Ablation of Distal Ulna as an Index Procedure in A Complex Open Distal Radius-Ulna Fracture with Defective Soft Tissue Coverage
Journal Title: Biomedical Journal of Scientific & Technical Research (BJSTR) - Year 2019, Vol 13, Issue 4
Abstract
Unstable open fracture of the distal ulna with severe soft tissue disruption in association with distal end radius fracture may be beyond the scope of fixation. There is little scientific support to guide the management of this devastating fracture. We opted to perform a distal ulna resection in a young patient at the time of definitive rigid fixation of the distal radius and successfully managed to close the wound primarily. This technique has provided a reproducibly satisfactory reconstruction and maintenance of reasonably near normal wrist joint biomechanics.Open comminuted intra-articular fractures of the distal ulna with significant skin defect associated with fractures of the distal radius is rare. This prevailing fracture with concomitant destabilizing injury to the primary and secondary radio-ulnar ligamentous structures is invariably associated with distal radio-ulna joint instability. Anatomic fragment reduction and stable retention of the distal ulna may not be feasible by osteosynthesis. Extensive zone of injury at the wrist and forearm oppresses durable and viable soft tissue coverage. There is minimal guidance in the current literature regarding management of this difficult fractures. This case report describes the pivotal role of distal ulna resection in irreparable unstable fractures with soft tissue inadequacy.A 33-year-old male nurse who was involved in a road traffic accident had sustained a distal end left radius fracture AO 2.3-C1; and open comminuted fracture of the distal left ulna Biyani classification Type IV [1] with distal radio-ulnar joint instability as well as a contaminated wound measuring 2.5 x 1.5cm. The exposed ulna head was devoid of periosteum. The right hand dominant motorcyclist also acquired a radial head fracture Mason type 1 and fracture base of 5th metacarpal bone of the ipsilateral left upper extremity.. An urgent thorough osseous and soft tissue debridement was performed under general anesthesia in the emergency theatre. The distal radius was approached via the modified Henry’s, reduced and temporarily fixed with 2 cross k-wires and augmented with a spanning external fixator across the wrist. The distal ulna was approached dorsally incorporating the traumatic wound. Dorsal cutaneous branch of the ulna nerve was identified and preserved (Figure 1). The extensor retinaculum and distal radio-ulnar joint capsule was gravely damaged.The comminuted fragments of the distal ulna were reduced and temporarily fixed with multiple intrafocal pinning. Reduction of the ulna head into the sigmoid notch was laborious and recalcitrantly dislocated dorsally. The size of the wound after debridement had increased to 3.0 x 4.5cm exposing the underlying extensor carpi ulnaris (ECU) and extensor digiti quinti proprius (EDQP), their sheaths and the distal ulna. Closed reduction and percutaneous pinning of the base of the 5th metacarpal was done. The radial head was managed conservatively. The forearm was immobilized in a sugar thong slab. Intravenous cefuroxime and gentamycin were administered. Despite regular hydrogel dressing of the wound, the exposed ulna was dry and mildly necrotic. Definitive stable fixation of the radius via a variable angle locking plate was subsequently performed. The distal ulna was approached from the previous wound dorsally.
Authors and Affiliations
Rudy Reza Johan, Tan Jin Aun, Juzaily Fekry Leong
Keywords
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- EP ID EP598332
- DOI 10.26717/BJSTR.2019.13.002439
- Views 119
- Downloads 0
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