A three-year-old girl fell from a third-floor balcony of an apartment and sustained an injury to the right arm and elbow. Her general condition was good, and she was alert and oriented. Other injuries included only a small scalp laceration and multiple superficial abrasions over the lower extremities. Physical examination revealed a 3-cm transverse laceration on the posterior aspect of the distal part of the right arm (just proximal to the olecranon) with moderate contamination, and gross motion indicating skeletal instability. A missing segment of humerus measuring 7.5 cm was retrieved by the parents from the scene approximately sixty minutes after the accident. The entire length of the bone segment was intact without fracture. No soft tissue and periosteum were left on the surface of the extruded bone, which was contaminated with grass and soil (Figs. 1-A and 1-B). Peripheral neurovascular function of the right hand was intact.
Radiographs of the right elbow and upper arm showed a comminuted supracondylar fracture of the right humerus and loss of an intercalary bone segment of the humeral diaphysis (Fig. 2). The right shoulder and elbow joints remained in situ and were undamaged.
This high-energy segmental fracture was classified as grade IIIA according to the Gustilo-Anderson classification. Age-adjusted dosages of prophylactic antibiotics, including a combination of cefazolin and gentamicin, to guard against aerobic and anaerobic microorganisms were administered intravenously on presentation, in accordance with the “emergency room protocol for open fractures” of our hospital.
Based on the age of the child, the status of contamination, and the expectation that periosteum remained in the arm, we planned to reimplant the extruded humeral segment. The parents were notified of the potential risks (infection, nonunion, osteomyelitis, and the inevitable secondary limb salvage procedure or multiple surgeries) associated with the procedure.
The extruded segment was decontaminated, washed, and cleaned vigorously with a scrubbing brush and aqueous povidone-iodine solution. All devascularized soft tissues around the periosteal envelope were thoroughly debrided and irrigated with pulsatile aseptic saline solution. The bone segment was then immersed in a solution of diluted gentamicin (100,000 IU/L) and 10% povidone-iodine solution (10 cc/L) for one hour during surgical exploration of the right arm.
A posterior longitudinal incision was made on the right arm overlying the segmental bone defect, and soft-tissue dissection was performed. No major soft-tissue loss occurred, and the triceps muscle did not show devitalization. After splitting the triceps muscle and the periosteal sleeve protecting the radial nerve, the open wound was copiously irrigated and cleaned; the inner surface of the humeral periosteum was exposed. The sterilized humeral segment was then reimplanted in situ and fixed percutaneously to host bone by pinning with multiple Kirschner wires. There was no residual bone gap, and no bone graft was required. The opened periosteum was closed with absorbable suture material, and layered wound closure over a subcutaneous suction drain was performed at completion.
Intravenous antibiotic treatment included cefazolin and gentamicin for two weeks after reimplantation, followed by oral cephalosporin for an additional fourteen days. Motor and sensory function of the hand and wrist was intact postoperatively. Wound-healing was normal, and the skin stitches were removed after two weeks. At three weeks after reimplantation, radiographs showed remarkable periosteal reaction without any evidence of inflammation or infection, and the girl was discharged (Fig. 3). At the six-week follow-up, the patient had no evidence of infection, and radiographs demonstrated callus formation around the fracture sites. A full-time long-arm posterior splint with elbow flexion of 90° was applied for three weeks after surgery, and intermittent passive elbow motion was permitted while wearing the protective splint for another three weeks. At three months, no discontinuity was evident between the reimplanted bone fragment and the humerus, and unrestricted daily activities were permitted (Fig. 4). At six months, outdoor and sports activities were normal; at eighteen months, the reimplanted segment was fully incorporated. The proximal and distal physes of the humerus appeared intact on radiographs, although a cubitus varus deformity had developed (Fig. 5). A corrective osteotomy for this deformity was performed at this time. At the four-year (forty-six month) follow-up, there was no limitation of motion of the elbow or shoulder, and no pain or stiffness was apparent. Furthermore, there was no clinical motor weakness or sensory deficit below the distal part of the humerus, and radial nerve function of the wrist and hand was intact. Radiographs showed complete healing of the corrected cubitus varus and remodeling of the humerus, and the distal humeral physis appeared intact (Fig. 6). However, the right humerus was 5 mm shorter than the left. No episode of wound dehiscence or infection occurred after initial wound-healing; a large scar was visible on the right arm.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.