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Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases
Injury, Int. J. Care Injured 33 (2002) 511–515
Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases Rakesh Gupta∗ , Prakash Khanchandani Department of Orthopaedics, Postgraduate Institute of Medical Sciences, 42/9 J Medical Enclave, Rohtak 124001, India Accepted 20 September 2001
Abstract Intercondylar fractures of the distal humerus in adults are difficult management problems on account of the complex anatomy of the elbow, small sized fracture fragments and the limited amount of sub-chondral bone, which is often osteopenic. The results of managing these fractures non-operatively are compromised by the failure to get anatomical reduction and early mobilization. This often results in a painful stiff elbow and/or pseudarthrosis, thereby making an operative approach for these fractures, desirable. Fifty-five such fractures, operated on by the author during the last 9 years, were reviewed. All the fractures were managed by open reduction and internal fixation followed by early mobilization. The outcome in 51 of these cases was graded as excellent or good using the evaluation criteria of Aitken and Rorabeck. Thirty-three of these cases achieved a range of flexion of more than 130◦ . There was minimal incidence of complications like ulnar nerve neuropraxia or heterotopic bone formation. Anterior transposition of the ulnar nerve was performed in only one of the patients. Dorsal application of both the plates instead of the commonly advocated supracondylar crest placement resulted in a stable configuration requiring less extensive dissection and retraction of the ulnar nerve and resulting in a low incidence of complications. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction
2. Material and methods
Intercondylar fractures of the distal humerus in adults constitute a small percentage of fractures. These fractures are often difficult to treat with an uncertain outcome. Recommended management in the literature varies considerably, ranging from plaster of Paris (POP) cast immobilization or treatment as a bag of bones, to fully invasive open reduction and internal fixation [1–8]. Non-operative management of these fractures may lead to either a pseudarthrosis with gross instability or a painful stiff elbow [7–9]. Moreover, accurate reconstruction of the articular surface is not always possible by closed methods. As a result, many now favor open reduction and internal fixation, although to obtain acceptable results, it has to be followed by early mobilization of the elbow [1–3,5,6,9,10]. Authors recommending an operative approach differ widely in respect to the extent and type of internal fixation. In addition most of the authors advocating internal fixation propose placement of plates on the supracondylar crest and have reported a significant incidence of hetrotopic ossification and ulnar nerve involvement [10–12]. The present study analyses the long term results of the author’s experience of operative management of these fractures and attempts to address these problems.
Fifty-five patients with intercondylar fractures of the distal humerus in adults operated on by the first author during 1992–2000 and available for follow up, were reviewed. The series included long term follow up of 20 such cases reported earlier by the author [13]. Fall on the point of the elbow was the most common mode of trauma followed by road traffic crashes. Twelve of the patients had associated injuries elsewhere, including additional ipsilateral upper limb trauma (five patients). There were 37 males and 18 females and the average age of the patients was 39 years (range 18–65 years). Six of the patients had compound injuries of Gustilo type 1 (three patients) or type 2 (three patients) [14]. As per Muller et al. [15] classification, 18 fractures were of C1 type, 23 of C2 and the remaining 14 of C3 type. Two of the patients had an additional dislocation of the medial condyle from the olecranon notch of ulna. All but six of the patients were operated on within 7 days of injury. Delay in surgery usually resulted from late presentation of the patients though in some of the cases it was due to associated injuries. One patient presented 8 months after injury, with pseudarthrosis and gross instability at the fracture site, demonstrating failed conservative treatment. All the patients were operated on, in the lateral decubitus position with the forearm hanging by the side over a sand
∗ Corresponding author. Tel.: +91-1262-44799. E-mail address: [email protected] (R. Gupta).
0020-1383/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 0 9 - 8
512
R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515
Fig. 1. Pre-operative radiograph.
bag, placed against the patient’s chest. A posterior midline approach to the elbow was used and the ulnar nerve was exposed in all the cases. In 42 of the patients, an inverted “v” shaped triceps aponeurosis flap was reflected distally to expose the fracture site. In the remaining 13, a transverse or chevron osteotomy of the olecranon was performed to reflect triceps proximally. Holes were drilled in the ulna, prior to the osteotomy, for subsequent tension band wiring. A five hole 3.5 mm DCP/reconstruction plate was contoured in both planes to fit the posterior flat surface of the distal humerus and was used as a basic implant. It was used to stabilize the larger of the articular fragments to the corresponding pillar. The remaining articular fragments were either fixed to the other pillar or to the already reconstructed pillar or both, as determined by the assessment of stability. This was achieved by either an additional 3.5 mm plate (46 cases) on the posterior flat surface of distal humerus or screw fixation (8 cases). Fixation was supplemented with an additional transcondylar screw to enhance stability, particularly in the C3 type of fractures (Figs. 1 and 2). In one of the patients, the fracture was stabilized by multiple screws only. Special attention was paid to ensure proper reconstruction of the trochlear component and the adequacy of the
olecranon fossa. Stability of the reconstruction was confirmed per-operatively by looking for any movement in between the fragments. The olecranon osteotomy was stabilized with a tension band wire supplemented with K-wires (seven cases) or a 6.5 mm cancellous lag screw (six cases). A suction drain and a POP back slab were used in all the patients. Active mobilization of the elbow was permitted from the first post-operative day, after breaking the POP slab at the elbow. The slab was discarded after 2–3 weeks depending upon the fracture anatomy, the stability of fixation and the clinical progress of the patient. Subsequently, the patients were subjected to extensive active physiotherapy of the elbow. Patients were examined clinically and radiologically with regard to pain, activities of daily living, range of motion and fracture union. In addition, any deficit of ulnar nerve function, whether early or late and evidence of secondary osteoarthritis, were specifically looked into. Maximum follow up was 9 years with an average of 4 years.
3. Results All the fractures including osteotomies of the olecranon healed by 10–12 weeks. Full extension could be achieved in 15 of the patients, though loss of the last 5◦ of flexion was observed in 20 other patients (Table 1). No limitation of supination or pronation of the forearm was observed in any patient. Regaining elbow function was observed to be related to the stability of the fixation and to the extent of physiotherapy performed by the patients. The final outcome was observed to be better in younger patients, although it was probably more on account of their better physiotherapy record rather than their chronological age. The results were evaluated using the criteria of Aitken and Rorabeck [9] (Table 2). The final result was graded as excellent in 41 patients with an arc of flexion >110◦ and no pain or disability. In 10 of the patients, it was graded as good. Four patients had an unacceptable (fair or poor) outcome with an arc of flexion at elbow being <60◦ in two and >60◦ in the other two. The range of motion of the elbow movement was observed to improve up to 2 years following injury, but the majority of this occurred in the first 12 months. One patient with significant heterotopic ossification was graded as fair with a limited range of motion at the elbow (<75◦ ). Table 1 Range of motion at elbow
Fig. 2. Final radiograph showing consolidation.
Range of flexion (◦ )
Number of cases
Extension loss (◦ )
Number of cases
>130 110–130 75–110 60–75 <60
33 9 9 2 2
Nil <5 5–10 10–15 >15
15 20 15 2 3
R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515 Table 2 Evaluation criteria (Aitken and Rorabeck [9]) Arc of flexion (◦ )
Activity
Pain
Acceptable Excellent Good
110 75
No limitation Activities of daily living
None Minimal
Unacceptable Fair
>60
Activities of daily living Arm used as a prop
Mild occasional analgesic Constant
Poor
<60
He was able to perform most of his activities of daily living. One of the two patients with poor grading had pre-operative pseudarthrosis while the other one had post-operative deep infection, though both had no pain and some useful function could be performed by the limb. The complications included ulnar nerve paraesthesias in three patients, in the immediate post-operative period, which disappeared spontaneously by the third week. However, no late ulnar nerve paraesthesias/deficit was observed in any of the patients. None of the patients had any clinical or radiological evidence of secondary osteoarthritis in spite of long term follow up of the majority of cases. Two patients had early deep infection requiring the removal of implants after healing of the fracture. One of these had a grade 2 compound fracture while the other one had associated fractures of the ipsilateral shaft of the humerus and ulna which were operated on simultaneously. Another patient had late local superficial infection due to scar breakdown at the site of tension band wiring of olecranon, which healed after removal of the implants. Proximal migration of the K-wires was seen in four of the patients and this necessitated their removal. Failure of fixation was not observed in any of the patients, though one of the patients had late implant failure in the form of a broken one-third tubular plate which had been used as a second plate in one of the cases instead of the usual 3.5 mm reconstruction plate. Three patients developed heterotopic ossification around the elbow. In two of these patients, it was clinically not significant in view of the fact that it did not interfere markedly with the range of motion. The only patient with significant heterotopic ossification was an elderly male with a severely comminuted fracture and significant soft tissue trauma. One patient had a clinically apparent cubitus varus deformity but without any interference in elbow function. No significant loss of power in the triceps was observed in any of our patients.
4. Discussion Intercondylar fractures of the distal humerus in adults are difficult to treat because of the nature of injury. The non-operative approach to these fractures can neither ensure
513
good reconstruction of the articular surface nor permit early mobilization of the elbow, key factors in achieving good function. Operative management of these fractures has been criticized in literature for additional surgical trauma and inherent difficulty in securing stable fixation of small fragments. Consensus, though, is gradually building for surgical stabilization of these fractures, largely as a consequence of significant advances in surgical technique and implants during the last decade ensuring a stable osteosynthesis of small intra-articular fragments. Lateral position of the patient with his arm hanging by the side not only gives convenient patient access to the anaesthetist but is also comfortable for the surgeon. Moreover, flexion of the elbow in this position was observed to give a good view of the articular surface of the distal humerus. This is confirmed by the fact that the intercondylar screws could be easily passed, in a number of patients in the present series, without olecranon osteotomy. It may possibly also decrease the need for an olecranon osteotomy for stabilization of these fractures. An intact olecranon can act as a mould over which reconstruction of distal humerus is easy with the additional advantage of avoiding the creation of an additional intra-articular fracture. However, the authors are in agreement with Jupiter et al., that the trans-olecranon approach offers excellent exposure for reconstruction of the articular surface especially in type C3 fractures [5]. Proximal migration of K-wires was observed in four of the patients, where they were used for the stabilization of the osteotomy. The study reinforces the views expressed by Henley regarding the desirability of the use of 6.5 mm cancellous screws instead of K-wires for stabilization of the osteotomy, wherever it is performed [1]. Early active mobilization of the elbow has been universally accepted as a ground rule to ensure an acceptable outcome [1–3,5,9]. It is reaffirmed by the present study, as an excellent range of motion was achieved in all patients where early mobilization was possible due to stable internal fixation. In fact, all patients with a lesser range of motion were either old patients or with a poor post-operative physiotherapy record, quite often on account of associated injuries. Some loss of extension at the elbow was observed in 40 of our patients, which is similar to that reported by Sanders et al. [6]. The authors are of the opinion that an accurate reconstruction with special emphasis on adequacy of the olecranon fossa is desirable to ensure minimal loss of extension. A general perusal of literature regarding internal fixation of these fractures indicates a reasonably high incidence of ulnar nerve neuropraxia [10–12], so much so that Ring and Jupiter [2] and Wang et al. [16] have advocated routine anterior transposition of ulnar nerve in such cases. In addition some of the authors have also indicated an incidence of heterotopic ossification ranging from 4 to 49%, though most of these reports have not commented upon the extent of heterotopic ossification encountered or its clinical significance [1,3,10,17]. The majority of these authors have advocated the posterior midline approach with supracondylar
514
R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515
Fig. 3. Illustration showing exposure and placement of plates on posterior surface of humerus.
crest placement of plates, ostensibly for more secure fixation [6,8,10,12,16,18]. However, it is apparent that the combination of this approach and anatomical location of plates on supracondylar crests, requires an extensive dissection and retraction of the triceps and brachialis muscles besides significant retraction of the ulnar nerve. The placement of both plates on the posterior flat surface of the humerus, which is directly under vision by a posterior approach neither requires extensive dissection nor significant retraction of the ulnar nerve (Fig. 3), thereby, decreasing the incidence of both ulnar nerve neuropraxia or heterotopic ossification, as was observed in the present series. The only instance of significant heterotopic ossification observed in the present series was more on account of the severe nature of the pre-operative soft tissue trauma rather than surgical dissection. We are of the opinion that the placement of both plates on the posterior flat surface of humerus after suitable contouring causes less irritation of the ulnar nerve, compared to the sharp edge of the plate placed on the supracondylar crest. Moreover, zero incidence of fixation loss does indicate that posterior placement of both plates results in a equally stable fixation, which has been advocated as the main reason for the supracondylar crest placement of the plates. Interposition of triceps between the plate and the ulnar nerve takes care of any possible late irritation of the nerve also. This is suggested by the fact that no late ulnar nerve symptoms were observed in any of our patients in spite of long follow up. However, we are in complete agreement with Ring and Jupiter that wherever, per-operative assessment indicates a compromised ulnar nerve, it should definitely be transposed anteriorly [2].
Our only experience of implant failure was with a one-third tubular plate and it corroborates the views expressed by Henley [1] and Holdsworth and Mossad [18] that these plates are not strong enough and should be replaced with 3.5 mm reconstruction/DC plate for stabilization of these fractures. The rating system of Aitken and Rorabeck was used in this study for the final outcome as it takes into consideration additional features like pain and the activity level with the range of motion at the elbow [9]. Overall 93% of the patients had acceptable results (41 excellent, 10 good) which reinforces the desirability of an operative approach to these fractures and compares favorably with the reports in the literature [1,5,6]. A high percentage of acceptable results can probably be attributed to early open reduction, stable internal fixation and early post-operative mobilization of the elbow. The age group in the present series was relatively younger, with a good bone stock and this may have been the reason for a lack of fixation failures and the higher percentage of acceptable results. Kinik et al. [12] and Holdsworth and Mossad [18] have also indicated that old age is no contraindication for surgical management of these fractures and the final outcome is more dependent on the quality of bone rather than the chronological age of the patient. The authors are in agreement with Sodegard et al. [11] and Kuntz Jr. and Baratz [17] that the results are likely to be less gratifying if only elderly patients with poor bone stock are considered. The present study therefore reaffirms that early open reduction and stable internal fixation followed by early mobilization of elbow is the treatment of choice for these complex fractures. Posterior placement of both the plates provides an adequately stable fixation and requires less extensive dissection or retraction of the ulnar nerve, thereby, decreasing the incidence of two of the most commonly reported complication namely ulnar nerve neuropraxia and heterotopic ossification. References [1] Henley MB. Intra-articular distal humeral fractures in adults. Orthop Clin North Am 1987;18(1):11–23. [2] Ring D, Jupiter JB. Complex fractures of distal humerus and their complications. J Shoulder Elbow Surg 1999;8:85–97. [3] Helfet DL, Schemeling GJ. Bicondylar intra-articular fractures of the distal humerus. Clin Orthop 1993;292:26–36. [4] Eastwood WJ. The T shaped fractures of lower end of the humerus. J Bone Joint Surg 1937;19(A):364–9. [5] Jupiter JB, Neff U, Holzech P, Allgower M. Intercondylar fractures of the humerus: an operative approach. J Bone Joint Surg 1985;67(A):226–39. [6] Sanders RA, Raney EM, Pipkin S. Operative treatment of bicondylar intra-articular fractures of the distal humerus. Orthopaedics 1992;15:159–63. [7] Bickel WA, Perry RE. Comminuted fractures of the distal humerus. JAMA 1963;184(7):553–7. [8] Wadell JP, Hatch J, Richards R. Supracondylar fracturs of the humerus: results of surgical treatment. J Trauma 1988;28:1615–21.
R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515 [9] Aitken GK, Rorabeck CK. Distal humeral fractures in the adult. Clin Orthop 1986;207:191–7. [10] Kundel K, Braun W, Wieberneit J, Ruter A. Intra-articular distal humeral fractures: factors affecting functional outcome. Clin Orthop 1996;332:200–8. [11] Sodegard J, Sandelin J, Bostman O. Post-operative complications of distal humeral fractures: 22/96 adults followed up to 6 (2–10) years. Acta Orthop Scand 1992;63(1):85–9. [12] Kinik H, Atalar H, Mergen E. Management of distal humeral fractures in adults. Arch Orthop Trauma 1999;119:467–9. [13] Gupta R. Intercondylar fractures of the distal humerus in adults. Injury 1996;27(8):569–72. [14] Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long
[15]
[16]
[17] [18]
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bones: retrospective and prospective analysis. J Bone Joint Surg 1976;58(A(4)):453–8. Muller ME, Allgower M, Schneider R, Willenegger H. Manual of internal fixation: techniques recommended by the AO group. 3rd ed. New York: Springer, 1990. p. 118–50. Wang K, Shih H, Hsu K, Shih C. Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of ulnar nerve in a posterior operative approach. J Trauma 1994;36(6): 770–3. Kuntz Jr DG, Baratz ME. Fractures of the elbow. Orthop Clin North Am 1999;30(1):37–61. Holdsworth BJ, Mossad MM. Fractures of the adult distal humerus: elbow function after internal fixation. J Bone Joint Surg 1990;72(B):362–5.
Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases Rakesh Gupta∗ , Prakash Khanchandani Department of Orthopaedics, Postgraduate Institute of Medical Sciences, 42/9 J Medical Enclave, Rohtak 124001, India Accepted 20 September 2001
Abstract Intercondylar fractures of the distal humerus in adults are difficult management problems on account of the complex anatomy of the elbow, small sized fracture fragments and the limited amount of sub-chondral bone, which is often osteopenic. The results of managing these fractures non-operatively are compromised by the failure to get anatomical reduction and early mobilization. This often results in a painful stiff elbow and/or pseudarthrosis, thereby making an operative approach for these fractures, desirable. Fifty-five such fractures, operated on by the author during the last 9 years, were reviewed. All the fractures were managed by open reduction and internal fixation followed by early mobilization. The outcome in 51 of these cases was graded as excellent or good using the evaluation criteria of Aitken and Rorabeck. Thirty-three of these cases achieved a range of flexion of more than 130◦ . There was minimal incidence of complications like ulnar nerve neuropraxia or heterotopic bone formation. Anterior transposition of the ulnar nerve was performed in only one of the patients. Dorsal application of both the plates instead of the commonly advocated supracondylar crest placement resulted in a stable configuration requiring less extensive dissection and retraction of the ulnar nerve and resulting in a low incidence of complications. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction
2. Material and methods
Intercondylar fractures of the distal humerus in adults constitute a small percentage of fractures. These fractures are often difficult to treat with an uncertain outcome. Recommended management in the literature varies considerably, ranging from plaster of Paris (POP) cast immobilization or treatment as a bag of bones, to fully invasive open reduction and internal fixation [1–8]. Non-operative management of these fractures may lead to either a pseudarthrosis with gross instability or a painful stiff elbow [7–9]. Moreover, accurate reconstruction of the articular surface is not always possible by closed methods. As a result, many now favor open reduction and internal fixation, although to obtain acceptable results, it has to be followed by early mobilization of the elbow [1–3,5,6,9,10]. Authors recommending an operative approach differ widely in respect to the extent and type of internal fixation. In addition most of the authors advocating internal fixation propose placement of plates on the supracondylar crest and have reported a significant incidence of hetrotopic ossification and ulnar nerve involvement [10–12]. The present study analyses the long term results of the author’s experience of operative management of these fractures and attempts to address these problems.
Fifty-five patients with intercondylar fractures of the distal humerus in adults operated on by the first author during 1992–2000 and available for follow up, were reviewed. The series included long term follow up of 20 such cases reported earlier by the author [13]. Fall on the point of the elbow was the most common mode of trauma followed by road traffic crashes. Twelve of the patients had associated injuries elsewhere, including additional ipsilateral upper limb trauma (five patients). There were 37 males and 18 females and the average age of the patients was 39 years (range 18–65 years). Six of the patients had compound injuries of Gustilo type 1 (three patients) or type 2 (three patients) [14]. As per Muller et al. [15] classification, 18 fractures were of C1 type, 23 of C2 and the remaining 14 of C3 type. Two of the patients had an additional dislocation of the medial condyle from the olecranon notch of ulna. All but six of the patients were operated on within 7 days of injury. Delay in surgery usually resulted from late presentation of the patients though in some of the cases it was due to associated injuries. One patient presented 8 months after injury, with pseudarthrosis and gross instability at the fracture site, demonstrating failed conservative treatment. All the patients were operated on, in the lateral decubitus position with the forearm hanging by the side over a sand
∗ Corresponding author. Tel.: +91-1262-44799. E-mail address: [email protected] (R. Gupta).
0020-1383/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 0 9 - 8
512
R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515
Fig. 1. Pre-operative radiograph.
bag, placed against the patient’s chest. A posterior midline approach to the elbow was used and the ulnar nerve was exposed in all the cases. In 42 of the patients, an inverted “v” shaped triceps aponeurosis flap was reflected distally to expose the fracture site. In the remaining 13, a transverse or chevron osteotomy of the olecranon was performed to reflect triceps proximally. Holes were drilled in the ulna, prior to the osteotomy, for subsequent tension band wiring. A five hole 3.5 mm DCP/reconstruction plate was contoured in both planes to fit the posterior flat surface of the distal humerus and was used as a basic implant. It was used to stabilize the larger of the articular fragments to the corresponding pillar. The remaining articular fragments were either fixed to the other pillar or to the already reconstructed pillar or both, as determined by the assessment of stability. This was achieved by either an additional 3.5 mm plate (46 cases) on the posterior flat surface of distal humerus or screw fixation (8 cases). Fixation was supplemented with an additional transcondylar screw to enhance stability, particularly in the C3 type of fractures (Figs. 1 and 2). In one of the patients, the fracture was stabilized by multiple screws only. Special attention was paid to ensure proper reconstruction of the trochlear component and the adequacy of the
olecranon fossa. Stability of the reconstruction was confirmed per-operatively by looking for any movement in between the fragments. The olecranon osteotomy was stabilized with a tension band wire supplemented with K-wires (seven cases) or a 6.5 mm cancellous lag screw (six cases). A suction drain and a POP back slab were used in all the patients. Active mobilization of the elbow was permitted from the first post-operative day, after breaking the POP slab at the elbow. The slab was discarded after 2–3 weeks depending upon the fracture anatomy, the stability of fixation and the clinical progress of the patient. Subsequently, the patients were subjected to extensive active physiotherapy of the elbow. Patients were examined clinically and radiologically with regard to pain, activities of daily living, range of motion and fracture union. In addition, any deficit of ulnar nerve function, whether early or late and evidence of secondary osteoarthritis, were specifically looked into. Maximum follow up was 9 years with an average of 4 years.
3. Results All the fractures including osteotomies of the olecranon healed by 10–12 weeks. Full extension could be achieved in 15 of the patients, though loss of the last 5◦ of flexion was observed in 20 other patients (Table 1). No limitation of supination or pronation of the forearm was observed in any patient. Regaining elbow function was observed to be related to the stability of the fixation and to the extent of physiotherapy performed by the patients. The final outcome was observed to be better in younger patients, although it was probably more on account of their better physiotherapy record rather than their chronological age. The results were evaluated using the criteria of Aitken and Rorabeck [9] (Table 2). The final result was graded as excellent in 41 patients with an arc of flexion >110◦ and no pain or disability. In 10 of the patients, it was graded as good. Four patients had an unacceptable (fair or poor) outcome with an arc of flexion at elbow being <60◦ in two and >60◦ in the other two. The range of motion of the elbow movement was observed to improve up to 2 years following injury, but the majority of this occurred in the first 12 months. One patient with significant heterotopic ossification was graded as fair with a limited range of motion at the elbow (<75◦ ). Table 1 Range of motion at elbow
Fig. 2. Final radiograph showing consolidation.
Range of flexion (◦ )
Number of cases
Extension loss (◦ )
Number of cases
>130 110–130 75–110 60–75 <60
33 9 9 2 2
Nil <5 5–10 10–15 >15
15 20 15 2 3
R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515 Table 2 Evaluation criteria (Aitken and Rorabeck [9]) Arc of flexion (◦ )
Activity
Pain
Acceptable Excellent Good
110 75
No limitation Activities of daily living
None Minimal
Unacceptable Fair
>60
Activities of daily living Arm used as a prop
Mild occasional analgesic Constant
Poor
<60
He was able to perform most of his activities of daily living. One of the two patients with poor grading had pre-operative pseudarthrosis while the other one had post-operative deep infection, though both had no pain and some useful function could be performed by the limb. The complications included ulnar nerve paraesthesias in three patients, in the immediate post-operative period, which disappeared spontaneously by the third week. However, no late ulnar nerve paraesthesias/deficit was observed in any of the patients. None of the patients had any clinical or radiological evidence of secondary osteoarthritis in spite of long term follow up of the majority of cases. Two patients had early deep infection requiring the removal of implants after healing of the fracture. One of these had a grade 2 compound fracture while the other one had associated fractures of the ipsilateral shaft of the humerus and ulna which were operated on simultaneously. Another patient had late local superficial infection due to scar breakdown at the site of tension band wiring of olecranon, which healed after removal of the implants. Proximal migration of the K-wires was seen in four of the patients and this necessitated their removal. Failure of fixation was not observed in any of the patients, though one of the patients had late implant failure in the form of a broken one-third tubular plate which had been used as a second plate in one of the cases instead of the usual 3.5 mm reconstruction plate. Three patients developed heterotopic ossification around the elbow. In two of these patients, it was clinically not significant in view of the fact that it did not interfere markedly with the range of motion. The only patient with significant heterotopic ossification was an elderly male with a severely comminuted fracture and significant soft tissue trauma. One patient had a clinically apparent cubitus varus deformity but without any interference in elbow function. No significant loss of power in the triceps was observed in any of our patients.
4. Discussion Intercondylar fractures of the distal humerus in adults are difficult to treat because of the nature of injury. The non-operative approach to these fractures can neither ensure
513
good reconstruction of the articular surface nor permit early mobilization of the elbow, key factors in achieving good function. Operative management of these fractures has been criticized in literature for additional surgical trauma and inherent difficulty in securing stable fixation of small fragments. Consensus, though, is gradually building for surgical stabilization of these fractures, largely as a consequence of significant advances in surgical technique and implants during the last decade ensuring a stable osteosynthesis of small intra-articular fragments. Lateral position of the patient with his arm hanging by the side not only gives convenient patient access to the anaesthetist but is also comfortable for the surgeon. Moreover, flexion of the elbow in this position was observed to give a good view of the articular surface of the distal humerus. This is confirmed by the fact that the intercondylar screws could be easily passed, in a number of patients in the present series, without olecranon osteotomy. It may possibly also decrease the need for an olecranon osteotomy for stabilization of these fractures. An intact olecranon can act as a mould over which reconstruction of distal humerus is easy with the additional advantage of avoiding the creation of an additional intra-articular fracture. However, the authors are in agreement with Jupiter et al., that the trans-olecranon approach offers excellent exposure for reconstruction of the articular surface especially in type C3 fractures [5]. Proximal migration of K-wires was observed in four of the patients, where they were used for the stabilization of the osteotomy. The study reinforces the views expressed by Henley regarding the desirability of the use of 6.5 mm cancellous screws instead of K-wires for stabilization of the osteotomy, wherever it is performed [1]. Early active mobilization of the elbow has been universally accepted as a ground rule to ensure an acceptable outcome [1–3,5,9]. It is reaffirmed by the present study, as an excellent range of motion was achieved in all patients where early mobilization was possible due to stable internal fixation. In fact, all patients with a lesser range of motion were either old patients or with a poor post-operative physiotherapy record, quite often on account of associated injuries. Some loss of extension at the elbow was observed in 40 of our patients, which is similar to that reported by Sanders et al. [6]. The authors are of the opinion that an accurate reconstruction with special emphasis on adequacy of the olecranon fossa is desirable to ensure minimal loss of extension. A general perusal of literature regarding internal fixation of these fractures indicates a reasonably high incidence of ulnar nerve neuropraxia [10–12], so much so that Ring and Jupiter [2] and Wang et al. [16] have advocated routine anterior transposition of ulnar nerve in such cases. In addition some of the authors have also indicated an incidence of heterotopic ossification ranging from 4 to 49%, though most of these reports have not commented upon the extent of heterotopic ossification encountered or its clinical significance [1,3,10,17]. The majority of these authors have advocated the posterior midline approach with supracondylar
514
R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515
Fig. 3. Illustration showing exposure and placement of plates on posterior surface of humerus.
crest placement of plates, ostensibly for more secure fixation [6,8,10,12,16,18]. However, it is apparent that the combination of this approach and anatomical location of plates on supracondylar crests, requires an extensive dissection and retraction of the triceps and brachialis muscles besides significant retraction of the ulnar nerve. The placement of both plates on the posterior flat surface of the humerus, which is directly under vision by a posterior approach neither requires extensive dissection nor significant retraction of the ulnar nerve (Fig. 3), thereby, decreasing the incidence of both ulnar nerve neuropraxia or heterotopic ossification, as was observed in the present series. The only instance of significant heterotopic ossification observed in the present series was more on account of the severe nature of the pre-operative soft tissue trauma rather than surgical dissection. We are of the opinion that the placement of both plates on the posterior flat surface of humerus after suitable contouring causes less irritation of the ulnar nerve, compared to the sharp edge of the plate placed on the supracondylar crest. Moreover, zero incidence of fixation loss does indicate that posterior placement of both plates results in a equally stable fixation, which has been advocated as the main reason for the supracondylar crest placement of the plates. Interposition of triceps between the plate and the ulnar nerve takes care of any possible late irritation of the nerve also. This is suggested by the fact that no late ulnar nerve symptoms were observed in any of our patients in spite of long follow up. However, we are in complete agreement with Ring and Jupiter that wherever, per-operative assessment indicates a compromised ulnar nerve, it should definitely be transposed anteriorly [2].
Our only experience of implant failure was with a one-third tubular plate and it corroborates the views expressed by Henley [1] and Holdsworth and Mossad [18] that these plates are not strong enough and should be replaced with 3.5 mm reconstruction/DC plate for stabilization of these fractures. The rating system of Aitken and Rorabeck was used in this study for the final outcome as it takes into consideration additional features like pain and the activity level with the range of motion at the elbow [9]. Overall 93% of the patients had acceptable results (41 excellent, 10 good) which reinforces the desirability of an operative approach to these fractures and compares favorably with the reports in the literature [1,5,6]. A high percentage of acceptable results can probably be attributed to early open reduction, stable internal fixation and early post-operative mobilization of the elbow. The age group in the present series was relatively younger, with a good bone stock and this may have been the reason for a lack of fixation failures and the higher percentage of acceptable results. Kinik et al. [12] and Holdsworth and Mossad [18] have also indicated that old age is no contraindication for surgical management of these fractures and the final outcome is more dependent on the quality of bone rather than the chronological age of the patient. The authors are in agreement with Sodegard et al. [11] and Kuntz Jr. and Baratz [17] that the results are likely to be less gratifying if only elderly patients with poor bone stock are considered. The present study therefore reaffirms that early open reduction and stable internal fixation followed by early mobilization of elbow is the treatment of choice for these complex fractures. Posterior placement of both the plates provides an adequately stable fixation and requires less extensive dissection or retraction of the ulnar nerve, thereby, decreasing the incidence of two of the most commonly reported complication namely ulnar nerve neuropraxia and heterotopic ossification. References [1] Henley MB. Intra-articular distal humeral fractures in adults. Orthop Clin North Am 1987;18(1):11–23. [2] Ring D, Jupiter JB. Complex fractures of distal humerus and their complications. J Shoulder Elbow Surg 1999;8:85–97. [3] Helfet DL, Schemeling GJ. Bicondylar intra-articular fractures of the distal humerus. Clin Orthop 1993;292:26–36. [4] Eastwood WJ. The T shaped fractures of lower end of the humerus. J Bone Joint Surg 1937;19(A):364–9. [5] Jupiter JB, Neff U, Holzech P, Allgower M. Intercondylar fractures of the humerus: an operative approach. J Bone Joint Surg 1985;67(A):226–39. [6] Sanders RA, Raney EM, Pipkin S. Operative treatment of bicondylar intra-articular fractures of the distal humerus. Orthopaedics 1992;15:159–63. [7] Bickel WA, Perry RE. Comminuted fractures of the distal humerus. JAMA 1963;184(7):553–7. [8] Wadell JP, Hatch J, Richards R. Supracondylar fracturs of the humerus: results of surgical treatment. J Trauma 1988;28:1615–21.
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