The multi-modality approach in a case of fracture of the humerus with an ipsilateral loating knee: A case report

Ipsilateral fractures of humerus, femur and tibia is a rare entity. The number of fractures resulting due to road traf ic accidents is on the rise. These Type of injuries usually occur due to high-velocity road traf ic accidents. High-velocity road traf ic accidents are associated with multiple bony injuries as well as injuries to various internal organs. These injuries are often dif icult tomanage due to their complex nature. Mostlymultiple fractures are produced in ipsilateral limbs. This condition makes the management even more dif icult. Hence a multi-modality approach is often required. A 55-year-old male sustained loating kneewith ipsilateral shaft humerus fracture. After a three-staged surgical approach with three modalities for treating the compound injury, the patient had an excellent result with the full range of motion in the knee and complete coverage of wound. Compound loating injuries should be treated with simultaneous ixation of femur and tibia fractures to achieve early full range of knee motion with Vacuum-assisted closure followed by skin grafting for complete wound coverage.

Polytrauma, Ipsilateral humerus, Femur and tibia fracture, High-velocity road traf ic accidents, Floating knee A Ipsilateral fractures of humerus, femur and tibia is a rare entity. The number of fractures resulting due to road traf ic accidents is on the rise. These Type of injuries usually occur due to high-velocity road traf ic accidents. High-velocity road traf ic accidents are associated with multiple bony injuries as well as injuries to various internal organs. These injuries are often dif icult to manage due to their complex nature. Mostly multiple fractures are produced in ipsilateral limbs. This condition makes the management even more dif icult. Hence a multi-modality approach is often required. A 55-year-old male sustained loating knee with ipsilateral shaft humerus fracture. After a three-staged surgical approach with three modalities for treating the compound injury, the patient had an excellent result with the full range of motion in the knee and complete coverage of wound. Compound loating injuries should be treated with simultaneous ixation of femur and tibia fractures to achieve early full range of knee motion with Vacuum-assisted closure followed by skin grafting for complete wound coverage.

INTRODUCTION
Ipsilateral fractures of humerus, femur and tibia is a rare entity. The number of fractures resulting due to road traf ic accidents is on the rise. These Type of injuries usually occur due to high-velocity road traf ic accidents. High-velocity road traf ic accidents are associated with multiple bony injuries as well as injuries to various internal organs (Lundy and Johnson, 2001). These injuries are often dif icult to manage due to their complex nature. Mostly multiple fractures are produced in ipsilateral limbs. This condition makes the management even more dif icult. These injuries are usually associated with lifethreatening injuries to the head, chest and abdomen. There is a high incidence of fat embolism noted (Kao et al., 2010). Due to considerable variability in the presentation, management of these injuries vary according to involved organs. Many of these fractures are open with associated vascular injuries. Surgical stabilisation of both fractures at the same time and early mobilisation of the patient and extremity produce the best clinical outcomes (Oh et al., 2005). All the relevant reports in the literature emphasise the importance of early mobilisation of these patients to facilitate their better care and quick respiratory recovery. This recovery can only be achieved by good stabilisation of the fractures of the leg, which also promotes a successful and able functional result of the adjacent joints of the injured limb (Omer et al., 1968). However, there is no gen-erally accepted guideline in treating these fractures. The recommended methods of treatment vary very widely. In this case report, we have described how we have managed a patient with ipsilateral fractures of the humerus with an ipsilateral loating knee.

Case scenario
A 55 years old male presented to Casualty of Acharya Vinoba Bhave Rural Hospital Sawangi Meghe after a high-velocity road traf ic accident with pain and swelling over right arm, thigh and wound over the right leg. After primary management in the casualty which included immobilisation of right upper limb with universal splintage, cleaning and dressing of the wound over the right leg, immobilisation of right lower limb with Thomas splint and luid resuscitation patient was hemodynamically stabilised. The patient was examined to rule out internal injuries and then sent for X-Rays. X-rays showed that he had mid-shaft humerus fracture right side, supracondylar femur fracture right side and compound grade IIIB fracture mid-shaft tibia and ibula right side. The patient was found to have Type I loating knee. The patient was taken into emergency OT, and thorough debridement of the wound over right leg with biplanar external ixator application for mid-shaft shaft tibia ibula fracture was done. Stay sutures were placed. Supra-condylar femur fracture was managed with open reduction internal ixation with plate osteosynthesis in the same sitting. Humerus was operated in subsequent sitting with open reduction internal ixation plate osteosynthesis within a week. Broad-spectrum antibiotic coverage was given to prevent infection. A tailored physiotherapy regimen was designed for the patient, which included knee range of motion exercises as tolerated, quadriceps and hamstring building exercises with TENS therapy to enhance muscle contraction, chest physiotherapy, early wheelchair mobilisation. Serial debridements and Vacuum-Assisted Closure (VAC) application were made to enhance the formation of the granulation tissue at the wound site. After the formation of healthy granulation tissue, split-thickness Thiersch skin grafting was done at the wound site. One month later de initive ixation for mid-shaft tibia fracture was done with Tibia interlock nail. Figure 1 shows pre and postoperative clinical pictures, and Figure 2 shows pre and post-operative X-rays.

DISCUSSION
Though Ipsilateral fractures of humerus, femur and tibia is a rare entity, the number of fractures resulting due to road traf ic accidents is on the rise. These Type of injuries usually occur due to high-velocity road traf ic accidents. High-velocity road traf ic accidents are associated with multiple bony injuries as well as injuries to various internal organs. These injuries are often dif icult to manage due to their complex nature. Mostly multiple fractures are produced in ipsilateral limbs. This kind of fracture makes management even more dif icult. Poly-trauma with loating knee injuries is complex injuries with various co-morbid conditions. Given the challenges associated with managing both the loating knee injury and compound wound with ipsilateral shaft humerus fracture, such patients are likely best served in a centralised location such as a tertiary referral centre. Posttraumatic wound infection and osteomyelitis portend substantial morbidity (Theodoratos et al., 2001). Decreased function due to knee stiffness and likely need for multiple debridement procedures, extensive physiotherapy, pain, and overall quality of life all are negatively affected by loating knee injury associated with the compound wound. Besides, an ipsilateral humerus fracture will hinder the ability to achieve an early weight-bearing mobilisation, decreasing the likelihood of a stable, well-functioning and pain-free knee postoperatively without ensuing knee stiffness. Historically, the prognosis for recovery is considered to be low, but there have been relatively few studies with consistent data regarding the appropriate management of such injuries, likely due to the rarity of the injury.
Treatment of compound injuries is challenging. Primary stable ixation is not indicated in compound injuries because of extensive contamination of wound leading to local site infection and osteomyelitis as its sequelae (Adamson et al., 1992). There may be a role for Vacuum assisted closure in these cases at the time of the irst surgery (Liu et al., 2018). Patients who do not develop local site infection and have a bed of healthy granulation tissue following primary stabilisation can be considered for split-thickness skin grafting or skin lap to achieve wound closure. Recent studies have supported the use of Vacuum-assisted closure to gain faster healing of compound injuries with decreased risk of infection and improved outcomes (Costa et al., 2018).
The result of the present case was excellent; the patient had excellent ROM, the knee was stable, and the wound had good coverage. Three factors potentially explain these results: the early irst surgery, simultaneous ixation of tibia and femur fracture and the use of a multi-modality surgical approach (Schiedts et al., 1996). The primary stabilisation was performed on the day of injury, during which stable de initive ixation of distal femur fracture was done with stay sutures given for wound  over the leg to prevent the skin edges from retracting during subsequent days till vacuum-assisted closure was performed. After a week, vacuum-assisted closure was done. After 20 days of primary stabilisation and formation of healthy granulation tissue at the wound site, skin grafting with a de initive ixation for fracture shaft tibia was done. During this time the shaft humerus fracture ixed with plate osteosynthesis started showing sign of union (Modabber and Jupiter, 1998). At three months, the postoperative period patient had full knee, shoulder and elbow range of motion with full weight bearing on the affected side and returned to activities of daily living and work without assistance.

CONCLUSION
Polytrauma as a result of high-velocity Road traf ic accidents is a devastating injury with poor outcomes and pulmonary embolism, joint stiffness, wound infections, and osteomyelitis is frequent associations. Management of these problems is varied and depends on many factors (the type of injury, the timing of intervention, bone loss, associated neurovas-cular injuries and injuries to vital organs). Controversy exists concerning the best surgical treatment. The results of the present case were excellent; the patient had excellent knee, shoulder and elbow ROM, the wound completely healed without any sequelae, and he was able to return to work within three months. Three factors potentially explain these results: the early irst surgery with simultaneous ixation of tibia and femur fracture, use of the multi-modality approach for treating compound tibia fracture and a tailored physiotherapy regimen.