After a 2021 rollover accident in an all-terrain vehicle, a woman in her 30s sustained damage to her internal organs as well as proximal and midshaft fractures of the left humerus. The upper extremity fractures involved ulnar nerve injury, proximal forearm injury, and circumferential soft tissue laceration to the bone.
“This was one of the worst elbow injuries I’ve treated,” says Duke Health orthopaedic surgeon David S. Ruch, MD, chief of the hand, wrist, and upper extremity division. “She was missing 4 inches of the bone into the elbow. Realistically, she was a candidate for amputation in the midshaft humerus.”
After coordinating with the Duke orthopaedic trauma team and other specialties to stabilize the patient and treat her other injuries, Ruch needed to find a way to replace a significant portion of the patient’s upper arm. “When you’re missing that much bone around a joint, it’s very problematic,” says Ruch. “It requires a creative solution.
What novel technique did Ruch use to reconstruct the patient’s arm?
Ruch used an innovative graft technique to rebuild the patient’s humerus through multiple surgeries. After stabilizing the arm, Ruch installed a long plate to hold the upper arm to length using a bone cement spacer infused with antibiotics. The spacer helped to create a membrane conducive to integrating a subsequent bone graft.
Approximately six weeks later, Ruch and team removed the cement spacer to place an autologous bone graft from the patient’s femur. “You can only obtain such a massive amount of bone from the femur,” says Ruch. Orthopaedic trauma surgeon Malcolm DeBaun, MD, assisted with obtaining the graft.
With the original long plate holding the elbow at 90 degrees, the team installed additional plates on either side of the bone to stabilize the arm while the graft incorporated into the humerus as well as the extant bone fragments in the elbow. To preserve function and sensation, “we also transposed the ulnar nerve out of the way of the injury, and the nerve was able to recover,” Ruch adds.
After the graft healed, Ruch removed the long plate. Through occupational therapy, the patient was able to regain 60 degrees of motion in her elbow and retain the use of her hand, now two years postsurgery. “It’s a million percent better than it was,” the patient says. “I am so grateful just to have an arm, and it works great.”
The patient also returned to Duke to have Ruch treat carpal tunnel in her other wrist. “She’s done really well,” says Ruch.
Refer a patient to Duke Orthopaedics or learn more about the full spectrum of Duke's Hand and Upper Extremity services (PDF).