|Year : 2022 | Volume
| Issue : 2 | Page : 95-99
Outcome of fixation of distal humerus fracture via paratricipital approach – A prospective study
Sourav Ghosh1, Anindya Maiti2, Ananda Mandal3, Ritwika Nandi3, Gopinath Maiti3
1 Department of Orthopaedics, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karni Memorial Hospital, Kolkata, West Bengal, India
2 Department of Orthopaedics, Medical College, Kolkata, West Bengal, India
3 Department of Orthopaedics, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
|Date of Submission||31-Jan-2022|
|Date of Decision||02-Mar-2022|
|Date of Acceptance||03-Mar-2022|
|Date of Web Publication||28-May-2022|
No. 29/10/A, Hare Krishna Sett Lane, Dum Dum, Kolkata - 700 050, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Fractures of the distal humerus continue to challenge surgeons due to their complex nature and the multiple options of fixation. The olecranon osteotomy approach is considered the gold standard, especially in those fractures with an intra-articular comminution, but is associated with complications. In selected cases, utilizing the triceps-on or paratricipital approach should allow adequate fixation while decreasing the incidence of complications. Methods: Patients with distal humerus fractures were treated with open reduction and internal fixation via the paratricipital approach. All patients were evaluated based on their preoperative and intraoperative parameters. Postoperative rehabilitation was implemented and the functional outcome was assessed based on the range of motion and Mayo Elbow Performance Score. Results: The current study encompassed thirty patients with a mean age of 47.5 years. AO/OTA C1 type fracture was encountered in 13 patients. The mean operative time was around 90 min. The mean elbow flexion at 2 months was 127.5°. Union was achieved in all patients, and one patient had surgical site infection. Conclusion: Metaphyseal and simple inter-articular fractures may be adequately visualized and managed with the above approach. Early rehabilitation allows faster return to normal function.
Keywords: Distal humerus fracture, open reduction and internal fixation, paratricipital approach
|How to cite this article:|
Ghosh S, Maiti A, Mandal A, Nandi R, Maiti G. Outcome of fixation of distal humerus fracture via paratricipital approach – A prospective study. J Orthop Dis Traumatol 2022;5:95-9
|How to cite this URL:|
Ghosh S, Maiti A, Mandal A, Nandi R, Maiti G. Outcome of fixation of distal humerus fracture via paratricipital approach – A prospective study. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Jul 3];5:95-9. Available from: https://jodt.org/text.asp?2022/5/2/95/346211
| Introduction|| |
Distal humerus fractures continue to present as some of the most challenging injuries to manage. They are commonly multi-fragmented, occur in osteopenic bone in low-energy trauma and in younger individuals in high-energy trauma, and have complex anatomy with limited options for internal fixation. A painless, stable, and mobile elbow joint is desired as it allows the hand to conduct the activities of daily living, most notably personal hygiene, and feeding. The risk of functional impairment is relatively high when injuries are managed nonoperatively. Thought is required in determining the operative indications, managing the soft tissues, selecting a surgical approach, obtaining an anatomic articular reduction, and creating a fixation construct that is rigid enough to tolerate early range of motion.
The principles of internal fixation start with the selection of appropriate surgical approach. Most posterior approaches benefit from a posterior longitudinal skin incision which involves the elevation of full-thickness fasciocutaneous flaps. The posterior approaches are classified into three types: olecranon osteotomy, paratricipital (triceps-on), and triceps-off type approaches (such as triceps splitting, triceps reflecting, and the triceps tongue approaches).
The paratricipital approach has several advantages including avoidance of an olecranon osteotomy; therefore, the risk of nonunion and symptomatic olecranon hardware is avoided. In addition, the triceps tendon insertion is not disrupted, allowing early active range of motion. This approach also preserves the innervation and blood supply of anconeus muscle, which provides dynamic posterolateral stability to the elbow. Finally, if further articular exposure is required, the paratricipital approach can be converted into an olecranon osteotomy. The disadvantage of the paratricipital approach is the limited visualization of the articular surface of the distal humerus; therefore, the approach is usually inadequate for fixation of type C3 fractures.
The present study evaluates the paratricipital approach, preserving the triceps muscle and reaching the fracture site through creation of surgical window medial and lateral to triceps muscle and without necessitating an olecranon osteotomy.
| Methods|| |
The study was conducted in a tertiary care center in eastern India. Prior to the commencement of the study, ethical clearance was obtained from the Institutional Review Board (No/NMC/4069). Informed consent was taken from all patients prior to their inclusion. The study population constituted of patients presenting to outdoor and emergency with distal humerus fractures, from January 2017 to July 2018. The abovementioned authors were the treating physicians in all the cases.
Patients of both sexes of any age with closed or GA type I/II fractures of the distal humerus (AO/OTA types A2, A3, B1, B2, C1, and C2) were included in the study. Patients with GA type III wound, triceps laceration, associated olecranon fractures, severe arthritis, adhesive capsulitis, elbow instability, and uncooperative or unfit for surgery were excluded from the study. All the patients underwent surgical fixation within 10 days of admission after undergoing routine preanesthetic investigations. Computed tomography (CT) scan with three-dimensional reconstruction was routinely used for preoperative planning. Preoperative and postoperative clinical details were recorded for all the cases. Patients received preoperative antibiotic during induction of anesthesia, before the application of pneumatic tourniquet. All patients were rehabilitated using the same standard postoperative fracture management protocol by starting mobilization as soon as pain subsided. The length of hospital stay was noted for each case, and complications were also recorded for both the groups. The surgical technique for both the procedures is described below.
Regional anesthesia was preferred. The patients were positioned in lateral decubitus position with a bolster placed between the arm and the chest with the entire upper extremity draped free [Figure 1]. All cases were operated with tourniquet applied over the upper arm. If operative time exceeded more than 1 h 30 min, the tourniquet was deflated. Bony landmarks were marked including olecranon process, subcutaneous border of ulna, and medial and lateral epicondyles. A posterior midline longitudinal incision was made over the lower arm and extended distally beyond the elbow joint. Just above the tip of the olecranon, the incision was curved laterally or medially. It was continued 5 cm distal to tip of the olecranon. Deep fascia incised in the midline and full-thickness skin flaps are developed. Aponeurosis of the triceps exposed. Ulnar nerve palpated on the back of the medial epicondyle. Fascia over the ulnar nerve incised to expose the ulnar nerve. Distally, it was released from the cubital tunnel and dissected to its first branch. Articular branch of the ulnar nerve may be sacrificed.
Deep dissection of the soft-tissue structures was done to either side of the triceps muscle. Distally, dissection was done anterior to the anconeus muscle [Figure 2]a. The articular surface was exposed adequately; the fat pad was excised as and when required. Both columns were exposed after completing the dissection on either side of the triceps. Trochlea could be visualized by flexing elbow. The ulnohumeral joint was distracted by a Penrose drain pulling distally on the olecranon via the sigmoid notch. Provisional fixation was done using k-wires/guidewires once acceptable articular fixation was achieved [Figure 2]b. Definitive fixation was done using cannulated cancellous screws or herbert screws as required [Figure 2]c. Fixation stability and motion arcs were assessed prior to closure.,
|Figure 2: (a) Intraoperative clinical image – The triceps elevated from the bone as a flap. (b) Intraoperative clinical image – Provisional fixation of the fracture. (c) Intraoperative clinical image – Final construct after fixation|
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The ulnar nerve was not anteriorly transposed in any case. Implants were covered with soft tissue to prevent ulnar neuritis. The triceps were attached with the intermuscular septum. A negative suction drain was applied. Plaster of Paris back slab was applied. The drain was removed at 48 h. Suture removal was done on the 14th postoperative day.
The patients were put through active elbow motion of flexion and extension [Figure 3]a and [Figure 3]b pronation and supination within limits of pain from the 5th postoperative day. Patients were reviewed every 2 weeks for the first 2 months and monthly then onward for the next 12 months. The elbow function was assessed based on the range of motion and the Mayo Elbow Performance Score (MEPS).
|Figure 3: (a) Clinical photograph demonstrating the postoperative motion. (b) Clinical photograph demonstrating the postoperative motion|
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| Results|| |
Thirty patients with distal humerus fractures meeting the inclusion criteria presented to the study center within the study period. Thirteen (~43.3%) patients were female and 17 (~56.7%) patients were male. The mean age of the patients included was 47.5 ± 11.89 years. The fractures have been classified based on the AO/OTA Classification System [Figure 4]. The most commonly encountered fracture type was type C1 type. The median time interval from the injury to the surgery was 4.97 ± 1.12 days (range, 3–7 days) and it has no significant effect on read-only memory (ROM) or MEPS (P > 0.05), though delay in surgery decreases MEPS. The mean operative time was 87.47 ± 13.4 min. The mean operative time in type A fractures was less (A2 – 76 min and A3 – 67 min) as compared to type B fracture (B1 – 96 min and B2 – 104 min) and type C fractures (C1 – 110 min and C2 – 94 min). The operative time came out to be inversely related to ROM and MEPS (measured by Spearman's rho method) and significant (P = 0.08 and 0.053, respectively).
|Figure 4: Graph demonstrating the type of distal humerus fracture classified as per the AO/OTA Classification of the patients included in the study|
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All the patients completed the postoperative physical therapy and were motivated to achieve maximum function. The mean duration of follow-up was 6.16 ± 1.2 months. The mean elbow flexion at 2 months was 127.5° (range, 110°–140°). The median arc of motion was 125° (range, 100°–140°), with a mean motion arc of 120.8° (range, 100°–140°) and a median fixed flexion deformity of 5° (range, 0°–20°). Further analysis of the elbow motion arc demonstrated significant differences across fracture types (P = 0.01). The median motion arcs for fracture types A, B, and C were 130° (range, 120°–140°), 130° (range, 125°–130°), and 115° (range, 100°–125°), respectively.
The mean MEPS was good in this study which is 92.17 (standard deviation: 9.25) and showed no significant correlation with age. Mild-to-moderate pain was present in 12 patients (40%), whereas difficulty in combing was there in the case of two patients. The MEPI was good in all types of fracture with a mean of 92.50 in type A fractures, 95 in type B fractures, and 88.85 in type C1 and 88.75 in type C2 fractures. Although MEPS is better in type B fracture than type A in our study, it is not significant as calculated by Kruskal–Wallis test (P = 0.106) and is probably due to small number of cases (3 cases). Union was achieved in all cases; surgical site infection was observed in one case. The case was managed with debridement, intravenous antibiotics, and secondary suturing.
[Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d depicts the preoperative, intraoperative, and postoperative radiograph images in a case of right-sided distal humerus fracture managed with open reduction and internal fixation (ORIF) via paratricipital approach with orthogonal plating.
|Figure 5: (a) Clinical case: Preoperative radiograph. (b) Clinical case: Intraoperative clinical image: Medial plate. (c) Clinical case: Intraoperative clinical image: Lateral plate. (d) Clinical case: Postoperative radiograph|
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| Discussion|| |
The optimal approach for ORIF of distal humeral fractures that provides the surgeon adequate visualization of the distal part of the humerus and the articular surface but minimizes disruption of the soft tissue and elbow extensor mechanism is still a topic of investigation [7,8]. Traditionally, an olecranon osteotomy approach has been the gold standard for distal humeral exposure. There is limited literature regarding elbow motion, functional outcomes, and objective strength assessment following the paratricipital (extensor mechanism-on approach) utilized in this study,. Ali et al. reported that 82% of their patients had normal and 18% had good postoperative triceps muscle strength in their study of elbows treated with an extensor mechanism-on approach; however, objective measurement of triceps strength loss was not reported.
Yadav et al. conducted a study where 25 patients were treated with the paratricipital approach. The average age of the patients was 42.16 years (47.5 years being the average age in the current study). The mean elbow flexion was 121.08° with a range of 94°–142° comparable to 127.5° with a range of 110–140° in the present study. The mean MEPI score was reported to be 94.40 points as compared to this study which reports 92.17 points.
The current study concluded that an overall elbow function assessment revealed a mean MEPI of 92.17 points, with 17 excellent (90–100)), 11 good (75–89), 2 fair (60–74), and no poor grades, which is consistent with the results in other published studies. The median arc of elbow motion was 120.83°, which is a functional motion arc which is also comparable with those in other published studies.,, Morrey et al. studied 15 common activities of daily living and determined that a 100° arc of elbow motion was necessary to accomplish those tasks.
Patel et al. evaluated 43 patients who underwent ORIF at a level 1 trauma center. The most common fracture pattern was reported to be type C (53%) similar to the present study. They reported a larger complication rate as majority of the cases were performed via the posterior olecranon osteotomy approach. The mean duration between the injury and surgery was 3 days, which was about 5 days in the current study.
The decision to use this approach for complex fracture types with substantial intra-articular comminution, such as type C2 or C3 fractures, should be made on a case-by-case basis after careful review of imaging studies and consideration of the surgeon's familiarity with the approach. One of the advantages of this approach is the ease with which it can be converted to an olecranon osteotomy without additional soft-tissue trauma if the reduction cannot be obtained or be adequately assessed intraoperatively.
Amir et al. published a review of current therapy concepts and assessed the evolution of elbow fixation. He advocated the use of triceps-sparing approach in simple and partially articular fractures. Islam et al., concluded that the advantages of the triceps-sparing approaches include less scar formation and less blood loss resulting in a reduced postoperative contracture.
Some limitations of this approach include the inadequate visualisation of anterior and intra-articular fragments. Retaining the reduction is also difficult in this approach due to the presence of olecranon in the field, malreduction may be a complication of this approach due to improper visualization, but overall, this approach has lesser complications than the olecranon osteotomy approach.
| Conclusion|| |
The present study concluded that the paratricipital approach is a good approach in fixation of distal humerus fracture. This approach allows good visualization is cases of metaphyseal fractures and simple intra-articular fractures of distal humerus without any need for an extra osteotomy from lateral and medial windows created beside triceps muscle. Complications related to olecranon fixation such as nonunion, increased chance of elbow stiffness, and hardware-related complications of olecranon fixation can be avoided by this approach, with decreasing surgical time. Early pain-free range of motion exercises can be initiated.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to acknowledge all the faculty members and junior residents who helped relentlessly in conducting our research work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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