Acute Limb Shortening for Major Near and Complete Upper Extremity Amputations with Associated Neurovascular Injury: A Review of the Literature

Abstract

In the setting of near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non‐vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single‐stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well‐tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Introduction

Limb shortening of the upper extremity has been described acutely in the setting of significant soft tissue and bone loss in order to permit bony apposition and the closure of large defects1, 2, 3, 4. Acute shortening provides additional soft tissue for wound closure, allowing for more aggressive debridement, but perhaps more importantly, in the setting of associated injury, enables tensionless primary neurovascular repair and/or reduces the amount of graft material required to address defects. We searched PubMed, EMBASE, Cochrane Database, and CINAHL up to February 1, 2015, using the search terms “acute shortening osteotomy”, “upper extremity”, “forearm and/or humerus fracture”, and/or “high energy, open, segmental”. Inclusion criteria for articles were (i) in the English language, (ii) published after 1940, (iii) involving human subjects, and (iv) peer‐reviewed clinical studies of all levels of evidence and reviews.

Alternative management strategies include both external and primary internal fixation with neurovascular grafting and staged reconstructive procedures for the bone and soft tissue defects5, 6, 7. While these remain viable options, the authors contend that a single definitive surgery with tensionless neurovascular repair, if achievable, would provide for better outcomes. Sometimes, however, because of the degree of contamination, internal fixation is not advisable, and the surgeon may have limited options for skeletal stability.

A direct primary nerve repair is the gold standard, as it demonstrates superior recovery potential over both interpositional autograft and allograft8, 9, 10, 11, 12. Similarly, primary repair of vascular structures is preferable over grafting, as it achieves superior outcomes13, 14. Primary repair of neurovascular structures, without the need for inter‐positional grafts, is ideal, but it is often not possible due to large residual defects after debridement or resulting tension, even in smaller defects15.

In the upper extremity, limb shortening is very well‐tolerated and much less functionally significant than in the lower extremity16, 17, 18, 19, 20. The need for limb lengthening is furthermore relegated to severe deformity or chiefly for cosmesis16, 21, 22, 23. Acute shortening osteotomy is therefore an underrepresented, but excellent, option not only for segmental bone loss or large soft tissue defects but especially in the setting of segmental neurovascular injuries of the upper extremity.

This review discusses the literature surrounding the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and it aims to evaluate indications, surgical technique, clinical, and functional outcomes, and complications associated with performing acute shortening osteotomy with rigid internal fixation. Figure 1 provides an overview of the management of components of sever upper extremity trauma.

Figure 1.

Overview of acute shortening of severe upper limb injury.

Injury Mechanism of Severe Upper Extremity Trauma

High‐energy trauma to the upper extremity is most often sustained in industrial accidents, motor vehicle collisions (MVC), and from gunshot wounds (GSW), and may be associated with significant bone and soft tissue loss and concomitant neurovascular injury7, 24, 25, 26, 27, 28, 29. Epidemiologic data on open wounds of the upper extremity, however, is limited and largely based on regional reports. A review of 2325 patients treated at the Shock Trauma Center in Baltimore in 2007 found that the upper extremity, most often the distal humerus, was the most common site of open fractures, 20% of which were attributable to GSW24. GSW have become a significant contributor to severe upper extremity trauma7. Most literature on high‐velocity GSW is drawn from military conflicts, whereas most civilian injuries are low velocity6.

Mechanism of Neurovascular Injury

Neurovascular injury is not uncommon in the setting of GSW, especially with high‐velocity injuries5, 6, 7. In a series of 15 acute open humeral fractures, 60% had neurologic deficits, six of which were attributable to MVC and four to GSW7. Of the seven radial nerve deficits, two had complete disruption. Foster et al. similarly reported a 64% prevalence of anatomic radial disruption amongst a series of open humeral fractures30. In another series of 23 patients with open humeral fractures, Mostafavi et al. reported a 78% rate of neurologic injury, and nine of 14 involved multiple nerves31. The same authors reported a 55% incidence of significant vascular injury. Among a cohort of 25 Gustilo–Anderson type III injuries of the upper extremity, 11 were associated with significant arterial transection and 16 with 22 nerve injuries32. The authors utilized primary plating in nine cases, and combined external and internal fixation in three cases. For the arterial injuries, vein grafting was necessary in two and direct repair was possible in six.

Despite the severity of associated open injuries, in general, patients are most likely to suffer disability from associated neurologic injury5, 6. Neurapraxia is most commonly associated with fractures, followed by axonotmesis and least commonly neurotmesis33. The rate of spontaneous recovery is lower for open fractures, roughly 65%–70% in general, and most recover (90%) within the first 4 months33, 34. Nearly 80%–90% of nerve injuries associated with fractures occur in the upper extremity, most often the radial nerve34, 35. In fact, 60% of radial nerve injuries are associated with diaphyseal humeral fractures35. In one epidemiological study, up to 3% of patients presenting to a level I trauma center were found to have sustained peripheral nerve injuries, most often of the upper extremity, consisting of the radial (53%), ulnar (32%), and median (15%) nerves, in order of prevalence36.

Similar to peripheral nerve injuries, traumatic vascular injury is more common in the upper extremity. Injury to the brachial artery is reported to occur in up to 25% of patients who sustain major arterial trauma28. The epidemiology of vascular injuries of the upper extremities, however, is often inconsistent and unreliable for a number of reasons28. Within the brachium, distinguishing between the brachial and axillary artery is often difficult, resulting in combined incidence of injury to either vessel. In the antebrachium, injury to either the radial or ulnar arteries, which does not compromise perfusion distally, is often not reported.

Management of Severe Upper Extremity Trauma

While management of severe lower extremity trauma is well described, the upper extremity represents a separate entity. The upper extremity is unique in that proper function is essential to an individual's ability to be a productive member of society and to provide a satisfactory quality of life. Furthermore, the level of functionality currently obtained with upper extremity prosthetics has not obtained the same level as that of lower prosthetics. Moreover, upper extremity prosthetics are still not capable of replacing the delicate and integral functions of the upper extremity. Therefore, aggressive and prompt management of neurovascular injury should be paramount in the setting of significant upper extremity trauma.

Fracture Fixation

Fracture fixation should be performed first and is essential to provide a stable base for the ensuing vascular and neural repairs26. Vascular injury is an absolute indication for stable fracture fixation4. Nerve exploration is further indicated in a fracture with arterial injury or open wound necessitating open reduction and internal fixation of the associated fracture33.

Provisional Fixation

Provisional stabilization with staged reconstruction utilizes one of a number of later techniques, which more commonly includes distraction osteogenesis, bone transport, vascularized or non‐vascularized bone grafts, or the Masquelet technique. However, one must consider the complications associated with both initial provision external fixation and later reconstruction.

The outcomes of the management of acute open humeral shaft fractures are underreported7, 37, 38, 39. External fixation both as a provisional and as an ultimate means of management, is fraught with complications: pin tract infection and loosening, tethering of musculotendinous units, nonunion, and need for further surgeries7, 31, 39, 40, 41. In 15 patients treated with monolateral external fixation of open humeral shaft fractures for an average of 21 weeks, four patients required additional procedures including external fixator reapplication in two, and compression plating with bone grafting in another two, and eight developed pin tract infections7. At an average of 63 months post‐injury, four patients were unsatisfied, six had persistent functional limitations, and seven reported persistent pain. Smith and Cooney reported a 73% satisfactory outcome in 40 patients treated with external fixation for complex upper extremity trauma. There was a 20% incidence of minor complications related to the external fixator, and a 3% rate of deep infection39. In another series of 23 patients with open humeral fractures treated with immediate external fixation, the authors found three malunions, one delayed union, eight pin tract infections, two pin tract sequestrum formation, and two late fractures following external fixator removal31. At 34 months postoperation, 70% of patients rated their function as good to excellent and four reported poor results. Furthermore, Choong and Griffiths found a 57% incidence of nonunion for primary external fixation ultimately necessitating conversion to plating with bone grafting41.

The pins additionally need to be placed close enough to the fracture site to provide stability while remaining out of the zone of injury. This is often difficult with large open wounds of the upper extremity. Careful planning must be done and attention must be paid to placement of the external fixator pins due to the dense and complicated neurovascular network of the upper extremity. Conversely, plates may be placed through open wounds under direct visualization with little risk of injuring neurovascular structures and providing absolute stability.

Staged Reconstruction

In terms of reconstruction, large segmental bone defects can later be addressed through a variety of methods including acute shortening with distraction osteogenesis, bone transport, or vascularized as well as non‐vascularized structural autograft or allograft42, 43, 44, 45, 46.

Distraction osteogenesis of the upper extremity is not commonly employed, as the functional risks often outweigh the benefits16, 20. The procedure is associated with complications of the external fixators including pin tract infections, osteomyelitis, hardware loosening and failure, nonunion, malunion, and joint stiffness42, 44, 46, 47, 48, 49. It has been recommended for deficiencies of 5 cm or more18. However, limb length discrepancy in the upper extremity is very well‐tolerated, and surgery is often employed for purely cosmetic reasons.

Staged bone grafting is another option for large bone defects. However, there are a number of drawbacks to this method, including its technical complexity and a high incidence of complications. One series of 15 patients who underwent staged iliac crest bone grafting of segmental defects of the forearm found a high incidence of infection and unsatisfactory results secondary to the loss of forearm rotation26. Vascularized bone grafting is very technically demanding and is often complicated by graft fracture, nonunion, and donor site morbidity, which frequently requires reoperation50, 51, 52, 53, 54. In nine patients with complex segmental defects of the radius who underwent vascularized osteoseptocutaneous fibular autograft, the authors found one nonunion, two postoperative vascular complications necessitating reoperation, and three patients who were unable to return to their previous level of function at an average of 24 months postoperatively52. Though structural allograft inherently avoids donor site morbidity, it conveys a higher risk of infection as well as an observed lower incorporation rate55, 56. The Masqeuelet induced membrane technique allows for wide diaphyseal reconstruction; however, it requires reoperation for spacer removal and bone grafting44, 57, 58. Other less commonly used techniques include a cement spacer with delayed cancellous bone grafting or titanium mesh cage and plates44, 59.

Acute Shortening Osteotomy with Primary Rigid Internal Fixation

Initial management includes restoring perfusion to the distal extremity should the limb be dysvascular. This includes temporarily shunting of segmental vascular injuries. Non‐viable soft tissue and gross contamination of the wound is debrided, and the wound is irrigated copiously. Once the wound bed is clean, neurovascular structures are identified and tagged for later repair. At this point, in order to provide a stable platform for delicate and tensionless neurovascular repairs, the zones of injury are measured for each disrupted neurovascular structure. An appropriate shortening osteotomy is measured given the largest segmental defect post‐debridement. A long (narrow) 4.5 or 3.5 plate is tentatively secured distally, with at least two holes predrilled, measured, and tapped. The segment of the bone to be removed is determined. The plate is removed, and a saw is then utilized to resect the appropriate corresponding length from the humerus, either from the fractured ends or, if injured, from the intact bone. The plate is replaced and fixed in compression mode. Care is taken to obtain good bony opposition. The injured vascular and subsequently neurological structures are repaired primarily in an end‐to‐end and tension‐free fashion without the need for interpositional grafts. Disrupted tendons may be approximated at the new compartmental length to restore appropriate myofascial tension. Depending on the degree of contamination and soft tissue injury, the wound may then be primarily closed or negative pressure wound therapy may be applied. Lastly, depending on the duration of dysvascularity, appropriate distal fasciotomies may be performed to prevent problems associated with acute compartment syndrome due to swelling. Acute humeral or forearm shortening with internal fixation avoids a number of the aforementioned complications associated with both provisional external fixation as well as later reconstruction. Other advantages include reduction in devitalized tissue, facilitated wound closure with a decreased need for soft tissue reconstructive procedures, and allowance for primary tension‐free repair of neurovascular structures (Fig. 2A,B)4. This technique is occasionally utilized in the setting of replantation for the above reasons60, 61, 62, 63, 64, 65.

Figure 2.

Illustration of shortening technique: (A) the zone of injury involving a humerus fracture with associated segmental neurovascular injury. (B) The zone of injury is then reduced by acutely shortening the limb, removing compromised soft tissues, transversely cutting the fractured humeral ends, plating the humerus in compression, and performing primary tensionless end‐to‐end neurovascular repair. Acute internal fixation then permits primary neurovascular repair without intercalary graft.

Acute shortening, however, is not without risk and can result in an altered length‐tension relationship of muscle‐tendon units, native anatomy, and local arterial occlusion and vascular complications from kinking, which lead to soft tissue compromise, though with minimal dysfunction4, 66, 67, 68. The permissible degree of acute shortening of the humerus and forearm has not been born out in the literature. It has been suggested that 4 cm of acute shortening represents the limit, though clinical experience with shortening of this degree remains unpublished29.

In the lower extremity, shortening of the tibia up to 3 cm is well‐tolerated and does not result in any major functional deficit24. An angiographic evaluation of 17 patients who underwent acute tibial shortening osteotomy found that acute compression up to 8 cm can be performed without significant vascular kinking69. While increased tortuosity after 4 cm was evident, perfusion was not compromised. However, shortening of the lower extremity is an entirely separate entity in terms of both anatomy and functionality.

Acute Shortening of the Antebrachium

No literature specifically examining clinical or functional outcomes after either humeral or radioulnar shortening has been published. In the forearm, functional outcome following minor degrees of shortening can be inferred from studies involving diaphyseal radial or ulnar shortening for Kienbock's disease, triangular fibrocartilage complex tear, radial fracture malunion, or deformity, respectively, none of which has demonstrated adverse alteration in forearm function. In limited case reports, acute shortening of up to 3 cm of the forearm for resection of nonunion demonstrated minimally impaired function67, 68, 70, 71, 72, 73. Chauhan et al. reported a case of an uncomplicated comminuted both‐bone forearm fracture, which was shortened 1.5 cm acutely and plated68. No significant functional deficits were evident at 14 months. Sharma et al. reported acute shortening of 3 cm, the largest in literature, and found mildly reduced strength but no difference in function as compared to the contralateral extremity67. An indication for acute shortening osteotomy is demonstrated in the patient displayed in Fig. 3A–E.

Figure 3.

Indication for acute shortening osteotomy. (A) This is the presentation of a 16‐year‐old girl involved in a motor vehicle collision who sustained extensive soft tissue and bone loss to her non‐dominant left antebrachium. (B) The superficial, intermediate, and portion of the deep compartments are transected proximally. (C) The diaphyseal radius and ulnar are exposed with 5 and 3 cm defects, respectively. (D) Distally, the radial artery is severed with a 3 cm gap and associated contused vein, as is (E) the median nerve, with an associated 3.5 cm gap. An acute shortening osteotomy of the radius and ulna with internal fixation was performed allowing excision of segmental neurovascular injury and primary repair of the radial artery and median nerve.

Acute Shortening of the Brachium

Acute shortening of the humerus for nonunion has similarly demonstrated reliable healing with no significant functional implications74, 75. The literature is again limited to biomechanical studies and small case series from which functional outcomes can be extrapolated.

A biomechanical model of triceps muscle force after distal humeral shortening found that while shortening of the humerus by 1 cm would only minimally effect extension strength, shortening by 2 cm or more may result in a significant reduction in triceps strength by as much as 63%76. The clinical significance of this remains unclear. Furthermore, the effects on other collateral muscles, such as the biceps brachii, remain unclear; however, the predominant elbow flexor, the brachialis, would be unaffected so it would be expected that elbow flexion would be only minimally affected. As the osteotomy may require taking down muscular insertion, the location of the osteotomy and the degree of shortening should take into account the necessity to preserve remaining function in a partially denervated upper extremity.

Yu et al. reported humeral shortening of 13–20 cm in three patients to enable primary suture of nerve transfers for total brachial plexus root avulsions77. Although they reported that function was not significantly compromised, the primarily denervated extremity was shortened; therefore, recovery and function are contingent on both renervation and the preservation of the length‐tension relationships of that extremity, confounding the results. Cosmesis was additionally a major concern.

Wang et al. performed 4.5 cm shortening of the humerus to aid in transferring the contralateral C₇ for total brachial plexus root avulsions78. The authors reported that elbow flexion was not significant affected by the degree of shortening. The authors also comment that shortening the humerus more than approximately 12% to 14% of its original length may cause cosmetic concerns and also result in the malfunction of the triceps and biceps muscles78. Therefore, some authors have recommended <5 cm in adults and <3 cm in children as relative limits for humeral shortening78, 79. No such limits have been objectively determined for the forearm. In order to obtain reliable healing, careful dissection is recommended with adequate debridement and transverse osteotomy74.

Acute Internal Fixation

Acute internal fixation of open fractures of the upper extremity has traditionally been associated with increased risk of infection80, 81. However with modern techniques of aggressive soft tissue management and wound care, infection rates are comparable to external fixation without the aforementioned drawbacks82. In a review of 53 patients with open diaphyseal humerus fractures treated with immediate open reduction and plating, the authors found all fractures united primarily with satisfactory angulation, and no patient required a reoperation to obtain union82. Six were delayed unions, and complications were rare including three amputations and one synesthesia. No infections or iatrogenic nerve injuries were reported. Both acute and delayed open reduction and internal fixation has been shown to be superior to other means of treatment of fractures that resulted from low‐velocity GSW, including cast immobilization and external fixation, respectively5, 6.

Acute open reduction with internal fixation of diaphyseal humeral83, 84 and radioulnar fractures is supported by literature. In a series of 13 open fractures treated with plating, Vander Griend et al. found that all fractures went on to unite within 1 year25, 84, 85, 86. The authors further showed that fixation could be with little periosteal stripping. Two patients suffered a superficial wound achieved through the wound infections. Jones reported on 18 patients with Gustillo–Anderson grade III open diaphyseal forearm fractures treated with extensive primary debridement, acute open reduction, and compression plating85. Minor wound healing complication occurred in three patients, and one patient experienced a deep infection necessitating repeat debridement. Good to excellent results were obtained in 66% of patients, correlating with the degree of soft tissue injury. The authors reported a 5% infection rate. In a review of 57 open forearm fractures, 11 of which were Gustillo–Anderson grade III, treated with acute primary plating, Moed et al. found 85% good to excellent results with one deep infection and nonunion in only three of the 11 grade III open fractures86. There was no statistically significant difference between injury grades. Duncan et al. performed acute plating of 103 forearm fractures in 69 patients and found that 90% of patients with Gustillo–Anderson grade I, II, and IIIA had satisfactory results at an average of 2.5 years postoperatively25. Poorer results were found with grade IIIB and IIIC injuries. Only one nonunion occurred and was attributed to surgical error. Infections were relegated to the grade IIIB and IIIC injuries. Intramedullary fixation of open humeral fractures has also been described, though with a more limited success, which is reported to be as high as a 33% delayed and nonunion rate87, 88, 89.

Based on the existing literature, acute shortening osteotomy with primary internal fixation would be well‐tolerated functionally and demonstrates an adequate complication profile comparable to other means of acute upper extremity fracture fixation. The outcomes of acute fixation of severe open fractures of the upper extremity are influenced largely by the degree of soft tissue compromise. Therefore, the soft tissue redundancy provided by acute shortening enables surgeons to provide a more aggressive debridement and potentially decreases wound complications.

Soft Tissue Coverage

Acute shortening osteotomy assists substantially with soft tissue coverage for large open wounds that may otherwise necessitate flap coverage2, 3. Redundant soft tissue assists in both aggressive debridement and primary closure of the wound. Depending on the severity of the wound, the alternative would range from extended negative pressure therapy to flap coverage. Local flaps may not be an option due to surrounding tissue trauma, which leaves the surgeons with the sole option of free flaps. Free flaps require a great degree of surgeon experience and technical skill, and the availability of special instrumentation that not all centers have90, 91. Flaps furthermore convey significant donor site morbidity, and require special observation and management, an extended hospital stay, and a high likelihood of one if not multiple reoperations. Furthermore, free flap failure is not uncommon. In a review of 60 free flaps for traumatic lower extremity coverage, Hill et al. found a 13.3% failure rate. The authors reported increased failure rate with early free flap coverage91. In the upper extremity, however, the paradigm has shifted toward early free‐flap coverage90.

Vascular Repair

Vascular and subsequently neural repair should follow fracture stabilization. Similar to nerve repair, primary repair is ideal for arterial and venous disruption13, 14. However, grafting is an option if primary repair cannot be performed without tension. Venous allograft and synthetic grafts are much less durable and more prone to thrombosis and immune rejection92, 93, 94. There is agreement that if both major arteries to the hand are injured they should be repaired to optimize nerve recovery. If only one of the major arteries is damaged but the hand is well perfused, it need not be repaired4, 28, 32. It has been suggested that repair of damaged vessels in the forearm may be unnecessary in the situation of single arterial injury due to the risk of thrombosis from backflow of the patent artery28. However, failure to repair arterial injury with concomitant nerve injury has been associated with decreased function and poorer outcomes95, 96. Therefore, the authors recommend primary repair, if possible.

Neural Repair

While the importance of acute vascular repair is indisputable, optimal timing of nerve repair is somewhat less defined. With prolonged denervation, eventual irreversible loss of motor endplates occurs. Time to surgery has been shown to be a stronger predictor of outcome8, 97, 98. The outcome of radial nerve interfascicular grafting was found to be largely dependent on timing, with 85% of patients grafted within 6 months recovering useful function while none recovered after 12 months98. Similarly, in another study of radial nerve transections, time to grafting was found to be the most significant predictor of eventual functional recovery97. A number of factors determine the feasibility of early repair including wound contamination, integrity of the soft tissue envelope, concomitant vascular injury, and segmental nerve loss.

Despite microsurgical technique, nerve repair in the setting of segmental loss remains a challenge99. Microsurgical technique is open requisite in successful management of significant open upper extremity trauma due to the high incidence of neurovascular injury. Options include direct end‐to‐end and end‐to‐side repairs, nerve grafting, and transfer99.

With an interpositional graft, it is important to utilize a graft of similar diameter; however, even then, it is not possible to correctly match the proximal donor fascicles with the distal stump recipient100, 101. Furthermore, regenerating axons must cross two neurorrhaphy sites instead of only one10, 12. This leads to greater axonal loss with graft than primary repair. In a review of outcomes following nerve transfer versus grafting, it showed 96% and 83% good and very good results, respectively, while grafting provided a substantially lower recovery of 82% and 56% good and very good results, respectively102. Furthermore, allograft potentiates the risk of disease transmission and requires immune suppression, or scarring and failure of recovery may result9, 11. An autograft, however, conveys increased operative time as well as donor site morbidity.

Acute shortening osteotomy has been suggested to facilitate nerve transfer with primary anastomosis and avoid nerve grafting15, 77, 78. Primary repair has long been the gold standard and is preferable over both autograft and allograft due to greater rates of axonal recovery8, 10, 12, 15, 101, 102. Direct coaptation is at least equally effective and more straightforward than transfers involving interpositional grafts10. However, in the setting of a nerve gap, nerve grafting has been shown to be superior to primary repair under tension103, 104.

The best predictor of outcome is a short, primary, end‐to‐end, tensionless repair, as increasing degrees of tension decrease blood flow and thus likelihood of recovery9, 99, 105, 106. Tension on vascular structures leads to thrombosis and failure of the repair while nerves under tension suffer compromised perfusion, which is suboptimal for healing. The amount of strain required to compromise neural blood flow and conduction is well‐established106, 107, 108, 109, 110, 111, 112, 113. A less than 5% strain is well‐tolerated, with no observable physiologic changes108. At 5%–10% strain, decreased blood flow occurs, predominantly in venules, impairing conduction; however, nerve function recovers completely after relaxation112. With a 10%–15% strain, arterial flow is compromised leading to irreversible endoneurial damage105, 106, 108, 112. At greater degrees of strain, tensile failure will occur110. Thus in the setting of injury, blood flow should be optimized with tensionless neural repair. Ultimately, nerve recovery remains highly variable and unpredictable, but early primary tensionless repair should be the goal.

Further Management

Finally, depending on the duration of vascular compromise, prophylactic fasciotomies may be performed. The surgeons should have a low threshold for performing the fasciotomy. Postoperative management is dictated by the condition of the patients, means of fixation, neurovascular repairs performed, and the ultimate vascular status of the extremity.

Case Example

A 42‐year‐old man caught his right arm in an industrial backhoe, which crushed and avulsed his extremity (Fig. 4A,B). A CT‐angiogram demonstrated the vascular injury (Fig. 4C). The skin was partially intact, but upon opening the skin a large gap was found between skin and muscle. Additionally, complete neurovascular avulsion injury was present. Only the ulnar nerve was in continuity. The remaining median nerve, radial nerve, and brachial artery were identifiable, but not in continuity. The humerus was shortened approximately 3 cm to allow for direct repair of neurovascular structures. The bone was then compressed with a 4.5 mm limited‐contact dynamic compression plate (Fig. 4D). The wound was then covered with dermal matrix, and negative pressure wound therapy was initiated. The patient was placed in a long posterior slab splint to allow for neurovascular structure healing.

Figure 4.

Case example of acute humeral shortening osteotomy. (A) This is the presentation of a 42‐year‐old man who sustained a crush and subsequent avulsion of his right upper extremity after it was ensnared in an industrial backhoe. (B) The extremity was pulseless and dysvascular on presentation with extensive volar brachial and antebrachial soft tissue loss. (C) Radiographs demonstrated significant diastasis of the humeral fracture. Surgical exploration revealed complete avulsion of the brachial artery as well as all of the traversing neurovascular structures with the exception of the ulnar nerve. The brachial artery was temporarily shunted. (D) After extensive irrigation and soft tissue debridement, an acute 7 cm shortening osteotomy with internal fixation was performed, permitting tensionless end‐to‐end neurovascular repair.

Summary

Acute shortening osteotomy is an excellent option for segmental bone loss or large soft tissue defects in the setting of segmental neurovascular injuries of the upper extremity. Acute shortening is well tolerated in the upper extremity. The complication profile is comparable to other techniques of fixation in the setting of open fractures with soft tissue loss but is performed as a single procedure without the need for later reconstruction. Perhaps most importantly, this technique provides redundant soft tissue for aggressive debridement, together with timely wound closure, and enables tensionless primary neurovascular repairs. Acute shortening osteotomy of the upper extremity represents a formidable component of the orthopaedic surgeon's arsenal.