|Year : 2015 | Volume
| Issue : 1 | Page : 11-15
Management of distal humerus fracture is not always a surgeon's nightmare!
Ganesan Ram Ganesan1, Kunal Patel1, Balasugumar Thamadharan2, Vijayaraghavan Phagal Varthi1
1 Department of Orthopaedics, Sri Ramachandra Medical College, Chennai, Tamilnadu, India
2 Devadoss Orthopaedic Hospital, Madurai, Tamilnadu, India
|Date of Web Publication||19-Nov-2015|
Dr. Ganesan Ram Ganesan
Department of Orthopaedics, B2, Sri Ramachandra Medical Centre, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the functional outcome of distal humerus intercondylar fracture treated by open reduction and internal fixation.
Methods: The prospective study of 42 patients with intercondylar humerus fracture treated at Sri Ramachandra Medical Centre between March 2010 and March 2014. The inclusion criteria were age above 19 years, Type C fractures of the distal humerus and closed fracture's. The exclusion criteria were extraarticular fractures of the distal humerus, unicondylar with intercondylar extension and open fractures. The rating system of the Mayo elbow functional scoring system was used. The patients were followed for a minimum of 1-year.
Results: In 42 patients, 26 were males and 16 were females. In our series, we had 81% excellent/good results, 19% fair/poor result. We had complications in 7 patients. Two patients had early Kirschner-wire back out. One patient had an infection, and 4 patients had ulnar nerve neuritis.
Conclusion: Meticulous surgical technique, stable internal skeletal fixation, and early controlled postoperative mobilization are critical factors for a successful outcome. Trans-olecranon approach with the patient in lateral position offers excellent exposure of the articular surface. Arc of motion was more important than the total range of motion. The clinical evaluation did not always correlate with the follow-up radiograph.
Keywords: Distal humerus, intercondylar humerus, olecranon osteotomy, ulnar neuritis
|How to cite this article:|
Ganesan GR, Patel K, Thamadharan B, Varthi VP. Management of distal humerus fracture is not always a surgeon's nightmare!. Afr J Trauma 2015;4:11-5
|How to cite this URL:|
Ganesan GR, Patel K, Thamadharan B, Varthi VP. Management of distal humerus fracture is not always a surgeon's nightmare!. Afr J Trauma [serial online] 2015 [cited 2020 Oct 22];4:11-5. Available from: https://www.afrjtrauma.com/text.asp?2015/4/1/11/169816
| Introduction|| |
Intraarticular fractures of distal humerus are rare and difficult to treat since the original description by Desault in 1811 intercondylar fractures of the distal end of humerus have remained one of the most difficult of all of the fractures to manage. The anatomic complexity of the distal humerus combined with the frequency of comminution and displacement makes surgical reconstruction difficult. Recommendation of treatment has ranged widely from essentially no treatment to operative reduction and internal fixation. Even authors who have recommended open reduction deferred widely in their opinion with regard to the extent and the type of internal fixation to be used, as well as when postoperative mobilization, can be started. In this study, we reviewed the functional results obtained in a series of 42 intercondylar fractures of the distal end of humerus treated by open reduction and internal fixation.
| Methods|| |
A prospective study of 42 intercondylar fractures of distal humerus were internally fixed in Sri Ramachandra University from the period March 2010 to March 2014. The inclusion criteria were age above 19 years, Type C fractures of the distal humerus and closed fracture's. The exclusion criteria were extraarticular fractures of the distal humerus, unicondylar with intercondylar extension and open fractures. We used the classification system of Muller et al. (AO). Fracture assessment was done with X-ray elbow anteroposterior (AP) and lateral views and CT elbow with three-dimensional reconstruction (in the presence of metaphyseal commiuntion and articular comminution).
Surgery was done with the patient in lateral position. A pneumatic tourniquet was used routinely. Through a posterior approach in all the patients, an osteotomy of the olecranon  at the level of trochlea was done. The ulnar nerve was either retracted or transpositioned anteriorly. One-third tubular plate, Asian dynamic compression plate, or reconstruction plates were used to rigidly fix the fracture. Fracture fixation was directed toward achieving sufficient stability to allow early mobilization. The osteotomy of the olecranon was secured with two parallel Kirschner (K) wires piercing the opposite cortex along with tension band wiring. The operative time averaged between 1½ and 2 h. In general, the wounds were closed over suction drains, and active motion of the elbow was started on the 2nd postoperative day. The patients were allowed to carry weight only after radiological union.
The patients were followed for a minimum of 1-year. They were followed at 6 weeks, 3 months, 6 months, 1-year, and annually. Each patient completed a comprehensive questionnaire regarding functional capabilities, residual symptoms, existing disabilities and was examined. AP and lateral radiographs of the involved elbow were made at the follow-up examination. The rating system of the Mayo elbow functional scoring system  was used as per [Table 1]. The data on elbow motion were combined with the patients subjective symptoms to provide an overall functional rating.
| Results|| |
In 42 patients, 26 were males and 16 were females. The age group ranges from 19 to 68 and the mean age was 42. Thirty-four patients had dominant hand fractures. The 42 fractures were classified as C1, C2, and C3. Twelve patients had a C1 fracture, 22 patients had C2 fracture [Figure 1], [Figure 2], [Figure 3], [Figure 4] while the rest had a C3 fracture [Figure 5], [Figure 6], [Figure 7], [Figure 8]. Mode of injury was road traffic accident in 60% of patients while remaining had fractures from fall of an outstretched hand. Six patients had ipsilateral both bones leg fracture, 3 patients had a facial bone fracture, and 1 patient had contralateral patella fracture as associated injuries. The shortest follow-up was 1-year, and the longest was 3 years with a mean follow-up of 27 months. In our series, we had 81% excellent/good results, 19% fair/poor result. We had complications in 7 patients. Two patients had early K-wire back out. One patient had an infection, and 4 patients had ulnar nerve neuritis. The results of our series and the postoperative arc of motions were tabulated in [Table 2] and [Table 3], respectively.
|Table 2: Individualised result of C type fractures based on mayo elbow scoring system|
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| Discussions|| |
Our study was the results of a consistent, controlled surgical treatment at a single institution, making use of current operative techniques, equipment, and controlled postoperative mobilization. We have used the classification system of Muller et al. in our series, because of its simplicity and also because it is well suited for operative considerations. We found that the trans-olecranon approach  with the patient in lateral position offered excellent exposure of the articular surface. The incidence of complications in this series due to this approach was very low. Anatomical reposition and the bone union found to be enhanced by the use of a V-shaped osteotomy of the olecranon. This approach also facilitates identification and protection of the ulnar nerve. Anterior transposition was indicated when the nerve is contused from original trauma or intraoperative retraction, or when the medial implants will cause a mechanical irritation. Emphasis was placed on the accurate restoration of the trochlea. The inherent stability provided by its congruent relationship with the greater sigmoid notch of the proximal part of the ulna makes its anatomical reconstruction important in restoring elbow function and offsetting later degenerative arthritis.
In our technique, the lateral or radial plate is posterior, and therefore at right angles to the medial or ulnar plate; this enhances stability, and is possible because the articular surface of the capitellum is entirely anterior and distal. All the 8 patients (19.64%) who had Type C3 fractures had either a fair or poor score due to articular comminution and metaphyseal commiuntion which hindered not only anatomical reduction but also immediate mobilization. Type C3 fractures were more unstable intraoperatively after fixation when compared to Type C1 or C2 fractures, but the reduced arc of motion and joint stiffness in these fractures was a blessing to stability though functionally it was a disguise. In our series, there were 8 patients with C3 fracture out of which 6 had the fair score and 2 had poor scores.
Of 42 patients in our study, 34 (80.95%) patients had good/excellent results [Figure 9],[Figure 10],[Figure 11],[Figure 12]. This was comparable with Jupiter et al. study of 34 patients 26 (79.4%) patients showed good/excellent results. In a study by Doornberg et al. who had a series of 30 patients, 26 showed good/excellent (86%) results.
Our mean flexion contracture was 18.01°, and mean arc of motion was 100.32° as compared to McKee et al. who had 25° of mean flexion contracture and 108° of mean arc of motion. Our patients were somewhat younger, and our follow-up was shorter when compared to Jupiter  Mayo elbow functional scoring system was useful for it is a simple and surgeon based clinical assessment. The excellent range of motion was rated as only good because of some discomfort noted with exertion and subjective assessment that the elbow was not normal. In this study, those patients having a good arc of motion have good functional results while patients are having a poor arc of motion ended in having fair and poor functional results. This is also evident from Jupiter et al. study also.
We had 4 patients (9.52%) who needed early implant exit (secondary surgery) because of ulnar nerve irritation and K-wire prominence. Early K-wire back out was seen in two cases (4.76%) which was due to poor purchase in the opposite cortex. We had a superficial infection and wound dehiscence in 1 patient (2.35%) because of early K-wire back out which was treated with appropriate antibiotic. We had no nonunion of fractures and olecranon osteotomies. Ulnar nerve neuritis was seen in 4 (9.52%) patients. This was due to implant prominence on the medial side. These patients required early implant removal. The symptoms disappeared after implant removal.
| Conclusion|| |
Trans-olecranon approach with the patient in lateral position offers excellent exposure of the articular surface. Excellent range of motion was rated as only good in some patients because of some discomfort noted with exertion and subjective assessment that the elbow was not normal. The clinical evaluation did not always correlate with the follow-up radiograph. Fifteen degree to 130° is considered as a functional range of motion and though there was an average of 18° loss of extension in our excellent/good cases, it had no effect on the functional outcome. The arc of motion was more important than the total range of motion for the good functional outcome. Type C3 fractures had poorer outcome due to articular commiuntion. From my study, it is evident that meticulous surgical technique, stable internal skeletal fixation, and early controlled postoperative mobilization makes management of distal humerus fracture a sweat dream not a nightmare.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta V, Kalsotra N, Gupta R, Motten T, Singh M, Kamal Y, et al
. Operative management of intercondylar fractures of the distal end humerus in adults. The Internet Journal of Orthopedic Surgery 2009;17:1-5.
Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin, Germany: Springer, 1990.
McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82-A:1701-7.
Black BT, Barron OA, Townsend PF, Glickel SZ, Eaton RG. Stabilized subcutaneous ulnar nerve transposition with immediate range of motion. Long-term follow-up. J Bone Joint Surg Am 2000;82-A:1544-51.
Morrey BF, An KN. Functional evaluation of the elbow. In: Morrey BF, editor. The Elbow and its Disorders. 3rd
ed. Philadelphia: WB Saunders; 2000. p. 82.
Tak SR, Dar GN, Halwai MA, Kangoo KA, Mir BA. Outcome of olecranon osteotomy in the trans-olecranon approach of intra-articular fractures of the distal humerus. Ulus Travma Acil Cerrahi Derg 2009;15:565-70.
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.
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.
Jupiter JB. Fractures of distal humers. In: Morrey BF, editor. The Elbow and its Disorders. Philadelphia: W.B. Saunders; 1993.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3]