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ORIGINAL ARTICLE |
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Year : 2012 | Volume
: 5
| Issue : 2 | Page : 114-117 |
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Thirty cases of distal humerus intra-articular fractures treated by open reduction and internal fixation: A 3-year review
Ajit Swamy
Department of Orthopedics and Traumatology, Dr. D. Y. Patil Medical College Hospital & Research Centre, PIMPRI, Pune, Maharashtra, India
Date of Web Publication | 10-Nov-2012 |
Correspondence Address: Ajit Swamy Department of Orthopedics and Traumatology, Dr. D. Y. Patil Medical College Hospital & Research Centre, PIMPRI, Pune, Maharashtra India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.103332
Introduction: Fractures of the distal humerus involving articular surface remains one of the challenging situations for any orthopedic surgeon. Congruent articular reconstruction is mandatory for an acceptable functional recovery. Materials and Methods: This was a case series of 30 patients of distal humeral intraarticular fractures treated by open reduction and internal fixation and followed up at the end of 3 years.Fractures were classified according to AO [Arbeitsgemeinschaft für Osteosynthesefragen] and the results were evaluated using Cassebaums rating system, and other parameters. Results: Majority of the patients had a favourable outcome.There was no neurovascular complications and majority had a sound union. One case developed postoperative infection. Two cases resulted in nonunion. Conclusion: Open reduction and internal fixation with congruent articular reconstruction in young patients resulted in acceptable and good functional recovery. This was achieved with the use of recent AO ASIF plates. [AO/ASIF - Arbeitsgemeinschaft fuer Osteosynthesefragen - Association for the Study of Internal Fixation]. Keywords: Distal humerus, fractures, intraarticular, open reduction and internal fixation
How to cite this article: Swamy A. Thirty cases of distal humerus intra-articular fractures treated by open reduction and internal fixation: A 3-year review. Med J DY Patil Univ 2012;5:114-7 |
Introduction | | |
Distal humeral fractures present a challenge to the orthopedic surgeon.It requires a thorough understanding of the fracture geometry and subsequent articular reconstruction. Two patient subgroups can be demarcated.Young or middle-aged patients with good bone stock where early restoration of joint congruity and mobility is mandatory for sound elbow function.A second group which can be considered as "bag of bones" consists of elderly osteoporotic individuals in whom masterly neglect and early mobilization is recommended over the risks of open reduction and osteosynthesis. [1],[2],[3] The distinction between the two groups requires considerable surgical acumen. Significant trauma usually high velocity is required to cause such fractures in young patients. Elderly patients may sustain a similar fracture with just a fall due to the weakened bony architecture. In the past conservative treatment was advocated due to the morbidity of the surgical procedure. However, presently with adherence to good surgical technique one can hope for a good functional outcome in these major traumatic afflictions.
Materials and Methods | | |
A total of 46 patients underwent open reduction and internal fixation for distal humeral fractures between October 2003 and October 2005. Thirty patients were available for follow up at the end of three years, and they formed our study group. 12 fractures were Type C-1, 11 were Type C-2 and 7 were Type C-3 according to AO classification [Figure 1], [Figure 2]. Twenty-six patients were males and 4 were females. Majority were in the age group of 20-30 years. Twenty-seven patients had history of road traffic accident, 2 had direct trauma and puncture wounds around elbow and one patient had history of fall. Three patients had associated fracture femur and one had bilateral tibia fractures.
Operative Technique
High tourniquet was applied in all patients. Lateral decubitus position, midline posterior approach was made.In all patients olecranon V osteotomy was done after isolating the ulnar nerve. No predrilling of olecranon was done as it was fixed back with K-wires and tension band technique.
The first step was always TROCHLEAR ARTICULAR reconstruction followed by medial and lateral pillar stabilization. Medially one-third tubular plate was applied to medial surface and laterally reconstruction plate was applied to posterior surface thereby giving 90-90 construct [Figure 3], [Figure 4]. Bone grafting was not done in any of our cases in the primary sitting.
Olecranon was fixed back with 2 K-wires and stainless steel wire using figure of 8 loop [Figure 5]. Wound was closed over suction drain. Back slab was given in around 120 degree flexion in all patients.
Postoperative Care
Drain was removed after 24-48 hrs. Back slab was removed twice daily and the passive elbow range of motion exercises were started between 0 and 120 degrees in the first 2 weeks.Suture removal was done after 2 weeks and assisted active exercises were started for the range of motion. Back slab was kept for 6 weeks postoperatively followed by shoulder arm sling for another 4 weeks. Radiological follow-up was kept at 4 weekly interval until clinicoradiological fracture consolidation [Figure 6].
Results | | |
Results were evaluated with respect to the following parameters:
Cassebaums Elbow Rating System
Eleven patients had excellent results, 12 had good results, five had fair results and two patients had poor results.
Pronation - Supination
Twenty-one patients regained full range of motion, in six patients there was lack of motion of 10-20 degrees, three patients had restriction of around 20-30 degrees.
Shoulder movement was slightly restricted in four patients (13.3%). Two patients developed nonunion (6.7%). One was due to implant failure due to overzealous physiotherapy, which required bone grafting and extended immobilisation.There was one case of sepsis which required debridement and implant removal which resulted in painfree ankylosis. Twenty-eight patients went on to sound bony union on X-Ray (93.3%). Average duration of hospitalization was 2 weeks. There was no neurovascular compromise in any of our patients. There was minimal narrowing of joint space in 17 patients (56.7%). Moderate to severe degeneration was seen in seven patients (23.3%). Minimal joint space narrowing was not associated with significant functional impairment. Twenty-four (80%) patients did not complain of any pain. Four (13.3%) patients had minimal pain and two (6.7%) patients had significant pain at rest. Twenty-two patients (73.3%) had no functional disability, eight patients (26.7%) expressed some residual disability.
Discussion | | |
Although there have been proponents of conservative care for distal humerus fractures, it is now universally accepted that except probably in the rare situation of "bag of bones" in the "elderly osteoporotic" patient, this fracture requires a near normal reconstruction of the articular surface to optimize good function. [4]
With the availaibility of small AO ASIF plates and screws anatomical reconstruction and stable osteosynthesis is possible, although difficult with a steep learning curve. [5],[6]
Prolonged immobilization of displaced fractures leads to pain and stiffness and heralds a poor outcome.
Jupiter et al. [7] have reported satisfactory results with open reduction and internal fixation with AO plates via a tran-olecranon approach.The study supports the view of Jupiter et al. that the trans-olecranon approach affords the best possible visualization to fix this difficult fracture. By fixing the olecranon with K-wires and stainless steel wires, not a single case of olecranon osteotomy nonunion occurred. Ulnar nerve transposition has been advocated by Jupiter et al. [7] Need to transpose the nerve did not arise in the present series as there was no significant indication.
The AO classification was used as it is universally accepted, although Schatzker [8] has opined a few reservations regarding this classification.
Elbow being a hinge joint, the principal motion of flexion and extension range of motion was rated according to Cassebaum. [9] Other parameters were studied to evaluate the outcome of the surgical stabilization.
Accuracy to technical details was scrupulously adhered as laid down by Schatzker. [8]
Postoperatively it was felt that instead of allowing active exercises as advocated by Schatzker, a more conservative approach in the form of passive and then assisted active motion would lessen the load on the implants.
There is current interest in preserving the olecranon integrity and few papers have been published to highlight the advantage of triceps reflecting anconeus pedicle TRAP approach. [10],[11] However, in the present series no case of olecranon nonunion was encountered. Olecranon osteotomy is done in the cancellous area of the bone and as such nonunion is not a very troublesome issue, instead osteotomy affords a global and wide exposure for the articular reconstruction.
To conclude, open reduction and internal fixation of distal intra-articular fractures do represent a difficult challenge to even the most senior surgeon, but it offers the best hope of a sound functional elbow when performed with care and with strict adherence to technical operative details.
References | | |
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3. | Korner J, Diederichs G, Arzdorf M, Lill H, Josten C, Schneider E, et al. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma 2004;18:286-93. [PUBMED] |
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6. | Colton C, Fernandez Dell'Oca A, Holz U, Kellam J, Ochsner P. AO principles of fracture management. Stuttgart: Georg Thieme Verlag; 2003. |
7. | Jupiter JB, Morrey BF. Fractures of the distal humerus in the adult. In: Morrey BF, editor. The elbow and its disorders. 2 nd ed. Philadelphia, PA: WB Saunders Company; 1993. p. 328-66. |
8. | Schatzker J, Tile M. The rationale of operative fracture care. Springer-Verlag: Berlin; 1987. |
9. | Cassebaum WH. Open reduction of T & Y fractures of the lower end of the humerus. J Trauma 1969;9:915-25. [PUBMED] |
10. | Pankaj A, Mallinath G, Malhotra R, Bhan S. Surgical management of intercondylar fractures of the humerus using triceps reflecting anconeus pedicle (TRAP) approach. Indian J Orthop 2007;41:219-23. [PUBMED] |
11. | Ozer H, Solak S, Turanli S, Baltaci G, Colakoglu T, Bolukbasi S. Intercondylar fractures of the distal humerus treated with the triceps-reflecting anconeus pedicle approach. Arch Orthop Trauma Surg 2005;125:469-74. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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