PMC8311746_01
Initial presentation of open elbow fracture-dislocation with loss of important bones, olecranon articular surface and posterior distal humerus. (A). Soft tissue envelope damage with muscle and skin loss. The lesion was classified as type IIIB according to modified Gustilo classification; (B). X-ray
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In October 2017, a 39-year-old woman was involved in a car accident reporting an open contaminated elbow fracture-dislocation characterised by severe olecranon and posterior distal humeral condyle bone loss (Fig. 1).
Immediate damage control surgery consisting of one Kirschner wire (K-wire) for ulnar-trochlear temporary arthrodesis and a bridging external fixation (EF) placed to provide bone stability: (A). AP X-ray; (B). LL X-ray
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Finally, a bridging external fixation (EF) was placed to provide bone stability (Fig. 2).
Ten days after the trauma, the patient went to surgery for surgical exploration, toilet, and debridement. The picture reveals important soft tissues. Immediate skin coverage cannot be provided
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She underwent surgical exploration, toilet, and debridement (Fig. 3).
The reconstructive orthoplastic strategy was planned: the primary purpose was to provide an adequate soft tissue and skin coverage. The patient underwent plastic surgery to provide soft tissue coverage with a musculocutaneous latissimus dorsi rotational flap. (A). After VAC and hyperbaric therapy, a good and clean granulation tissue was achieved and definitive skin coverage could be provided. Skin elbow situation before skin coverage surgery; (B). Ulnar nerve gap (7 cm); (C). Harvesting of homolateral sural nerve; (D). Ulnar nerve gap was restored by harvesting homolateral sural nerve, which was duplicated and sutured end to end using microsurgical technique. It was covered by amniotic membrane; (E). Musculocutaneous latissimus dorsi rotational flap preoperative drawing; (F). Musculocutaneous latissimus dorsi rotational flap was harvested and rotated to cover the receiving area; (G). Final outcome
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Ulnar nerve gap was restored by harvesting the homolateral sural nerve, which was duplicated and end-to-end sutured, covered by the amniotic membrane (Fig. 4).
Six months after trauma: (A). AP x-ray; (B). LL x-ray; (C). Elbow active ROM in flexion of 100  ; (D). Elbow active ROM in extension of 30
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At that time, elbow active ROM in flexion-extension was 30-100  and ROM in pronosupination 30-40  (Fig. 5).
(A). Right elbow 3D model (the pathologic one); (B). Left elbow 3D model (the healthy one); (C). Mirror image with respect to the sagittal plane of the left elbow, i.e., the healthy copy of the right elbow; (D). Right elbow 3D printed model (the pathologic one); (E). Mirrored left elbow 3D printed model (the healthy one); (F). "Boolean subtraction" of right injured 3D model and mirrored healthy 3D model. Landmarks on coronoid have been used to overlap the two geometries. We obtained a 3D model of the proximal ulnar bone loss and we measured the bone loss
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We performed a semi-automatic segmentation by threshold and we exported each elbow 3D model for 3D printing (Fig. 6). Thus, the mirror image was produced with respect to the sagittal plane of the left elbow, i.e., obtaining a healthy copy of the right elbow (Fig. 6C). The two geometries were overlapped by using landmarks on coronoid (Fig. 6F). It allowed to obtain a proximal ulnar bone loss 3D model, in order to visualise the gap and to plan the graft surgery. (Fig. 6F) shows the bone loss measurement.
Close to two years from DEF removal and almost three years from the trauma, X-rays were performed, showing complete healing of fractures. Moreover, we reported initial humeroulnar signs of arthrosis and modicum proximal radioulnar diastasis. (A). AP X-ray; (B). LL X-ray; (C). Elbow active ROM in flexion of 130  ; (D). Elbow active ROM in extension of 5  ; (E). Elbow active ROM in pronation 45  ; (F). Elbow active ROM in supination 60
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Elbow radiographs showed initial humeroulnar signs of arthrosis and modicum proximal radioulnar diastasis (Fig. 7).