Algorithm of surgical treatment for diaphyseal defects of the forearm bones due to gunshot injuries

Introduction In the current system of providing medical aid to wounded servicemen, along with the conservative primary surgical treatment and minimally invasive extrafocal fixation, high-tech surgical interventions of considerable complexity with the use of additive and tissue-engineering technologies have been coming to the forefront. It is necessary to determine their place in the current algorithm of limb bone defect management, which was the substantiation of our study.

The purpose of the study was to improve the algorithm for selecting a treatment method for patients with associated gunshot defects of the forearm based on the literature and clinical observations.

Materials and Methods We analyzed scientific articles in PubMed and Scientific Electronic Library (eLIBRARY.ru) platforms, published from 2004 to 2024, on the basis of which we could refine the algorithm of treatment method selection for patients with associated gunshot defects of the forearm. The developed algorithm was used to treat 178 patients with gunshot fractures of the forearm.

Results The review of the literature established the main provisions and principles that are applied in the reconstruction of the forearm with an associated defect. When choosing the method of bone defect management, a great number of authors tend to build a “reconstructive ladder”, moving from less severe (one bone) and extended defects (small defect up to 2 cm) to more complex (both bones) and massive defect (more than 10 cm). Upon having considered the revealed regularities, we improved the algorithm of surgical treatment of the latter, which is based on two classification principles: defect extention and location. Reconstruction of the forearm as a dynamic system after diaphyseal fractures requires consider the state of the radioulnar joint. The function of the latter depends on the length ratio of the radius and ulna bones. Therefore, we substantiated small (up to 2 cm) forearm bone defects that can be managed by simple surgical methods. Another fundamental addition to the algorithm was the allocation of a patients’ group with a defect of one forearm bone and a fracture of the other bone (defect-fracture); this combination allows avoiding complex surgical methods for reconstruction and use segment shortening.

Discussion The treatment of associated forearm defects is challenging, the choice of reconstruction technique remains uncertain, and the required consensus is lacking. Several forearm reconstruction techniques are available, yet there is no reliable evidence of their effectiveness in terms of treatment time, complications, reoperations, and functional recovery.

Conclusion The algorithm proposed for the treatment of extensive gunshot-associated defects of the forearm allows us to consider the change in the anatomy, make a surgical plan based on the reconstruction vector, and select optimal surgical techniques.

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