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MULTIPLE FRACTURES IN A SINGLE UPPER EXTREMITY: HUMERAL SHAFT, OLECRANON, DISTAL RADIUS AND FOURTH METACARPAL BONE FRACTURES IN AN ELDERLY PATIENT AFTER A FALL: A CASE REPORT

Multiple fractures in a single upper extremity: humeral shaft, olecranon, distal radius and fourth bone fractures in an elderly patient after a fall: a case report. ABSTRACT Floating limb is a complicated injury and is associated with limb deformation and increased morbidity and mortality. We report a rare case of a floating upper limb in a 77-year old woman with ipsilateral humeral shaft, olecranon, distal radial and metacarpal bone fractures after a simple fall. The patient underwent surgery for humerus shaft, olecranon, and distal radius and was treated surgically with the 4 th metacarpal conservative method. At the final follow-up 3 years after surgery, the patient had no complaints, all fracture had healed completely and elbow-wrist range of motion was complete. We discuss the surgical proce-dures that we used for the fractures, the mechanism of injury and the functional and radiological results. Multiple bone fractures in the same limb are rare and typically associated with high-trau-ma. We reported a unique case of an elderly patient with os-teoporosis having multiple fractures in the same extremity that occurred as a result of low-energy trauma.


INTRODUCTION
Humeral shaft fractures are common in elderly patients with low-energy trauma and account for 3%-5% of all fractures in adults (1). Although olecranon and distal radius fractures are most commonly observed in elderly patients, concurrent ipsilateral olecranon and distal radius fractures are extremely rare.
Concurrent ipsilateral fractures of the humeral shaft and forearm result in a so-called floating elbow. There are relatively few case reports in the literature on ipsilateral olecranon fractures associated with distal radius fractures, the so-called floating forearm injury, and these pertain to paediatric cases.
Herein, we describe the case of a 77-year-old woman who had a combination of the aforementioned injuries in the ipsilateral limb. To the best of our knowledge, this is the first case report of a combined floating elbow and floating forearm injury in the same limb in an elderly patient. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

CASE REPORT
A 77-year-old woman was admitted to our emergency department following a fall from one stair step. She complained of pain in her right upper extremity. Physical examination revealed a deformity in the arm and wrist. There was tenderness with palpation of the humeral shaft, olecranon, distal radius and fourth metacarpal bone. The neurovascular and radial nerve examinations were normal, and there was no other extremity trauma. She had hypertension and osteoporosis. The T-score detected at the lumbar vertebra was −2.7.
Radiological assessment included antero-posterior (AP)-lateral radiograph of the right humerus, elbow, wrist and AP and lateral and oblique radiograph of hand and confirmed the diagnosis of the right humeral shaft, olecranon, distal radius and fourth metacarpal bone fractures (Figure 1). All fractures were closed. According to the AO Fracture and Dislocation Classification, the humeral shaft fracture was AO 1-2-A2, the olecranon fracture was 2-1-B1, the distal radius fracture was 2-3-A2 and the fourth metacarpal fracture was a neck fracture. Surgical treatment was planned for the humeral shaft, olecranon and distal radius fractures, and conservative treatment was planned for the fourth metacarpal fracture. The patient's right upper extremity was splinted extending from the tip of the shoulder to the fingertips.

SURGICAL TECHNIQUE
First, the patient underwent open reduction for the humeral shaft fracture with an anterolateral approach un- A B D C der general anaesthesia, and an anatomical locking plate was applied. Thereafter, she underwent surgery for the olecranon fracture with a posterior approach, and an anatomical locking plate was applied. Finally, she underwent closed reduction for the distal radius fracture with percutaneous Kirschner (K) wire fixation. Reduction was stabilised using two K wires ( Figure 2). An arm sling and a short forearm splint were used postoperatively for the metacarpal fracture. Elbow range of motion (ROM) exercises were initiated after one week of arm-sling usage.
The patient postoperatively developed radial nerve palsy symptoms with difficulty in straightening her wrist and fingers. The forearm splint was removed, and the patient began to use a radial nerve splint after two weeks and take pregabalin orally 75 mg twice a day and B-12 vitamin pills once a day.
At the 6 th week postoperatively, the distal radius and the fourth metacarpal bone were healed radial nerve symptoms were not completely recovered; thus, the use of the radial nerve splint and pregabalin administration were continued. At the 3-month follow-up, radial nerve palsy symptoms were completely resolved, and the splint and medications were discontinued. The patient achieved an elbow ROM of 20°-100°.
At the final follow-up three years after surgery, the patient had no complaints regarding fracture healing ( Figure 3). She had an elbow ROM of 10°-130°, wrist joint ROM of 45° of dorsiflexion and 45° of volar flexion and full pronation and supination (Figure 4).

DISCUSSION
'Floating elbow' is a term used to describe a combination of ipsilateral forearm and humeral fractures (2). The term 'floating forearm' describes a combination of ipsilateral proximal and distal forearm fractures (3); these injuries are extremely rare. This case, which describes a combination of an ipsilateral floating elbow and a floating forearm in an elderly patient after an injury that resulted from a fall from one stair, is very rare.
Humeral shaft, olecranon and distal radius fractures are very common injuries by themselves, but the simultaneous occurrence of these fractures after a fall from one stair step is unusual. We hypothesise that the mechanism of this injury was an outstretched arm with the forearm pronated and wrist hyperextended. This mechanism would explain the olecranon and distal radius fractures, whereas the humeral and fourth metacarpal fractures may be explained by direct trauma from the edge of the stairs.
Multiple fractures in the concurrent limb usually require a high-energy trauma. However, in our case, these fractures resulted from a low-energy trauma most likely due to osteoporosis. Patients with multiple fractures carry a higher risk of developing neurovascular injuries, compartment syndrome and open fractures than that of patients with isolated fractures (4)(5)(6). Unfortunately, there is no consensus in the literature on the order of treatment in the upper limb in the event of multiple fractures. In our case, surgery was initiated for the most severely deformed fracture, the humeral shaft fracture. After the humeral fracture was reduced and fixed, the reduction of the olecranon and distal radius fractures was easier.