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Multiple fractures of the elbow – results of multifragmentary fracture of left elbow

Short summary

43-year-old female has suffered a multifragmentary fracture of the distal left humorous that wasn't properly reduced, fixed or healed and evolved into pseudoarthrosis. She still has a severely restricted range of motion and seriously painful symptoms in the left elbow.

Patient's questions

1) Do you confirm that this additional surgery is needed?
2) Are there any effective therapeutic alternatives to surgery?
3) What is the prognosis?

Medical opinion
Patient's History
Sex: F, Age: 43 years
Medical history:
            Menarche in ---
            Appendectomy in ---
            3 full-term pregnancies with natural delivery.
            Modified mastectomy with axillary dissection, for mammary cancer, after 4 chemotherapy cycles.
After that, 3 years of Zoladex injections and Nolvadex.
Multifragmentary fracture of left elbow following a fall from a horse. Patient was hospitalized at the Hospital of Varese and underwent the following surgery:
“… an incision was made in the posterior face of the elbow; the triceps tendon was dissected with a reverse V and the joint was opened. The bone fragments were dispersed in the soft tissues: These fragments (6) were extracted and, with great difficulty, the joint face of the humerus was reconstructed. The condyles were secured with two transverse Kirschner wires (the ulnar nerve was isolated and moved back); the other fragments were secured with two other oblique Kirschner wires. After having visually scoped the reconstruction of the gliding joints and the fastening of the fragments, the incision was closed in layers and the elbow was immobilized with plaster at a 90-degree angle.” The results of an x-ray on the day of the patient's discharge were as follows: “… the displacement of the fracture focus persists in the extreme distal of the left humerus.” The results of an x-ray on ----, after the discharge, highlighted the following: “… proper alignment of the fractured stumps.”
Also the patient was hospitalized for the removal of the Kirschner wires in the left elbow and of the stitches.
At the time of the hospitalization, the physiatrist noted a paresis of the ulnar nerve in the area previously subjected to surgery as follows: “considerable stiffness of left elbow (particularly when stretching). Deficit of the abductor muscle of Finger V – ulnar flexor of the wrist and interosseal of Fingers IV and V with hypoesthesia of the ulnar area. Outpatient rehabilitation therapy scheduled…” An electromyography test , concluded: “voluntary motor activity is noted in the abductor muscle of Finger V of the left hand. Indication to continue the kinesitherapy…).”
The patient was hospitalized again in order to extricate the ulnar nerve that had been entangled in the first surgery. The description of the surgery was as follows: “under general anesthesia, an incision was made in the epitrochlear groove of the left elbow. The ulnar nerve appeared augmented in volume above the groove, which had been fully opened: The nerve section immediately took on color. An incision was made in the epitrochlear muscles and, after having extricated the nerve from fibrous lobes that kept it adhering to the groove floor, it was moved forward in the muscular groove. Layered suture. Preparation of plaster with the elbow at 90 degrees and a stretched wrist.”
The patient was hospitalized again for the regional supracondyloid reconstruction of the left humerus in pseudoarthrosis of the elbow, as per the following excerpt from the surgery notes: “… osteotomy of the olecranon and biceps reversal. A lax supra- and intrercondyloid pseudoarthrosis of the humerus was noted. The fibrous tissue was removed and the two condyles were shortened and synthesized using a malleolar screw after having sought congruency with the joint. An attempt was made to adapt the pseudoarthrosic proximal stump with the distal, paying special attention to the rotation of the condyles. The fragments were secured with 3 screws, two radial and one ulnar. The transplant was avoided from the ulnar side in order to allow the olecranon to glide. The olecranon was positioned in its anatomical site and was synthesized..."
The patient was hospitalized in order to remove the synthesis set of the left elbow that was in pseudoarthrosis.
The report of the orthopaedic examination confirmed the diagnosis of lax pseudoarthrosis of the previous inter- and supracondyloid fracture of the left elbow. The indications made by the specialist followed the timetable below:
1)    2D and 3D CAT scan
2)    Removal of synthesis set -> extrication of ulnar nerve <40
3)    Bone reconstruction >40 <50
4)    Physiatric therapeutic program > 55 – 60
Complementary to the clinical information, the report on the left elbow x-ray, is also available. The following is the result of the x-ray: “When compared with the previous, identical x-ray, the x-ray of the elbow shows that the multiple fracture of the elbow, evolved into pseudoarthrosis, remains unchanged. In particular, the fragments of the supracondyloid fracture of the humerus have not been consolidated and their position remains unchanged.”
To this date, the patient still has seriously painful symptoms in the left elbow that extend also to the fingers and restrict their functionality.
As for the case history and the CT scan, it is clear that this unfortunate young patient has suffered a comminuted fracture of the distal left humorous which was never properly reduced, fixed or healed. She is suffering now from atrophic non-union and pseudoarthrosis of the supracondyler humeral fracture.
It is my understanding, per the clinical information report, that she has a severely restricted range of motion and she is suffering from pain.
The ulnar nerve's neuropathy is not an uncommon complication of this fracture's treatment course and further nerve release (neurolysis) would be beneficial if she opts for further surgery.
Providing the non-union is not infected, which is not trivial, and considering the patient's young age, I would recommend taking the following medical measures:
1.    Surgery involving an exploration of the surgical wound, neurolysis and transposition of the ulnar nerve, if feasible, are recommended. Next, removal of all metals including the tension band. Contracture release, cultures and pathology.
2.    If the cultures are positive, I would treat the patient with a full course of Antibiotics for at least 6 weeks.
3.    If any significant improvement occurs after this surgery, and provided the cultures are all negative, then I would probably stop at this stage and allow the patient to move her elbow and function through the pseudoarthrosis and whatever range of motion is left, if at all, of the elbow joint.
4.    If no improvement occurs in the range of motion, and the patient still suffers pain, I would take her to a second surgery, for olecranon osteotomy. This is a wide exploration joint and excision of the pseudoarthrosis and non-union tissue, contracture release, capsulectomy, and ostheosynthesis with two locked plates and screw.
This is a very complicated orthopaedic reconstructive surgery that requires a committed treatment plan, possible multiple surgeries, and a long rehabilitation program, preferably accompanied by a personal trainer. The patient needs to  understand the limits of surgical intervention at this stage and adjust her expectations accordingly.