Traumatic Humeral Diaphysis Extrusion and Replantation With Periosteal Involvement

Open fractures that produce an extruded long bone diaphysis, such as this case, are an exceedingly rare incident, with even fewer cases documented, leading to difficult medical decision-making for the operative management of such situations. Options for operative management include replantation following sterilization of the extruded fragment, bone transport, a vascularized fibular graft, and even allograft reconstruction. Each option is associated with high and variable levels of risk. The authors report a case study of a 35-year-old female, status post motor vehicle collision (MVC), who sustained a fracture and expulsion of her humeral diaphysis during the incident. She presented to the emergency department by ambulance after colliding into a light post at 50 miles per hour. Upon presentation and examination, the patient scored 14 on the Glascow Coma Scale (GCS) with a positive Focused Assessment with Sonography in Trauma (FAST) exam, consistent with splenic and hepatic injuries. In addition to this, the patient exhibited a flaccid left upper extremity combined with an absent left radial pulse and a small puncture wound on the left anterolateral antecubital area. Radiographic imaging revealed a 6-inch fragment of mid to distal humeral diaphysis missing. Moments later the initial Emergency Medical Services (EMS) crew returned from the scene of the accident with the missing 6-inch fragment of humerus contained in an emesis bag, which was found on the floorboard of the patient's vehicle. This fragment was preserved at -20 °C for 2 days and later used as an autograft in an open reduction internal fixation surgery. This case highlights and details the techniques for proper storage, treatment, and sterilization of the bone fragment during the period of patient stabilization following trauma, to optimize the replantation and union of the fragment. This includes contrasting the different techniques that could be utilized to preserve and sterilize bony fragments, such as autoclaving, gamma radiation, chemical sterilization with iodine, or deciding whether the fragment needs to be discarded altogether with the utilization of allograft.