Intra-articular fractures of the distal humerus-a review of the current practice

Clinical outcomes of triceps reflecting anconeus pedicle and olecranon osteotomy approach for distal humerus intercondylar fractures

BACKGROUND

The preferred treatment for distal humeral intercondylar fractures is open reduction and internal fixation. While there is consensus about the posterior approach, several posterior approaches have been developed. It is debatable as to which approach is best.

AIM

To compare triceps reflecting anconeus pedicle (TRAP) and olecranon osteotomy approaches for internal fixation of distal humeral intercondylar fracture.

METHODS

In total, 40 cases of Arbeitsgemeinschaft für Osteosynthesefragen/Association of the Study of Internal Fixation type C, closed, and Gustilo type I intercondylar humeral fractures were included. Patients ranged in age from 18 years to 70 years. The patients were randomized into two groups: TRAP group and olecranon osteotomy group, with 20 cases in each. All were followed up at 6 wk, 3 months, 6 months, and 12 months. Functional outcomes were measured in terms of flexion-extension arc, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score.

RESULTS

The mean age was 43.2 years in the TRAP group and 37.5 years in the olecranon osteotomy group. The mean operative time and mean duration of hospital stay in the TRAP group were significantly higher than in the olecranon osteotomy group (119.5 vs 111.5 min and 9.85 vs 5.45 d, respectively). The mean arc of flexion-extension, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score were comparable without any significant difference in the groups at the 12-month follow-up (107.0 vs 106.2, 18.3 vs 15.7, and 84.2 vs 86.2, respectively). Ulnar paresthesia and superficial infections were comparable in both groups (2 cases vs 3 cases and 3 cases vs 2 cases, respectively). Hardware prominence was significantly higher in the olecranon osteotomy group, mostly due to tension band wiring.

CONCLUSION

Both approaches were equivalent, but there is a need for further study including higher numbers of subjects and longer study duration to prove the benefits of one approach over the other.

Neglected Bicondylar Fracture of the Distal Humerus Treated With Total Elbow Arthroplasty

A 69-year-old woman suffered a distal humerus fracture including the medial and lateral condyles. She received conservative treatment with a posterior arm splint at a local healthcare center where she was evaluated by a non-specialist physician. Eight months later, she presented to our department complaining about severe instability. An upper limb specialist examined the patient at the time, and after thoroughly explaining the condition, he suggested a surgical approach with total elbow arthroplasty (TEA), which was then performed. At the one-year follow-up, the patient had a full range of motion without any complications or pain complaints. TEA in neglected fractures of the distal humerus is a poorly researched topic in the field of upper limb surgery with only scarce literature available. In this case report, we present the excellent outcomes of the procedure performed on an elderly patient after non-union regaining her quality of life and suggest that TEA can be a viable solution in elderly patients with complicated or non-united elbow fractures.

Weak Points of Double-Plate Stabilization Used in the Treatment of Distal Humerus Fracture through Finite Element Analysis

BACKGROUND

Multi-comminuted, intra-articular fractures of the distal humerus still pose a challenge to modern orthopedics due to unsatisfactory treatment results and a high percentage (over 50%) of postoperative complications. When surgical treatment is chosen, such fractures are fixed using two plates with locking screws, which can be used in three spatial configurations: either parallel or one of two perpendicular variants (posterolateral and posteromedial). The evaluation of the fracture healing conditions for these plate configurations is unambiguous. The contradictions between the conclusions of biomechanical studies and clinical observations were the motivation to undertake a more in-depth biomechanical analysis aiming to indicate the weak points of two-plate fracture stabilization.

METHODS

Research was conducted using the finite element method based on an experimentally validated model. Three variants of distal humerus fracture (Y, λ, and H) were fixed using three different plate configurations (parallel, posterolateral, and posteromedial), and they were analyzed under six loading conditions, covering the whole range of flexion in the elbow joint (0-145°). A joint reaction force equal to 150 N was assumed, which corresponds with holding a weight of 1 kg in the hand. The biomechanical conditions of bone union were assessed based on the interfragmentary movement (IFM) and using criteria formulated by Steiner et al. Results: The IFMs were established for particular regions of all of the analyzed types of fracture, with distinction to the normal and tangential components. In general, the tangential component of IFM was greater than normal. A strong influence of the elbow joint's angular position on the IFM was observed, with excessive values occurring for flexion angles greater than 90°. In most cases, the smallest IFM values were obtained for the parallel plaiting, while the greatest values were obtained for the posteromedial plating. Based on IFM values, fracture healing conditions in particular cases (fracture type, plate configuration, loading condition, and fracture gap localization) were classified into one of four groups: optimal bone union (OPT), probable union (PU), probable non-union (PNU), and non-union (NU).

CONCLUSIONS

No plating configuration is able to ensure distal humerus fracture union when the full elbow flexion is allowed while holding a weight of 1 kg in the hand. However, flexion in the range of 0-90° with such loadings is acceptable when using parallel plating, which is a positive finding in the context of the early rehabilitation process. In general, parallel plating ensures better conditions for fracture healing than perpendicular plate configurations, especially the posteromedial version.

Surgical flip-dislocation of the bicolumnar approach without olecranon osteotomy versus olecranon osteotomy in type AO 13C3 distal humeral fracture: a matched-cohort study

BACKGROUND

Our experience with the surgical flip-dislocation of the bicolumnar (SFDB) approach for type AO 13C3 humeral fractures indicates that this surgical approach can be performed safely and effectively in appropriately selected patients. We aimed to evaluate the clinical outcomes of the SFDB approach without olecranon osteotomy (OO) for type AO 13C3 distal humeral fractures.

METHODS

We retrospectively reviewed 65 cases of type AO 13C3 distal humeral fractures treated between April 2008 and July 2018; 33 patients were treated with the SFDB approach, and the remaining were treated with OO. Propensity score matching was used to control for sex, age, and the American Society of Anesthesiology score. Elbow pain, range of motion, stability, and function were assessed using the Mayo Elbow Performance Index (MEPI) and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Clinical complications, reoperation rates, and radiographic results were compared between the groups.

RESULTS

Operative time and blood loss were significantly lower in the SFDB group than in the OO group (P = 0.001, P = 0.002, respectively). At the final follow-up, the mean postoperative MEPI did not significantly differ between the groups (P = 0.628). According to Morrey's criteria, a typical functional range of elbow motion was achieved in 12 and 15 patients in the SFDB and OO groups, respectively.

CONCLUSIONS

The SFDB approach achieves superior exposure of the articular surface without injury to the extensor mechanism in type 13C3 articular surface fracture treatment. This approach also results in good early functional recovery and clinical outcomes, with a low risk of complications.

Musculoskeletal Computed Tomography: How to Add Value When Reporting Adult Upper Limb Trauma

ABSTRACT

There is increasing reliance on computed tomography to evaluate fractures and dislocations following routine evaluation with plain radiography, critical in preoperative planning; computed tomography can provide multiplanar reformats and 3-dimensional volume-rendered imaging, providing a better global assessment for the orthopedic surgeon. The radiologist plays a critical role in appropriately reformatting the raw axial images to illustrate best the findings that will help determine further management. In addition, the radiologist must succinctly report the pertinent findings that will have the most significant bearing on treatment, assisting the surgeon in deciding between nonoperative and operative management. The radiologist should also carefully review imaging to look for ancillary findings in the setting of trauma beyond the bones and joints, including the lungs and rib cage when visualized.In this review article, we will systematically describe key features for fractures of the scapula, proximal humerus, distal humerus, radial head and neck, olecranon, coronoid process through a case-based approach, and distal radius. Although there are numerous detailed classification systems for each of these fractures, we aim to focus on the core descriptors that underpin these classification systems. The goal is to provide the radiologist with a checklist of critical structures they must assess and findings that they should mention in their report, emphasizing those descriptors that influence patient management.

Combined use of minimal screw synthesis and external articulated fixation is effective for the management of supra-intercondyloid humeral fractures in the elderly? A retrospective study

Background

Fractures of the distal humerus are relatively rare and can be a source of disabling outcomes especially if not properly treated. Therefore, the objective of the treatment must be to obtain a stable synthesis that allows early mobilization, avoiding complications such as muscular hypotonotrophy, joint rigidity or delays in consolidation that may be due to prolonged immobilization of this joint. Although ORIF treatment of these fractures may intuitively appear to be the gold standard, there is still no consensus in the literature on which type of treatment is most suitable.

Patients and method

We report in this retrospective case series analysis our experience on 31 elder patients (more than 65 years old), affected by a supra-intercondyloid humerus fracture, treated using a minimal internal fixation with cannulated screws combined with the use of an external articulated elbow fixator. This methodology is less invasive but allows a stable synthesis and an early mobilization.Clinical and radiographic examinations were performed for each patient at 1, 2, 3 and 6 months after surgery. At 6 months the residual joint excursion was evaluated and the data were collected. In addition, at 6 months, each patient underwent three different functional capacity assessment questionnaires: MAYO Elbow Performance score, The Disability of the ARM, Shoulder and Hand Score (QuickDASH) and Oxford Elbow Score.

Results

The healing rate was 100% with no cases of non-union, despite the old age of our patients. The average range of motions obtained at 6 months from the surgery was 111° in flexion-extension and 157° in pronation-supination for the patient with an extra-articular fracture, 88° in flexion-extension and 153° in pronation-supination for the patients with a partial articular fracture and 85° in flexion-extension and 149° in pronation-supination for the patients with a complete articular fracture. Our results in the recovery of an arc of motion in flexion-extension are slightly less performing than the results obtained with an ORIF treatment. Indeed, according to literature the mean postoperative flexion arc in an ORIF treatment of distal humerus fractures in adults is 110°.The functional results obtained were satisfactory, with an average score at 6 months from the surgery of 95/100 (Mayo score) for the patients with an extra-articular fracture, 83.3/100 for the patients with a partial articular fracture and 79/100 for the patients with a complete articular fracture.

Conclusion

The results obtained, in terms of range of motions, function, pain and healing and complications rate lead us to affirm that, in selected patients, this technique can represent a valid treatment and therefore a valid option that could be considered.

Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study

BACKGROUND

There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures.

METHODS

We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared.

RESULTS

A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7).

CONCLUSIONS

The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.

Long-Term Functional Outcomes and Complications of Intra-Articular (AO type B, C) Distal Humerus Fractures in Adults: A Retrospective Review

Introduction

Treatment of intra-articular fractures of the distal humerus is challenging due to their complexity, comminution, and associated complications. The evolution of surgical approaches and the design of elbow-specific implants over the last decades have failed to improve clinical and radiological outcomes. Studies are sparse regarding the long-term influence of surgical treatment of these types of fractures in the upper limb function. The purpose of the current study was to retrospectively review the long-term functional outcome and complications of all intraarticular (AO type B, C) distal humerus fractures treated surgically in a university hospital during the last 25 years.

Material and methods

The study included patients who were surgically treated for an intra-articular distal humerus fracture between March 1991 and May 2016. Our initial search, using ICD-10 codes, identified 63 patients in the specific time period. Twelve patients had died, nine declined to participate, eight had emigrated, nine could not be located and one patient was excluded as he suffered from quadriplegia unrelated to the initial injury. The remaining 25 patients (mean age at surgery 44.2±19.67) were included in a follow-up study protocol. Functional outcome was evaluated according to Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Pain was assessed using the Numerical Pain Rating Scale (NPRS) and subjects were asked to rate their satisfaction. Perioperative and late complications were recorded as well.

Results

The average follow-up was 158.16 ± 73.73 months. The average score was 89.4 ± 12.36 for MEPS, 42.68 ± 4.03 for OES, and 8.1 ± 15.38 for the QuickDASH. The patient satisfaction was rated 3.8 ± 1.08 on average. The mean flexion of the affected elbow was 137.6 ± 12.68 degrees while extension deficit was present in 14/25 patients, with a mean of 8.6 ± 8.96 degrees. We did not observe any mal- or non-unions. The re-operation rate was 32% primarily due to stiffness and irritation from the hardware. We noticed one spontaneously resolved ulnar nerve palsy, one combined radial, and ulnar nerve palsy after extensive arthrolysis that also resolved two cases of heterotopic ossification, one case of implant failure, and two cases of infection - one superficial, which was managed with antibiotics, and the other was deep managed with surgical drainage.

Conclusions

In our series, we found a satisfying range of motion, good functional outcome, and adequate ability to perform daily activities at a very long follow-up. Posttraumatic arthritis, whenever present, does not seriously affect functional performance.

Level of evidence: IV

Functional Outcome and Inflammatory Response of Patients with Extra-Articular Distal Humeral Fractures following Implantation of Anatomically Precontoured Locking Compression Plates through a Posterior Approach

Distal humeral fractures are challenging injuries to surgically correct and account for up to 2% of all adult fractures. Surgical management of extra-articular distal humeral fractures is challenging considering surgical approach, implant selection, and position of the implant owing to the availability of different precontoured implants and plate configurations. Anatomically precontoured locking compression plates (APLCPs) allow the placement of angular stable screws right underneath the reduced joint surface fragments. To date, there is a lack of evidence supporting its superiority to conventional locking plate osteosynthesis (LPO) in treating extra-articular distal humeral fractures. The objective of the study is to evaluate the efficacy and safety of APLCPs in the treatment of extra-articular distal humeral fractures. A total of 100 patients diagnosed with humeral fractures and receiving treatments in our hospital between May 2018 and May 2020 fulfilled inclusion and exclusion criteria and were randomly assigned to LPO and APLCP groups according to the odd-even of the order of hospital admission, 50 cases per groups. Clinical endpoints were assessed including operation time; in-bed time; length of hospital stay; volume of intraoperative blood loss; VSA scores before and 24, 48, and 72 h after surgery; MEPS scores before and 3, 6, and 12 months after surgery; range of motion, flexion, and extension of the elbow; serum levels of CK, CRP, and IL-6; and incidence of complications after surgery. It was found that the APLCP group exhibited shortened operation time and in-bed time, decreased length of hospital stay, and reduced volume of intraoperative blood loss compared to the LPO group (all P < 0.001). The two groups had declined VSA scores concomitant with increased MEPS scores after surgery in a time-dependent manner (P < 0.001). Notably, the VSA scores in the APLCP group were all lower than those in the LPO group at indicated time points (24, 48, and 72 h) after surgery (P < 0.001). Besides, the MEPS scores in the APLCP group were all higher than those in the LPO group at indicated time points (3, 6, and 12 months) after surgery (P < 0.001). It was revealed that the patients receiving extra-articular distal humeral APLCP through posterior approaches exhibited greater ranges of motion, flexion, and extension of the elbow than those receiving LPO after surgery (P < 0.001). The patients receiving extra-articular distal humeral APLCP through posterior approaches exhibited lower serum levels of IL-6, CRP, and CK than those receiving LPO after surgery (IL-6: P=0.007, CRP: P=0.001, CK: P=0.001). The APLCP had a lower total incidence rate of complication than the LPO group (48.00% vs. 18.00%, P=0.003). In conclusion, these data support the notion that the implantation of anatomically precontoured APLCP through a posterior approach allows for improved functional outcomes and attenuated inflammatory response and prevents the incidence of postoperative complications compared to conventional LPO for internal fixation of extra-articular distal humeral fractures.

Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications

OBJECTIVES

To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13).

DESIGN

Retrospective comparative cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy).

INTERVENTION

Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy.

MAIN OUTCOME MEASURE

Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI).

RESULTS

Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001).

CONCLUSIONS

Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty

Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions. In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.

Chronic type C3 distal humeral fracture associated with massive bone defects treated by open reduction and internal fixation with iliac crest autografts: a case report

Background

Chronic intercondylar fractures of the distal humerus with massive bone defects and severe comminution in the metaphysis are rare and complex injuries that are challenging for surgeons to treat, as reconstructing the triangular structure of the distal humerus is difficult and may have a severe impact on functional outcomes, especially in young patients, for whom total elbow arthroplasty is usually not a suitable option due to significant impairment in upper limb strength. Here, we report a patient in such scenario who was young and active and was treated by structural iliac bone autografting and internal fixation.

Case presentation

A 26-year-old male patient experienced a major car accident and was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus with massive bone defects and severe intra-articular involvement, without neurovascular injuries or other associated injuries. Surgical debridement, negative pressure vacuum sealing drainage, and immobilization by braces were initially performed, and the wound was closed after 15 days. When the wound had finally healed and the soft tissue was in good condition without infection or effusion 45 days later, this young and active patient was diagnosed with a chronic type C3 distal humeral fracture associated with massive bone defects at the supracondylar level in both columns and severe comminution at the trochlear groove. We performed surgical debridement and arthrolysis around the fracture site, and then, we successfully reconstructed the triangular structure of the distal humerus using structural iliac crest autografts in both columns as well as in the defective trochlear groove. Finally, internal fixation via a parallel double-plate configuration was performed. Over a follow-up period of 3 years, the patient achieved almost full recovery of range of motion and an excellent functional score, without minor or major postoperative complications.

Conclusion

In this study, we proposed a surgical reconstruction strategy for complex chronic distal humeral fractures associated with massive bone defects and severe articular involvement in young and active patients using metaphyseal shortening and structural iliac crest bone autografting together with open reduction and internal fixation via a parallel configuration.

Some outcomes of patients treated operatively for distal humerus fractures are affected by hand dominance

PURPOSE

This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm.

METHODS

A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed.

RESULTS

Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314).

CONCLUSION

Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair.

LEVEL OF EVIDENCE

Level III.

Complications and functional outcomes after transolecranon distal humerus fracture

BACKGROUND

Transolecranon distal humerus fractures are uncommon injuries. This is the first multipatient case series to describe outcomes and complications following transolecranon distal humerus fractures in the adult population.

METHOD

Design: retrospective; setting: single level 1 trauma center; patients/participants: 16 patients; intervention: surgical management of transolecranon distal humerus fracture; main outcome measurement: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after a minimum of 12 months.

RESULTS

A total of 16 patients with open (n = 12) or closed (n = 4) transolecranon distal humerus fractures were identified. Nine female and 7 male patients with a mean age of 47 years were included. Mechanisms of injury included motor vehicle collisions (n = 3), motorcycle crashes (n = 4), ground-level falls (n = 3), falls from height (n = 4), train collision (n = 1), and an industrial accident (n = 1). Seven patients (44%) presented with nerve injury. Patients underwent open reduction with internal fixation (n = 15), external fixation (n = 6), or both (n = 5). Additional surgeries were ultimately required in 11 patients (69%), with a mean of 3 surgeries to manage each patient's elbow injuries. All patients returned for at least 3 clinical follow-up visits; mean clinical follow-up was 15.8 months and mean radiographic follow-up was 12.3 months. Complications were observed in 15 patients (94%). Eleven patients (69%) had limited range of motion with a flexion arc of less than 100° at their last clinic visit. Seven patients (44%) developed deep wound infections requiring repeat débridement and intravenous antibiotics. Implant removal was performed in 10 patients (62.5%) because of infection (n = 5), symptomatic hardware (n = 4), or device failure (n = 1). Heterotopic ossification was seen in 8 patients (50%) and post-traumatic arthrosis in 4 (25%). Two patients (12.5%) required flap reconstruction for soft tissue defects. Nonunion occurred in 7 patients (44%). DASH scores were obtained for 10 patients (62.5%) at a mean of 3.8 years after injury. The mean DASH score was 40.2, ranging from 4.2 to 76.5. Among respondents, 7 (70%) were able to resume working, with an average DASH work module score of 25.

CONCLUSION

Management of transolecranon distal humerus fractures remain a challenge for orthopedic surgeons. Complication rates, including deep infection and nonunion, are high, with frequent long-term functional limitations posed to the patient, as evidenced by DASH scores.

Analysis of Factors Affecting Return to Work After Surgical Treatment in Patients with AO Type C Distal Humerus Fractures

BACKGROUND

The purpose of this study is to evaluate the functional results of distal humerus fractures which were treated by open reduction and fixation with pre-contoured angular stable plates in young patients, and investigate whether the patients could return to their pre-injury work and patients' financial conditions while they were not working.

MATERIALS AND METHODS

The data of 48 patients, ages between 18 and 55 years, working in a job and having AO/OTA type C distal humerus fracture were retrospectively evaluated. Mayo Elbow Performance Score (MEPS) was used to determine functional results. Postoperative radiographs were evaluated to determine the rate of union, degenerative changes, malunion and heterotopic ossification. Financial outcome form was constituted by the authors and the patients asked whether she/he could return to their pre-injury works after treatment finished and the financial status of the patients during the treatment and after the treatment.

RESULTS

The mean flexion-extension arc was 114° ± 12°(range 85°-135°) and the mean MEPS score was 85 ± 11(range 65-100). The average time to return to work was 6.5 ± 2.4 months (3-12 months). AO type C2 and C3 fractures and heterotopic ossification negatively affected the functional results and also adversely affected the patients' return to their pre-injury works. 38 (79%) patients returned to pre-injury work and 29 (76%) of them started to work at the same position before the fracture occured. Nine of 38 patients (24%) had to change their positions. Among the 48 patients, 10 patients (21%) could not return to the same work, 7 of them found light duty and 3 of them had not been to work.

CONCLUSION

Although the functional results of surgical treatment of intra-articular distal humerus fractures are good, at the end of the treatment, especially heavy workers may have difficulties in returning to their former works.

Clinical outcome of AO/OTA type C fracture of the distal humerus using the expanded paratricipital approach and cadaveric comparison of the exposure of the paratricipital and expanded paratricipital approaches to the distal humerus

BACKGROUND

We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach.

METHODS

Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows.

RESULTS

The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection.

CONCLUSIONS

The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.

Predrilled locking compression plate is more accurate than tension band wiring in restoring articular geometry of the ulnar greater sigmoid notch after olecranon Chevron osteotomy

INTRODUCTION

The olecranon Chevron osteotomy (OCO) is commonly used to approach complex intra-articular fractures of the distal humerus. Predrilled tension band wiring (TBW) has historically been used to fix OCO. However, clinical outcomes are burdened by secondary loss of reduction and up to 21.3% non-union rates. The biomechanical stability of anatomic locking compression plate (LCP) was reported to be superior to TBW in olecranon fracture fixation. We hypothesised that this implant may also be superior to TBW in the anatomic reconstruction of the articular surfaces of the ulnar greater sigmoid notch after OCO by predrilling the holes of the angular stable plate with the threaded drill guide prior to osteotomy.

MATERIALS AND METHODS

Lateral standardised and calibrated radiographs of twenty synthetic ulnar bones were obtained using a custom-made holder prior to preparation by a senior orthopaedic trauma surgeon. Ten specimens were then predrilled using the threaded drill bit guide of an olecranon LCP, while the other ten samples were predrilled with two 1.6 mm Kirschner wires. A distal "V" OCO was performed using a 0.6 mm oscillating saw. After repositioning and fixation with the corresponding device, lateral radiographs were repeated. Two independent observers used the TraumaCad planning software to document the articular geometry of the ulnar greater sigmoid notch pre- and postoperatively. The diameter of the best-fitting circle (diameter), the distance between the tip of the coronoid and the olecranon processes (distance) and the maximum articular depth were measured.

RESULTS

With the TBW technique, after OCO and fixation, all three postoperative measurements were significantly (p≤0.001) different from preoperative measurements. The diameter and distance increased by a mean of 1.5±0.5 mm and 0.9±0.3 mm, respectively, while the depth decreased by a mean of 0.2±0.1 mm. In contrast, no significant differences between pre- and postoperative measurements were observed with the LCP technique (p≥0.13). Inter and intra-observer measurement reliability was strong to very strong (intraclass correlation coefficients≥0.793) for all three variables.

CONCLUSION

Our study reveals that the predrilled LCP technique is more accurate than the predrilled TBW in restoring the anatomic articular geometry of the ulnar greater sigmoid notch after OCO.

Shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in the elderly

PURPOSE

The aim of this paper was to present our experience and the outcomes in 3 elderly patients who underwent combined shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in our center. Also, we evaluate difficulties in their treatment and report their final follow-up.

MATERIAL AND METHODS

Three cases of elderly patients who underwent shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus were reviewed. Demographic, clinical, and radiological data were analyzed. Also, Constant Shoulder Score, Mayo Elbow Performance Score, Short-Form Health Survey, and four-point Likert scale were evaluated.

RESULTS

All patients were females (100%). Mean age was 75 years (range 73-78). Mean follow-up was 36.6 months (SD 11.5). Mean time between injury and surgery was 12 days (SD 7.6). The 3 patients had a displaced and comminuted fracture of the humeral head (4-part, by Neer classification) and a comminuted intraarticular fracture of the distal humerus (13-C3, by AO classification). One patient presented a wound infection that required debridement. Despite the complications, at final follow-up, all patients showed a sufficient capacity to perform comfortably in their daily activities. Radiographs showed good fixation of all components, without evidence of prosthetic loosening or migration. All evaluated scores had good or excellent results.

CONCLUSIONS

Our study provides further evidence that the shoulder and elbow arthroplasty could be a reliable management for ipsilateral fractures of the proximal and distal humerus in the elderly. In our study, this technique showed in the final follow-up patient's good outcomes.