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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 3-6 |
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Results of intra-articular distal humerus fracture treated with open reduction and internal fixation
Ishani Patel, Tarkik K Amin, Vipul R Makwana, Mrudul M Prajapati, Amit Virabhai Patel, Dhaval R Modi, Shivam K Kavi
Department of Orthopaedics, NHL Medical College, Ahmedabad, Gujarat, India
| Date of Submission | 02-Aug-2022 |
| Date of Decision | 05-Nov-2022 |
| Date of Acceptance | 10-Nov-2022 |
| Date of Web Publication | 27-Dec-2022 |
Correspondence Address:
Shivam K Kavi
Junior Resident, Department of Orthopaedics, Smt. NHL Medical College, Ahmedabad - 380 007, Gujarat
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jodp.jodp_61_22
Introduction: Distal humerus fractures are uncommon injuries that account for fewer than 2% of all adult fractures. The complex shape of the elbow joint, the adjacent neurovascular structures, and the soft-tissue envelope combine to make these fractures difficult to treat. The treatment usually consists of determining the injury mechanism and developing a treatment algorithm to regain full mobility of the joint. Materials and Methods: This is a prospective study of 20 cases of distal humerus intra-articular fracture treated by open reduction and internal fixation at our institute during 2017–2019. All the patients in this study were above 18 years of age. These patients were treated with open reduction and internal fixation either by paratricipital approach for fractures with minimal intra-articular comminution or by olecranon osteotomy approach for fractures with more intra-articular comminution. Results: In this study of 20 patients with distal humerus fracture treated with open reduction and internal fixation with ages ranging from 18–65 years, 13 (65%) were male patients and 7 (35%) were female patients. 12 (60%) patients had fracture on the left side, and 8 (40%) patients had fracture on the right side. 11 (55%) patients sustained fractures following the fall from height, and 9 (45%) patients had fracture due to a road traffic accident. Postoperatively, 2 (10%) patients had superficial infection; both patients recovered with antibiotics. In our study, 17 (85%) patients had excellent results, and 3 (15%) patients had a good result according to the Mayo Elbow Performance Score. Conclusion: Distal humerus intra-articular fractures require anatomical reduction of intra-articular components. Vigorous, active physiotherapy is a must for good results. Rigid internal fixation is best accomplished by low-profile anatomical plate fixation, which provides an optimal biomechanical stability; hence, early mobilization can be started, and a good functional outcome can be achieved with a low complication rate.
Keywords: Distal humerus, internal fixation, intra-articular, plating
How to cite this article:
Patel I, Amin TK, Makwana VR, Prajapati MM, Patel AV, Modi DR, Kavi SK. Results of intra-articular distal humerus fracture treated with open reduction and internal fixation. J Orthop Dis Traumatol 2023;6:3-6 |
How to cite this URL:
Patel I, Amin TK, Makwana VR, Prajapati MM, Patel AV, Modi DR, Kavi SK. Results of intra-articular distal humerus fracture treated with open reduction and internal fixation. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 5];6:3-6. Available from: https://jodt.org/text.asp?2023/6/1/3/365287 |
| Introduction | |  |
Distal humerus fractures are uncommon injuries that account for fewer than 2%[1] of all adult fractures. The complex shape of the elbow joint, the adjacent neurovascular structures, and the soft-tissue envelope combine to make these fractures difficult to treat. In the last 20 years, advances in the science of fracture care have had a dramatic effect on the care of difficult fractures. The injured elbow joint presents more difficulty than almost any other, because it has three joints that move synchronously.
The functions of the elbow joint are essential for performing day-to-day activities such as dressing, eating, and combing hair. Supracondylar fractures of the distal humerus are difficult to treat successfully because they are often associated with significant displacement, comminution, and osteopenia. Treatment of these fractures, both surgical as well as nonsurgical, has been associated with a high rate of complications and poor outcome compared to other injuries.
In the last quarter of a century, improved outcomes have been reported with surgery for distal humerus fractures. The last decade has seen advances in the understanding of elbow anatomy, improvements in surgical approaches, new innovative fixation devices, and an evolution of postoperative rehabilitation protocols, which have vastly improved the results of operative treatment.
An attempt to achieve painless, stable, and mobile elbow requires a systematic approach. The recent treatment protocols support these goals and early postoperative active mobilization. The availability of new implants, however, has increased the reliability of operative stabilization while placing additional demands on the surgeon's expertise. Newer metaphyseal/anatomical plates are precontoured and allow to pass of smaller screws in the distal fragments, which provides a stable fixation and good anatomical alignment. This allows early mobilization without loss of fixation, implant failure, and stiffness.
In this study, we have reviewed the functional results obtained in a series of patients aged 18 years and above with closed intra-articular fractures of the lower end of the humerus treated by open reduction and internal fixation.
| Materials and Methods | | |
This is a prospective study of 20 patients of intra-articular fracture of distal humerus treated with open reduction and internal fixation at our institute between 2017 and 2019 with a minimum follow-up of 6 months.
Patients above 18 years of age having closed fractures who presented within 2 weeks of the injury were included in this study. Patients <18 years of age with open fractures, pathological fracture, and fractures with vascular injury were excluded from this study.
The patients were admitted after primary assessment and general examination. Radiographs and computed tomography (CT) scans with three-dimensional (3D) reconstruction of the affected elbow joint were done. The above-elbow slab was applied.
Patients were then taken up for elective surgery under general anesthesia or interscalene block. Tourniquet was applied as high as possible on the arm and for a limited duration. The patient was placed in the lateral decubitus position. In this position, the arm was rested on a padded bar which allowed elbow flexion up to 120° and easy visualization of the fracture under image intensifier. Among all the approaches, we have used paratricipital approach for fractures with minimal intra-articular comminution, while olecranon osteotomy approach was preferred for fractures with more intra-articular comminution.
The intra-articular fragments were reduced and provisionally fixed with K-wires. If there was no intra-articular comminution, fragments were fixed with a 4.0-mm cannulated screw. If there was comminution with bone loss, one or two fully threaded screws were placed across the condyles avoiding compression of fragments to preserve trochlear width.
The shaft is aligned with the distal fragments and provisionally fixed with K-wires from the medial and lateral columns. The construction of medial and lateral pillars is done, and the complete restoration of the triangle is achieved. Dual plate fixation was done. Plates were generally oriented at 90° to each other with one plate directly medial and other on the posterior aspect of the lateral column.
Fixation of olecranon osteotomy was done with tension band wiring with two parallel K-wires [Figure 1]. | Figure 1: Intraoperative fixation of distal humerus fracture with dual plating and TBW for olecranon osteotomy. TBW: Tension band wiring
Click here to view |
Postoperatively, the posterior above-elbow slab was given. Postoperative radiograph was done. Mobilization was started as per patients' comfort, and fracture fixation was achieved. Injectable antibiotics were given till the 4th postoperative day. After that, oral antibiotics were given till suture removal. Local wound care and dressing were done regularly, and sutures were removed between 12th and 14th postoperative day.
Patients were followed up at 1 month after surgery for clinical and radiological assessments, and active shoulder, elbow, and wrist mobilization were started in most of the patients. Regular follow-up was done at monthly intervals till the fracture union, and after that, every 3 months [Figure 2]. The evaluation of the results was done with the help of the Mayo Elbow Performance Scoring System. | Figure 2: (a) Preoperative X-ray (b) Immediate postoperative X-ray (c) 6 months postoperative X-ray
Click here to view |
| Results | | |
This is a prospective study of 20 cases of distal humerus intra-articular fracture treated by open reduction and internal fixation at our institute during 2017–2019.
All the patients in this study were above 18 years of age. The youngest patient was 18 years old, and the eldest patient was 65 years old. The mean age was 38.75 years.
Thirteen patients were male and seven patients were female. In the Indian society, males are more involved in outdoor activities than females, and so, chances of injury are higher in males. Eight patients had injury on the right arm, and 12 patients had injury on their left arm.
In our study, the most common intra-articular fractures were type-C (19), and only one patient had type B2 fracture because the modes of injury are fall from height and Road traffic accident (RTA), which leads to a high-energy injury; thus, it causes more complex varieties of fracture. Among type-C fractures, type-C1: eight cases, type-C2: 10 cases, and type-C3: one case.
Half of the cases were operated using olecranon osteotomy approach, and half of the cases were operated using paratricipital approach.
The average operative time in our study was 192 min, the minimum being 150 min and maximum being 240 min. This is a technically demanding surgery which requires expertise to get anatomical reduction of the joint.
Mobilization was started after 3 weeks in most of the cases (11 cases – 55%), after 4 weeks in seven cases (35%), and after 2 weeks in one case (5%). In only one case, mobilization was started after 6 weeks as patient had fracture of humerus shaft as well. Mobilization was started between 2 weeks and 4 weeks as per patients' comfort, and fracture fixation was achieved.
Two patients had local infection which was treated by antibiotics. No patients had nonunion, ulnar nerve palsy, implant failure, and olecranon osteotomy nonunion.
There was no incidence of myositis ossificans in the present series that suggest it is a preventable complication by limited soft-tissue dissection, early active mobilization, and prohibition of passive mobilization.
Nonunion of olecranon osteotomy was absent in our series as we have used chevron osteotomy, which is inherently stable, and we took due care in reduction and fixation. In our series, implant failure is absent due to improved implants and better fixation techniques.
In our study, 17 out of 20 patients had 10° or less restriction of extension of the elbow, i.e., nearly full range of motion. The average flexion was 114°. The mean extension deficit in our series was 10.5°. The functional range of motion at the elbow was 75°–120°. All patients achieved a functional range of motion [Figure 3].
In our study, 3 (15%) patients achieved full range of pronation and supination, while 6 (30%) patients had a loss of 10°–20° in pronation and supination, 8 (40%) patients had a loss of 20°–30°, and 3 (15%) patients had a loss of 30°–40°. However, it did not interfere with their routine activities as it is compensated by the movement at the shoulder joint.
All patients in our study returned to their occupation after recovery except one patient, who was on the verge of retirement and retired early due to trauma though he was able to perform all his routine activities.
17 (85%) patients had excellent results, and 3 (15%) patients had a good result. The mean Mayo Elbow Performance Score in our study was 93.5.
| Discussion | | |
The technique recommended by the AO group includes the fixation of articular fragments with cannulated screws, followed by the stabilization of the column by two plates perpendicular to each other. Fixation is generally performed by the use of one plate on the medial column and another plate on the lateral column posteriorly.[2]
The age of patients in this study ranges from 18 years to 65 years, with a mean age of 38.75 years, which is comparable with the Indian series of Patel et al.,[3] in which the mean age was 41.2 years.
There were 13 (65%) male patients compared to 7 (35%) female patients in this study. 12 (60%) patients had fracture on the left side, and 8 (40%) patients had fracture on the right side.
11 (55%) patients sustained fractures following the fall from height, and 9 (45%) patients had fracture due to a road traffic accident. The most common mode of injury, according to Rockwood and Green's fractures for adults[1] and Jupiter et al.[4] series is a fall; however, due to the increasing number of motor vehicles, there is also an increase in the road traffic accident in our series.
2 (10%) patients had a superficial infection, both patients recovered with a proper antibiotic cover. In our study, none of the patients had implant failure, myositis ossificans, postoperative ulnar nerve palsy, and nonunion, which were reported in other studies by Mishra et al.,[5] Singh et al.,[6] and Kaiser et al.[7]
All the patients achieved a functional range of motion.[8]
By evaluating our results by the Mayo Elbow Performance Score, 17 (85%) patients had excellent results, and 3 (15%) patients had good results [Table 1].
Huang et al.[9] showed good-to-excellent results in 100% of patients with type-C distal humerus fractures fixed with two orthogonal plates. Aslam and Willett[10] reported good-to-excellent results in 70% of patients with the mean flexion arc of 112° and grip strength of 82% compared to normal side in 26 patients of type-C distal humerus fractures treated with dual orthogonal plating.
Excellent results are more common with early mobilization due to early active physiotherapy, which decreases fibrosis and intra-articular adhesions.
The management of the lower end of humerus fracture has progressed from a conservative approach in the form of cuff and collar sling, olecranon pin traction, closed reduction and pinning, closed reduction, and plaster immobilization to the modern era of operative management in the form of open reduction and rigid internal fixation.
As it has been pointed out by many investigators, it is notoriously difficult to treat type-C distal humerus fractures. The difficulties can originate from the architecture of the distal humerus or the pattern of fracture itself; often, there is a combination of osteoporosis and comminution. The grade of comminution and osteoporosis makes the reduction and fixation very difficult.
A better understanding of surgical anatomy and biomechanics of elbow joints, the development of new implants, improved surgical techniques as well as newer imaging modalities like 3D reconstruction CT scan have improved the results of operative treatment of supracondylar fractures.
The modern distal humerus anatomical plates are precontoured and allow to pass smaller screws in distal fragments, which provides a good anatomical alignment with a stable fixation. By following the AO principles for reduction and fixation, it is possible to achieve good-to-excellent results in these fractures.
| Conclusion | | |
An active physiotherapy is a must for good results. Rigid internal fixation is best accomplished by low-profile anatomical plate fixation, which provides optimal biomechanical stability; hence, early mobilization can be started, and a good functional outcome can be achieved with a low complication rate.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Distal Humerus Fractures. Rockwood and Green's Fractures in Adults. 8 th ed.,Philadelphia: Lippincott Williams and Wilkins 2015 Vol. 1. Ch. 35.  |
| 2. | Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am 2000;31:103-13. |
| 3. | Patel J, Motwani G, Shah H, Daveshwar R. Outcome after internal fixation of intraarticular distal humerus (AO type B&C) fractures: Preliminary results with anatomical distal humerus LCP system. J Clin Orthop Trauma 2017;8:63-7. |
| 4. | Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am 1985;67:226-39. |
| 5. | Mishra A, Singh V, Chaurasia A, Lakhtakia PK. operative management of intraarticular distal humeral fractures with locking plates. J Evol Med Dent Sci 2015;4:15923-6. |
| 6. | Singh V, Uikey S, Ganvir A, Ds M, Gaur S. Outcome analysis of intercondylar humers fractures treated by locking compression plates. Int J Med Res Rev 2016;4:414-9. |
| 7. | Kaiser T, Brunner A, Hohendorff B, Ulmar B, Babst R. Treatment of supra and intra-articular fractures of the distal humerus with the LCP distal humerus plate: A 2-year follow-up. J Shoulder Elbow Surg 2011;20:206-12. |
| 8. | Vasen AP, Lacey SH, Keith MW, Shaffer JW. Functional range of motion of the elbow. J Hand Surg Am 1995;20:288-92. |
| 9. | Huang TL, Chiu FY, Chuang TY, Chen TH. The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: A critical analysis of the results. J Trauma 2005;58:62-9. |
| 10. | Aslam N, Willett K. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta Orthop Belg 2004;70:118-22. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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