Date: Mon, 15 Mar 2004 09:16:51 +0500
From: Alexander Chelnokov
Subject: Gun-shot forearm fracture
Hello All,
A male 36 years old 5 month ago sustained a gun-shot wound with the radial fracture and lesion of a. radialis and n. medianus. Debridement was performed at the initial hospital, full-thickness skin grafting and intramedullary fixation of the radius by a small wire, which later was removed. No sinuses and signs of infection to date. A linear scar on the radial side and the healed flap (see image). Healing was not reached (see x-rays).
|
|
Neurosurgeons hope to do something with the peripheral nerves but only in case of stabilization of the radius.
Which treatment modality should be preferred? I would perform gradual alignment with the Ilizarov, and perform secondary closed nailing. Even not to expect to reach union, just to restore length and alignment with the "shaft endoprosthesis". Or it is worth to think about other options?
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 15 Mar 2004 05:15:29 EST
From: Aobonedoc
Hello:
Presumably not infected. Picture of forearm shows possible thumb flexion contracture (could be positional) but definite flexion contracture of the little finger. Is this ulnar clawing (fixed versus flexible deformity) or extrinsic flexor contractures. Location of scar/incision (ulnar) suggests possible ulnar nerve injury.
Concerning noninfected radius shaft nonunion: explore with internal fixation (I would use a locking 3.5 mm plate but use a standard compression plate if not available). Bone grafting (possible BMP but costs $5,000 in the US). Explore all involved nerves, repair if possible, graft if not. Nerve exporation/repair/grafting can be done at same time. Tendon transfers possible much definitely at later date, only after bone union and assessment of residual nerve healing. Good luck.
Sincerely and respectively,
M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
Arlington Heights, Illinois 60005
Date: Mon, 15 Mar 2004 20:55:59 +0500
From: Alexander Chelnokov
Hello Bryan,
AAC> Location of scar/incision (ulnar) suggests possible ulnar nerve injury.
Yes, fingers IV-V are also not sensible.
AAC> Concerning noninfected radius shaft nonunion: explore with internal fixation (I would use a locking 3.5 mm plate but use a standard compression plate if not available).
Why not closed nail? Tissues are rigid, excessive scars, and the segmental piece looks malunited to the proximal radial fragment, so it would cause a problem with plate placement. The nail is safe and low invasive, and it would allow not to care about the union.
AAC> Bone grafting (possible BMP but costs $5,000 in the US).
8-[ ] Wow! The nail is much cheaper. If one can spare the money would he obtain its part? ;-)
AAC> Explore all involved nerves, repair if possible, graft if not. AAC> Nerve exporation/repair/grafting can be done at same time.
We leave such surgeries either for hand surgery clinic or neurosurgery center.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Wed, 17 Mar 2004 22:55:16 EST
From: Tadabq
This patient has a radius shaft segmental fracture with nonunion, healed soft tissue with scar, nerve and probably tendon injuries but a well perfused hand, probably not infected and an intact ulna.
This would most commonly be treated with plate fixation of the radius shaft and the bone would typically heal in good position and give the best chance at optimal recovery of the various soft tissue problems. Although one could argue for intramedullary fixation on a theoretical basis, plates workvery well on the radius shaft in both practice and theory.
At 5 months post injury you could either reduce the distal nonunion and span the intercalary segment (4 screwsin the proximal and distal fragments) accepting some imperfect alignment at the proximal fracture site or take down the "nascent imperfect" union at the proximal fracture site. Although the fracture may be "healed", by carefully scraping away the callus you can typically develop the original fracture line and improve the reduction in the manner of Jupiter and distal radius "nascent" malunions. The callus will provide adequate bone graft to fillthe apparent small bonedefect at the distal nounion site. Restoring length, rotation and stability immediately and obtaining ultimate bone healing will greatly enhance the potential for soft tissue recovery. (in contrast to accepting a chronic nonunion around some kind of small intramedullary device). To me, there is a good treatment option available with reasonably good chance of success and no need to try something innovative.
TD
Date: Thu, 18 Mar 2004 12
Hello Tom,
TAC> Although one could argue for intramedullary fixation on a theoretical basis, plates work very well on the radius shaft in both practice and theory.
Recent years we nail without site opening all shaft forearm fractures by individually customized titanium nails.
TAC> Restoring length, rotation and stability immediately
By a quite invasive open mobilization and reduction... So it seems reasonable to restore length and axis gradually. A distractor was applied, an, the x-ray is performed after strong manual traction.
 |
TAC> and obtaining ultimate bone healing will greatly enhance the potential for soft tissue recovery. (in contrast to accepting a chronic nonunion around some kind of small intramedullary
Proper alignment and good stability is reachable by a closed nail, at least of that sort we use. Anyway final result will mostly depend on hand function/sensitivity rather than radial (non)union. Which itself didn't bother the patient.
TAC> To me, there is a good treatment option available with reasonably good chance of success and no need to try something innovative.
If the the stable aligned radius can be reached without excessive incision and open mobilization why neglect the option?
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Thu, 18 Mar 2004 18:52:48 EST
From: Tadabq
All good points you make.
I do think hand and soft tissue recovery would be enhanced by solid bone union of a reasonably reduced radius. Your mention of accepting nonunion with a "shaft endoprosthesis" suggests that youmight also beconcerned that IM nailing might have a resonably high persistent nonunon rate. I suspect it would be higher than with plating. But plating has it's drawbacks, notably extensive dissection as you noted. By the way, yesterday I saw for the first time, a titanium roof being put on a house.
TD
Date: Fri, 19 Mar 2004 16:46:57 +0530
From: tigeorge
Alex,
I have not been following this discussion in detail. However would like to give a comment on your statement.
AC : If the the stable aligned radius can be reached without excessive incision and open mobilization why neglect the option?
Having put the patient on ring fixator, the intervention required for nerve exploration, repair and grafting are delayed till the fixators are removed. This is bound to affect the end result of nerve repair/ grafting. If an open procedure like plating was resorted to, then nerve intervention also could have been taken up simultaneosly and total recovery period could have been shorter with probably a better end result.
Dr. T. I. George.
Date: Fri, 19 Mar 2004 17:22:03 +0500
From: Alexander Chelnokov
Hello Tom,
TAC> "shaft endoprosthesis" suggests that you might also be concerned that IM nailing might have a resonably high persistent nonunon rate.
No, i mean cases like this where nonunion is likely because of bone defect, poor bone vascularizaion after open injury and so on.
TAC> I suspect it would be higher than with plating.
We don't have representative series of similar injuries treated with nails or plates. In acute shaft fractures the nails provide quite good results. Since 2001 i met only one radial nonunion (of more than 30 forearms) - but asymptomatic.
TAC> By the way, yesterday I sawfor the first time, a titanium roof being put on a house.
Good idea.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Fri, 19 Mar 2004 20:10:13 +0500
From: Alexander Chelnokov
Hello,
t> Having put the patient on ring fixator, the intervention required for nerve exploration, repair and grafting are delayed till the fixators are removed.
Exactly.
t> This is bound to affect the end result of nerve repair/ grafting.
Do you suppose the end result would be markedly affected if the fixator was applied in 5.5 months since the initial injury, and is to be removed within 2-3 weeks, in 6 months?
t> nerve intervention also could have been taken up simultaneosly and total recovery period could have been shorter with probably a better end result.
I would expect a better result if nerve/vessel repair would be performed by a skilled team which is not available in my settings.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sat, 20 Mar 2004 02:17:34 +0530
From: tigeorge
Dear Alex,
If the fixator is going to come out in 2-3 weeks time, then it should not make a difference. If you are planning to internally stabilise at this time, then are you sure that the nail will be sufficient for the subsequent procedure?
I agree that it makes a difference to get an experienced person to do the nerve and vascular repair. If your centre has sufficient trauma load it may be worth to send someone for this training and he/she will be an asset to the team and centre.
Dr. T. I. George
Date: Sun, 21 Mar 2004 21:36:01 +0500
From: Alexander Chelnokov
Dear T.I. George
t> time, then are you sure that the nail will be sufficient for the subsequent procedure?
Like nerve repair/grafting? Definitely.
t> nerve and vascular repair. If your centre has sufficient trauma load it may be worth to send someone for this training and he/she will be an asset to
Not enough such cases for "critical mass" to initiate the activity. We meet ~1-2 similar cases a year so the person wouldn't have enough practice to maintain the skills.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 22 Mar 2004 19:43:22 +0500
From: Alexander Chelnokov
Hello All,
In attachment - image 1 after performed distraction, and 2 - after acute conversion to the nail (5 mm).
 |
 |
It took some efforts to find and ream the canal at the proximal fragment. I hope the patient can leave for the neurosurgery clinic within 3-4 days. Critics/comments are welcome.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 22 Mar 2004 15:59:56 EST
From: Tadabq
Alex
Comment It looks like the titanium pin is outside the medullary canal of the intercalary segment. Length and alignment are improved and I guess callus will heal the two fracture sites.
TD
Date: Wed, 24 Mar 2004 16:47:05 +0530
From: tigeorge Dear Alex,
Xray looks good. How do ensure that in such a forearm with adherent soft
tissues, you will not cause additional damage during closed reaming?
Dr. T. I. George,
Head of Ortho Unit III,
Little Flower Hospital,
Angamaly
Kerala, India