Mangled Upper Extremity Salvaged with Spatial Frame, Skin Grafts, Radial Lengthening, and Wrist Fusion

A 24 year old male sustained a mangled right upper extremity after ejection from his motor vehicle. He was found unconscious in a ravine 8 h after a short drive to a friend’s house. He presented with a grossly contaminated (bugs reportedly in the wound) both bone forearm fracture. The distal 6 cm of his ulna was missing as was the ulnar artery and nerve at this level. Four debridements were completed in the first 8 days of admission. All extensor tendons except to the thumb were irreparable, and a nonviable 6 cm segment of the distal radial shaft required removal. The articular distal radius was intact. Limb reconstruction began with spatial frame application, an acute shortening of the forearm bony and soft tissues, and an osteotomy of the proximal radius. The radius was lengthened 3.5 cm to fill the distal segmental defect. The spatial frame gradually lengthened the forearm. Six months later a dorsal wrist fusion plate replaced the spatial frame. At this operative setting, the extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons were wrapped around the distal ulna to limit its translation. The patient has made various adaptive devices to continue activities such as playing the drums. At all stages of treatment a below the elbow amputation was discussed. The patient is very satisfied that during his weeks of intubation and sedation, limb salvage was pursued. He has no plans for an amputation. The initial aggressive debridements and negative pressure wound therapy enabled progression to the limb reconstruction phase.