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      High-Energy Blast Injury Requiring Transradial Amputation with Associated Essex Lopresti and Terrible Triad Injuries of the Elbow: A Rare Presentation

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          Abstract

          Case

          Blast injuries to the upper extremity can be devastating and emotionally stressful injuries. We describe a case of a high-energy blast injury to an upper extremity from an explosive. The transfer of energy caused severe soft tissue/bony damage to the hand, but also led to associated Essex Lopresti and terrible triad injuries. The patient required emergent transradial amputation by hand surgery as well as definitive fixation by our orthopaedic team.

          Conclusion

          We describe a unique salvage operation that established forearm pronosupination, elbow flexion, and proper prosthetic fitting. We feel that describing our technique could help others in treating this injury if encountered.

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          Most cited references13

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          Upper-limb prosthetics: critical factors in device abandonment.

          Tom Chau, Elaine Biddiss (2007)
          To investigate the roles of predisposing characteristics, established need, and enabling resources in upper-limb prosthesis use and abandonment. A self-administered, anonymous survey was designed to explore these factors. The questionnaire was available online and in paper format and was distributed through healthcare providers, community support groups, and one prosthesis manufacturer. Two hundred forty-two participants of all ages and levels of upper-limb absence completed the survey. Of participants, 20% had abandoned prosthesis use. Predisposing factors, namely, origin of limb absence, gender, bilateral limb absence, and, most importantly, level of limb absence, proved influential in the decision not to wear prostheses. Enabling resources such as the availability of health care, cost, and quality of training did not weigh heavily on prosthesis rejection, with the exception of the fitting time frame and the involvement of clients in the prosthesis selection. Conversely, the state of available technology was a highly censured factor in abandonment, specifically in the areas of comfort and function. Perceived need emerged as a predominant factor in prosthesis use. Future research should focus on continued development of more comfortable and functional prostheses, particularly for individuals with high-level or bilateral limb absence. Improved follow-up, repair, and information services, together with active involvement of clients in the selection of prostheses meeting their specific goals and needs, is recommended.
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            Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures.

            David Pugh, Lisa Wild, Emil H Schemitsch … (2004)
            The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees +/- 11 degrees and forearm rotation averaged 136 degrees +/- 16 degrees. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.
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              Terrible triad injury of the elbow: current concepts.

              Bradley R. King, Varinder S. Athwal, Oommen Mathew (2009)
              Fracture-dislocations of the elbow remain among the most difficult injuries to manage. Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. An elbow dislocation associated with a displaced fracture of the radial head and coronoid process almost always renders the elbow unstable, making surgical fixation necessary. The primary goal of surgical fixation is to stabilize the elbow to permit early motion. Recent literature has improved our understanding of elbow anatomy and biomechanics along with the pathoanatomy of this injury, thereby allowing the development of a systematic approach for treatment and rehabilitation. Advances in knowledge combined with improved implants and surgical techniques have contributed to better outcomes.
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                Author and article information

                Contributors
                Paul Knapp:
                ORCID: https://orcid.org/0000-0003-2276-782X
                Journal
                Journal ID (nlm-ta): Case Rep Orthop
                Journal ID (iso-abbrev): Case Rep Orthop
                Journal ID (publisher-id): CRIOR
                Title: Case Reports in Orthopedics
                Publisher: Hindawi
                ISSN (Print): 2090-6749
                ISSN (Electronic): 2090-6757
                Publication date Collection: 2021
                Publication date (Electronic): 3 March 2021
                Volume: 2021
                Electronic Location Identifier: 6645082
                Affiliations
                1Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA
                2Ascension Providence Hospital, 16001 W Nine Mile Rd, Southfield, MI 48075, USA
                3Ascension St. John Hospital and Medical Center, 22101 Moross Road, Detroit, MI 48236, USA
                Author notes

                Academic Editor: George Mouzopoulos

                Author information
                https://orcid.org/0000-0003-2276-782X
                Article
                DOI: 10.1155/2021/6645082
                PMC ID: 7952166
                SO-VID: fca2429a-2522-4565-aacf-bb6147d52238
                Copyright © Copyright © 2021 Paul Knapp et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 23 December 2020
                Date revision received : 9 February 2021
                Date accepted : 24 February 2021
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Orthopedics
                Data availability:
                ScienceOpen disciplines: Orthopedics

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