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The "floating forearm" injury in a child: a case report.

Gausepohl T, Mader K, Kirchner S, Pennig D - Strategies Trauma Limb Reconstr (2007)

Bottom Line: The case of a eleven-year-old girl who had a fracture dislocation of the left elbow with entrapment of the ulnar nerve into the dislocated ulnar epicondyle anlage and unstable forearm fracture of the ipslateral upper extremity is described.This severe injury to the elbow and the ipsilateral forearm is termed "floating forearm" injury.The forearm was stabilized percutaneously and the elbow fracture dislocation, remaining unstable after internal fixation was treated with a pediatric elbow fixator with motion capacity.

View Article: PubMed Central - PubMed

Affiliation: Department of Trauma Surgery, Hand and Reconstructive Surgery, Paracelsus-Kliniken, Marl, Germany.

ABSTRACT
The case of a eleven-year-old girl who had a fracture dislocation of the left elbow with entrapment of the ulnar nerve into the dislocated ulnar epicondyle anlage and unstable forearm fracture of the ipslateral upper extremity is described. This severe injury to the elbow and the ipsilateral forearm is termed "floating forearm" injury. The forearm was stabilized percutaneously and the elbow fracture dislocation, remaining unstable after internal fixation was treated with a pediatric elbow fixator with motion capacity.

No MeSH data available.


Related in: MedlinePlus

Postoperative anteroposterior radiograph of the left wrist
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Fig14: Postoperative anteroposterior radiograph of the left wrist

Mentions: An 11-year-old, right-hand dominant girl had a fall 4 m from a tree and landed on the outstretched left hand. She presented initially to our hospital with pain, substantial swelling and gross deformity of both the elbow region and the forearm (Fig. 1). There was an incomplete motor and sensory ulnar nerve palsy, and no external wounds or distal vascular deficit. Radiographs of the left elbow and forearm revealed a fracture dislocation of the elbow (Fig. 2) and an unstable forearm fracture (Fig. 3). For a better understanding of the pathology of the ulnar epicondyle, a CAT scan of the left upper extremity was performed, with positioning of the outstretched arm above the patient’s head (Figs. 4, 5). This was tolerated well without general anaesthesia. The operation was performed one hour after admission without tourniquet in general anaesthesia. After closed reduction of the forearm fracture internal fixation was effected using fine-threaded wires (FFS; Orthofix Inc., Italy, USA, UK; Fig. 6). Using an ulnar approach, the dislocated ulnar epicondyle with the flexor muscle group attached was identified, and the ulnar nerve was proved to be entrapped between the distal humerus and the dislodged ulnar epicondyle (Fig. 7). After decompression and repositioning of the ulnar nerve into the ulnar sulcus the ulnar epicondyle with the ulnar ligament complex was refixed using an FFS implant armed with a clawed washer (Fig. 8). Clinical examination after refixation of the ulnar epicondyle and the medial ligament complex revealed a grossly unstable elbow joint with accentuated valgus instability and direct redislocation after reduction (Fig. 9, video 1 [electronic supplementary material]). An elbow fixator with motion capacity with paediatric hinges was applied in order to regain stability. After insertion of a 2.0-mm guidewire into the centre of rotation of the elbow joint (Fig. 10), a humeroulnar external fixator with motion capacity was applied with respect to anatomical landmarks [7] and according to the surgical protocol described elsewhere [8, 9]. Intraoperative testing for stability of the elbow joint after application of the elbow fixator revealed stability of the joint in the entire range of motion (Figs. 11 and 12, video 2 [electronic supplementary material]). Postoperatively, the elbow was immobilised by locking the central unit of the elbow fixator for 4 days to allow for swelling to subside followed by active exercises under physiotherapeutic guidance. Postoperative radiographs revealed both anatomic alignment of the elbow joint and the forearm fracture (Figs. 13, 14). To avoid heterotopic ossification of the soft tissues at the elbow, indomethacin 25 mg bid was administered for four weeks postoperatively. The elbow fixator was removed as an outpatient procedure without anaesthesia after six weeks. Clinical testing of the elbow for stability showed a stable joint without apprehension to dislocation, and provocation tests for posterolateral instability were negative (Fig. 15). The implants in the forearm were removed after 8 weeks (Figs. 16, 17). At final follow-up 18 months after removal of the external fixator the girl had regained full function of both elbow and forearm with extension/flexion of 0°–130°, pronation and supination of 80° each, andfunction of the left wrist was equal to the uninjured side (Figs. 18–21, video 3 [electronic supplementary material]). The ulnar nerve function recovered completely and there was no postoperative complication. The child took part in regular physical activities at school and her hobby of horse-riding four months after removal of the device. She coped well with the external device and the objective functional elbow index rating [10] at final follow-up examination was excellent, with a Mayo performance index of 94 points.Fig. 1


The "floating forearm" injury in a child: a case report.

Gausepohl T, Mader K, Kirchner S, Pennig D - Strategies Trauma Limb Reconstr (2007)

Postoperative anteroposterior radiograph of the left wrist
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2321724&req=5

Fig14: Postoperative anteroposterior radiograph of the left wrist
Mentions: An 11-year-old, right-hand dominant girl had a fall 4 m from a tree and landed on the outstretched left hand. She presented initially to our hospital with pain, substantial swelling and gross deformity of both the elbow region and the forearm (Fig. 1). There was an incomplete motor and sensory ulnar nerve palsy, and no external wounds or distal vascular deficit. Radiographs of the left elbow and forearm revealed a fracture dislocation of the elbow (Fig. 2) and an unstable forearm fracture (Fig. 3). For a better understanding of the pathology of the ulnar epicondyle, a CAT scan of the left upper extremity was performed, with positioning of the outstretched arm above the patient’s head (Figs. 4, 5). This was tolerated well without general anaesthesia. The operation was performed one hour after admission without tourniquet in general anaesthesia. After closed reduction of the forearm fracture internal fixation was effected using fine-threaded wires (FFS; Orthofix Inc., Italy, USA, UK; Fig. 6). Using an ulnar approach, the dislocated ulnar epicondyle with the flexor muscle group attached was identified, and the ulnar nerve was proved to be entrapped between the distal humerus and the dislodged ulnar epicondyle (Fig. 7). After decompression and repositioning of the ulnar nerve into the ulnar sulcus the ulnar epicondyle with the ulnar ligament complex was refixed using an FFS implant armed with a clawed washer (Fig. 8). Clinical examination after refixation of the ulnar epicondyle and the medial ligament complex revealed a grossly unstable elbow joint with accentuated valgus instability and direct redislocation after reduction (Fig. 9, video 1 [electronic supplementary material]). An elbow fixator with motion capacity with paediatric hinges was applied in order to regain stability. After insertion of a 2.0-mm guidewire into the centre of rotation of the elbow joint (Fig. 10), a humeroulnar external fixator with motion capacity was applied with respect to anatomical landmarks [7] and according to the surgical protocol described elsewhere [8, 9]. Intraoperative testing for stability of the elbow joint after application of the elbow fixator revealed stability of the joint in the entire range of motion (Figs. 11 and 12, video 2 [electronic supplementary material]). Postoperatively, the elbow was immobilised by locking the central unit of the elbow fixator for 4 days to allow for swelling to subside followed by active exercises under physiotherapeutic guidance. Postoperative radiographs revealed both anatomic alignment of the elbow joint and the forearm fracture (Figs. 13, 14). To avoid heterotopic ossification of the soft tissues at the elbow, indomethacin 25 mg bid was administered for four weeks postoperatively. The elbow fixator was removed as an outpatient procedure without anaesthesia after six weeks. Clinical testing of the elbow for stability showed a stable joint without apprehension to dislocation, and provocation tests for posterolateral instability were negative (Fig. 15). The implants in the forearm were removed after 8 weeks (Figs. 16, 17). At final follow-up 18 months after removal of the external fixator the girl had regained full function of both elbow and forearm with extension/flexion of 0°–130°, pronation and supination of 80° each, andfunction of the left wrist was equal to the uninjured side (Figs. 18–21, video 3 [electronic supplementary material]). The ulnar nerve function recovered completely and there was no postoperative complication. The child took part in regular physical activities at school and her hobby of horse-riding four months after removal of the device. She coped well with the external device and the objective functional elbow index rating [10] at final follow-up examination was excellent, with a Mayo performance index of 94 points.Fig. 1

Bottom Line: The case of a eleven-year-old girl who had a fracture dislocation of the left elbow with entrapment of the ulnar nerve into the dislocated ulnar epicondyle anlage and unstable forearm fracture of the ipslateral upper extremity is described.This severe injury to the elbow and the ipsilateral forearm is termed "floating forearm" injury.The forearm was stabilized percutaneously and the elbow fracture dislocation, remaining unstable after internal fixation was treated with a pediatric elbow fixator with motion capacity.

View Article: PubMed Central - PubMed

Affiliation: Department of Trauma Surgery, Hand and Reconstructive Surgery, Paracelsus-Kliniken, Marl, Germany.

ABSTRACT
The case of a eleven-year-old girl who had a fracture dislocation of the left elbow with entrapment of the ulnar nerve into the dislocated ulnar epicondyle anlage and unstable forearm fracture of the ipslateral upper extremity is described. This severe injury to the elbow and the ipsilateral forearm is termed "floating forearm" injury. The forearm was stabilized percutaneously and the elbow fracture dislocation, remaining unstable after internal fixation was treated with a pediatric elbow fixator with motion capacity.

No MeSH data available.


Related in: MedlinePlus