Analysis of functional outcome of complex forearm injuries

Saranjeet Singh Jagdev, Subodh Kumar Pathak, Abhijeet Salunke, Pritam Maheshwari, Prahlad Ughareja


Background: Complex forearm injuries are often associated with contamination, crushing, loss of tissues and patient arrives at odd hours when specialists are not available. These injuries can lead to complications like infective non-union, stiffness, disabilities and secondary amputations.

Methods: 23 patients having complex forearm injuries treated primarily at tertiary care center by single surgeon were included in the study. Pinch strength, grip strength, residual deformity and DASH score was assessed at final follow-up. In 23 patients treated, 16 patients underwent primary internal fixation of both bone, primary external fixator was done in 4 patient, delayed fixations in 6patients, primary bone grafting in 3 patients and in 1 patient delayed bone grafting was done Skin grafting was performed in 6 cases, and flaps in 13 patients. Vascular repair was done in four patients.

Results: All 23 patients came for follow-up. An average number of surgery performed per patient was 3.81 and mean hospital stay of 28.2 days. The mean duration of follow up was 47.2 months. The average DASH score was 10.24 with average key and tip pinch and grip strength of 62.24%, 58.48% and 54.75% respectively. 3 patients had superficial infection and two patient deep infections. Superficial infections were managed with IV antibiotics. The patients with nerve and vascular injuries had higher DASH score.

Conclusions: Early wound coverage can improve functional outcomes. Training in plastic coverage of wounds using pedicle flaps and skin grafting, microsurgical nerve and vessel repairs for orthopedic surgeon can be of great help for the patients.


Open fractures, Complex injury, Forearm fracture, Flaps, DASH

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Joshipua MK, Shah HS, Patel PR, Divetia PA. Trauma care system in India- An overview: Indian J Crit Care Med. 2004;8(2):93-7.

Gregory RT, Gould RJ, Peclet M, Wagner JS, Gilbert DA, Wheeler JR, et al. The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity. J Trauma. 1985;25(12):1147–50.

Galanakos SP, Bot AG, Zoubos AB, Soucacos PN. Psychological and social consequences after reconstruction of upper extremity trauma: methods of detection and management. J Reconstr Microsurg. 2014;30(3):193-206.

Lister G, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg Am. 1988;13(1):22-8.

Eiser C, Darlington AE, Stride CB, Sarcoma RG. Quality of Life Implications as a Consequence of Surgery: Limb Salvage, Primary and Secondary Amputation. 2001;5(4):189–95.

Paul H. Kim, Seth S. Gustilo-Anderson Classification. Leopold Clin Orthop Relat Res. 2012;470(11):3270–3274.

Ege T, Unlu A, Tas H, Bek D, Turkan S, Cetinkaya A. Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries. Indian J Orthop. 2015;49(6):656–60.

Hudak PL, Amadio PC, Bombardier C, Beaton D, Cole D, Davis A. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand). Am J Industrial Med. 1996;29(6):602-8.

Murray CK, Hsu JR, Solomkin JS, Keeling JJ, Andersen RC, Ficke JR, et al. Prevention and management of infections associated with combat-related extremity injuries. J Trauma. 2008;64:239–51.

Weitz-Marshall AD, Bosse MJ. Timing of closure of open fractures. J Am Acad Orthop Surg. 2002;10(6):379-84.

Chapman MW, Gordon JE, Zissimos AG. Compression plate fixation of acute fracture of the diaphysis of the radius and ulna. J Bone Joint Surg Am. 1989;71(2):159-69.

Anderson LD, Sisk D, Tooms RE, Park WI 3rd. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am. 1975;57(3):287-97.

Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285-92.

Lister G, Schekar L. Emergency free flap to the upper ectremity. Jhand Surg. 1988;13(1):22-8.

Rigoard P, Lapierre F. Review of the peripheral nerve. Neuro-Chirurgie. 2009;55(4-5):360-74.

Karabeg R, Jakirlic M, Dujso V, Obradovic G, Arslanagic S. Outcomes of ulnar nerve grafting. Med Arch. 2013;67(1):39.

Ruijs AC, Jaquet JB, Kalmijn S, Giele H, Hovius SE. Median and ulnar nerve injuries: a meta-analysis of predictors of motor and sensory recovery after modern microsurgical nerve repair. Plast Reconstr Surg. 2005;116(2):484-94.

Vordemvenne T, Langer M, Ochman S, Raschke M, Schult M. Long-term results after primary microsurgical repair of ulnar and median nerve injuries: A comparison of common score systems. Clin Neurol Neurosurg. 2007;109(3):263-71.

Terzis JK, Kokkalis ZT. Outcomes of secondary reconstruction of ulnar nerve lesions: our experience. Plastic and reconstructive surgery. 2008;122(4):1100-10.

Bolitho DG, Boustred M, Hudson DA, Hodgetts K. Primary epineural repair of the ulnar nerve in children. J Hand Surg Am. 1999;24(1):16-20.

Barrios C, Amillo S, de Pablos J, Cañadell J. Secondary repair of ulnar nerve injury: 44 cases followed for 2 years. Acta Orthopaedica Scandinavica. 1990;61(1):46-9.

Kirby EJ, Stewart DH, Vasconez HC, Rinker B. Functional Recovery of Mangling Injuries to the Forearm. In The 2006 Annual Meeting; 2006.

Vedder NB, Hanel DP. The mangled upper extremity. Green's Operative Hand Surgery. 5th edition. Philadelphia, Pa: Elsevier/Churchill Livingstone; 2005: 1587-1628.

Graham B, Adkins P, Tsai TM, Firrell J, Breidenvach WC. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg. 1998;23(5):783-91.