- Email: [email protected]
Double tension band osteosynthesis in supra- and transcondylar humeral fractures
305
Double tension band osteosynthesis in supra- and transcondylar humeral fractures P. F. J. Houben’, K. J. BongerG and F. A. J. M. v. d. Wildenberg’ ‘University
Hospital
Maastricht,
The Netherlands,
%ophia Hospital
Distal i&a-articukar bicondylar humeraIfractures are usually treated by means of cancellotls screw(s) for the condylar block and one or two plates for fixation of the block to the shaft. The method and results of double tension band osteosynthesis instead of double plating forjixation of the condylar block to the shaft are desrribed here. The advantages of double fension band wiring are an easier and faster procedure, less periosteal and muscle damage, and symmetrical compression. The functional resulfs and complications of patients treated by this method are compared with the results of patients treated wifh plate fiation,
Injury,
1994, Vol. 25,305-309,
July
Introduction Treatment of intra-articular bicondylar fractures of the distal humerus is difficult. Until 30 years ago treatment consisted of plaster splintage, traction or functional therapy. Poor results were achieved (Krotschek et al., 197.3; Gabel et al., 1987; Henley, 1987). In the 1960s a more aggressive approach was gradually adopted, partly under influence of the Arbeifsgemeinschaff fiir Osfeosynfhesefragen (AO). By means of rigid internal fixation, an anatomical reduction and early mobilization were obtained. The functional results have improved (as supported by most references in the Reference list). Although several scoring Table I. Results of operative treatment of i&a-articular
Lob et al. (1984) Jupiter et al. (1985) Henley (1987) Gabel et al. (1987) Seiler and Trentz (1988) Waddell et al. (1988) Holdsworth and Massad (1990) Kizl and Fleischmann (1991) Sodergard et al. (1992) Sodergard et al. (1992) Noack et aLb (1987), seniors Feil et al. (1988), openC
Zwolle, The Netherlands
systems were used in the evaluation of functional results, most series produced a figure of f 80 per cent of operated cases with ‘good or excellent results’ (see TableI). The fixation technique most often used is that advocated by the AO: reconstruction of the condylar block using a cancellous screw, and fixation of this block to the shaft using two plates. If necessary a spongiosaplasty can be performed. These authors’ impression is that, especially in the shaft-to-block fixation, non-union or delayed union occurred frequently. A study of the literature of the last decade revealed a f5 per cent incidence of definitive non-union and a 15 per cent incidence of early fixation problems, such as loss of reduction and loosening of material (see Table I). Double-sided tension band osteosynthesis represents an alternative method of fixation. It carries the theoretical advantages of less devitalization of minor fragments, less muscle damage and better compression. The authors investigated the results of patients who presented with an intra-articular bicondylar fracture in a 5 year period and who were treated by either tension band wiring or plate fixation.
Materials and methods Between January 1987 and April 1992,lO patients presented to the University Hospital Maastricht with an intraarticular bicondylar Y-shaped fracture of the distal hum-
distal humeral fractures
N
Plates used
Non-union
%
Fixation problems
412 34 33 10 81 46 57 50 96 61 16 60
? 15 All? 10 *40 27 ? ? 7 ? 14 ?
21 2 3 0 4 2 1 3 3 4 1 7
5.2 5.9 9.1 0 4.9 4.3 1.6 6.0 3.1 6.6 6.3 11.7
? 2 5 0 7 2? 4 5 16 18 1 22
Infections 12 : 0 4 1 1 6 ? 0 18
Nerve IesionsS
Good or excellent result
40 5 0 0 &-) 29 (2) 0 12 (3) 13 3 20 (9)
BNumber of permanent lesions, if indicated, given in parentheses; bonly patients over 60 years of age; “only open fractures; ?= not from fext. 0 1994 Butterworth-Heinemann 0020-1383/94/050305-05
Ltd
*60% 27134 23125 s/10 37159 24127 44157 ? ? 52/61 12114 20160
evident
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No.
306
5
Table II. Patient data and results
Patient 1 2 3 4
Sex F M M M
Age (years) 67 69 49 15
Ctassification’ 13~3.2 ~3.2 c2.2 c2.1
Fixation method* 2 2 1 1
PI W6) ~1 (W)
PI (10) PI (7)
Operation time (min)
Postoperative immobilization (weeks)
180 140 180 240
2 2 4 2
Consolidation (weeks) 13
ComplicationsC Infection Non-union
13 9
~3.2 2 PI (7/5) 180 2 10 5 F 77 Average 55 years; (average operation time 184 minutes; average consolidation 11.25 weeks. 6 7 8 9 10 Average
F
76
M F
81 63 F 27 F 61 61 years; average
cl.2
2TW
190
0
Re-osteosyntheses ~3.2 2TW 150 0 2b M 69 c2.2 1 PI (8) 240 0 9b F 27 Average operation time 195 minutes; average consolidation 13 weeks
13 13
Subjective reslIlP
o-35-1 40 O-40-1 30 o-1 o-1 50
g P f e
O-20-1
g
10
o-1 o-1 40
e
PA0 PTD Non-union
O-25-1 10 o-o-1 50 o-1 o-1 20
g e P e
PRNP TRNP
O-20-1 50 o-1 o-1 30
g g
15
c2.2 1 T’A’/t PI (6) 135 13 cl.1 2Tw 110 S 8 c2.2 2 T’A’/l PI (8) 270 6 ~3.2 2TW 180 0 9 operation time 177 minutes; average consolidation 11.25 weeks.
Raflge of motio&
‘Fracture classification according to A0 (Mueller et al., 1991); bOne or two cancellous screws were always used to reconstruct the condylar block; in patients 2b and 9b (re-operations after 4 months) autologous bone graft was added; (pl= plates, TW= tension wire; hole length of the plates used is given in parentheses); CPAO = peri-articular calcification, PTD = post-traumatic dystrophy, PRNP = permanent radial nerve palsy, TRNP =temporary radial nerve palsy; drange of motion according to AMA guidelines (1988) (0= neutral position (full extension); normal range O-O-1 50; figures indicate, respectively, neutral position - maximal extension - maximal flexion); ‘p= poor, f =fair. g= good, e = excellent.
Figure 2. I, A step in the normal double plating osteosynthesis:
temporary fivation with K-wires while adjusting the plates (reproduced with permission from the A0 manual); b, simple conversion of the K-wire fixation to a double tension band wire osteosynthesis.
Figure 1. Positioning
of the patient. A bloodless field is not used. Bilateral incisions to allow for an olecranon osteotomy are made if necessary.
erus. All fractures were classified according to the A0 fracture classification. The choice of fixation method depended on the trauma surgeon on call: five patients were
treated primarily with double tension band wiring and five patients primarily with plating. Patient data are summarized in Table II. Age, sex and fracture classification were similar in the two groups. Upon operation all patients were placed in a lateral position with the injured humerus on a rest, the forearm hanging down (see Figure I). A bloodless field was not used. Medial and lateral incisions (ulnar and radial) were made, distally interconnected at the ulnar ridge to allow for an olecranon osteotomy (see Figure I). In this way a perfect view of the humeral articular surface was obtained. In both groups the condylar block was reconstructed first using one 6.0 mm or two 4.00 mm cancellous screws, or sometimes one cancellous screw and one K-wire. In the ‘plated group’, 3.5 mm dynamic compression plates of varying
Houben et al.: Double tension band osteosynthesis in humeral fractures length were applied. In the ‘tension band group the K-wires which were used to provide a temporary fixation of the block to the shaft were incorporated in a tension band wire at the ulnar and radial side. Proximally, small 2.0 mm holes were drilled, through which to pass the wire. All olecranon osteostomies were fixed by tension band wiring as well. In each case a suction drain was used for 24 h. All osteosyntheses were considered to be stable at operation, and no additional immobilization was considered necessary. However, postoperatively the elbow was immobilized for 2 weeks in six patients for wound healing purposes. Additional immobilization was given in two patients because of persistent swelling and a haematoma, with a subsequent delayed skin healing. All patients were re-examined after an average time of 2.5 years (range 0.5-5.5 years) and were asked for a subjective assessment of the result.
Results In both groups one case of non-union occurred after 4 months. Treatment consisted of tension band wiring in the case of a failed plate osteosynthesis and plate fixation in the other, leaving 12 cases for evaluation. The final results are listed in Table II.
Figure 3. a, Y-type fracture (13~3.2) in a 61-year-old
307
Excluding the two cases of non-union, the average time of consolidation in both groups was 11.25 weeks. After both re-osteosyntheses (including cancellous bone grafting) consolidation took slightly longer (13 weeks). Both re-osteosyntheses resulted in a radial nerve palsy, one temporary and the other permanent. Exploration in the latter case revealed an irreparable transection. One superficial infection was seen, and was treated with open drainage. After this procedure healing was uneventful. One patient developed a post-traumatic dystrophy, which resolved completely after 6 months with adequate physical therapy. In one case peri-articular calcification occurred, with a slight restriction of range of motion. This patient, however, suffered no pain, and was completely satisfied. The range of motion in both groups was the same. Five patients judged their results as excellent and four as good; one patient considered the outcome to be poor because of a flexion deficit of 40”, loss of power and inability to continue his job in construction. At the patients’ request the osteosynthesis material was removed in six cases, after which no deterioration of function occurred.
patient; b, tension band wiring is possible after reduction of the complex fracture to two fragments. The condylar block is reconstructed using two cancellous screws; a loose fragment is fixed to the shaft using a lag screw. The double tension band is then applied. The tension wire is elevated from the bone surface, demonstrating optimal compression at the fracture site.
308
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No.
Discussion Bicondylar intra-articular fractures of the distal humerus are difficult to treat and form a challenge to surgeons performing osteosyntheses. However, operative treatment leads to better functional results (as supported by most references in the Reference list). As these procedures take several hours, a bloodless field cannot be used. The most important complications of operation are iatrogenic nerve injury (mostly reversible), infection and periarticular ossification. Furthermore, breakage of implants may occur. Almost all studies report a number of mechanical complications, such as loosening or breakage of material and partial loss of reduction, often resulting in non-union. One contributory factor may be that few surgeons have the opportunity to attain enough experience with this rather rare complex fracture. A second factor is the thin cortical bone. In most reports a full description of the material used for internal fixation is absent. It should be noted that double plating appears to be superior to single plating or to the use of screws and Kirschner wires alone (Gabel et al., 1987; Feil et al., 1988; Helfet and Hotchkiss, 1990; Sodergard et al., 1992). Both the A0 manual (Mueller et al., 1991) and Schatzker and Tile (1987) advise the use of double plates in Y-shaped fractures. The authors have described double tension band wiring as a method of internal fixation. This has scarcely been reported (Noack et al., 1987). The method was originally developed by the second author (Bongers, in press) and applied in the authors’ clinic. The results were evaluated in
5
a relatively homogeneous group, and compared with patients treated with plates. No important differences were found. The advantages of the method are an easier and faster procedure - as only K-wires need to be used, and these are already present for initial fixation (Figure2) - and less damage to muscle and periosteum. Finally, it is much easier to achieve symmetrical interfragmentary compression with tension band wiring than with plating (Figure.3). It is not recommended for severely comminuted fractures since the cortices lack support for compression. In the authors’ opinion, double plating including a bone graft is necessary in such cases. Osteoporosis presents a problem in either method, but, as can be seen from the figures, acceptable results can be obtained. After mechanical failure one should not hesitate to perform re-osteosynthesis (Figure 4), since the results are better compared with conservative treatment (Holdsworth and Mossad, 1990; Kinzi and Fleischmann, 1991). Although nerve injury is reported to occur more often after re-osteosyntheses (Feil et al., 1988), Sodergard et al. (1992) showed that even re-osteosynthesis may yield good results. The present report seems to confirm this statement. In the authors’ opinion, tension band wiring is also a good choice in cases of re-osteosynthesis.
Conclusion Operative treatment of intra-articular bicondylar fractures of the distal humerus and reosteosynthesis after mechanical failure and non-union lead to a satisfactory functional result. Tension band wiring offers an easy and equivalent alternative to dual plating in such cases.
References American Medical Association (1988) Guide to the Eva&ion of PermanentImpaimzent. 3rd Ed.
Bongers K. J. (in press) Eine einfache Method zur Stabilisierung der supra-condylaeren Oberarmfraktur. Aktuelk Tyaumtologic.
Figure4
a, Y-fracture (13~3.2) and b, re-osteosynthesis of a non-union with tension band wiring in a 69-year-old patient. In this case a cancellous bone graft was added. This resulted in a permanent radial nerve palsy but otherwise the functional result
was good (O-20-150).
Houben et al.: Double tension band osteosynthesis
Feil J., Buni C. and Kiefer H. (1988) Offene Frakturen des Ellbogengelenkes. Orthopuede 17,272. Gabel G. T., Hanson G., Bennett J. B. et al. (1987) IntraarticuJar fractures of the distal humerus in the adult. Clin Orth. 216,99. Helfet D. L. and Hotchkiss R. N. (1990) Internal fixation of the distal humerus: a biomechanical comparison of methods. _J.Orthop. Trauma 4, 260. Henley M. B. (1987) lntraarticular distal humeral fractures in adults. Orthop. Clin. North Am. 18,11. Holdsworth B. J. and Mossad M. M. (1990) Fractures of the adult distal humerus. Elbow function after internal fixation. /. Bone joint Surg. [Br] 72,362. Jupiter J. B., Neff U., HoJzach P. and Ahgoewer M. (1985) Intercondylar fractures of the humerus. An operative approach. J. Bone loint Surg. [Am] 67, 226. KinzJ L. and Fleischmann W. (1991) The treatment of distal upper arm fractures. Unfallchimrg 94,455. Krotschek H., Jahna H. and Wittlich H. (1973) Die Brueche am distalen Oberannende. Hefre Unfallkeilk. 114, 37. Lob G., Burri C. and Feil J. (1984) Die operative Behandlung von distalen intraartikulaeren Humerusfrakturen: Ergebnis von 412 nachkontrollierten Faellen (A0 Sammelstatistik). Langenbecks Arch. Ckir. 364, 357.
THE ANNUAL
309
in humeral fractures
Mueller M. E., AJJgoewer M., Schneider R. and Willenegger H. eds (1991) Manual ofInternal Fixufion. 3rd Ed. Berlin: Springer. Noack W., Kreusch-Brinker R. and Trepte C. T. (1987) Indications and results of the surgical treatment of distal intraarticuJar humeral fractures in the elderly. Z. Ortkop. 125, 233. Schatzker J. and Tile M. eds (1987) IIre Rationale of Operative Fracture Care. Berlin: Springer. Seiler H. and Trentz 0. (1988) Bikondylaere Frankturen. Ortkopaede 17, 262. Sodergard J., Sandelin J. and Bostman 0. (1992) Mechanical failures of internal fixation in T and Y fractures of the distal humerus. J. Trauma 33, 687. Waddell J. P., Hatch J. and Richards R. (1988) Supracondylar humeral fractures - results of surgical treatment. J. Trauma 28, 1615.
Paper accepted
IO March 1994.
Requests for reprints should be addressed to: P. Houben, Department of General Surgery, University Hospital AZM, Postbox 5800, 6202 AZ Maastricht, The Netherlands.
GENERALMEETING OF THE
BRITISH TRAUMA SOCIETY FRIDAY7~13 & SATURDAY~TH OCTOBER,1994 LONDON Further information:
Mr F.W. Cross Department of General Surgery The Royal London Trust Whitechapel London El 1BB Telephone: 071 377 7000
Double tension band osteosynthesis in supra- and transcondylar humeral fractures P. F. J. Houben’, K. J. BongerG and F. A. J. M. v. d. Wildenberg’ ‘University
Hospital
Maastricht,
The Netherlands,
%ophia Hospital
Distal i&a-articukar bicondylar humeraIfractures are usually treated by means of cancellotls screw(s) for the condylar block and one or two plates for fixation of the block to the shaft. The method and results of double tension band osteosynthesis instead of double plating forjixation of the condylar block to the shaft are desrribed here. The advantages of double fension band wiring are an easier and faster procedure, less periosteal and muscle damage, and symmetrical compression. The functional resulfs and complications of patients treated by this method are compared with the results of patients treated wifh plate fiation,
Injury,
1994, Vol. 25,305-309,
July
Introduction Treatment of intra-articular bicondylar fractures of the distal humerus is difficult. Until 30 years ago treatment consisted of plaster splintage, traction or functional therapy. Poor results were achieved (Krotschek et al., 197.3; Gabel et al., 1987; Henley, 1987). In the 1960s a more aggressive approach was gradually adopted, partly under influence of the Arbeifsgemeinschaff fiir Osfeosynfhesefragen (AO). By means of rigid internal fixation, an anatomical reduction and early mobilization were obtained. The functional results have improved (as supported by most references in the Reference list). Although several scoring Table I. Results of operative treatment of i&a-articular
Lob et al. (1984) Jupiter et al. (1985) Henley (1987) Gabel et al. (1987) Seiler and Trentz (1988) Waddell et al. (1988) Holdsworth and Massad (1990) Kizl and Fleischmann (1991) Sodergard et al. (1992) Sodergard et al. (1992) Noack et aLb (1987), seniors Feil et al. (1988), openC
Zwolle, The Netherlands
systems were used in the evaluation of functional results, most series produced a figure of f 80 per cent of operated cases with ‘good or excellent results’ (see TableI). The fixation technique most often used is that advocated by the AO: reconstruction of the condylar block using a cancellous screw, and fixation of this block to the shaft using two plates. If necessary a spongiosaplasty can be performed. These authors’ impression is that, especially in the shaft-to-block fixation, non-union or delayed union occurred frequently. A study of the literature of the last decade revealed a f5 per cent incidence of definitive non-union and a 15 per cent incidence of early fixation problems, such as loss of reduction and loosening of material (see Table I). Double-sided tension band osteosynthesis represents an alternative method of fixation. It carries the theoretical advantages of less devitalization of minor fragments, less muscle damage and better compression. The authors investigated the results of patients who presented with an intra-articular bicondylar fracture in a 5 year period and who were treated by either tension band wiring or plate fixation.
Materials and methods Between January 1987 and April 1992,lO patients presented to the University Hospital Maastricht with an intraarticular bicondylar Y-shaped fracture of the distal hum-
distal humeral fractures
N
Plates used
Non-union
%
Fixation problems
412 34 33 10 81 46 57 50 96 61 16 60
? 15 All? 10 *40 27 ? ? 7 ? 14 ?
21 2 3 0 4 2 1 3 3 4 1 7
5.2 5.9 9.1 0 4.9 4.3 1.6 6.0 3.1 6.6 6.3 11.7
? 2 5 0 7 2? 4 5 16 18 1 22
Infections 12 : 0 4 1 1 6 ? 0 18
Nerve IesionsS
Good or excellent result
40 5 0 0 &-) 29 (2) 0 12 (3) 13 3 20 (9)
BNumber of permanent lesions, if indicated, given in parentheses; bonly patients over 60 years of age; “only open fractures; ?= not from fext. 0 1994 Butterworth-Heinemann 0020-1383/94/050305-05
Ltd
*60% 27134 23125 s/10 37159 24127 44157 ? ? 52/61 12114 20160
evident
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No.
306
5
Table II. Patient data and results
Patient 1 2 3 4
Sex F M M M
Age (years) 67 69 49 15
Ctassification’ 13~3.2 ~3.2 c2.2 c2.1
Fixation method* 2 2 1 1
PI W6) ~1 (W)
PI (10) PI (7)
Operation time (min)
Postoperative immobilization (weeks)
180 140 180 240
2 2 4 2
Consolidation (weeks) 13
ComplicationsC Infection Non-union
13 9
~3.2 2 PI (7/5) 180 2 10 5 F 77 Average 55 years; (average operation time 184 minutes; average consolidation 11.25 weeks. 6 7 8 9 10 Average
F
76
M F
81 63 F 27 F 61 61 years; average
cl.2
2TW
190
0
Re-osteosyntheses ~3.2 2TW 150 0 2b M 69 c2.2 1 PI (8) 240 0 9b F 27 Average operation time 195 minutes; average consolidation 13 weeks
13 13
Subjective reslIlP
o-35-1 40 O-40-1 30 o-1 o-1 50
g P f e
O-20-1
g
10
o-1 o-1 40
e
PA0 PTD Non-union
O-25-1 10 o-o-1 50 o-1 o-1 20
g e P e
PRNP TRNP
O-20-1 50 o-1 o-1 30
g g
15
c2.2 1 T’A’/t PI (6) 135 13 cl.1 2Tw 110 S 8 c2.2 2 T’A’/l PI (8) 270 6 ~3.2 2TW 180 0 9 operation time 177 minutes; average consolidation 11.25 weeks.
Raflge of motio&
‘Fracture classification according to A0 (Mueller et al., 1991); bOne or two cancellous screws were always used to reconstruct the condylar block; in patients 2b and 9b (re-operations after 4 months) autologous bone graft was added; (pl= plates, TW= tension wire; hole length of the plates used is given in parentheses); CPAO = peri-articular calcification, PTD = post-traumatic dystrophy, PRNP = permanent radial nerve palsy, TRNP =temporary radial nerve palsy; drange of motion according to AMA guidelines (1988) (0= neutral position (full extension); normal range O-O-1 50; figures indicate, respectively, neutral position - maximal extension - maximal flexion); ‘p= poor, f =fair. g= good, e = excellent.
Figure 2. I, A step in the normal double plating osteosynthesis:
temporary fivation with K-wires while adjusting the plates (reproduced with permission from the A0 manual); b, simple conversion of the K-wire fixation to a double tension band wire osteosynthesis.
Figure 1. Positioning
of the patient. A bloodless field is not used. Bilateral incisions to allow for an olecranon osteotomy are made if necessary.
erus. All fractures were classified according to the A0 fracture classification. The choice of fixation method depended on the trauma surgeon on call: five patients were
treated primarily with double tension band wiring and five patients primarily with plating. Patient data are summarized in Table II. Age, sex and fracture classification were similar in the two groups. Upon operation all patients were placed in a lateral position with the injured humerus on a rest, the forearm hanging down (see Figure I). A bloodless field was not used. Medial and lateral incisions (ulnar and radial) were made, distally interconnected at the ulnar ridge to allow for an olecranon osteotomy (see Figure I). In this way a perfect view of the humeral articular surface was obtained. In both groups the condylar block was reconstructed first using one 6.0 mm or two 4.00 mm cancellous screws, or sometimes one cancellous screw and one K-wire. In the ‘plated group’, 3.5 mm dynamic compression plates of varying
Houben et al.: Double tension band osteosynthesis in humeral fractures length were applied. In the ‘tension band group the K-wires which were used to provide a temporary fixation of the block to the shaft were incorporated in a tension band wire at the ulnar and radial side. Proximally, small 2.0 mm holes were drilled, through which to pass the wire. All olecranon osteostomies were fixed by tension band wiring as well. In each case a suction drain was used for 24 h. All osteosyntheses were considered to be stable at operation, and no additional immobilization was considered necessary. However, postoperatively the elbow was immobilized for 2 weeks in six patients for wound healing purposes. Additional immobilization was given in two patients because of persistent swelling and a haematoma, with a subsequent delayed skin healing. All patients were re-examined after an average time of 2.5 years (range 0.5-5.5 years) and were asked for a subjective assessment of the result.
Results In both groups one case of non-union occurred after 4 months. Treatment consisted of tension band wiring in the case of a failed plate osteosynthesis and plate fixation in the other, leaving 12 cases for evaluation. The final results are listed in Table II.
Figure 3. a, Y-type fracture (13~3.2) in a 61-year-old
307
Excluding the two cases of non-union, the average time of consolidation in both groups was 11.25 weeks. After both re-osteosyntheses (including cancellous bone grafting) consolidation took slightly longer (13 weeks). Both re-osteosyntheses resulted in a radial nerve palsy, one temporary and the other permanent. Exploration in the latter case revealed an irreparable transection. One superficial infection was seen, and was treated with open drainage. After this procedure healing was uneventful. One patient developed a post-traumatic dystrophy, which resolved completely after 6 months with adequate physical therapy. In one case peri-articular calcification occurred, with a slight restriction of range of motion. This patient, however, suffered no pain, and was completely satisfied. The range of motion in both groups was the same. Five patients judged their results as excellent and four as good; one patient considered the outcome to be poor because of a flexion deficit of 40”, loss of power and inability to continue his job in construction. At the patients’ request the osteosynthesis material was removed in six cases, after which no deterioration of function occurred.
patient; b, tension band wiring is possible after reduction of the complex fracture to two fragments. The condylar block is reconstructed using two cancellous screws; a loose fragment is fixed to the shaft using a lag screw. The double tension band is then applied. The tension wire is elevated from the bone surface, demonstrating optimal compression at the fracture site.
308
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No.
Discussion Bicondylar intra-articular fractures of the distal humerus are difficult to treat and form a challenge to surgeons performing osteosyntheses. However, operative treatment leads to better functional results (as supported by most references in the Reference list). As these procedures take several hours, a bloodless field cannot be used. The most important complications of operation are iatrogenic nerve injury (mostly reversible), infection and periarticular ossification. Furthermore, breakage of implants may occur. Almost all studies report a number of mechanical complications, such as loosening or breakage of material and partial loss of reduction, often resulting in non-union. One contributory factor may be that few surgeons have the opportunity to attain enough experience with this rather rare complex fracture. A second factor is the thin cortical bone. In most reports a full description of the material used for internal fixation is absent. It should be noted that double plating appears to be superior to single plating or to the use of screws and Kirschner wires alone (Gabel et al., 1987; Feil et al., 1988; Helfet and Hotchkiss, 1990; Sodergard et al., 1992). Both the A0 manual (Mueller et al., 1991) and Schatzker and Tile (1987) advise the use of double plates in Y-shaped fractures. The authors have described double tension band wiring as a method of internal fixation. This has scarcely been reported (Noack et al., 1987). The method was originally developed by the second author (Bongers, in press) and applied in the authors’ clinic. The results were evaluated in
5
a relatively homogeneous group, and compared with patients treated with plates. No important differences were found. The advantages of the method are an easier and faster procedure - as only K-wires need to be used, and these are already present for initial fixation (Figure2) - and less damage to muscle and periosteum. Finally, it is much easier to achieve symmetrical interfragmentary compression with tension band wiring than with plating (Figure.3). It is not recommended for severely comminuted fractures since the cortices lack support for compression. In the authors’ opinion, double plating including a bone graft is necessary in such cases. Osteoporosis presents a problem in either method, but, as can be seen from the figures, acceptable results can be obtained. After mechanical failure one should not hesitate to perform re-osteosynthesis (Figure 4), since the results are better compared with conservative treatment (Holdsworth and Mossad, 1990; Kinzi and Fleischmann, 1991). Although nerve injury is reported to occur more often after re-osteosyntheses (Feil et al., 1988), Sodergard et al. (1992) showed that even re-osteosynthesis may yield good results. The present report seems to confirm this statement. In the authors’ opinion, tension band wiring is also a good choice in cases of re-osteosynthesis.
Conclusion Operative treatment of intra-articular bicondylar fractures of the distal humerus and reosteosynthesis after mechanical failure and non-union lead to a satisfactory functional result. Tension band wiring offers an easy and equivalent alternative to dual plating in such cases.
References American Medical Association (1988) Guide to the Eva&ion of PermanentImpaimzent. 3rd Ed.
Bongers K. J. (in press) Eine einfache Method zur Stabilisierung der supra-condylaeren Oberarmfraktur. Aktuelk Tyaumtologic.
Figure4
a, Y-fracture (13~3.2) and b, re-osteosynthesis of a non-union with tension band wiring in a 69-year-old patient. In this case a cancellous bone graft was added. This resulted in a permanent radial nerve palsy but otherwise the functional result
was good (O-20-150).
Houben et al.: Double tension band osteosynthesis
Feil J., Buni C. and Kiefer H. (1988) Offene Frakturen des Ellbogengelenkes. Orthopuede 17,272. Gabel G. T., Hanson G., Bennett J. B. et al. (1987) IntraarticuJar fractures of the distal humerus in the adult. Clin Orth. 216,99. Helfet D. L. and Hotchkiss R. N. (1990) Internal fixation of the distal humerus: a biomechanical comparison of methods. _J.Orthop. Trauma 4, 260. Henley M. B. (1987) lntraarticular distal humeral fractures in adults. Orthop. Clin. North Am. 18,11. Holdsworth B. J. and Mossad M. M. (1990) Fractures of the adult distal humerus. Elbow function after internal fixation. /. Bone joint Surg. [Br] 72,362. Jupiter J. B., Neff U., HoJzach P. and Ahgoewer M. (1985) Intercondylar fractures of the humerus. An operative approach. J. Bone loint Surg. [Am] 67, 226. KinzJ L. and Fleischmann W. (1991) The treatment of distal upper arm fractures. Unfallchimrg 94,455. Krotschek H., Jahna H. and Wittlich H. (1973) Die Brueche am distalen Oberannende. Hefre Unfallkeilk. 114, 37. Lob G., Burri C. and Feil J. (1984) Die operative Behandlung von distalen intraartikulaeren Humerusfrakturen: Ergebnis von 412 nachkontrollierten Faellen (A0 Sammelstatistik). Langenbecks Arch. Ckir. 364, 357.
THE ANNUAL
309
in humeral fractures
Mueller M. E., AJJgoewer M., Schneider R. and Willenegger H. eds (1991) Manual ofInternal Fixufion. 3rd Ed. Berlin: Springer. Noack W., Kreusch-Brinker R. and Trepte C. T. (1987) Indications and results of the surgical treatment of distal intraarticuJar humeral fractures in the elderly. Z. Ortkop. 125, 233. Schatzker J. and Tile M. eds (1987) IIre Rationale of Operative Fracture Care. Berlin: Springer. Seiler H. and Trentz 0. (1988) Bikondylaere Frankturen. Ortkopaede 17, 262. Sodergard J., Sandelin J. and Bostman 0. (1992) Mechanical failures of internal fixation in T and Y fractures of the distal humerus. J. Trauma 33, 687. Waddell J. P., Hatch J. and Richards R. (1988) Supracondylar humeral fractures - results of surgical treatment. J. Trauma 28, 1615.
Paper accepted
IO March 1994.
Requests for reprints should be addressed to: P. Houben, Department of General Surgery, University Hospital AZM, Postbox 5800, 6202 AZ Maastricht, The Netherlands.
GENERALMEETING OF THE
BRITISH TRAUMA SOCIETY FRIDAY7~13 & SATURDAY~TH OCTOBER,1994 LONDON Further information:
Mr F.W. Cross Department of General Surgery The Royal London Trust Whitechapel London El 1BB Telephone: 071 377 7000