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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 89-94

Study of surgical fixation of extra-articular distal humerus fractures using extra-articular distal humerus locking plate


Department of Orthopedics, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission24-Jan-2022
Date of Decision05-Mar-2022
Date of Acceptance06-Mar-2022
Date of Web Publication28-May-2022

Correspondence Address:
Manikandan Kumarasamy
Department of Orthopedics, Sri Manakula Vinayagar Medical College and Hospital, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_8_22

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  Abstract 


Background: The aim of this study was to evaluate the mechanical properties of distal humerus fracture fixation using extra-articular distal humerus locking plate osteosynthesis. There are numerous types of plates used in this region and one among them is the extra-articular distal humerus locking plate. This anatomically precontoured plate is specifically designed for the fixation of extra-articular distal humerus fractures. Usually, distal humeral extra-articular fractures are often associated with complications. This study reports satisfactory outcomes with the usage of extra-articular plate osteosynthesis for extra-articular humerus fracture management. It has now become a choice of management in our center for the management of extra-articular distal humerus fractures because of its advantages. We evaluated the clinical and functional outcomes of treating these fractures. Materials and Methods: We studied 20 patients who underwent fixation over 2 years. Mayo Elbow Performance Score was used to analyze functional outcomes. The time for union, range of motion at shoulder and elbow, and secondary procedures were recorded in follow-up. Shoulder and elbow function was assessed using the Mayo Elbow Performance Score. Results: During the study of 20 cases of distal humerus fractures treated by extra-articular distal humerus locking plate. Majority (40%) of the study participants were in the age group of 18–30 years. The mean age group is 39.8 years. Among 20 patients, thirteen were males and seven were female patients showing a male preponderance. About 14 and 6 patients with the right and left sides were involved, respectively. Eighty-five percent of the fractures united within 16 weeks, whereas for three patients (15%), fracture united at 18 weeks. The mean average time to union is 15.2 weeks. Eighteen (90%) patients had excellent elbow movement. Two (10%) patients had elbow stiffness. This was reduced to 32 weeks. All the patients were mobilized on day 2 after surgery. Eighteen patients (90%) had excellent results. Fair results were observed in two patients.

Keywords: Closed reduction internal fixation, dynamic compression plate, extra-articular distal humerus locking plate, locking compression plate, Mayo Elbow Performance Score


How to cite this article:
Kumarasamy M, Uma Anand K P, Romans M. Study of surgical fixation of extra-articular distal humerus fractures using extra-articular distal humerus locking plate. J Orthop Dis Traumatol 2022;5:89-94

How to cite this URL:
Kumarasamy M, Uma Anand K P, Romans M. Study of surgical fixation of extra-articular distal humerus fractures using extra-articular distal humerus locking plate. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Jul 3];5:89-94. Available from: https://jodt.org/text.asp?2022/5/2/89/346221




  Introduction Top


Distal humerus fractures remain some of the most challenging injuries in management. They have complex anatomy with limited options for internal fixation. Injuries to this region require a systematic approach in managing the soft tissues, achieving anatomic reduction, and a stable construct.

With a recent trend to high-velocity injuries, treatment of distal humerus fractures has become difficult. Fracture pattern, soft-tissue injury, and bone quality critically influence the fixation technique. Operative management includes plate osteosynthesis, screw fixation, K-wire fixation, external fixators, intramedullary nailing, and total elbow arthroplasty are the various options available. Among these, intramedullary nailing is not feasible in this region due to the distal nature of the injury because of which the distal screws cannot be placed and to the possibility of rotational malalignment during the course of fracture healing. External fixators can lead to inaccurate reduction, malunion, nonunion, and pin tract infection.[1] Primary elbow arthroplasty has evolved to become a viable treatment option for elderly patients with articular fragmentation, comminution, and osteopenia.[2]

Open reduction and internal fixation (ORIF) of extra-articular distal third humerus fractures provide skeletal stability, allow early rehabilitation, and decrease soft-tissue complications.[3] Fixation of the distal humerus fractures can be problematic due to its unique architecture. The anatomically precontoured 3.5 mm locking compression plate (LCP) extra-articular distal humerus plate (EADHP) was specifically designed for the fixation of extra-articular distal humerus fractures. The plate is contoured to fit the anatomy of the posterolateral distal humerus and provides an increased number of distal fixations. The purpose of this study was to evaluate the functional outcome of the 3.5 mm LCP EADHP in the fixation of distal extra-articular distal humerus diaphyseal fractures.

Locking plates are plates in which the screw heads are threaded and, when tightened lock into the threads in the plate. A fixed-angle construct is thus created. Such constructs are much less prone to loosening or toggling than traditional nonlocking plates.[4] The precise anatomic shape of the 3.5 mm LCP extra-articular distal humerus locking plate prevents primary fracture fixation failure due to inexact contouring of other plates.

Screw locking minimizes the compressive forces exerted by the plate on the bone and thus avoids disturbance to the bone‒blood supply. The LCP provides greater bending stiffness, torsional stiffness, and less chances of failure. In an improved plate design, the self-compression and the locking mechanisms have been combined to impart dual ability to compress and lock. A plate with an integrated hole offers fixation with conventional bone screws, fixation with threaded head screws, and fixation with conventional and threaded head screws.[5]

Proximally, the plate uses elongated 3.5 mm combination hole system with locking and nonlocking screw options in the humeral shaft. Distally, it curves along the lateral supracondylar ridge, thus, avoiding the olecranon fossa and has five screw holes angled medially for achieving a strong purchase in the trochlea and capitellum. The plate head is tapered to minimize soft-tissue irritation.[6] As the plates are anatomically contoured, there are different plates for the right and left sides and it is available from four holes (122 mm) to 14 (302 mm) hole length.

Aims and objectives

To access the clinical and radiological outcome of distal humerus diaphyseal fractures [Figure 1] managed surgically with extra-articular distal humerus locking plate.
Figure 1: Preoperative X-ray

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  Materials and Methods Top


It is a hospital-based prospective study to access the clinical and radiological functional outcome of distal humerus diaphyseal fractures which is managed surgically with extra-articular distal humerus locking plate after obtaining permission from the institutional ethics committee. The radiological and clinical outcomes will be accessed in the outpatient Department of Orthopaedics at Sri Manakula Vinayagar Medical College and Hospital, Pondicherry, India. Universal sampling technique will be adopted in this study.

Sample size and sampling

Universal sampling technique will be adopted in this study. All the patients fulfilling the inclusion criteria during the abovementioned study period will be included in this study.

The inclusion criteria

  1. Closed distal humerus fractures
  2. Patients with age 18 years and above
  3. AO/OTA classification of distal humerus fractures. Extra-articular distal humerus fractures-Type A
  4. Oblique, transverse, and juxtaepiphyseal fractures.


The exclusion criteria

  1. Patients with age <18 years
  2. AO/OTA classification of distal humerus fractures. Partial articular and complete articular distal humerus fractures-Type B and C
  3. Patients with pathological distal humerus fractures other than osteoporosis
  4. Distal humeral fractures with neurovascular deficit
  5. Patients managed conservatively for other medical reasons.


All the patients fulfilling the inclusion criteria during the abovementioned study period will be included. Patient is placed in the lateral position under general anesthesia, with the arm hanging by the side. A triceps-reflecting posterolateral approach of Gerwin et al.[7] is utilized to expose the fracture site. After performing a midline skin incision on the posterior aspect of the arm, full-thickness flaps are developed on the lateral side.

On the lateral side, using blunt dissection, the lower lateral cutaneous nerve of the arm is identified and its origin traced to the radial nerve. The triceps is elevated from the lateral intermuscular septum and the lateral supracondylar ridge, and the radial nerve is then carefully dissected. After adequate fracture visualization, reduction clamps are used to reduce the fracture fragments. Provisional fixation is achieved with K wires, and lag screws are used wherever possible to increase the strength of the construct and achieve adequate compression in spiral fractures. Finally, EADHP is applied over the posterior surface of humeral shaft and fixed with locking screws distally and a combination of cortical and locking screws proximally. The plate is positioned so that its shaft portion is located centrally on the posterior aspect of the humerus, while the distal end is curved along the posterior aspect of the lateral column. Plate bending is required in some cases for better seating of the plate to the bone surface. Postoperatively, the patient is placed in a soft dressing and arm pouch sling and early range of motion of the elbow, wrist, and shoulder is started.

All patients were resuscitated as per the advanced trauma and life support protocol. During the resuscitation phase, all injuries were identified and adequately imaged. Primary screening roentgenograms including chest, pelvis, cervical spine, and involved long bones were taken. Long bone fractures were identified and splinted.

After acute resuscitation, all patients were evaluated with anteroposterior and lateral roentgenograms of humerus with the elbow joint. In case of intraarticular fractures, computed tomography scan was performed. All fractures were classified as per AO classification.

After obtaining anesthetic fitness, fracture fixation using extra-articular distal humerus locking plate was performed by two senior surgeons after reserving adequate blood depending on individual requirements. Prophylactic intravenous antibiotics were administered just before the induction of anesthesia.

Patient is placed in the lateral position under general anesthesia, with the arm hanging by the side. A triceps-reflecting posterolateral approach of Gerwin et al.[7] is utilized to expose the fracture site. After performing a midline skin incision on the posterior aspect of the arm, full-thickness flaps are developed on the lateral side. On the lateral side, using blunt dissection, the lower lateral cutaneous nerve of the arm is identified and its origin traced to the radial nerve. The triceps is elevated from the lateral intermuscular septum and the lateral supracondylar ridge, and the radial nerve is then carefully dissected.

After adequate fracture visualization, reduction clamps are used to reduce the fracture fragments. Provisional fixation is achieved with K wires, and lag screws are used wherever possible to increase the strength of the construct and achieve adequate compression in spiral fractures. Finally, EADHP, which is stainless steel implant from Sharma company, is applied over the posterior surface of humeral shaft and fixed with locking screws distally and a combination of cortical and locking screws proximally. The plate is positioned so that its shaft portion is located centrally on the posterior aspect of the humerus, while the distal end is curved along the posterior aspect of the lateral column. Plate bending is required in some cases for better seating of the plate to the bone surface. Postoperatively, the patient is placed in a soft dressing and arm pouch sling and early range of motion of the elbow, wrist, and shoulder is started. Patients were allowed elbow, wrist, and shoulder mobilization immediately after the pain subsided. Drain was removed on the 2nd postoperative day. Sutures were removed on the 12th postoperative day. Patient was then discharged from the hospital. Outpatient physiotherapy was instituted.

Patients were followed up for a minimum period of 10 weeks maximum up to 6 months. Patients were assessed once in 3 weeks both clinically and radiologically [Figure 2]. Radiologically, sign of callus formation [Figure 3] was noted and clinically, the improvement in the range of motion [Figure 4] and the reduction in pain were noted. All patients were assessed according to Mayo Elbow Performance Index. In patients who requested for the implant to be removed, it was done after consolidation of the callus was noted in the radiographs, usually not before 18 months from surgery.
Figure 2: Immediate postoperative X-ray

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Figure 3: 6-month follow-up

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Figure 4: Postoperative flexion of the elbow at 12 weeks

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  Results Top


The following observations were made from the data collected during the study of 20 cases of distal humerus fractures treated by extra-articular distal humerus locking plate. The age of patients in the study ranged from 20 to 70 years, and majority (40%) of the study participants were in the age group of 18–30 years. The mean age group is 39.8 years. Among 20 patients, thirteen were males and seven were female patients showing a male preponderance. About 14 and six patients with the right and left sides were involved, respectively. The incidence of injury was more in indirect injury than direct trauma. All patients were operated early and surgery was delayed for those with comorbidities.

The duration of fracture union found to be 75% union rate within 16 weeks is highly significant compared to 25% within 24 weeks shown in [Table 1]. The mean average time to union is 15.2 weeks.
Table 1: Distribution of study participants based on the duration of fracture union (n=20)

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Seventeen (85%) patients had excellent elbow movement [Figure 5] (arc >100°) three (15%) patients had elbow stiffness. This was reduced to 32 weeks. Two (10%) patients had plate prominence but it did not affect their functional ability shown in [Table 2]. We did not have any wound infection or skin breakdown in our study. We had two cases with implant prominence with no disturbance in function.
Figure 5: Postoperative extension of the elbow at 12 weeks

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Table 2: Distribution of study participants based on complications (n=20)

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Overall outcome in our study showed highly significant of seventeen patients (85%) had excellent results (Mayo Elbow Score 90 points) and good results were observed in three patients (15%) (Mayo Elbow Score 80 points) who were above 40 years of age group shown in [Table 3].
Table 3: Association between age and final outcome (n=20)

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  Discussion Top


Management of extra-articular distal humerus fractures are demanding and difficult because of its periarticular location, comminution, and a little distal fragment available. However, the goal of any fixation in these fractures is stable fixation and early mobilization of the elbow joint. Hence, surgical management is preferred over conservative management.

Scolaro et al.[3] found in their study that single posterolateral column fixation of extra-articular humerus fractures is appropriate for more proximal fractures but that dual plate fixation is superior for more distal fractures.

Kharbanda et al.[8] on their study with 20 patients suggested that the provision of greater screw hole density of the plate distally and using 3.5-mm screws instead of 4.5 mm allows adequate number of screws to be placed in the distal fragment.

Fawi et al.[9] conducted a study on 23 patients and found the advantage of this plate is that the distal contour obviates the risk of olecranon impingement in the treatment of distal one-third humerus fractures as observed in our study.

Kumar et al.[10] showed the advantage of EADHP is that its distal contour removes the risk of olecranon fossa impingement, it has low profile to minimize soft-tissue irritation and it has high density of distal locking screws to maximize the fixation. However, in our study, two thin-built patients had plate prominence which did not have impact on the outcome.

Anand et al.[11] proved that the use of single extra-articular plating is more advantageous than bipillar plating having benefits such as less soft-tissue damage, low cost, less mean surgical timing, and less chances of infection.

Gupta et al.[12] emphasized on the low rate of implant failure indicates that the technique is promising. There is no implant failure in our study.

Chawda et al.[13] advocated that the use of interfragmentary screw gives superiority to construct and also stated that optimal stabilization of distal humerus with locking precontoured plate helps early mobilization and prevent stiffness at the elbow. Two cases, we did interfragmentary fixation and did early mobilization.

In our study, we evaluated the functional outcome after ORIF of extra-articular distal humerus using extra-articular distal humerus locking plate. All 20 patients showed radiographic healing with maintained reductions, with anatomic alignment and with adequate callus. Seventeen patients had an elbow arc of motion of more than 100° and three patients had an arc of motion of <100° because of inadequate mobilization after discharge of which one patient improved with physiotherapy and elbow range of motion (ROM). Early elbow range of movement was initiated in all our cases to avoid stiffness of the elbow joint. Mayo Elbow scoring index showed excellent results in 17 cases, good results in three cases. No case in our study had fair or poor results.

There is no case has the risk of olecranon impingement in the treatment of distal one-third humerus fractures as observed Fawi et al.[9] study.

The advantage of EADHP is that its distal contour removes the risk of olecranon fossa impingement, it has low profile to minimize soft-tissue irritation and it has high density of distal locking screws to maximize the fixation.

In respect to neurovascular injuries, there was no case with preoperative or postoperative radial nerve palsy. Plate prominence was evident in two thin-built individuals which did not have impact on the outcome as there was no pain or restriction of movement. In radiological findings, union was evident in all the cases at the end of the follow-up, with the maintenance of the metaphyseal-diaphyseal angle, humeral-ulnar angle, and shaft-condylar angle. These are some of the benefits attained in extra-articular distal humerus locking plate.

The extra-articular distal humerus locking plate works as a single column plating. There are distal locking screws adequately which increases the stability of the locking construct. The posterior surface of lateral column is nonarticular which gives the advantage of the placement of plate without risk of injury to cartilage and also avoids impingement with flexion and extension.

In this study, we used the triceps splitting approach, extending 8 cm below the anconeus and the olecranon fossa according to the site of fracture.[14] The exposure can be extended proximally and distally; proximal exposure up to the spiral groove and distally up to the olecranon fossa access is effective. This approach has a relatively reduced bloodshed plane, tourniquet was not used in any of our studies. Radial nerve was exposed only if needed and was not exposed routinely, so we did not encounter any nerve injury in our study.

Mayo Elbow Performance Score [Table 4] was used to assess the functional outcome. The questionnaire involves patient's symptoms, ability to perform activities, range of motion, and also the stability of the elbow joint is taken into account.
Table 4: Mayo Elbow Score

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There were limitations to this study, relatively small sample size, and lack of comparison with other methods of management.

Extra-articular distal humerus diaphyseal fractures are challenging as it requires sufficient to hold and stable fixation distally, which are encountered and found to do well with EADHP. These plate osteosyntheses have a benefit of distal curve contouring the lateral condylar ridge posteriorly with angled locking screws distally to maximize stability and fixation with reducing failure chances.


  Conclusion Top


EADHP has been shown to successfully treat distal-third diaphyseal humerus diaphyseal fractures. The advantage of this plate is that the distal locking system reduces the risk of olecranon impingement during flexion or extension, also offers good functional outcomes to these patients in our study group. This system can be considered as the treatment of choice for these types of fractures particularly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rammelt S, Endres T, Grass R, Zwipp H. The role of external fixation in acute ankle trauma. Foot Ankle Clin 2004;9:455-74.  Back to cited text no. 1
    
2.
Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta PD, McKee Mundefined. Rockwood and Greens Fractures in Adults. Philadelphia: Wolters Kluwer Health; 2015. p. 1229-45.  Back to cited text no. 2
    
3.
Scolaro JA, Hsu JE, Svach DJ, Mehta S. Plate selection for fixation of extra-articular distal humerus fractures: A biomechanical comparison of three different implants. Injury 2014;45:2040-4.  Back to cited text no. 3
    
4.
Cantu R, Koval K. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14:183-90.  Back to cited text no. 4
    
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Thakur AJ. Elements of Fracture Fixation. New Delhi: Elsevier; 2015. p. 77-85.  Back to cited text no. 5
    
6.
Jain D, Goyal GS, Garg R, Mahindra P, Yamin M, Selhi HS. Outcome of anatomic locking plate in extraarticular distal humeral shaft fractures. Indian J Orthop 2017;51:86-92.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Gerwin M, Hotchkiss R, Weiland A. Alternative operative exposures of the posterior aspect of the humeral diaphysis. With reference to the radial nerve. J Bone Joint Surg 1996;78:1690-5.  Back to cited text no. 7
    
8.
Kharbanda Y, Tanwar YS, Srivastava V, Birla V, Rajput A, Pandit R. Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach. Strategies Trauma Limb Reconstr 2017;12:1-9.  Back to cited text no. 8
    
9.
Fawi H, Lewis J, Rao P, Parfitt D, Mohanty K, Ghandour A. Distal third humeri fractures treated using the Synthes™ 3.5-mm extra-articular distal humeral locking compression plate: Clinical, radiographic and patient outcome scores. Shoulder Elbow 2014;7:104-9.  Back to cited text no. 9
    
10.
Kumar R, Karwasra A, Kunal K. Study of surgical fixation of extra-articular distal third humerus fractures with a posterolateral locking compression plate. Int J Res Orthop 2019;5:216.  Back to cited text no. 10
    
11.
Anand K, Patel J, Mehta M, Katariya J, Gandhi R. Comparison of outcome of distal humerus fracture: Single extra articular humerus plating versus bipillar plating. Indian J Orthop Surg 2018;4:325-31.  Back to cited text no. 11
    
12.
Gupta RK, Gupta V, Marak DR. Locking plates in distal humerus fractures: Study of 43 patients. Chin J Traumatol 2013;16:207-11.  Back to cited text no. 12
    
13.
Chawda VR, Patel JV, Ninama MD, Hirpara BS. A distal third extra articular humeus fracture treated with precontoured single anatomical locking plate: A retrospective study of 11 cases. Natl J Clin Orthop 2019;3:22-5.  Back to cited text no. 13
    
14.
Hoppenfeld S, DeBoer P, Buckley R. Surgical exposure in Orthopaedics. 4th ed. Philadelphia: Lipincott Williams & Wilkins; 2009. p. 88.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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