An unusual association of a distal radius fracture on one limb concomitant with a radial head fracture and an olecranon fracture of the contralateral limb: how we treated them (a case report)

¹Mohammed V University, Faculty of Medicine and Pharmacy, Department of Orthopedic Surgery and Traumatology, 10100, Rabat, Morocco

^&Corresponding author
Moustapha Etape, Mohammed V University, Faculty of Medicine and Pharmacy, Department of Orthopedic Surgery and Traumatology, 10100, Rabat, Morocco

Introduction    

Isolated distal radius fractures are among the most common injuries in orthopedics and can occur at any age. However, these fractures show a bimodal distribution, affecting children under 18 and adults over 50. One challenge for physicians is selecting the appropriate surgical technique and fixation method, which is influenced by individual experience and preference [1,2]. Radial head fractures are typically stable, undisplaced, or minimally displaced partial fractures without associated elbow or forearm injuries. However, when unstable displaced fractures occur, they can be linked to other elbow fractures. Proper treatment is essential to prevent disability from stiffness, deformity, post-traumatic arthritis, and nerve damage. Fragmented, unstable radial head fractures are prone to fixation failure and non-union. While radial head excision offers good long-term outcomes, prosthetic replacement is preferred for patients with elbow or forearm instability [3,4]. Isolated olecranon fractures account for 10% of all elbow fractures, often resulting from low-energy injuries. Displaced olecranon fractures with a stable ulno-humeral joint and minimal articular fragmentation can be managed with tension-band wiring, plate osteosynthesis, intramedullary fixation, or suture repair [5]. In this paper, we present a rare case of combined distal radius, radial head, and olecranon fractures. The patient sustained these injuries after a fall from a ladder and underwent one-stage surgery for treatment.

Patient and observation     

Patient Information: a 56-year-old right-handed man, with no relevant medical history, sustained closed trauma to his left wrist and right elbow after a fall from a ladder. He presented to the emergency department with pain and a restricted range of motion in both limbs. He reported landing on the palmar aspect of his left hand in an outstretched position of this limb, followed by impact on the dorsal aspect of his right elbow.

Clinical findings: physical examination revealed a healthy man with normal vital signs. His left wrist and right elbow were swollen, with no skin openings or signs of distal neurovascular compromise, although ecchymosis was present on the right elbow.

Timeline of the current episode: the patient sustained bilateral injuries to his upper limbs from a fall off a ladder while performing personal domestic maintenance (changing electric bulbs) and was admitted to the emergency department that same day. After an initial diagnostic assessment confirmed the presence of multiple bone fractures requiring surgery, posterior splints were applied to both upper limbs, and analgesics were administered. This was followed by a complete pre-operative workup. The patient was taken to the operating room on the same day.

Diagnostic assessment: X-rays at the emergency department showed a displaced transverse fracture of the right olecranon (Figure 1 A), a simple displaced transverse (two fragments) fracture of the radial head (Figure 1 B), and a non-displaced split fracture of the lateral margin of the distal radius (Figure 1 C, Figure 1 D). Pre-operative workup was unremarkable.

Diagnosis: the distal radius fracture was classified as type B1 of the Müller AO classification. For the elbow injury, the olecranon fracture was classified as Mayo type II, whereas for the radial head fracture, intra-operative fluoroscopy revealed a multi-fragmentary fracture pattern in contrast to the simple two fragments seen on the X-ray of the emergency department, hence it was classified as Mason type III.

Therapeutic interventions: after completing the pre-operative work-up, the patient was taken to the operating room for a one-stage surgical treatment under general anesthesia. The left wrist was treated first, followed by the right elbow. The split marginal fracture of the distal radius was treated with percutaneous pinning using two 1.8 mm Kirschner wires (Figure 2) under fluoroscopic guidance. After wound washing, closure, and dressing, an anterior below-elbow splint was applied. The right elbow fractures were addressed through an open surgery via a posterior approach. The olecranon fracture was repaired with tension-band wiring using two parallel 1.8 mm Kirschner wires, followed by fixation with a 1.5 mm cerclage wire in a figure-of-eight pattern, under fluoroscopic control (Figure 3). Intra-operative fluoroscopy of the proximal radius revealed a multifragmentary radial head fracture, prompting the decision for radial head excision. Four fragments were extracted, confirming the multifragmentary fracture pattern. After thorough wound washing, closure, and dressing, a posterior splint with elbow at 110° was applied. Both upper limbs were kept elevated post-operatively to reduce edema.

Follow-up and outcome of interventions: the patient's immediate post-operative recovery was uncomplicated. He was discharged on oral analgesics and reviewed after two weeks for wound healing assessment (Figure 4) and control X-rays (Figure 5). At two weeks, the surgical wounds were healing well, and a 9-week non-load-bearing, gradual rehabilitation program for the right elbow was initiated. Kirschner wires in the left wrist were removed at six weeks´ follow-up, followed by a 3-week non-load-bearing rehabilitation program, progressing to load-bearing exercises. Amplitude of motion of injured joints were progressively regained (Figure 6, Figure 7). By six months, the patient had regained full range of motion in the right elbow, with normal pronation-supination, and full range of motion in the left wrist. At a one-year follow-up, the patient reported no pain in the injured elbow or wrist.

Patient perspective: the patient was very happy and satisfied with the results following the combination of surgical intervention and rehabilitation therapy. The patient´s statements can be summarized as follows: "The first three weeks after my upper limb injuries were extremely challenging, as I was unable to use my arms for everyday activities. I even needed help to eat. Now that I have fully regained the functionality of my injured limbs, I am autonomous and can do things on my own."

Highlights: this case highlights the importance of carefully analyzing intraoperative fluoroscopic images, not only to assess and document the reduction of fracture fragments during orthopedic surgery, but also to gain a more accurate analysis of fracture patterns. X-rays taken in the emergency department may provide incomplete information. In this instance, while the pre-operative X-ray indicated a simple two-fragment radial head fracture, intraoperative fluoroscopy revealed a multifragmentary pattern, leading to the decision for radial head excision.

Informed consent: an informed consent was obtained from the patient.

Discussion     

Isolated distal radius fractures are among the most common injuries encountered in orthopedics and can occur at any age. The two most affected age groups are children under 18 years old and adults over 50 years old. The primary goal of treating distal radius fractures, as with all orthopedic injuries, is to achieve a successful functional outcome. Treatment options range from cast immobilization and percutaneous pinning to open surgery (open reduction and internal fixation or ORIF). The choice of treatment depends on patient factors (age and functional demands), surgeon factors (skills and preferences), and available resources [1,2]. Displaced, multi fragmentary fractures of the radial head require appropriate treatment to prevent disability due to stiffness, deformity, and post-traumatic arthritis. These fracture patterns are prone to early fixation failure and nonunion, making prosthetic replacement and radial head excision viable options. A successful outcome depends on restoring mechanical stability, which enables early motion and prevents stiffness. While prosthetic replacement of the entire radial head is currently the preferred treatment in high-income countries, radial head excision is not only cost-effective but has also shown good long-term outcomes. In low-resource settings, radial head excision is often the primary treatment for such injuries due to its simplicity and speed. However, the specific indications for replacement, excision, or internal fixation continue to be studied [3,4].

Olecranon fractures are common in adults, accounting for 10% of upper limb fractures and representing the most frequent type of elbow fracture. They are often the result of low-energy injuries, with approximately 85% of olecranon fractures in adults being isolated [5,6]. These fractures can range from simple, non-displaced fractures to complex fracture dislocations. As all olecranon fractures are intra-articular, they require anatomical reduction and restoration of the joint surface to allow for early motion and the recovery of functional elbow movement and strength, hence, they are managed surgically, with several methods of open reduction and internal fixation available. The two primary methods of operative management are tension-band wiring and plate fixation. The choice of technique is influenced by surgeon factors (skills and preferences), patient factors (fracture pattern, age, osteoporosis), and resource availability. In low-resource settings, tension-band wiring is often preferred due to its simplicity, approval, and low cost [6,7].

In this case, the unusual combination of injuries - a distal radius fracture in the left arm, along with a radial head fracture and an olecranon fracture in the contralateral limb - resulted from a domestic accident (fall from a ladder). The injury mechanisms for both the left wrist and right elbow are consistent with findings in the literature. The left wrist fracture occurred as the patient fell on an outstretched limb, while the right elbow injury was caused by direct trauma from landing on the elbow. The choice of definitive treatment was based on current guidelines, available resources, and the surgeon´s experience. Although the preoperative X-ray indicated a simple two-fragment radial head fracture, intraoperative fluoroscopy revealed a multifragmentary pattern, leading to the decision for radial head excision. Careful analysis of intraoperative fluoroscopic images is crucial, not only to assess and document fracture fragment reduction during orthopedic surgery but also to gain a more accurate understanding of fracture patterns before making final treatment decisions, as emergency department X-rays may provide incomplete information. This case demonstrates an excellent outcome in a low-resource setting, as the patient experienced a prompt and complete recovery. Follow-up revealed a full range of motion and an absence of pain in the injured limbs.

Conclusion     

This case illustrates the complexity of managing multiple fractures involving the distal radius, radial head, and olecranon, particularly when they co-occur in a single patient. The use of intra-operative fluoroscopy played a pivotal role in refining the initial diagnosis and guiding the choice of surgical treatment, ultimately leading to a successful outcome. The patient's full recovery, with no residual pain or functional limitations at one-year follow-up, highlights the importance of individualized treatment plans that account for fracture complexity, surgeon experience, and resource availability. This case also emphasizes the value of radial head excision in multifragmentary fractures where reconstruction is not feasible. The prompt and effective treatment, combined with a structured rehabilitation program, enabled the patient to regain full range of motion in both the elbow and wrist, underscoring the success of early intervention and tailored management in complex fractures.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Salim Bouabid, Badr Chalouah, Mamfoumbi Mbadinga Noel Juslin, Moustapha Etape and Mohamed Amine Boutahiri. Data collection: Moustapha Etape, Mamfoumbi Mbadinga Noel Juslin, and Mohamed Amine Boutahiri. Manuscript drafting: Moustapha Etape, Mamfoumbi Mbadinga Noel Juslin. Manuscript revision: Salim Bouabid, Mohammed Benchakroun, Omar Zaddoug, Azzelarab Bennis, Badr Chalouah, Moustapha Etape, Mamfoumbi Mbadinga Noel Juslin, Ekono Nna Albert Patrick and Hamza Kettani. All the authors have read and agreed to the final manuscript.

Figures     

Figure 1: plain X-ray images of right elbow and left wrist on admission showing the fractures; A) lateral view X-ray of right elbow with the yellow arrow showing the displace transverse olecranon fracture; B) anterior-posterior view X-ray of right elbow with the yellow arrow showing the displace transvers fracture of the radial neck; C) anterior-posterior view X-ray of left wrist with the yellow arrows showing the non-displace transverse fracture of the lateral margin of distal radius; D) lateral view X-ray of left wrist that permit to exclude anterior-posterior displacement of the fractured fragment

Figure 2: per-operative fluoroscopic images of the left wrist; the yellow arrows on the images are showing the kirschner´s wires used for the fixation; A) anterior-posterior view; B) lateral view X-ray

Figure 3: per-operative fluoroscopic images of the right elbow; the yellow arrows on the images are showing the kirschner´s and cerclage wires used for the fixation while the red arrow is showing the space after radial head excision; A) anterior-posterior view; B) lateral view X-ray

Figure 4: popost-operative clinical images for wound healing assessment: A) the dorsal aspect of the right elbow with the yellow arrows shows a good wound healing state with no sign of infection, while the red arrow shows ecchymosis due to the trauma; B) lateral aspect of the left wrist with the yellow arrow showing a good wound healing state with no sign of infection

Figure 5: second week post-operative X-ray control images; A, B) anterior-posterior and lateral views respectively of left wrist showing kirschner´s wires; C, D) 3/4 and lateral views respectively of right elbow showing implants used for tension band

Figure 6: sixth week's post-operative clinical images of the right upper limb showing the extent of the amplitude of motions: A) extension of the elbow; B) flexion of the elbow; C) pronation of forearm and; D) supination of the forearm

Figure 7: fourth month´s post-operative clinical images of both upper limb showing extent of amplitude of motions and control X-ray images: A) extension of elbow and palmar flexion of wrists; B) flexion of elbow and palmar flexion of wrists; C) fist and dorsal flexion of wrists and; D) X-ray images with tension band of the right elbow still in place, and the left wrist after implants removal

References