Surgical treatment of distal intraarticular humeral fractures in adults (original) (raw)
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Journal of Clinical Orthopaedics and Trauma, 2017
The treatment of intraarticular fractures of the distal humerus is challenging and involves the risk of complications and bad functional results. Anatomical and stable internal fixation with early postoperative mobilization is expected to improve the functional outcomes. The objective of this study was to evaluate the functional and radiological results, along with the complications associated, of open reduction and internal fixation using precontoured anatomical locking LCP plate system for intraarticular distal humerus fractures in adult patients. Methods: This prospective study consist of 31 patients with a mean age of 41.2 years (range 19-62) were treated with open reduction and angular stable internal fixation. All underwent posterior transolecranon surgical approach. Mean follow-up to the final interview was 10 months (from 6 to 20 months). All operated patients were available at the time of last followup. AO classification showed 26 C-fractures (9*13C 1, 12*13C2,5* 13C3) and 5 B-fracture (1* 13B1,1* 13B2,3* 13B3). There were 25 closed fractures and 6 open grade 1 fractures. The clinical followup using Mayo elbow performance score (MEPS) and radiographic follow up with elbow anterior-posterior and lateral view X-rays were performed postoperatively. Results: The mean MEPS was 87.9 points out of 100 (range 55-100) with 61% Excellent, 29% good and 10% fair and poor scores. Mean elbow flexion of 115.8 (range 85-150). The mean deficit in extension was 19 (range 5-35). All olecranon osteotomy were united .Nonunion of distal humerus fracture occurred in 2 cases. Other complications were hardware prominence in 3 cases, superficial infection in 4 cases and Ulnar nerve neuropraxia in 1 case which was recovered uneventfully. Revision surgery was not required in any complication. Conclusion: Open reduction and internal fixation with precontoured distal humerus anatomical locking plate system is a good method of treatment for complex Supra-intercondylar fracture of distal humerus with good functional outcome and low rates of complications. Even though early results are promising, longer term investigations and larger patient groups are necessary to confirm the presented data.
Journal of Shoulder and Elbow Surgery, 2012
Fractures of the distal humerus are uncommon injuries, constituting between 0.5% and 7% of all fractures and 30% of all elbow fractures. 2,15 Up to 96% of these injuries are intercondylar, or AO type C, distal humeral fractures involving the articular surface. 29 These fractures are notoriously difficult to treat, presenting the surgeon with multiple challenges including the complex anatomy of the elbow joint itself, articular surface comminution, and frequently, osteopenic or osteoporotic bone stock. 41 Anatomic reduction of the joint surface, restoration of the overall anatomic axes of the extremity, and stable fixation allowing for early elbow mobilization are keys to achieving a good surgical outcome. 9,16 Early motion is critically important after open reduction and internal fixation (ORIF) of these fractures 32 because the elbow joint capsule is very prone to scarring, and immobilization past 3 weeks has been linked with poorer outcomes. 27,29,39 A number of well-described approaches are at the surgeon's disposal for exposure of the distal humerus. These include the olecranon osteotomy, 9,17-19,21,27,31 triceps-reflecting anconeus pedicle (TRAP), 25 Bryan-Morrey (triceps reflecting), 5 paratricipital (Alonso-Llames, bilaterotricipital, triceps sparing), 1,8,33 triceps splitting (Campbell), 6,42 anconeus flap transolecranon osteotomy, 4 combination triceps split and reflection, 34 and tricepseflexor carpi ulnaris approaches. 12 All involve either detaching or mobilizing the extensor mechanism from the elbow to expose the joint. The triceps-splitting approach (Fig. 1), Bryan-Morrey approach 24 (Fig. 2), paratricipital approach 33 (Fig. 3), and olecranon osteotomy (Fig. 4) are the most commonly used approaches. 10,40 Cadaveric studies have quantified the percentage of articular surface exposed with the various surgical approaches 10,40 and have consistently shown superiority of the olecranon osteotomy with regard to the amount of articular surface exposed. However, the functional result associated with each approach remains unclear because issues such as prolonged immobilization to enable bone-tobone or tendon-to-bone healing, extension weakness, triceps rupture, and need for reoperation continue to hamper outcomes. 9,31,37,40 Thus, controversy remains regarding the optimal approach for use in surgical management of these fractures. Various approaches have their own proponents, with Pollock et al 28 recommending olecranon osteotomy for AO type C distal humeral fractures, Ek et al 14 and Qi et al 30 both recommending a Bryan-Morrey approach, and Ozer et al 26 advocating for the TRAP approach. The purpose of our study was to systematically review the existing literature that compares functional outcomes after ORIF of closed, intra-articular distal humeral (AO type C) fractures by the surgical approach used to determine whether, from an evidencebased standpoint, one approach is associated with a superior functional outcome over another.
Acta orthopaedica Belgica, 2004
The authors present the results achieved in 26 patients who presented with intra-articular fractures of the distal humerus (8 AO type C1, 8 C2 and 10 C3) and who were operatively treated between 1999 and 2001; they were retrospectively evaluated after a mean follow-up period of 70.2 months. There were 12 males and 14 females with a mean age of 46.1 years. After a standard posterior approach with olecranon osteotomy, internal fixation was achieved with unilateral or bilateral plates and screws, or isolated screws and/or Kirschner wires. Anterior intramuscular transposition of the ulnar nerve was performed in 14 of the patients. The results were evaluated using the criteria of Morrey. The results were graded as excellent in 6 patients (23.1%), very good in 15 (57.6%) and fair in 5 (19.3%). Complications included postoperative ulnar nerve palsy (1), wire migration (4), heterotopic ossification (3), infection (2) and material failure (2). The overall re-operation rate was 38.4%. The aut...
National Journal of Clinical Orthopaedics
Introduction: The management of distal humeral fractures has evolved over the last few years. In intra articular fracture of the lower end Humerus the primary goal is to achieve a stable and mobile elbow. Until now, disagreement has existed on how to treat these fractures in elderly patients. Recommendations range from conservative treatment to primary total elbow replacement. So far, reports in the literature on whether or not open reduction and internal fixation in these patients is justified are very rare. Materials and methods: Fifty four patients (Average age 45 years) from Jan 20013 To Dec 2014 were included in this series. There were 38 males and 16 females. Mechanism of injury was fall with back of elbow striking the ground (70%) and Road traffic accident (30%). The author has used AO classification 5 for categorizing the fractures accordingly, 10 fractures were of B2, 14 were B3, 12 were C1 type and 10 belonged to C2 and 8 belonged to C3 Type. Results and discussion: The average follow up was 16 months with a minimum of one year. 14 cases had loss of extension measuring 30 0 and less. Only 12 cases had no loss of extension. Flexion of elbow more than 1200 got recovered in 28 cases. 10 patients had pain in elbow on prolonged activity and changes in weather condition. The final evaluation showed 70 % Excellent and good results, 24% had Fair results and 6% had poor results. When "K' wire alone were used fixation was not stable enough and required longer external immobilization. And delay in start of physiotherapy with consequent loss of movements. Olecranon osteotomy gives better visualization. and reduction of fracture fragments and their articular surface. Conclusion: Rigid Anatomical Fixation & Early Mobilisation is the Key. High complications in Elderly Osteoporotic patients. Younger the patient Better the results. Communition of Fragments show increased Difficulty in Fixation, & results in loss of movements also.
International Journal of Research in Medical Sciences, 2021
Background: Distal humerus fractures are commonly encountered in the orthopedic emergency. The goals in the treatment of these fractures are aimed at perfect anatomical reduction which could be obtained by open reduction and internal fixation.Methods: A prospective cohort study was conducted from July 2019 to December 2020 in Government Medical College, Jammu on 35 patients with AO type C distal humerus fractures. Functional outcomes were recorded and evaluated at end of 6 months using mayo elbow performance score (MEPS) score. 3 patients were lost in the follow up and were not included in the study.Results: 32 patients in the age group 20-65 years were included in the study with a mean age of 42.5 years. Males outnumbered females in ratio of 3:1. Patients undergoing olecranon osteotomy for fixation of distal humerus fractures had mean elbow flexion (121±8.3), loss of elbow extension (10.3±4.2). The functional outcome was made using MEPS score with a mean of 84±8.4 at final follow u...
Turkish journal of trauma & emergency surgery, 2017
BACKGROUND: To investigate the outcomes of patients undergoing open reduction and internal fixation with olecranon osteotomy due to AO type13C fractures of the distal humerus. METHODS: Data of 39 patients (mean age, 44.7 years; males, 56.4%) undergoing surgery with the diagnosis of AO type 13C distal humeral fractures were retrospectively evaluated. Patients' demographic characteristics, medical history, and radiological and functional outcomes were recorded. The patients were evaluated at the final follow-up according to the Mayo Elbow Performance Index (MEPI). RESULTS: The mean degrees of flexion and extension loss were 102.2 degrees (range, 60-120 degrees) and 11.4 degrees (range, 0-25 degrees), respectively, at the final follow-up. According to the MEPI score, outcomes were excellent in seven, good in 12, fair in 13, and poor in seven patients. All patients achieved a radiological union of the fracture site within the first postoperative six months. It was found that the loss of extension was more severe, the range of flexion was decreased, and the mean MEPI score was lower in the patients with type C3 fractures than in those with type C1 and type C2 fractures. No significant difference was determined between fixation techniques (tension band vs. cannulated screw) regarding the functional outcomes. CONCLUSION: Our results revealed better prognosis in AO type C1 and type C2 fractures than in AO type C3 fractures and no different effects of two fixation techniques in olecranon osteotomy on the outcomes.
Controversies in the management of intra-articular fractures of distal humerus in adults
Indian Journal of Orthopaedics, 2011
The surgical approach, type of olecranon osteotomy, method of stabilization of osteotomy, type of fracture stabilization, orthogonal vs parallel plate fixation, need for transposition of ulnar nerve, place for primary total elbow replacement, and type of rehabilitation schedule after surgical fracture treatment are the controversial issues in the treatment of complex intra-articular distal humerus fractures (C2 and C3) in adults. Severe comminution, bone loss, and osteoporosis at the site of distal articular fractures of humerus often lead to unsatisfactory results due to inadequate fixation. We hereby report the outcome of a series of intracondylar fractures of the humerus treated by open reduction and internal fixation and discuss the controversies in light of published literature. Materials and Methods: One hundred and eighty-four patients of intra-articular fractures of distal humerus (C2 and C3) were operated by posterior transolecranon approach between January 1980 and December 2008. Initially, in the first part Chevron intra-articular osteotomy (n=108) was performed out of which 94 have been published in another publication. In later second part (1993 onward), extra-articular olecranon osteotomy (n=76) was routinely performed. Both columns were stably fixed by orthogonal methods; (n=174) however, during the last 2 years, in 10 patients with severe comminution with bone loss, stabilization was achieved by parallel plating. The osteotomy was routinely stabilized by tension band wiring with two parallel K-wires introduced up to the anterior ulnar cortex. The results were evaluated by the staging system of Caja et al. at a minimum follow-up of 2 years. Results: In the first part of the study (n=94), there was delayed union in 4% (n=4), with the fracture taking more than 20 weeks for union. There was delayed union of ulnar osteotomy (n=3) and failure of one tension band wiring, requiring revision. Some loss of motion was seen in 20% of cases and these patients did not achieve full flexion and extension. However, all these patients had useful range of function, with 20°-110° of flexion and full pronation-supination. As per the staging system of Caja et al., the results were in the range of excellent to good in 72% cases (n=67), fair in 19% (n=18), and poor in 9% patients (n=9). In the second part of study (n=90) dual plate fixation of both columns by orthogonal methods (n=80) and parallel plate fixation in 10 patients was performed. The results were excellent to good in 78 patients (86%).
Acta clinica Croatica, 2012
Intra-articular distal humeral fractures (DHF) present great challenge to an orthopedic-trauma surgeon. We analyzed the relationship between functional results of DHF surgical treatment and elements that can affect patient recovery. During the 5-year follow-up study, 32 patients were treated for DHF at our Trauma Department, 30 of them by surgical procedure. Functional results of surgical treatment were scored according to the Jupiter criteria. According to the A-O classification of DHF, there were 11 type A fractures, 5 type B fractures and 14 type C fractures. Postoperative complications were infections, neural lesions, inadequate healing, and instability of osteosynthesis. Analysis of functional results in patients with operated C type fractures according to different elements influencing postoperative result revealed correct healing in 74% of patients, which was statistically significantly higher than the percentage of unsatisfactory results (p < 0.05). Study results provided...
Results after internal fixation of humerus distal fractures in patients aged over 65 years
Revista Española de Cirugía Ortopédica y Traumatología (English Edition), 2014
Introduction and objective: Distal humerus fractures in the elderly frequently associated with poor bone quality and comminution, making it harder to achieve proper osteosynthesis. Our aim is to evaluate the radiological and functional results of open reduction and internal fixation of these fractures. Material and methods: Retrospective study of 26 patients treated by open reduction and internal fixation between the years 2005 and 2010. Mean follow-up was 42 months. At final follow-up, a radiography evaluation (Knirk and Jupiter score) and clinical examination using Mayo Elbow Performance Score and Quick-Disabilities of the Arm, Shoulder and Hand Score was performed. Mean age of the group was 76.8 years (65-89), with 83% of the patients being female. Sixteen patients suffered type C fractures and 8 type A by AO classification. All underwent posterior surgical approach. Results: Mean elbow flexion reached 118.86 • , with a mean extension deficit of 25 •. More than 3 quarters (79.1%) of the patients showed 0-1 grade degenerative changes on the X-ray films at final follow-up. Functional results reached an average 19.87 points on Quick-Disabilities of the Arm, Shoulder and Hand Score, and 85 points on Mayo Elbow Performance Score. Nonunion occurred in 2 cases: distal humerus in one patient and olecranon osteotomy in another. Ulnar nerve neuropraxia was recorded in 2 cases, and radial nerve in one. All 3 recovered uneventfully. Revision surgery was required, with 2 patients needing hardware removal and one a new fixation. Discussion: Treatment by open reduction and internal fixation with plating in elderly people for type A and C distal humerus fractures gives good functional results regarding this population, and thus scarcely disturbs their quality of life.
JPMA. The Journal of the Pakistan Medical Association, 2020
A case series was extracted from the trauma registry at Aga Khan University Hospital from the period June 2015 to June 2019. Included were 16 adult patients who presented with intra-articular distal humerus fracture type C2. The functional, clinical and radiological outcomes of fractures treated with or without olecranon osteotomy up to 12 months follow-up were compared. Outcomes were assessed at 6 weeks, 3, 6 and 12 months re-visits. Among the 16 studied patients, 9 (56%) were males and 7 (44%) were females. In the group without osteotomy, there was a good functional and clinical outcome with a mean Quick Disability of the Arm, Shoulder and Hand score of 32±30 at 3 months post-procedure. Bone healing was noticed at 6 months after surgery. In the osteotomy group, 50%-70% bone union was seen at 3 months post-surgery while fair functional and clinical outcome was achieved at 6 months after surgery.