Distal radius fractures are among the most common upper limb injuries, accounting for 15–20% of all fractures presenting to emergency departments. They display a bimodal distribution occurring in younger patients after high-energy trauma such as road traffic accidents and in elderly, postmenopausal women following low-energy falls on osteoporotic bone (1,2). While many are simple extra-articular fractures, complex variants involve intra-articular extension, severe comminution, metaphyseal–diaphyseal dissociation, or soft-tissue compromise. These complex fractures jeopardize articular congruity of the radiocarpal and distal radioulnar joints, often leading to stiffness, chronic pain, malunion, or post-traumatic arthritis if inadequately treated. Several classification systems assist in assessing severity and planning management Frykman (joint involvement), Fernandez (mechanism-based), and AO/OTA (surgical planning; C2–C3 types denoting comminuted intra-articular fractures) (3–5). The primary goals of treatment are to restore radial height, inclination, and volar tilt; achieve anatomical reduction; and provide stable fixation to permit early mobilization. Modern fixation techniques, including volar locking plates, fragment-specific fixation, and adjuncts such as external fixation or bone grafting, have markedly improved outcomes (6–8). Elbow fracture–dislocations represent another complex injury pattern involving simultaneous bony and soft-tissue disruption, leading to instability and functional impairment. The elbow derives stability from the ulnohumeral articulation and secondary constraints provided by the radial head, medial collateral ligament (MCL), lateral ulnar collateral ligament (LUCL), and capsule (9,10). Although elbow dislocations constitute 10–25% of all elbow injuries, fracture–dislocations are less common but carry greater risk of stiffness and recurrent instability. They typically result from axial loading combined with valgus and rotational stress. The mechanism is closely related to posterolateral rotatory instability, as described by O’Driscoll. The “terrible triad” injury posterior dislocation with fractures of the radial head and coronoid—represents failure of both primary and secondary stabilizers. Other variants include Monteggia fracture–dislocations (proximal ulna fracture with radial head dislocation) and transolecranon fracture–dislocations (olecranon disruption with preserved proximal radioulnar alignment) (11). Modern classification systems such as those by Hotchkiss (terrible triad), Bado (Monteggia), Regan & Morrey and O’Driscoll (coronoid), and Ring (transolecranon) guide surgical decision-making and prognosis (12). Historically, these injuries were managed conservatively, often leading to poor function due to stiffness and instability (13). With advancements in imaging, fixation techniques, and recognition of ligamentous injury, management now focuses on anatomical reconstruction, rigid fixation, and early rehabilitation. Procedures such as radial head arthroplasty and ligament repair or reconstruction have further improved outcomes (14). Despite these advances, elbow fracture–dislocations remain challenging due to risks of stiffness, heterotopic ossification, and post-traumatic arthritis. Successful recovery depends on timely diagnosis, meticulous surgical technique, and structured rehabilitation (15). In the present case, due to the patient’s limited financial resources, the surgical plan prioritized essential fixation using the best available implants and alternative reduction techniques to achieve stability and restore functional capacity of both the distal radius and elbow.

Patient Information A 25-year-old male construction worker sustained polytrauma following a fall from the second floor of a construction site in Secunderabad on 03/01/2025. He presented with pain and swelling of both elbows and wrists, along with head and facial injuries. There was no loss of consciousness, ENT/oral bleeding, nausea, vomiting, abdominal, or chest pain reported at presentation. Clinical Examination and Investigations External examination revealed a 5 × 6 cm contusion over the left eye. CT Brain showed: • Hemorrhagic contusion in the left frontal lobe • Fractures involving the left maxillary sinus, sphenoid sinus, left frontal bone, and multiple facial bones • Left frontal extradural hematoma with air focus • Minimal pleural effusion Orthopedic evaluation demonstrated bilateral distal radius fractures • Left: Frykman Type IV, Malone Type I • Right: Frykman Type VII, Malone Type IV along with bilateral elbow fracture-dislocations. Radiological Evaluation Preoperative X-rays: Bilateral wrists and elbows revealed distal radius fractures and fracture-dislocations of both elbows. Final Diagnosis: Bilateral distal radius fractures and bilateral elbow fracture-dislocations as defined by the Frykman and Malone classifications. Operative Management Left Distal Radius Fracture Under general anesthesia, the patient was positioned supine on a radiolucent table with the arm on a hand table. A pneumatic tourniquet was applied. A modified Henry’s anterior approach was used: • Longitudinal incision along the flexor carpi radialis (FCR) tendon. • FCR sheath opened; tendon retracted ulnarward; radial artery protected laterally. • Flexor pollicis longus (FPL) retracted to expose pronator quadratus (PQ), which was incised in an L-shaped manner and reflected. • Fracture site cleared of hematoma and debris. Reduction and Fixation: • Fracture fragments reduced under fluoroscopic guidance and temporarily stabilized with K-wires. • Pre-contoured volar variable-angle locking plate applied proximal to the watershed line. • Distal fragments fixed with variable-angle locking screws; proximal fixation achieved with cortical or locking screws. • Supplementary K-wires were used for small marginal or articular fragments. • Reduction and implant positioning confirmed in AP, lateral, and oblique views. After irrigation, the PQ was repaired where feasible, and layered closure was done. A sterile dressing and volar splint were applied. Right Distal Radius Fracture The right wrist was managed via a modified Henry’s volar approach. • Fracture reduced under fluoroscopic guidance. • Fixation performed with a pre-contoured variable-angle volar locking plate. • Marginal fragments (radial styloid and volar rim) were stabilized using neutralization sutures and supplementary percutaneous K-wires. • Fluoroscopic confirmation of reduction and implant positioning was obtained before layered closure and volar splintage. Bilateral Elbow Fracture-Dislocations Under general anesthesia, both elbows were prepared and draped. • Closed reduction achieved under fluoroscopic guidance. • Percutaneous K-wire fixation used to stabilize bony fragments. • Through a lateral Kocher approach, the lateral collateral ligament (LCL) was repaired using suture anchors to restore lateral stability. • Fluoroscopy and intraoperative assessment confirmed stable reduction through the full range of motion. • Wounds were irrigated, closed in layers, and immobilized with posterior slabs Postoperative Assessment and Follow-Up Early Postoperative Period Immediate postoperative radiographs of both wrists and elbows showed: • Anatomical reduction • Stable fixation • Restoration of articular congruity Three-Week Follow-Up Radiographs at 3 weeks demonstrated: • Callus formation • Blurring of fracture lines in both AP and lateral views • Stable fixation and satisfactory alignment Six-Week Evaluation At 6 weeks, radiological and functional assessments were performed. Radiographic Findings: • Radial height: Maintained within 2–3 mm of normal (≈11–12 mm) • Radial inclination: ≥15° (normal ≈22°) • Volar tilt: 0–15° (normal ≈11° volar) • Articular congruity: Step-off/gap <2 mm • Ulnar variance: Within ±2 mm of neutral • Distal radioulnar joint: Stable and congruent Functional Findings: • Pain-free wrist motion with good stability • Restoration of functional range of motion at the elbows Radiographic Evaluation Criteria Distal Radius Parameters: • Radial height: Distance from radial styloid tip to ulnar corner on PA view • Radial inclination: Angle between radial styloid–ulnar corner line and a line perpendicular to the radial shaft • Volar tilt: Angle between distal articular surface and perpendicular to radial shaft on lateral view • Articular step-off: <2 mm considered acceptable • Ulnar variance: Relative length of distal ulna vs. radius Elbow Evaluation: • Clinical: Pain, deformity, ROM, neurovascular status • Radiographic: AP and lateral views assessing o Radio-capitellar line alignment o Ulno-humeral relationship o Coronoid/radial head/olecranon involvement o Articular step-off or gap >2 mm o Associated soft-tissue signs (fat pad, effusion) • Functional: Varus/valgus stress testing and hinge motion to confirm post-reduction stability Outcome At six weeks, both distal radius fractures demonstrated satisfactory alignment and radiological union. The elbow joints exhibited good stability and functional recovery, with no residual deformity or restriction of motion. The outcome was considered favorable, particularly given the patient’s limited financial resources that constrained implant choice yet optimal fixation and technique ensured functional restoration of both wrists and elbows.

This report presents a rare case of bilateral distal radius fractures associated with bilateral elbow fracture-dislocations in a polytraumatized patient a highly uncommon and complex injury pattern. The case underscores the diagnostic and therapeutic challenges encountered in managing simultaneous upper-limb fractures involving both the wrist and elbow joints. The discussion integrates current orthopedic literature to contextualize the case findings and outcomes. Complex distal radius fractures demand an individualized approach aimed at restoring anatomic alignment and functional integrity. Precise restoration of radial height, inclination, and volar tilt, along with articular congruity and distal radioulnar joint stability, remains critical to achieving optimal outcomes. The introduction of volar locking compression plates (LCPs) and fragment-specific fixation systems has revolutionized the treatment of unstable and comminuted fractures, allowing rigid internal fixation and early postoperative mobilization. These techniques have shown superior biomechanical stability compared with external fixation or pinning alone and have significantly reduced the incidence of complications such as malunion, stiffness, and post-traumatic arthritis (6). In the present case, despite resource limitations, the use of variable-angle volar locking plates combined with supplementary K-wires provided adequate fixation, resulting in radiographic union and good restoration of wrist function. Elbow fracture-dislocations especially terrible triad injuries, Monteggia, and transolecranon variants remain among the most challenging injuries in upper-extremity trauma. Successful outcomes rely on anatomic reconstruction of osseous structures and repair of key ligamentous stabilizers to restore joint congruity and prevent recurrent instability. Surgical strategies often involve fixation of bony fragments, reconstruction or repair of the lateral collateral ligament (LCL), and, when required, radial head replacement or fixation. The literature consistently reports high rates of postoperative complications, including limited range of motion, heterotopic ossification, nerve palsy, and persistent instability, particularly in high-energy or polytrauma cases (16). In this case, early stabilization with K-wires and suture-anchor repair of the LCL achieved satisfactory stability, facilitating early mobilization and functional recovery. Management of polytrauma involving both orthopedic and craniofacial injuries requires an integrated multidisciplinary approach. Coordination between trauma surgeons, orthopedic specialists, neurosurgeons, anesthesiologists, radiologists, and rehabilitation teams is vital for comprehensive care. Early prioritization of life-threatening and function-threatening injuries, timely surgical intervention, and structured physiotherapy are crucial to achieving favorable outcomes and minimizing long-term disability (17). The present case demonstrates the importance of sequential and prioritized surgical management addressing neurocranial injuries and orthopedic stabilization in a stepwise manner to ensure overall recovery and preserve limb function. The postoperative course in this patient was satisfactory, with stable fixation, radiological evidence of callus formation, and functional restoration of wrist and elbow motion at six weeks. These findings align with existing literature that emphasizes the role of rigid fixation and early rehabilitation in improving functional scores following complex upper-extremity injuries (18-20). However, this case also highlights a practical limitation: financial constraints can significantly influence implant selection and surgical planning in resource-limited settings. Despite these challenges, appropriate use of available implants and adherence to sound surgical principles resulted in a favorable prognosis and functional recovery.

Bilateral distal radius fractures combined with bilateral elbow fracture-dislocations represent an exceedingly rare and complex presentation in orthopedic trauma. The case underscores the importance of meticulous surgical technique, biomechanical understanding, and multidisciplinary coordination in achieving good outcomes. Even under resource constraints, successful management can be achieved through careful planning, precise reduction, and stable fixation. Early mobilization, radiographic monitoring, and physiotherapy remain key determinants of functional success. This case reinforces that adherence to sound orthopedic principles and teamwork can yield excellent recovery even in the face of complex injuries and limited resources.

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