Publication:

A rare combination of comminuted distal ulna fracture with flexor tendons injury, median nerve injury and ulnar artery injury managed by staged fixation: a case report

Isolated distal ulna fractures are uncommon and the combination with flexor tendon injury, partial median nerve injury, and ulnar artery disruption is exceedingly rare. These injuries present a significant reconstructive challenge requiring careful planning for skeletal stabilization and soft-tissue management. A 44-year-old male sustained high-energy trauma to the right forearm. Clinical evaluation revealed an open injury over the distal forearm with exposed bone and soft tissue, flexor tendon disruption, median nerve sensory-motor deficit and compromised ulnar artery perfusion. Radiographs demonstrated a comminuted distal ulna fracture. Intraoperatively, a partial median nerve injury and ulnar artery injury, flexor digitorum superficialis tendons injury were confirmed, while the ulnar nerve remained intact. Due to extensive soft-tissue compromise, the fracture was initially stabilized using an external fixator. After soft-tissue recovery, staged internal fixation with plate and screws was performed along with ipsilateral autologous fibular bone grafting to restore distal ulna alignment and stability. Radiological union was achieved with satisfactory functional recovery of wrist and finger movements with mild neurological deficits. This case highlights the rarity of combined distal ulna comminution with flexor digitorum superficialis tendon injury, median nerve injury and ulnar artery disruption. A staged approach using temporary external fixation followed by delayed internal fixation can optimize outcomes in complex wrist trauma with significant soft-tissue compromise.