of complications such as VIC, malunion, elbow stiffness, and even gangrene to start with.[16],[17],[18],[19]


  Conclusion Top


Ipsilateral elbow and wrist fractures are a dangerous and rare injury which requires urgent treatment [Flowchart 1].



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raza HK, AgrawalAC. Paediatric ipsilateral elbow and forearm injuries. Orthopaedic J M PChap 2004;13:19-22.  Back to cited text no. 1
    
2.
Biyani A, Gupta SP, Sharma JC. Ipsilateral supracondylar fracture of humerus and forearm bones in children. Injury 1989;20:203-7.  Back to cited text no. 2
    
3.
Dodge HS. Displaced supracondylar fractures of the humerus in children – Treatment by Dunlop's traction. J Bone Joint Surg Am 1972;54:1408-18.  Back to cited text no. 3
    
4.
Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years' experience with long-term follow-up. J Bone Joint Surg Am 1974;56:263-72.  Back to cited text no. 4
    
5.
Fowles JV, Kassab MT. Displaced supracondylar fractures of the elbow in children. A report on the fixation of extension and flexion fractures by two lateral percutaneous pins. J Bone Joint Surg Br 1974;56B: 490-500.  Back to cited text no. 5
    
6.
Haddad RJ Jr., Saer JK, Riordan DC. Percutaneous pinning of displaced supracondylar fractures of the elbow in children. Clin Orthop Relat Res 1970;71:112-7.  Back to cited text no. 6
    
7.
Rogers JF, Bennett JB, Tullos HS. Management of concomitant ipsilateral fractures of the humerus and forearm. J Bone Joint Surg Am 1984;66:552-6.  Back to cited text no. 7
    
8.
Kumar K, Gadegone WM. Ipsilateral supracondylar fractures of the humerus with fracture of the forearm bones in children. IJO 1986;19:140-4.  Back to cited text no. 8
    
9.
Micheli LJ, Hall JE. Supracondylar fractures in children. Am Pam Phys1979;3:100.  Back to cited text no. 9
    
10.
Mitchell WS, Adams JP. Supracondylar fractures of the humerus in children: A ten-year review. JAMA 1961;175:583.  Back to cited text no. 10
    
11.
Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872-7.  Back to cited text no. 11
    
12.
Papavasilou V, Nenopoulos S. Ipsilateral injuries of the elbow and forearm in children. J Ped Ortho 1986;6:58-60.  Back to cited text no. 12
    
13.
Reed FE Jr., Apple DF Jr. Ipsilateral fractures of the elbow and forearm. South Med J 1976;69:149-51.  Back to cited text no. 13
    
14.
Palmer EE, Neeman KM. Supracondylar fracture of the humerus in children. JBJS 1978;60A: 653.  Back to cited text no. 14
    
15.
Sen RK, Verma RL, Lakhanpal VP. Simultaneous fractures of elbow and forearm. IJO 1990;24:179-81.  Back to cited text no. 15
    
16.
Smith L. Deformity following supracondylar fractures of the humerus. J Bone Joint Surg Am 1965;47:1668.  Back to cited text no. 16
    
17.
Stanitski CL, Micheli LJ. Simultaneous ipsilateral fractures of the arm and forearm in children. Clin Orthop Relat Res 1980;153:218-22.  Back to cited text no. 17
    
18.
Kotwal PP, Mani GV, Dave PK. Open reduction and internal fixation of displaced supracondylar fractures of the humerus. Int Surg 1989;74:119-22.  Back to cited text no. 18
    
19.
Mani GV, Kotwal PP. Medial approach in the open reduction and internal fixation of supracondylar fractures of the humerus. J. Western Pacific Orth Assoc 1986;23:15-7.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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