Fracture Of The Proximal Ulna In Association With An Ipsilateral Complex Distal Radius Fracture: A Case Report

摘要

IntroductionSimultaneous ipsilateral proximal and distal fractures of the forearm are rare.Case presentationA 10-year-old Caucasian boy presented with a unique combination of ipsilateral distal radius and proximal ulna fractures in the forearm. The fractures were managed with closed reduction under general anaesthetic. A good outcome was achieved using closed reduction.ConclusionTo the best of the authors’ knowledge there have been limited reports of similar cases in the literature with the same presenting combination of fractures. It is important to be aware of this type of injury to avoid missing the concomitant fracture, which may be overlooked due to the distracting injury and to enable management in a timely manner. Introduction Simultaneous ipsilateral distal and proximal fractures of the forearm are rare [1-3]. There have been case reports describing an olecranon fracture associated with an ipsilateral distal radius epiphyseal injury[1], a Monteggia lesion with an associated ipsilateral distal radius epiphyseal injury[4] or associated with ipsilateral distal radius and ulna metaphyseal fractures[5, 6]. Furthermore, there are limited numbers of cases describing concomitant lateral humeral epicondyle fractures in association with a Monteggia fracture[7, 8]. We describe the case of a child sustaining a displaced complex Salter Harris type II transepiphyseal fracture of the left distal radius in association with an ipsilateral simple proximal ulnar shaft fracture and undisplaced fractures of the ulna styloid and lateral epicondyle of the humerus. The management was to treat the distal radius and proximal ulnar shaft fracture with closed reduction and plaster application as two separate fractures, which resulted in a good outcome. Case report A 10-year-old Caucasian boy was admitted to our department after falling from 12 feet onto his left non-dominant arm. On examination he had injuries to the elbow and wrist both of which were closed and neurovascularly uncompromised. Radiographs revealed a displaced complex transepiphyseal Salter Harris type II fracture of the left distal radius in association with an ipsilateral simple proximal ulnar shaft fracture and undisplaced fractures of the ulna styloid and lateral epicondyle of the humerus (Figures 1, 2 and 3). He was immobilised in an above elbow backslab and was taken to the operating theatre the next day to undergo manipulative reduction and aboveelbow cast application under a general anaesthetic. Immediate postoperative radiographs demonstrated an acceptable reduction. Figure 4 shows the position at three weeks, demonstrating a metaphyseal fragment separated from the more distal radius growth plate; however, the growth plate was well aligned. Five weeks post-injury, his range of movement at the elbow was from 20-110 degrees and he could pronate the forearm about 15 degrees from the mid-prone position. He had weakness of the interossei laterally and of palmar abduction; however, no weakness was found in finger or wrist extension. He had sensory loss in the median and ulnar nerve distribution, with the median nerve more affected. No sensory loss was detected in the forearm; however, a positive Tinel’s sign was found at the elbow. Electrophysiological studies demonstrated a severe left median nerve neuropathy mainly affecting the sensory components of the nerve; however, due to absent sensory potentials, it was difficult to localise the sight of damage. The ulnar sensory potential was relatively attenuated suggesting he may have had a mild neuropraxia affecting the left ulnar nerve. Radiographs demonstrated evidence of union at the fracture sites (Figures 5 and 6).In a further review at 10 weeks post-injury, movement at the elbow and sensation was improved. At 14 weeks, he had full prono-supination but lacked the last 5-10 degrees of extension at the elbow. The only residual symptom was a small area of altered sensation in the tip of his middle finger. He was advised to continu