A staged approach to managing a combination of a terrible triad injury and an Essex–Lopresti fracture dislocation: an open forearm crush injury—a case report

Abstract

Background

Open and crushed forearm injury is a complex and rare injury affecting the upper extremity. It results in damage to various structures, including bones, soft tissues, and neurovascular bundles, ultimately leading to functional impairment. Typically, these injuries occur owing to high-energy trauma.

Case presentation

A 19-year-old South Asian male was seen at our trauma center emergency department following an accident where his arm got entangled in a machine belt. He sustained a serious open injury on his left forearm, spanning from the elbow to the wrist, affecting the proximal radio-ulnar joint, ulna bone, interosseous membrane, and distal radio-ulnar joint. The initial plan of care involved stabilizing the injury using an external fixator, while reconstructive surgery was scheduled for a later date.

Conclusion

Timely intervention for wound debridement and joint stabilization plays a crucial role in the restoration of a crushed forearm. Following this, a collaborative effort from a multidisciplinary team becomes essential. Planning multiple surgeries is important, with the primary goal of achieving early range of motion of the elbow and wrist to prevent stiffness. This comprehensive approach aims at optimizing the recovery and functionality of the affected limb. The combination of early intervention, damage control surgeries, and carefully planned procedures sets the foundation for successful management of a crushed and open forearm injury. Furthermore, early range of motion and physiotherapy rehabilitation has a key role in stiffness prevention and the restoration of function.

Background

Forearm injuries manifest in diverse patterns, ranging from isolated fractures to complex scenarios involving intraarticular complications and fracture dislocations such as Monteggia, Galeazzi, and Essex–Lopresti types and so on.

The primary objective of this paper is to comprehensively detail the management of a severe crush and open injury to the forearm, specifically involving the elbow joint, proximal radio-ulnar joint (PRUJ), ulna shaft, and distal radio-ulnar joint (DRUJ). The case study sheds light on a unique forearm injury and provides insights into a surgical intervention employed to address the complexity of the presented injuries.

Case presentation

A 19-year-old South Asian male was seen at our trauma center emergency department following an accident where his arm got entangled in a machine belt. He sustained a serious open injury on his left forearm, spanning from the elbow to the wrist, affecting the proximal radio-ulnar joint (PRUJ), ulna bone, interosseous membrane (IOM), and distal radio-ulnar joint (DRUJ). The initial plan of care involved stabilizing the injury using an external fixator, while reconstructive surgery was scheduled for a later date.

Introduction

The forearm, comprising the radius and ulna, forms a dynamic unit interconnected by a fibrous membrane, transcending the conventional perception of two separate long bones [1]. This unique anatomical arrangement gives rise to the proximal radio-ulnar joint (PRUJ) above and the distal radio-ulnar joint (DRUJ) below, emphasizing the functional joint nature of the forearm. Forearm injuries manifest in diverse patterns, ranging from isolated fractures to complex scenarios involving intraarticular complications and fracture dislocations such as Monteggia, Galeazzi, and Essex–Lopresti types. These injuries can manifest in closed and open forms, presenting distinct challenges and considerations [1]. The interosseous membrane (IOM) between the radius and ulna exhibits a sophisticated structure with proximal, central, and distal bundles. Its integral role in maintaining longitudinal stability within the forearm is pivotal [2]. Injuries to the IOM can lead to forearm instability, risking the integrity of the PRUJ and DRUJ. A dysfunctional IOM may result in radial shortening, radial capitellar impingement, arthritis, ulnar carpal impaction, and the loss of symmetrical rotation of the radius about the ulna [3]. Given the urgency of the situation, surgical intervention is necessary. Diagnosing interosseous membrane injuries in forearm trauma can be challenging since they are not easily visible on standard X-rays. This highlights the importance of considering it as a clinical diagnosis in cases of extensive forearm injuries [1].

Timely fixation becomes imperative to prevent chronic injuries that may culminate in complications affecting the elbow and wrist joints [2]. An IOM injury creates an imbalance in the load distribution between the proximal radius and ulna. With the load on the proximal ulna reduced, instability in the PRUJ can occur. The disruption of the IOM leads to biomechanical discrepancies between the ulna and radius, resulting in joint instability. Therefore, it is essential to properly restore the interosseous membrane during surgical treatment to prevent future joint instability [2]. While traditional surgical approaches involve the use of a bone–patellar tendon–bone graft for IOM fixation [4], innovative techniques utilizing cadaveric experiments explored the use of flexor carpi radialis (FCR) tendon and Achilles tendon (ACT) [5]. Open fractures of the IOM introduce additional complexities, elevating the risk of infections, particularly when coupled with the severity of the injury and premature closure [6]. Crush injuries, a distinct challenge, are notorious for inducing joint stiffness and immobility, often extending their impact to structures both distal and proximal to the affected area [7].

The primary objective of this paper is to comprehensively detail the management of a severe crush and open injury to the forearm, specifically involving the elbow joint, PRUJ, ulna shaft, and DRUJ. This case study sheds light on a unique forearm injury and provides insights into a surgical intervention employed to address the complexity of the presented injuries.

Case presentation

A 19-year-old South Asian male presented to the emergency department (ED) in our trauma center after his arm got stuck in a machine belt. The patient complained of pain and swelling in his left forearm and sustained severe damage to the soft tissue of his forearm extending from the elbow to the wrist.

There was no relevant past medical, family, or psychosocial history. Physical examination of the left upper limb showed severely crushed limb with exposed bone, muscles, and interosseous membranes. Furthermore, there was an open ulna dislocation, a closed dislocated elbow, and a dislocated DRUJ (Fig. 1).

Fig. 1

A Severe crush forearm injury with exposed bone, muscles, and interosseous membrane. B Left upper limb X-ray showing elbow dislocation, distal ulnar bone fracture, and possible disruption of interosseous membrane

Distal pulses of the left hand were detectable, and capillary refill was within normal range. The patient was unable to move his left forearm fully. Owing to the severe soft tissue injury, evaluation of the natural range of motion (ROM) was not possible; however, the patient’s sensory nerve function was normal, including the distal sensation of the hand and radial nerve. There was no other concomitant injury. A plain radiograph of the left upper limb revealed an elbow dislocation, distal ulnar bone fracture, interosseous membrane disruption, and severe soft tissue injury (Fig. 1).

In response to the patient’s condition during presentation, the emergency department performed initial debridement, administered a single shot of IV antibiotics, and administered a tetanus toxoid. The team promptly transferred the patient to the operating theater (OT). Left elbow dislocation, radial head dislocation, interosseous membrane rupture, ulnar shaft fracture, and comminuted distal ulnar fracture were evident. Debridement followed by an elbow-spanning external fixator was applied to stabilize the injuries.

Forty-eight hours after the surgery, the patient was taken again to the theater for a second-look debridement of his left forearm and further assessment. Intraoperatively, the patient’s elbow was found to be unstable, with a dislocated radial head but intact annular ligament. Furthermore, the anterior elbow capsule was torn, and the ulnar nerve was found to be entrapped. In addition, the medial collateral ligament (MCL) and common flexor origin (CFO) were torn. Distally, the interosseous membrane was torn, and the lower end of the ulna was fragmented. The annular ligament was reduced, and the elbow joint was stabilized. The anterior capsule, MCL, and CFO were repaired with two 3.5 suture anchors. Finally, anterior transposition of the ulnar nerve and covering it with muscle was done. Going distally, transfixing the radius and ulna with three Kirschner wires (K-wires) was done. The comminuted distal ulna fracture underwent open reduction and internal fixation with two Kirschner wires (K-wires) (Fig. 2).

Fig. 2

Intraoperative clinical images (A) and X-ray fluoroscopy (B) showing application of external fixator to the left elbow and Kirschner wire fixation of the radius and ulna and distal ulna

The postoperative period was uneventful, with daily wound dressing and physiotherapy. Postoperative X-rays were done (Fig. 3).

Fig. 3

Postoperative anteroposterior and lateral X-rays of the left forearm showing elbow fixation via external fixator and distal ulna fixation using two Kirschner wires and radio-ulnar transfixing with three Kirschner wires

The patient received intravenous (IV) antibiotics targeting Gram-positive, Gram-negative, and anaerobic bacteria. Infection parameters were monitored by regularly reviewing his complete blood count (CBC) and conducting daily temperature checks.

Two weeks postoperatively, the patient was taken to the theater for the removal of the external fixator. After removing the external fixator, the elbow was manipulated under anesthesia and full range of motion (ROM) was achieved. Both left elbow and wrist joints were stable clinically and under an image intensifier.

A postoperative plan of gradual ROM, allowing gentle elbow flexion and extension but avoiding supination and pronation, was implemented. Repeat X-rays were done after the patient had recovered from the effect of anesthesia and were found to be satisfactory (Fig. 4).

Fig. 4

Postoperative anteroposterior and lateral X-rays of the left forearm after removal of the external fixators. The two distal ulnar Kirschner wires and the three radio-ulnar transfixing Kirschner wires can still be seen in situ

After elbow stabilization and good daily rehabilitation progression, the patient was scheduled for surgical removal of the three radio-ulnar Kirshner wires, followed by removal of the two distal ulnar wires 2 weeks following the removal of the external fixator.

The patient was put in an arm sling and was instructed to continue physiotherapy rehabilitation with gradual elbow flexion and extension and to initiate supination and pronation of the forearm. Five weeks after the K-wires were removed, follow-up X-rays were acquired, and the patient’s left elbow ROM was assessed (Fig. 5), showing great improvement in left elbow and wrist ROM.

Fig. 5

Final anteroposterior and lateral X-rays of the elbow showing (A) two anchor sutures and forearm (B) clinical photos (C) of the patient flexing and extending the elbow and supinating and pronating the forearm at follow-up exactly one month from sustaining the injury

Discussion

Our case presents a complex scenario, combining elements from the terrible triad (TT) injury of the elbow and Essex–Lopresti (EL) injury of the forearm, further complicated by the severity of being crushed and open.

According to Wang [8], both TT and EL are severe and uncommon upper limb injuries, typically discussed as separate entities. This case is noteworthy as it reports the combination of these injuries, which have not been previously reported.

Terrible triad (TT) and Essex–Lopresti injury (EL)

TT typically results from an axial load, leading to posterior elbow dislocation of the olecranon–trochlear joint, accompanied by fractures of the radial head and coronoid process [9]. EL is also often caused by an axial load applied to the arm, transmitting force to the radius and resulting in the dislocation of the radius and injury to the interosseous membrane (IOM) and DRUJ dislocation.

Our case displays elements of TT, including posterior elbow dislocation, radial head injury, ligament damage, and EL features owing to IOM injury.

Treatment approaches for EL

EL treatment involves IOM repair to restore forearm stability. Various methods have been reported, but controversy exists regarding acute-phase IOM reconstruction, with a preference for delayed treatment [10]. Brin et al. [11] reported a case of acute IOM repair using the TightRope device. They concluded that the TightRope system was a good tool for achieving and maintaining the reduction and healing of the IOM, while allowing treatment of other components in EL injury.

Techniques for chronic-phase IOM reconstruction include bone–patellar tendon–bone graft, flexor carpi radialis (FCR) autograft, and synthetic devices such as suture-button and Tightrope [8]. Most of these techniques were initially tested on cadavers, highlighting the importance of clinical application for further assessment of outcomes on forearm stability.

Management of multiple injuries

Our patient experienced multiple injuries at the elbow, forearm, and wrist, complicated by severe soft tissue damage.

The management involved a staged approach. An external fixator was used to provide provisional elbow stabilization and aid in soft tissue healing. Subsequent use of anchor sutures and K-wires achieved definitive fixation for the ligamentous injuries at the elbow and the IOM injury with distal ulnar bone fracture, respectively.

Staged fixation for IOM injury

Severe IOM injury, particularly with associated soft tissue damage, warranted a staged approach to fixation. The external fixator, anchor sutures, and K-wires were employed sequentially, allowing time for soft tissue recovery and restoring functional stability in the upper limb.

Our case underscores the challenges and complexities in managing combined TT and EL injuries. The staged approach, combining external fixation, anchor sutures, and K-wires proved effective in promoting soft tissue recovery and restoring functional stability in the upper limb. Moreover, such injuries necessitate a multidisciplinary approach involving multiple teams, including orthopedic and trauma surgery, hand surgery, plastic surgery, and vascular surgery. In addition, there should be a postoperative assessment and follow-up by the physical therapy and rehabilitation team, up until full recovery.

Conclusion

We highlighted the surgical management involving a severely crushed forearm injury with multiple joint involvements. The IOM demands a staged procedure with a provisional external fixator to aid in soft tissue repair, emphasizing the importance of early range of motion to prevent elbow stiffness. The postoperative care should also include a tailored physiotherapy program to promote quicker mobility and functional restoration.

At the 6-month postoperative outpatient visit, the patient’s elbow range of motion was assessed using the Anderson scoring system [12] (Table 1).

Table 1 Anderson’s scoring system for functional assessment of elbow

According to the aforementioned classification, our patient achieved excellent flexion and extension at the elbow joint and good supination and pronation, this reflects positive outcomes in functional assessment and demonstrates the success of our surgical technique. It offers valuable insights for inheriting our surgical intervention to effectively manage similar injuries in future patients.