|Year : 2018 | Volume
| Issue : 1 | Page : 15-20
Functional outcomes of type c distal humerus fractures in adults fixed by orthogonal double plating
Kapil Mani KC, Parimal Acharya, Dirgha Raj RC, Arun Sigdel
Department of Orthopedics, Civil Service Hospital, Minbhawan, Kathmandu, Nepal
|Date of Web Publication||2-Apr-2018|
Kapil Mani KC
Civil Service Hospital, Kathmandu
Source of Support: None, Conflict of Interest: None
Background: Surgical reconstruction of intra-articular distal humerus fractures imposes a challenge to even experienced surgeons as it is complicated by anatomy of elbow, small area of fixation, associated comminution, and osteopenia of articular surfaces. Single-column plating does not provide stable construct for comminuted distal humerus fractures as compared to the double-column plating methods. The purpose of this study is to evaluate the functional outcomes, technical difficulties, complications, and patients' satisfactions after orthogonal double plating. Materials and Methods: This was a retrospective analytical study of 54 patients with Type C distal humerus fractures fixed with orthogonal plating from 2012 to 2016. Time to unite the fractures and functional outcomes along with other major and minor complications were noted. Results: Seven (13%) fractures were C1, 12 (22.2%) were C2, and 35 (64.8%) were C3 types according to the AO classification. Major complications were noted in 5 patients and minor complications in 19 patients. Eleven (20.4%) patients were rated as excellent, 33 (61.1%) rated as good, 7 (12.9%) rated as fair, and 3 (5.6%) rated as poor. Mayo Elbow Performance Score in overall patients (n = 54) was 81.62 ± 10.28, C1/C2 subgroup (n = 19) was 89.05 ± 60, and C3 subgroup was 77.60 ± 9.91 (P = 0.627). Similarly, the Disabilities of the Arm Shoulder and Hand Score in overall patients was 17.96 ± 15.67, C1/C2 subgroup was 8.78 ± 7.07, and C3 subgroup was 22.82 ± 16.78 (P = 0.285). Conclusion: Orthogonal dual-plate configurations can provide anatomical reconstruction and stable fixation of Type C intra-articular distal humeral fractures and allow early mobilization of the elbow after surgery; however, a significant number of patients do not satisfy after surgery.
Keywords: Complication, distal humerus fractures, functional outcomes, orthogonal plating, parallel plating
|How to cite this article:|
KC KM, Acharya P, RC DR, Sigdel A. Functional outcomes of type c distal humerus fractures in adults fixed by orthogonal double plating. Apollo Med 2018;15:15-20
| Introduction|| |
Distal humerus fractures are rare and represent only 2% of all fractures in adult population., Surgical reconstruction of intra-articular distal humerus fractures imposes a challenge to even an experienced surgeon as it is complicated by anatomy of elbow, its small area of fixation, associated comminution, and osteopenia of articular surfaces. Stable fixation and anatomical joint restoration are crucial factors for optimal outcomes of elbow joint., However, because of frail articular cartilage, unique shape of distal humerus, limited subchondral bone, and poor tolerance of long-term elbow immobilization, it remains a big challenge for every orthopedic surgeons to achieve the goal of anatomical reduction and stable fixation for this type of fractures.
Single-column plating does not provide stable construct for comminuted distal humerus fractures as compared to the double-column plating methods., Double-column plating is currently the established technique for the intra-articular fractures of distal humerus based on the various clinical and biomechanical studies.,, Dual-plating technique is either orthogonal or perpendicular where one plate is placed in medial column and another plate is placed in posterolateral column or parallel configuration with placement of plates on both medial and lateral column. Even though controversies exist regarding the positions of dual plating, there is no significant difference in functional outcomes between these two techniques.
However, functional outcomes depend on the different parameters such as comminution of fractures, quality of bone, associated swelling around elbow joint, stability of fracture fixation, attitude of patients, regular physiotherapy, associated myositis ossificans and even age of the patients. The aim of our study is to evaluate functional results, complications, and associated risk factors for optimal results after osteosynthesis of distal humerus (AO/OTA) Type C fractures with orthogonal dual-plating system.
| Materials and Methods|| |
This was a retrospective study performed in Civil Service Hospital, Kathmandu, Nepal, from March 2012 and June 2016. Ethical consent was taken from the Institutional Review Board of our hospital. A total of 54 patients with Type C distal humeral fractures treated with double orthogonal plating were enrolled in the study. Patients with single distal humerus fracture, Type I compound fractures, Type C varieties of fractures based on AO classification, those without pain or arthritis of elbow before surgery, and no any congenital or acquired deformity of injured limb before surgery were included in the study. Patients with age more than 80 years and <16 years, previous history of elbow surgery, associated neural and vascular complications, pathological fractures, Gustilo Type II or III fractures, and those associated with ipsilateral radius or ulna fractures or elbow dislocations were excluded from the study.
All the surgeries were performed under general anesthesia or brachial plexus block in lateral decubitus position after application of tourniquet. A longitudinal midline incision was given over posterior aspect of elbow around 10 cm proximal and 5 cm distal to the joint with slight curvature over olecranon prominence. The ulnar nerve lying in the bony groove on the back of the medial epicondyle was fully dissected out. A V-shaped olecranon osteotomy was done approximately 2 cm distal to its tip with the help of drill bit and osteotome. The triceps muscle along with osteotomized bony fragment was wrapped with wet gauze and retracted proximally to expose the fractured fragments. The intra-articular fragments were first of all reduced and provisionally fixed with K wires followed by fixation with partially threaded cannulated screws to convert the complicated intercondylar fractures to supracondylar varieties. The reduced articular fragment was then fixed to the shaft of humerus. If articular bones were severely comminuted, either condyle was first reduced and fixed to the shaft as it provided a good key for reduction. Now, articular fragments were reconstructed and opposite condyle was also fixed to the main bone. When satisfactory reduction was achieved, definitive fixation was performed by the orthogonal plating system where one plate was put on medial column and another plate on the posterolateral column of distal humerus [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]. Each screw was needed to pass through the plate in distal fragment to maintain the stability at supracondylar level and engage as many as fragments. Extreme care should be taken to avoid the narrowing of trochlea due to lag screws in case of bone loss. The olecranon osteotomy was fixed with tension bind wiring using either two 2 mm K-wires or 6.5 mm partially threaded cannulated screw. In case of fixation by the screw, a hole was made by cannulated drill bit before doing the osteotomy. Extreme care was taken not to cross the screws beyond articular cartilage. The nerve was anteriorly transposed in all the cases and skin was closed after applying the closed suction drain.
|Figure 1: Anteroposterior and lateral views of elbow showing Type C1 distal humerus fracture|
Click here to view
|Figure 2: Immediate postoperative X-ray of elbow showing orthogonal fixation for distal humerus fracture and tension bind wiring for olecranon osteotomy|
Click here to view
|Figure 3: X-ray of elbow showing orthogonal double plating 3 months after surgery|
Click here to view
|Figure 4: United distal humerus fractures fixed by orthogonal double plating 1 year after surgery|
Click here to view
|Figure 5: Range of movement of elbow joint 3 years after surgery at the time of removal of implant|
Click here to view
|Figure 6: Anteroposterior and lateral views of elbow showing Type C3 fractures of distal humerus|
Click here to view
|Figure 7: X-ray of elbow showing orthogonal double plating 3 months after surgery|
Click here to view
|Figure 9: Anteroposterior and lateral views of elbow showing Type C2 fractures of distal humerus|
Click here to view
|Figure 10: Immediate postoperative X-ray of Type C2 distal humerus fracture fixed by orthogonal double plating|
Click here to view
A posterior slab was applied at the time of surgery which was removed intermittently 3 days after surgery. Passive elbow mobilization exercise was started only 3 days after surgery while a full range of active and passive exercises were started after removal of suture. Patients were followed up in OPD 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and then yearly after surgery. The functional results of elbow were assessed by Mayo Elbow Performance Score (MEPS), Disabilities of the Arm Shoulder and Hand Score (DASH), and total range of motion of elbow joint [Figure 5] and [Figure 8] at least 1 year after surgery and patient's satisfaction based on surgical outcomes were assessed individually. Statistical analysis was done with SPSS version 16. All continuous variables were expressed as mean ± standard deviation while a two sample t-test was used for comparing means of two subgroups. P ≤ 0.05 was considered statistically significance.
| Results|| |
There were 27 (50%) males and 27 (50%) females in our study. Average age of the patients was 36.72 ± 14.99 years (range 18–74 years). Seven (13%) fractures were C1 [Figure 1], 12 (22.2%) were C2 [Figure 9], and 35 (64.8%) were C3 [Figure 6] types according to the AO classification. The overall MEPS, DASH score, total ROM, flexion, and extension lag of elbow are mentioned in [Table 1].
|Table 1: Functional outcomes of elbow based on Mayo Elbow Performance Score, Disabilities of the Arm Shoulder and Hand Score and range of motion of elbow joint|
Click here to view
Time to unite the fracture was 23.13 ± 3.29 weeks (range 18–32 weeks). Final results were interpreted only after minimal follow-up of 1 year after surgery. Mean duration of trauma to surgery was 3.61 ± 1.41 days (range 2–10 days). Mean operative time was 141.31 ± 22.41 min (range 96–194 min). We removed the implants in 43 (79.6%) patients out of total 54 patients, and average time for removal of implants was 27.30 ± 5.04 months (range 21–44 months) after initial surgery. We encountered major complications in 5 patients that required surgical intervention and minor complications in 19 patients that did not require surgical intervention as mentioned in [Table 2]. Functional outcomes were assessed based on MEPS, DASH, and total ROM of elbow joint. Eleven (20.4%) patients were rated as excellent, 33 (61.1%) rated as good, 7 (12.9%) rated as fair, and 3 (5.6%) rated as poor.
| Discussion|| |
The aim of treatment for distal humerus fracture is to achieve the painless and stable elbow with satisfactory functions. This requires stable fixation of fracture fragments, anatomical reconstruction of intra-articular surface, re-establishment of geometry of elbow joint to allow early mobilization, and full rehabilitation. However, it is not easy to achieve these goals particularly in the presence of substantial articular comminution.,,, Even though controversies exist regarding the appropriate management of distal humerus fractures, double plating fixation has remained the gold standard technique even for the complex intra-articular fractures., A number of studies have shown that there is no significant difference of clinical outcomes in between the parallel and perpendicular plating systems in terms of functions, range of motion, MEPS, and other clinical results. The technique recommended by AO group includes fixation of articular fragments with cannulated screws followed by stabilization of column by two plates perpendicular to each other. Fixation is generally performed by use of one plate on medial column and another plate on lateral column posteriorly.
In the current study, 44 (81.5%) out of 54 patients had excellent or good results with a mean MEPS 81.62 ± 10.28 (range 54–100), DASH 17.96 ± 15.67 (range 54–100), total ROM 107.57° ± 15.85° (range 75°–100°), flexion 127° ± 8.71° (range 93°–142°), and extension lag 19.61° ± 9.41° (range 0°–45°). The functional results were better in type C1/C2 groups (n = 19) as compared to the Type C3 groups (n = 35); however, there was no statistically significant difference of outcomes in two groups. Huang et al. showed good-to-excellent results in 100% patients with Type C distal humerus fractures fixed with two orthogonal plates. Aslam and Willett  reported good-to-excellent results in 70% patients with mean flexion arc of 112° and grip strength of 82% compared to normal side in 26 patients of Type C distal humerus fractures treated with dual orthogonal plating. Gofton et al. reported 23 patients with Type C distal humerus fractures treated by orthogonal double plates. They found 93% satisfactory outcomes with flexion arc of 122°, 17% loss of flexion torque, and 22% loss of extension torque. Early and painless postoperative exercise is a key to obtaining of optimal outcomes of this kind of fracture fixation. The aim is to obtain stable fracture fixation and early postoperative elbow mobilization. Patients were advised to start the passive exercise after removal of suction drainage with gravity driving the forearm and elbow joint from continuous passive stretch to maximum activity with support by another hand. The exercise was performed three times a day with use of NSAID if needed. Removable posterior slab was used during the interval of exercises within 2 weeks after surgery. After 2 weeks, posterior slab was removed completely and both active and passive exercises were started vigorously. The method of physiotherapy was simple with slow and gentle action causing minimal pain and avoiding the further soft-tissue injury and myositis ossificans by violent stretching and passive flexion of elbow joint.
Even though satisfactory results are found, complications rates are reported to be high. Postoperative complications up to 48% have been found after surgical fixation for Type C distal humerus fractures.,, In the present study, one patient suffered complete ulnar nerve palsy and another two sustained incomplete ulnar nerve palsy. The incomplete ulnar nerve palsy in two patients improved spontaneously to normal state within 3 months after surgery. Complete ulnar nerve injury in one patient was due to winding of nerve over drill bit while drilling the bone. Hence, we have to be careful while drilling the bone from ulnar side. We routinely did the anterior transposition of nerve that reduced the chances of ulnar nerve injury. The reported prevalence of heterotopic ossification following surgical treatment of distal humerus fractures ranges from 4 to 49%, although no functional deficit was involved in the majority of cases. In the present study, only 3 patients (5.5%) suffered the heterotrophic ossification. This low incidence (5.5%) of heterotopic ossification may be attributed to the routine use of naproxen or indomethacin postoperatively. Therefore, we suggest the patients to take a nonsteroidal drug routinely after intercondylar fracture fixation.
In our study, 2 (3.7%) cases of screws loosening were found distal to the fractures in radial column; however, plate breakage was not reported. Korner et al. found loosening of screws and plate breakage in 27% of patients in their retrospective clinical study. They noted significant impairment of elbow motion when immobilization was continued more than 15 weeks. The outstanding importance of stable fracture fixation and early mobilization of elbow was emphasized by Papaioannou et al. who noted that clinical outcomes were significantly improved when stable fixation was achieved. These findings were supported by the study of Charissoux who found fair and poor results in 87% of patients where early physiotherapy was not started after surgery. Similarly, Proust noted the poor functional outcomes in case of distal humerus fracture fixation when immobilization was required for longer time. In this study, there were 2 (3.70%) cases of deep infection (osteomyelitis) and 3 (5.55%) cases of superficial infection. Superficial infection was healed with use of antibiotics for 2 months while deep infections were treated by repeated debridement and prolonged use of antibiotic. Early implant removal was performed in one case because of recurrent infection. In the current study, we found one case of nonunion and 2 cases of delayed union. Cases of delayed union were healed over a period of time while a case of nonunion was treated with bone grafting 6 months after surgery. Nonunion was commonly found over the supracondylar region rather than intercondylar area. The region of humerus over olecranon fossa is watershed, so iatrogenic injury to blood vessel should be avoided in this region. Breakage of plates secondary to the nonunion is well-established fact. Another case of plate breakage secondary to the nonunion was reported by Rubberdt; however, bending of plate was main culprit here. Bending should not be performed in long hole of plate to avoid weakening of plate. Similarly, fracture gap should be avoided at the supracondylar level because stiffness of implant-bone-construct prevents bone contact and callus formation. Nevertheless, stability of fracture fixation has outmost importance because 78% of fracture fixation in nonunion humerus was not found to be stable reported by the study of Proust.
In our study, all patients were assessed individually 1 year after surgery regarding their satisfaction. Even though fracture was united and they were doing all kinds of activities, many patients were not fully satisfied with surgical outcomes. They were arguing with lack of full movement of elbow, prominence of hardware, long follow-up in outpatient department, difficulty to perform long-term physiotherapy, suboptimal outcomes, and overall economic burden to patient. Hence, we should properly counsel the every patient regarding the functional outcomes and technical difficulties after this surgery even though dual orthogonal plating is the absolute option in intercondylar fractures of distal humerus.
| Conclusion|| |
Orthogonal dual-plate configurations can provide anatomical reconstruction and stable fixation of Type C intra-articular distal humeral fractures and allow early mobilization of the elbow after surgery; however, a significant number of patients do not satisfy after surgical intervention. Functional outcomes are better in Type C1/C2 than the Type C3 fracture patterns even though the results are not statistically significant in two groups.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM. Adult distal humeral metaphyseal fractures: Epidemiology and results of treatment. J Orthop Trauma 2003;17:38-47.
Schmidt-Horlohé KH, Bonk A, Wilde P, Becker L, Hoffmann R. Promising results after the treatment of simple and complex distal humerus type C fractures by angular-stable double-plate osteosynthesis. Orthop Traumatol Surg Res 2013;99:531-41.
Moon JG, Lee JH. Orthogonal versus parallel plating for distal humeral fractures. Clin Shoulder Elbow 2015;18:105-12.
Korner J, Lill H, Müller LP, Hessmann M, Kopf K, Goldhahn J, et al.
Distal humerus fractures in elderly patients: Results after open reduction and internal fixation. Osteoporos Int 2005;16 Suppl 2:S73-9.
Liu JJ, Ruan HJ, Wang JG, Fan CY, Zeng BF. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder Elbow Surg 2009;18:646-51.
Lan X, Zhang LH, Tao S, Zhang Q, Liang XD, Yuan BT, et al.
Comparative study of perpendicular versus parallel double plating methods for type C distal humeral fractures. Chin Med J (Engl) 2013;126:2337-42.
Goel DP, Pike JM, Athwal GS. Open reduction and internal fixation of distal humerus fractures. Oper Tech Orthop 2010;20:24-33.
Tejwani NC, Murthy A, Park J, McLaurin TM, Egol KA, Kummer FJ. Fixation of extra-articular distal humerus fractures using one locking plate versus two reconstruction plates: A laboratory study. J Trauma 2009;66:795-9.
O'Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005;14 1 Suppl S:186S-94S.
Schuster I, Korner J, Arzdorf M, Schwieger K, Diederichs G, Linke B. Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma 2008;22:113-20.
Green A. Surgical treatment of bicolumn distal humeral fractures: Relevant anatomy and classification. Instr Course Lect 2009;58:505-7.
Li SH, Li ZH, Cai ZD. Bilateral plate fixation for type C distal humerus fractures: Experience at a single institution. Int Orthop 2011;35:433-8.
Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elbow Surg 2010;19:2-9.
Jeong BO, Lee DK. Treatment for type C fractures of the distal humerus with the LCP distal humerus system. Eur J Orthop Surg Traumatol 2012;22:565-9.
Kamrani RS, Mehrpour SR, Aghamirsalim MR, Sorbi R, Bashi RZ, Kaya A. Pin and plate fixation in complex distal humerus fractures: Surgical technique and results. Int Orthop 2012;36:839-44.
Sanchez-Sotelo J, Torchia ME, O'Driscoll SW. Complex distal humeral fractures: Internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am 2007;89:961-9.
Celli A, Donini MT, Minervini C. The use of pre-contoured plates in the treatment of C2-C3 fractures of the distal humerus: Clinical experience. Chir Organi Mov 2008;91:57-64.
Arnander MW, Reeves A, MacLeod IA, Pinto TM, Khaleel A. A biomechanical comparison of plate configuration in distal humerus fractures. J Orthop Trauma 2008;22:332-6.
Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am 2000;31:103-13.
Huang TL, Chiu FY, Chuang TY, Chen TH. The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: A critical analysis of the results. J Trauma 2005;58:62-9.
Aslam N, Willett K. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta Orthop Belg 2004;70:118-22.
Gofton WT, Macdermid JC, Patterson SD, Faber KJ, King GJ. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am 2003;28:294-308.
Reising K, Hauschild O, Strohm PC, Suedkamp NP. Stabilisation of articular fractures of the distal humerus: Early experience with a novel perpendicular plate system. Injury 2009;40:611-7.
Lim R, Tay SC, Yam A. Radial nerve injury during double plating of a displaced intercondylar fracture. J Hand Surg Am 2012;37:669-72.
Douglas K, Cannada LK, Archer KR, Dean DB, Lee S, Obremskey W. Incidence and risk factors of heterotopic ossification following major elbow trauma. Orthopedics 2012;35:e815-22.
Papaioannou N, Babis GC, Kalavritinos J, Pantazopoulos T. Operative treatment of type C intra-articular fractures of the distal humerus: The role of stability achieved at surgery on final outcome. Injury 1995;26:169-73.
Charissoux JL, Mabit C, Fourastier J, Beccari R, Emily S, Cappelli M, et al.
Comminuted intra-articular fractures of the distal humerus in elderly patients. Rev Chir Orthop Reparatrice Appar Mot 2008;94(4 Suppl):S36-62.
Proust J, Oksman A, Charissoux JL, Mabit C, Arnaud JP. Intra-articular fracture of the distal humerus: Outcome after osteosynthesis in patients over 60. Rev Chir Orthop Reparatrice Appar Mot 2007;93:798-806.
Hausman M, Panozzo A. Treatment of distal humerus fractures in the elderly. Clin Orthop Relat Res 2004;(425):55-63.
Kimball JP, Glowczewskie F, Wright TW. Intraosseous blood supply to the distal humerus. J Hand Surg Am 2007;32:642-6.
Strauss EJ, Schwarzkopf R, Kummer F, Egol KA. The current status of locked plating: The good, the bad, and the ugly. J Orthop Trauma 2008;22:479-86.
Rübberdt A, Surke C, Fuchs T, Frerichmann U, Matuszewski L, Vieth V, et al.
Preformed plate-fixation system for type AO 13C3 distal humerus fractures: Clinical experiences and treatment results taking access into account. Unfallchirurg 2008;111:308-22.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2]