Date: Tue, 4 Mar 2003 22:37:07 +0530

Subject: Subject: Unusual forearm injury

My dear Colleagues,

I am herewith presenting a case for your valuable opinion. 3 months back I was called to the casualty to see a case of Fracture both bones of left forearm sustained by a 72 year old male patient in a road traffic accident (Image1). On removing the splint the whole forearm and elbow were found to be very much swollen. An Xray of the whole forearm INCLUDING the elbow and wrist was requested for (Remembering T.I.George!!!). The findings in the Xray were unbelievable (Image 2).

We have managed this case to the best of our ability and judgement. Before I show the full followup with the final picture I would like to know the opinion of list members regarding their options of treatment of this case.

P.S. There were no external injuries. There was no neuro vascular deficit.

Thanking you all in advance, With regards,

Dr. R. Sachidanandan
Sree Sudheendra Medical Mission Hospital

Reply at: Orthopaedic Trauma Association forum

Date: Wed, 5 Mar 2003 17:05:14 +0530



Thanks for remembering my googly and acknowledging it. (Dr Sachidanandan is refering to a case I had posted in Indiaorth discussion group with a catch. Acase of fracture both bones forearm but the initial X-ray did not include the elbow. The elbow radiograph showed dislocated head of radius and was presented after the discussion).

I would have probably gone for:

1) Closed nailing of ulna first using Lambrudini wires thanks to Sholapur group.
2) Then try a closed reduction of elbow and then
3) Closed nailing of radius again with Lambrudini wires. POP slab support.

Of course if patient was willing I would have readily transferred him to you.

Check Xray with each change of dressing to see if the elbow reduction is maintained as swelling is settling. If grossly unstable would not hesitate to sent a thick K wire from ulna to humerus. A delayed radial head excision if after union of other fractures there is limitation of supination and pronation. Bone grafting might find a place if there is no sign of union at about 10 to 12 weeks.

Consultant Orthopaedic Surgeon,
Polytrauma, Micrvascular and Hand Surgery Unit,
Metropolitan Hospital,
Trichur. South India

Date: Sun, 9 Mar 2003 16:52:30 -0600

From: Frederic B. Wilson, M.D.

Dear Dr. Sachidananden,

I think that the most significant injury is that of the elbow, which needed emergent reduction. Because of the swelling (how much time had elapsed >from injury to treatment?) I would worry about compartment syndrome (the amount of damage on x-rays, combined with the mechanism of injury and swelling, makes this a high energy injury).

Neurovascular status alone is not sufficient to rule out compartment syndrome. While I believe the diagnosis to be mainly clinical, it is worth measuring the compartments in these cases. We have seen enough of these to have become especially cautious about attempting any acute open reduction and internal fixation in the setting of the amount of swelling you describe. Better to reduce the elbow (stabilizing with a spanning external fixator placed so as to be out of the way for eventual surgery to repair the radial head and Both-Bone Forearm Fracture- BBFF- at a later time.

Campbell's Operative Orthopaedics contains a good description of the technique for releasing the compartments in the forearm, a good outline description can be found  in the on-line Wheeless Textbook of Orthopaedic Surgery.   Elevating the arm helps to relieve the swelling but keep in mind that you may not be able to achieve definitive fixation even at 48 hrs., when you come back to look at and washout the fasciotomies. Often wound closure is a problem, and may require split-thickness skin grafting.

When swelling has been controlled, my order of fixation would be to stabilize the distal fractures which, if the elbow is stable from your original reduction (+/- external fixation), will place the arm out to length. I would then very carefully reduce and fix the proximal radius fracture. In doing so I would not sacrifice any bony fragments until using them to determine a "read" on the fracture. I would also be careful to avoid stripping the major fragment as much as possible. These are very difficult and demanding cases.

Mercifully, releasing compartments, controlling swelling, and temporary fixation (mindful of your final fixation) may buy you enough time to take a deep breath and sit down to carefully plan out your definitive fixation. I still favor writing out my surgical tactic, making drawings and templating (using radiographs of the contralateral forearm) to have this all prepared before the case. Did I mention the deep breath part? I generally take several in cases such as these. Anxiously awaiting the outcome!

Best regards,

Frederic B. Wilson, M.D.
Assistant Professor Trauma & Adult Reconstruction
Department of Orthopaedic Surgery
Tulane University School of Medicine New Orleans, Louisiana, USA

Date: Tue, 11 Mar 2003 14:05:01 +0530


My dear Colleagues,

I thank all of you who took part in the discussion of my case of Unusual forearm injury. I wonder how my thinking exactly matched that of Prof.V.M.Iyer!! This patient had no external injuries, neuro vascular problems or a compartmental syndrome. We managed this case on the following lines:

1. As an emergency we reduced the elbow dislocation and immobilised the extremity in a posterior POP slab.

2. The limb was kept well elevated for 7 days.

3. On the 8th day under brachial block closed fixation of the radial fracture was done using a Rush nail. In spite of all attempts the nail could not be negotiated through the comminuted proximal fragment. The proximal tip of the nail remained outside the bone. (Image3). Since the reduction was acceptable and the nail was snugly fitting in the proximal fracture the nail was left to itself.

4. The ulnar fracture was fixed using a Rush nail. Since closed reduction failed, a limited open reduction had to be done.

5. Immobilisation in POP slab continued.

6. At 3 weeks motion at elbow started.

7. At 6 weeks slab discarded and rotation of forearm started. Xrays taken at 3 months show good union of the fractures (Image4) Present condition: Elbow-flexion full,extension limited by about 5 degrees. Wrist movements full. Pronation about 50 degrees. Supination possible only up to about 20 degrees.

Your comments are welcome. My questions:Will an early removal of the radial nail improve forearm rotation?

With regards,

Dr. R. Sachidanandan.

Date: Tue, 11 Mar 2003 14:52:55 +0530



Apart from radial nail removal, I might consider excision radial head since proximal radio-ulnar joint definitely appears incongruous. Excellentpresentation andexcellent management.

Consultant Orthopaedic Surgeon,
Polytrauma, Micrvascular and Hand Surgery Unit,
Metropolitan Hospital,
Trichur. South India

Date: Tue, 11 Mar 2003 08:05:24 -0500

From: James Carr

I would remove the rod as it missed the proximal piece of the radius, and may be impinging . I would offer further surgery for specific symptoms only. You can get a more anatomic bow on the radius if the starting point for the radius rod is near the radio-ulnar joint distally/dorsally. The major problem with that starting point is late rupture of the EPL, so the rod has to be buried, or at least advanced distally. Dr Sage actually designed his first nails to start there, but EPL rupture was viewed as such a major disaster in those earlier days of fracture care that he changed it to the radial styloid. Dr Rush's fracture manual has numerous examples of "bag o bones" treated with his rods, with surprisingly good results as you nicely show here.

Jim Carr

James B. Carr, MD
Palmetto Health Orthopedics

Date: Tue, 11 Mar 2003 18:12:20 -0700

Subject: Re: Unusual forearm injury

Removing the Rush pin in the radius might improve pro/sup given that the tip of the pin appears to be in the proximal radioulnar articulation. That being said, I would be very surprised it there isn't some significant permanent loss of pro/sup due to the malunion at both radial fracture sites. In my experience a little loss of the normal radial bow can lead to a lot of limitation of forearm rotation. But considering what you had to start with, I'd say you helped this guy immensely.

Terry Finlayson
Alpine Orthopaedic Specialists
North Logan, UT