Dilip D Shah

Hon. Professor and Consultant

Orthopedic Surgeon

Nair Hospital

TN Medical College

Breach Candy Hospital

HN Hospital, Mumbai

Abstract

Compound comminuted fracture of upper limbs are common in road traffic accidents. We report the case of a 20-year-old male who presented with pain, swelling and bleeding from the right elbow associated with painful restriction of all elbow movements. He was diagnosed to have a compound comminuted fracture of right elbow.

A 20-year-old male patient came with the alleged history of road traffic accident while traveling on a two wheeler being hit by a four wheeler leading to fall over the right elbow. Patient c/o pain, swelling and bleeding from the right elbow associated with deformity. Patient was unable to move right elbow with painful restriction of all elbow movements. Patient was given primary treatment at Nagothane. Contused lacerated wound (CLW) suturing done over the bleeding wound, above elbow POP slab was given and referred to Sir HN Hospital for further management. On examination in casualty, patient had Compound Grade 2B external injury with profuse bleeding from the sutured wound present over the posterior aspect of the right elbow. Distal neurovascularity was checked and right radial artery was not palpable with diminished ulnar nerve sensations. Fresh above elbow POP slab given in less flexion when radial  pulse returned, IV antibiotics were started and the patient shifted on the same night to the operation theater (OT) for wound debridement. Wound was checked in the OT. Sutures, dirt and debris were removed with thorough NS + Betadine + hydrogen peroxide wash. Portable X-rays were taken in the OT with right elbow in full extension and longitudinal traction.

X-rays on arrival at Hospital.

Patient had Grade 13-C3 AO classification distal humerus, complete articular multifragmentary fracture with metaphyseal wedge fragmentation.

The articular region had fractures in sagittal as well as coronal planes. Stay sutures were given and planned for definite surgery after two days. All the implants and instruments were kept ready the day before surgery. On the day of the surgery, patient was put in lateral position. Right elbow lateral support, which was essential for exposure and taking intraoperative images of the patient, was given. Wound was incised and fracture configuration noted. Olecranon osteotomy was not required since patient was already having an olecranon fracture, which was displaced proximally. Fracture fragments were fixed with multiple K-wires. Two different plate configuration system were available: 1) Parallel plating and 2) perpendicular plating. Perpendicular plating system was chosen. Medial column were fixed first with precontoured locking plate. Then K-wires were used as joystick to maneuver articular fragment and fixed with pericortical interfragmentary screws. Lateral column was fixed with Recon locking plate. Olecranon was reattached to the shaft of the ulna with tension band wire system. Wound was closed with the ulnar nerve left in the same position (not transposed) and POP slab was applied. Elbow range of movement exercises started in the plaster slab which was broken at elbow purposely.

Wound after debridement.

Portable X-rays in OT at the time of debridement with traction.

Exposure.

Immediate postoperative X-rays.

Status of wound at 48 hours dressing.

X-rays after four weeks.

Regular dressing was done and the patient started doing exercises regularly as taught.

After four weeks of mobilization in broken slab patient was without any support.

After six weeks patient had 80% of the range of movements of the elbow and ulnar nerve had fully recovered.