|Year : 2023 | Volume
| Issue : 1 | Page : 13-19
Orthogonal dual plating: A reliable choice for complex distal humerus fractures
Anil Kumar Nathi1, Gopal M Shinde2, Baladitya Sarma Sista3, Sivananda Pathri4, Varun Kumar Paka5, Jameer Shaik6, Pramoda Nakka7, Chandana Pathri8
1 Department of Orthopaedics, GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
2 Department of Orthopaedics, SBMT Institute of Medical Sciences and Research Centre, Nashik, Maharashtra, India
3 Department of Orthopaedics, Pinnacle Hospital, Visakhapatnam, Andhra Pradesh, India
4 Department of Orthopaedics, King George Hospital, Visakhapatnam, Andhra Pradesh, India
5 Department of Orthopaedics, Nimra Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India
6 Department of Orthopaedics, Chaitra Hospital, Eluru, Andhra Pradesh, India
7 Department of Orthopaedics, Rangaraya Medical College, Kakinada, Andhra Pradesh, India
8 Department of Orthoapedics, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
|Date of Submission||23-Mar-2022|
|Date of Decision||28-Jul-2022|
|Date of Acceptance||01-Aug-2022|
|Date of Web Publication||27-Dec-2022|
Anil Kumar Nathi
Department of Orthopaedics, GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Distal humerus fractures are difficult to manage and perfect intra-articular reduction is a prerequisite for a successful outcome. Dual plating is the norm, and this may be in the form of orthogonal or parallel plating. Controversy regarding the choice between these modes of plating is a topic of debate. Aims and Objectives: To show that perpendicular or orthogonal plating is an adequate mode of treatment option to handle all patterns of distal humerus fractures compared to later-introduced parallel plating. Patients and Methods: We, here, report a case series of 30 cases of AO type C distal humerus fractures, in patients aged between 20 and 60 years, managed by orthogonal plating. All patients were operated between 2015 and 2019 by a single surgeon at our institute. Results: A total of 22 (73.33%) patients showed good or excellent results. Six (20%) patients had fair results. Two (6.66%) patients had poor results. About 86% of the total patients were satisfied with their outcomes. Conclusion: Orthogonal plating offers a satisfactory outcome in AO type C distal humerus fracture with reasonable functional output through early mobilization due to the inherent stability offered by the construct.
Keywords: Chevron osteotomy, dual plating, Mayo Elbow Performance score, transient ulnar nerve neuropathy
|How to cite this article:|
Nathi AK, Shinde GM, Sista BS, Pathri S, Paka VK, Shaik J, Nakka P, Pathri C. Orthogonal dual plating: A reliable choice for complex distal humerus fractures. J Orthop Dis Traumatol 2023;6:13-9
|How to cite this URL:|
Nathi AK, Shinde GM, Sista BS, Pathri S, Paka VK, Shaik J, Nakka P, Pathri C. Orthogonal dual plating: A reliable choice for complex distal humerus fractures. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:13-9. Available from: https://jodt.org/text.asp?2023/6/1/13/365275
| Introduction|| |
Distal humerus fractures contribute to around 2% to 6% of adult fractures and about 30% of elbow fractures. In younger age groups, high-velocity trauma is the cause compared to elderly where relatively low-energy trauma like simple fall may contribute to fracture. Reconstruction of the distal humerus poses a challenge due to the complexity of anatomy in this region, the osteoporotic nature of bone, the relatively small area available for fixation, and common association with comminution., A poor outcome with permanent disability is usually attributed to these fractures. Open reduction of the fracture is the norm to attain accurate intra-articular correction. Dual plate system is the preferred method of fixation to achieve good results through stable fixation and fracture union. It can be either orthogonal or parallel configuration which offers a stable fixation. However, there is a lot of debate regarding optimal plate position.
| Patients and Methods|| |
This is a prospective observational study of 30 cases of distal humerus fractures of AO Classification type C, with intercondylar extension admitted at our institute, for 4 years between August 2015 and July 2019; all of which were treated surgically with dual plating (orthogonal orientation). The Ethical Committee approval was taken before initiating the study. Informed written consent was obtained from all patients included in the study.
Inclusion criteria were closed, AO type C fractures of the distal humerus in patients aged between 20 and 60 years, attending emergency unit of our institute between August 2015 and July 2019. Patients with a prior history of elbow injury, childhood injuries and deformities, pre-existing neurological conditions affecting the elbow, and those not consenting for the study were excluded from the study. Compound fractures (Grade III and IV), those with associated humerus shaft or forearm fractures, ipsilateral hemiparesis, and medically unfit patients were excluded from the study.
Preliminary examination/evaluation was done to rule out any associated injury. Proper history was taken, and general examination was performed to look for comorbidities. The local examination included ruling out of the presence of any associated wound and neurovascular injury. Radiographic images of the involved elbow included the anteroposterior, lateral, and oblique views [Figure 1]a. CT scan images of the elbow were obtained for joint reconstruction and preoperative planning [Figure 1]b. Routine investigations such as complete blood profile, renal functional test, viral screening, Chest X-ray, and electrocardiogram were done in all patients. An above-elbow plaster of Paris slab and bandage were applied to provide support until definitive fixation of the fracture was performed. After surgical profile screening, patients were posted for surgery after securing their consent (informed, written).
|Figure 1: Preoperative radiological images. (a) X-ray image of the same elbow (b) 3D reconstruction images of elbow|
Click here to view
Patients were operated on the 3rd day on an average with a range of 2–8 days following the injury. In patients with gross swelling, elevation was strictly followed, and surgery was delayed until the swelling subsided significantly.
Key to efficient outcome depends on the sequence of correction [Figure 2]. All the patients were operated under general anesthesia or brachial block. The patient was placed in the prone position on a radiolucent side table with a pneumatic tourniquet applied to the operating arm placed on a side post [Figure 3]a. Preference for prone position in this series is based on the observation that most of the patients with short stature with short bulky arms were better suited for placements of bolsters in this position than lateral. It allows for a better fracture orientation and easy C-arm positioning of all views. Prone position is particularly useful in obese patients. Posterior midline olecranon (Chevron) osteotomy [Figure 3]b approach with a distally directed apex was used in all patients. The absolute anatomical reduction was achieved under direct vision by reducing both columns to the principal bone. Provisional fixation of the reduced fragments was done using pointed clamps and multiple subchondral k-wires [Figure 3]c. Column reconstruction was done after intra-articular reconstruction [Figure 3]d. Orthogonal type of dual plating using medial and posterolateral plates was done [Figure 3]e. Anatomical precontoured column-specific locking compression plates of the 3.5 system (DePuy Synthes Locking Compression Plate (VA LCP) System for distal humerus) were used with the view to provide angular stability. Compression of the fracture at the metaphyseal region was ensured, and differential length of plates was used. Special care was taken to carefully explore and protect the ulnar nerve [Figure 3]f. A curvilinear incision was planned to avoid painful scar over olecranon [Figure 3]g. The first plate is applied on the more stable column fixed in the supracondylar region, followed by the other side. Reconstructed bone fragments should first be fixed to the more stable column, especially useful for the medial column which cannot stand shear forces.
|Figure 2: C-arm images showing sequence of fixation. (a) Pattern of fracture is confirmed on C-arm before fixation. (b) Provisional k-wire fixation is the first step of reconstruction. (c) screw fixation of intercondylar segment done prior to plate application. (d) Application of the first plate on the more stable column. (e) Orthogonal application of the second plate. (f) Fixation of osteotomy shown in lateral view. (g) Immediate postoperative X-ray|
Click here to view
|Figure 3: Key steps in the surgical procedure. (a) Prone positioning of the patient with the operating arm placed on a side post. (b) Chevron osteotomy with a distally directed apex. (c) Provisional k-wire fixation of the fragments to attain perfect intra-articular reduction. (d) Screw fixation of fragments. (e) fixation of plates with screws. (f) Ulnar nerve is secured carefully to avoid impingement by plate. (g) Incision is curved at the olecranon tip|
Click here to view
The plates used should be of different lengths and should end at different levels. The plate on the posterolateral side extends distally up to the posterior edge of capitellum. This construct should ideally have at least three screws each in the proximal and distal column for each applied plate. It is of uttermost importance to check for the range of movements after fixation before wound closure, to rule out any instability and mechanical block. Distal apex-directed Chevron osteotomy at the bare area is productive. Transolecranon approach offers much superior access to the distal humerus.
The average duration of surgery was around 2 h, with the shortest lasting for 1 h 45 min and the longest over 2 h 20 min. Tourniquet, if used, was removed before 1 h 30 min. Once deflated, tourniquet was not reinflated up to the end of the surgery.
All the surgeries were performed at a single center, by a single surgeon with a 10-year-experience in dealing with complex elbow trauma. An above-elbow slab was applied after surgery only in patients with osteoporotic bone quality.
Passive movements of the elbow were started from day two, and active movements were allowed after 2 weeks [Figure 4]. Postoperative immobilization was not done routinely. An above-elbow slab was applied only in patients with osteoporotic bone quality.
|Figure 4: Preoperative and postoperative X-ray image reduction with early rehabilitation protocol. (a) Preoperative X-ray image. (b) Immediate postoperative x ray image showing well-achieved reduction. (c) 2 months postoperative X-ray showing well-sustained reduction. (d-f) Early mobilization to prevent stiffness associated with elbow injuries. (g) Curved incision over elbow that allows early movement. (h-j) Active full range of movements permitted after 2 weeks|
Click here to view
follow-up visits were scheduled at the end of 2, 6, and 12 weeks after surgery. Thereafter, patients were advised to attend the follow-up visits once in every 2 months up to 2 years postsurgery. At each follow-up, a detailed clinical evaluation was done for the assessment of pain, swelling, and restriction of movements. X-ray of the involved elbow was taken [Figure 5]. Assessment of patients' function was made using the Mayo Elbow Performance score (MEPS) compared with the opposite normal elbow [Figure 6].
|Figure 5: Serial follow-up X-rays taken during visits. (a) Immediate postoperative X-ray. (b) 1 month postoperative X-ray. (c) 8 months follow-up X-ray. (d) 1 year follow-up X-ray. (e) 2 years follow-up X-ray. (f) 2 and a ½ years follow-up X-ray|
Click here to view
|Figure 6: Follow-up functional evaluation of a patient from the case series. (a and b) 3D and plane CT images showing the severity of injury, which is an important determinant to the final outcome. (c-e) Functional evaluation at 2 months follow-up (f-j) Functional evaluation at 3 years follow-up|
Click here to view
| Results|| |
A total of 30 patients with AO type C distal humerus fractures were enrolled in the study [Table 1]. All the included patients were successfully followed for an average follow-up period of 2 years (ranges 1½ to 3 years). Patients were followed up for a period ranging between 1½ years and 3 years 8 months with a median follow-up of 2 years. No patients were lost in the follow-up. Patients aged from 20 years to 60 years were included in the study with a mean age of 35 years. Of the 30 patients, 18 (60%) were male and 12 (40%) were female. The right side was involved in 19 (63.33%) of them, while in the remaining 11 (36.66%), the left side was involved. Road traffic accident was the most common mode of injury, followed by self-fall.
The mean time for the bone union was 15.2 weeks with the shortest reported being 10 weeks and the longest taking 24 weeks. No cases of nonunion were reported in this current series. Reasonable degree of anatomical restoration was secured in most of the patients by the orthogonal orientation of plates. The criterion to consider reduction as reasonable during the follow-up was based on the shaft-condylar axis, anterior humeral line, ulnohumeral line, radiocapitellar line, and articular reduction on the follow-up X-rays. Serial X-rays during the follow-up were checked for these lines and signs suggestive of the union in the metaphyseal and articular regions and also for any implant or screw loosening. It was well sustained with adequate stability necessary for early mobilization.
The mean arc of flexion (elbow flexion and extension) was 0°–114°. The mean MEPS was 80, with 22 (73.33%) out of 30 patients showing good (75–89 score) or excellent (90–100 score) results. Six (20%) patients had fair (60–74 score) results. 2 (6.66%) patients had poor (<60 score) results. 26 (86.66%) of the total patients were satisfied with their results and the improvement in visual analog scale (VAS) score they attained at the end of the follow-up (preoperative VAS mean 3 and postoperative VAS mean 8).
Complications noted in the present study were 13.33% (4 out of 30 patients); complications mainly noticed in the present study were superficial infection and transient ulnar nerve neuropathy. Two patients (6.66%) developed superficial infections that resolved over time with a limited course of oral antibiotics. Surgical intervention was not needed in either of them. Two patients (6.66%) developed transient ulna nerve neuropathy that spontaneously resolved without any residual motor weakness or sensory impairment for 4–10 weeks postonset.
| Discussion|| |
Comminution and intra-articular extension are common in distal humerus fractures. Further complex anatomy and lack of sufficient subchondral bone complicate surgical management. Anatomic reduction and column-specific fixation are the cornerstones for a successful outcome. Dual plating offers stable and accurate reduction and allows early mobilization of joint, which is intolerant to immobilization. Orthogonal and parallel orientation are the two popular methods of dual plating. Proper planning before surgery and execution of the same is crucial to a satisfactory outcome.
Orthogonal plating involves the application of two plates, one on the medial column and the other along the posterolateral column. It differs from parallel plating in the orientation of the lateral plate which is applied along the lateral supracondylar ridge. It is useful for complex fracture patterns with impaired bone quality to deliver good results. Orthogonal plating is useful for coronal shear fractures that require posterior-to-anterior fixation to provide additional stability to the intra-articular fractures (Lee SK et al., 2014). Excellent results can be secured through a proper use of this dual mode of plating.
During fracture reduction, provisional bone fixation is the first step that should be performed with K-wires and bone clamps. These K-wires should be placed close to subchondral bone to avoid interference with screw fixation. Maintenance of the original olecranon fossa or recreating it with cortical bone burring forms a useful step in the surgery. Metaphyseal comminution can be addressed by bone graft. Bone quality density has an effect on the screw purchase.
The mean MEPS in the current study was 80; good-to-excellent results were obtained in 73.33% of the patients, which is close to 70% reported by Aslam and Willett. This mean score denotes the degree of functional recovery obtained postsurgery. Overall patient satisfaction after surgery was around 86.66%, while Gofton et al. reported a 93% as satisfaction percentage. The patient satisfaction rate was more than what the MEP score depicted. It may be attributed to the lack of awareness on the part of the patients about minor deficits which may go unnoticed. The mean arc of flexion in the present study was 114°. Gofton et al. reported flexion arc of 122°.
A very few long-term studies, like the Doornberg et al.'s study, in 2007, are available concerning the quality of outcome postdistal humerus fracture management. Complications may surface over a period. Complication rates as high as 48% have been reported in some of the earlier studies on type C, AO distal humerus fractures. Heterotopic ossification, transient ulnar nerve neuropathy, and ankylosis were some of the complications reported by most of the studies. The complication rate in the present study was 13%, of which 50% were of superficial infection and the other half were due to transient ulnar nerve neuropathy. Heterotopic ossification is the most commonly presenting complication varying from 4% to 49% in incidence. No cases of heterotopic ossification were recorded in our study, which may be partly due to the meticulous handling of tissue coupled with early mobilization and prophylactic use of indomethacin (75 mg sustained release, once daily for 3 weeks) in all the patients operated. Babhulkar and Babhulkar 2011, in their study, mentioned the principles to follow to achieve good results and avoid unwanted complications.
The main limitation of the present case series is the small sample size, absence of a control group, and monocentric nature of the study. Randomized controlled trials with a large sample size are necessary to infer useful findings that help to guide in choosing the optimum treatment modality for these fractures.
| Conclusion|| |
Perfect anatomical intra-articular reduction and early mobilization are crucial to obtaining a good radiological and functional outcome in distal humerus fractures. Orthogonal orientation of dual plating fulfills both these objectives. The strength and stability offered by the construct prevent the development of elbow stiffness, which is likely in these injuries. It can resist the deforming forces. We conclude that orthogonal plating is a reliable option for distal humerus fractures irrespective of the fracture pattern with good, consistent and satisfactory outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kumar S, Singh S, Kumar D, Kumar N, Verma R. Intercondylar humerus fracture- parallel plating and its results. J Clin Diagn Res 2015;9:RC01-4.
Aslam N, Willett K. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta orthopaedica belgica 2004;70:118-22.
Kulkarni VS, Saxena S, Kulkarni SG, Shah PB, Dixit P, Arora N, et al
. Management and functional outcome of closed intercondylar distal humerus fractures treated with dual plating in adults. J Trauma Orthop 2016;11:24-9.
Huang JI, Paczas M, Hoyen HA, Vallier HA. Functional outcome after open reduction internal fixation of intra-articular fractures of the distal humerus in the elderly. J Orthop Trauma 2011;25:259-65.
Yu X, Xie L, Wang J, Chen C, Zhang C, Zheng W. Orthogonal plating method versus parallel plating method in the treatment of distal humerus fracture: A systematic review and meta-analysis. Int J Surg 2019;69:49-60.
Newey ML, Ricketts D, Roberts L. The AO classification of long bone fractures: An early study of its use in clinical practice. Injury 1993;24:309-12.
Lee SK, Kim KJ, Park KH, Choy WS. Acomparison between orthogonal and parallel plating methods for distal humerus fractures: A prospective randomized trial. Eur J Orthop Surg Traumatol 2014;24:1123-31.
Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: A critical analysis of 55 cases. Injury 2002;33:511-5.
Reising K, Hauschild O, Strohm PC, Suedkamp NP. Stabilisation of articular fractures of the distal humerus: Early experience with a novel perpendicular plate system. Injury 2009;40:611-7.
Virani SR, Sonone S, Dahapute AA, Panda I, Roy KD. Functional results of communited intra-articular distal humerus fractures treated with bicolumnar plating. J Clin Diagn Res 2017;11:RC01-3.
Longo UG, Franceschi F, Loppini M, Maffulli N, Denaro V. Rating systems for evaluation of the elbow. Br Med Bull 2008;87:131-61.
Gofton WT, Macdermid JC, Patterson SD, Faber KJ, King GJ. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am 2003;28:294-308.
Doornberg JN, van Duijn PJ, Linzel D, Ring DC, Zurakowski D, Marti RK, et al.
Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years. J Bone Joint Surg Am 2007;89:1524-32.
Bryant L, Shnier R, Bryant C, Murrell GA. A comparison of clinical estimation, ultrasonography, magnetic resonance imaging, and arthroscopy in determining the size of rotator cuff tears. J Shoulder Elbow Surg 2002;11:219-24.
Babhulkar S, Babhulkar S. Controversies in the management of intra-articular fractures of distal humerus in adults. Indian J Orthop 2011;45:216-25.
] [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]