Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up

A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options

Background

Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management.

Methods

A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates.

Results

Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)).

Discussion

Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Biomechanical comparison of three internal fixation configurations for low transcondylar fractures of the distal humerus

BACKGROUND

We aimed to evaluate the biomechanical stiffness and strength of different internal fixation configurations and find suitable treatment strategies for low transcondylar fractures of the distal humerus.

METHODS AND MATERIALS

Thirty 4^th generation composite humeri were used to create low transcondylar fracture models that were fixed by orthogonal and parallel double plates as well as posterolateral plate and medial screw (PPMS) configurations (n=10 in each group) using an anatomical locking compression plate-screw system and fully threaded medial cortical screws. Posterior bending (maximum 50 N), axial loading (maximum 200 N) and internal rotation (maximum 10 N·m) were tested, in that order, for each specimen. Stiffness under different biomechanical settings among different configurations were compared. Another 18 sets of fracture models were created using these three configurations (n=6 in each group) and the load to failure under axial loading among different configurations was compared.

RESULTS

Under posterior bending, the stiffness of parallel group was higher than orthogonal group (P<0.001), and orthogonal group was higher than PPMS group (P<0.001). Under axial loading, the stiffness of parallel group was higher than orthogonal group (P=0.001) and PPMS group (P<0.001); however, the difference between orthogonal and PPMS group was not statistically significant (P>0.05). Under internal rotation, the stiffness of parallel group was higher than orthogonal group (P=0.044), and orthogonal group was higher than PPMS group (P=0.029). In failure test under axial loading, the load to failure in the orthogonal group was lower than parallel group (P=0.009) and PPMS group (P=0.021), but the difference between parallel group and PPMS group was not statistically significant (P>0.05). All specimens in orthogonal group demonstrated "distal medial failure"; most specimens had "distal medial and trochlear failure" in the parallel group; most specimens exhibited "contact failure" in the PPMS group.

CONCLUSION

For treating low transcondylar fractures, the overall stiffness and strength of the parallel configuration were superior to those of the orthogonal and PPMS configurations. Nevertheless, the PPMS configuration can provide adequate stability and stiffness comparable to double-plate configurations under axial loading. Therefore, the PPMS construct may have certain clinical value.

Outcomes and complications after open reduction and internal fixation of distal humeral fractures with precontoured locking plates

Objectives

The aim of this study was to evaluate functional and radiographic results after open reduction and internal fixation of distal humeral fractures using precontoured locking plates. Our main hypothesis was that patients older than 65 years have inferior outcomes compared with younger patients.

Methods

All patients treated for a distal humeral fracture with precontoured locking plates between 2006 and 2017 at a level 1 trauma center were identified. Included patients underwent a clinical examination, and new radiographs were obtained. Functional outcomes were evaluated using Quick Disability of the Arm, Shoulder and Hand, Mayo Elbow Performance Score, visual analog scale elbow satisfaction, and range of motion. Complications and reoperations were recorded.

Results

Fifty-seven patients with a median age of 60 years were included in this study. Median Quick Disability of the Arm, Shoulder and Hand was 14, and median Mayo Elbow Performance Score was 85. There was no difference in functional scores in patients younger than 65 years or 65 years or older. However, the median flexion-extension arc was 121 degrees in patients younger than 65 years and 111 degrees in patients 65 years or older (P = 0.01). The overall complication rate was 68%, and 24 patients had at least 1 reoperation. Ulnar neuropathy was the most common complication followed by reduced range of motion.

Conclusions

Operative management of distal humeral fractures with precontoured locking plates provides good functional outcome. The patient-reported outcomes were good, independent of patient age. The implant failure rate is low with precontoured locking plates; however, the complication rate remains high, and reoperations are common.

Level of Evidence

Level 4, retrospective study.

Elbow hemiarthroplasty vs. open reduction internal fixation for acute Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 13C fractures—A systematic review

Background

Open reduction and internal fixation (ORIF) is the standard treatment for multifragmentary intra-articular distal humeral fractures. Fractures not amenable by ORIF are treated with total elbow arthroplasty (TEA). In recent years, elbow hemiarthroplasty (EHA) has been used as an alternative to TEA, as weight bearing restrictions and risk of component loosening are lower. We systematically reviewed the literature reporting functional outcomes and complication rates after either EHA or ORIF for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 13C fractures.

Methods

We searched PubMed, Embase, The Cochrane Library, and Scopus. The inclusion criteria were at least 5 patients, aged ≥50 years, AO/OTA type 13C fracture treated with ORIF or EHA, and evaluation with the Mayo Elbow Performance Score. Literature screening and data extraction were conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. The results were synthesized qualitatively using weighted means. No comparative statistical analyses were done.

Results

We included 27 articles, which included 96 patients treated with EHA and 535 patients treated with ORIF. We identified 1 randomized controlled trial and 26 case series. The weighted mean Mayo Elbow Performance Score was 86.9 (n = 89) in the EHA group and 84.7 (n = 535) in the ORIF group. There were 26 (33%) complications (n = 78) in the EHA group and 103 (38%) complications (n = 270) in the ORIF group. Complication rates were generally high in both groups.

Conclusion

We found comparable results of EHA and ORIF, which indicate that EHA is a viable treatment option for AO/OTA type 13C fractures not amenable by ORIF. Because of high risk of bias, interpretation of the results should be done with caution.

Complications associated with open reduction and internal fixation for adult distal humerus fractures: a multicenter retrospective study

Background

Open reduction and plate fixation are the preferred treatment options for most distal humerus fractures in adults. However, it is often challenging for orthopedic surgeons because of the complex anatomy and the difficulty in achieving stable fixation. This multicenter study aimed to analyze the complication types and rates of patients with distal humerus fractures treated with open reduction and plate fixation, and compare the results with those found in the literature. In addition, we describe the clinical outcomes.

Methods

This retrospective multicenter study was conducted between September 2001 and March 2021 and included data from four hospitals. In total, 349 elbows underwent surgical treatment at these hospitals during the study period. Patients > 17 years of age who were treated by plate fixation were included, and patients who were treated by other fixation methods were excluded. A total of 170 patients were included in the study. The following types of complications were investigated: (1) nerve related; (2) fixation and instrument related; (3) osteosynthesis related; (4) infection; and (5) others.

Results

The following complications were found: (1) 26 (15.3%) cases of postoperative ulnar nerve symptoms; 4 (2.4%) of postoperative radial nerve symptoms; (2) one (0.6%) case of screw joint penetration and screw loosening; and eight (4.7%) cases of hardware removal due to instrument skin irritation; (3) seven (4.1%) cases of nonunion; (4) two (1.2%) and four (2.2%) cases of superficial and deep infection, respectively, and seven (3.9%) cases of wound complication; and (5) 37 (21.8%) cases of heterotrophic ossification, 79 (46.5%) cases of elbow stiffness (did not achieve functional range of motion [ROM]), and 41 (24.1%) cases of osteoarthritis over Broberg and Morrey Grade I.

Paradoxically, the postoperative ulnar nerve symptoms were more frequent in the prophylactic ulnar nerve anterior transposition group. However, this difference was not statistically significant (p = 0.086). The mean ROM was 123.5° flexion to 9.5° extension. The average Disabilities of the Arm, Shoulder and Hand (DASH) score was 14.5 ± 15.6.

Conclusions

Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes. Surgeons must be vigilant about ulnar nerve complications.

Level of Evidence Therapeutic Level III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03292-1.

Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome

Purpose

This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options.

Materials and methods

Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus.

Results

The mean follow-up time was 8.7 years [range 2–15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6–10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0–49) and 83.3 (range 25–100), respectively.

Conclusion

In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function.

How to cite this article

Athanaselis ED, Komnos G, Deligeorgis D, et al. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022;17(1):7–13.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis

BACKGROUND

Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years.

METHODS

We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating.

RESULTS

Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01).

CONCLUSIONS

This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.

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.

Olecranon osteotomy vs. triceps-sparing for open reduction and internal fixation in treatment of distal humerus intercondylar fracture: a systematic review and meta-analysis

Background

The open reduction and internal fixation (ORIF) was a standard treatment approach for fracture at distal humerus intercondylar, whereas the optimal way before ORIF remains inconclusive. We, therefore, performed a systematic review and meta-analysis to assess the efficacy and safety of olecranon osteotomy vs. triceps-sparing approach for patients with distal humerus intercondylar fracture.

Methods

The electronic searches were systematically performed in PubMed, EmBase, Cochrane library, and Chinese National Knowledge Infrastructure from initial inception till December 2019. The primary endpoint was the incidence of excellent/good elbow function, and the secondary endpoints included Mayo elbow performance score, duration of operation, blood loss, and complications.

Results

Nine studies involving a total of 637 patients were selected for meta-analysis. There were no significant differences between olecranon osteotomy and triceps-sparing approach for the incidence of excellent/good elbow function (odds ratio [OR]: 1.37; 95% confidence interval [CI]: 0.69–2.75; P = 0.371), Mayo elbow performance score (weight mean difference [WMD]: 0.17; 95% CI: −2.56 to 2.89; P = 0.904), duration of operation (WMD: 4.04; 95% CI: −28.60 to 36.69; P = 0.808), blood loss (WMD: 33.61; 95% CI: −18.35 to 85.58; P = 0.205), and complications (OR: 1.93; 95% CI: 0.49–7.60; P = 0.349). Sensitivity analyses found olecranon osteotomy might be associated with higher incidence of excellent/good elbow function, longer duration of operation, greater blood loss, and higher incidence of complications as compared with triceps-sparing approach.

Conclusions

This study found olecranon osteotomy did not yield additional benefit on the incidence of excellent/good elbow function, while the duration of operation, blood loss, and complications in patients treated with olecranon osteotomy might be inferior than triceps-sparing approach.

[Sub- and intercondylar fractures of the distal humerus in adults]

Introduction

les fractures articulaires complètes de l’extrémité inférieure de l’humérus de l’adulte sont des lésions rares et graves. Les options thérapeutiques sont nombreuses mais le traitement chirurgical par ostéosynthèse est ardemment défendu. L’objectif de notre travail a été de décrire les caractéristiques épidémiologiques, clinico-radiologiques et thérapeutiques de ces fractures, ainsi que d’évaluer les résultats fonctionnels obtenus chez nos patients.

Méthodes

nous avons mené une étude prospective sur une période de 3 ans, portant sur 38 patients admis pour fracture articulaire complète sus et inter-condylienne de l’humérus distal (classée type C selon la classification de l’AO), traités chirurgicalement par voie postérieure trans-olécranienne avec un recul moyen de 34 mois.

Résultats

nous avons remarqué une distribution bimodale avec une atteinte du sujet jeune de sexe masculin d’une part, et une survenue chez les femmes âgées d’autre part. Les étiologies étaient dominées par les accidents de la voie publique chez 78%. Lors du suivi, nous avons noté un seul cas d’infection superficielle du site opératoire et il n’y a eu aucun cas de démontage du matériel ni de pseudarthrose. De surcroit, aucune complication de l’ostéosynthèse de l’olécrane n’a été enregistrée. Les résultats fonctionnels ont été très satisfaisants avec un score de Mayo-Clinic Elbow Performance Score (MEPS) moyen de 86.

Conclusion

nous considérons que la voie postérieure trans-olécranienne semble être la meilleure voie d’abord de ces fractures puisqu’elle permet une bonne exposition articulaire, condition sine qua non pour une restitution anatomique parfaite et une ostéosynthèse stable afin d’entreprendre une rééducation précoce et adaptée.

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.

Results of plate fixation for transcondylar fracture of the distal humerus: a rare pattern of fractures

Background

The pattern of transcondylar fracture of the humerus is unique and the incidence rate is very low. Stable internal fixation may be difficult to achieve, and complications have been reported at a higher rate. The purpose was to report the outcomes of open reduction and internal fixation (ORIF) for transcondylar fractures of the humerus.

Methods

Seventeen patients were included between January 2014 and December 2017. ORIF was performed using anatomic distal humerus plates. Results were evaluated by range of motion, Mayo Elbow Performance Score (MEPS), and complications. We analyzed the results according to ulnar nerve transposition status and fixation pattern.

Results

The mean range of elbow motion was 117° flexion and 20° extension. The MEPS was excellent in 12, good in 3, fair in 1, and poor in 1. There were in total 5 cases of complications among 17 patients: 1 with nonunion, 1 with ulnar neuropathy, 2 with delayed union, and 1 with heterotopic ossification. The results according to ulna nerve transposition and fixation pattern showed no difference.

Conclusions

For reliable and good results, rigid fixation using anatomic plates and appropriate immobilization of the fracture site are key factors in the treatment. In our case series, the overall outcome was good and there were 2 major complications. The ORIF using anatomic plates can be a reliable treatment option for transcondylar humeral fractures.

Correlation between modified trochleocapitellar index and post-traumatic elbow stiffness in type C2-3 distal humeral fractures among adults

BACKGROUND

The purpose of this study was to propose the modified trochleocapitellar index (mTCI), assess its reliability, and evaluate its correlation with post-traumatic elbow stiffness in type C2-3 distal humeral fractures among adults.

METHODS

From January 2013 to June 2017, a total of 141 patients with type C2-3 distal humeral fractures were included. The mTCI was calculated as the ratio between the modified trochlear and capitellar angles relative to the humeral axis (mTCI-HA), lateral humeral line (mTCI-LHL), and medial humeral line (mTCI-MHL) from anteroposterior radiographs taken immediately after the operation. The patients were divided into group A (with elbow stiffness) and group B (without elbow stiffness) based on follow-up results. To determine risk factors for elbow stiffness, univariate and logistic regression analyses were performed on each radiographic parameter separately, together with other clinical variables. Interrater reliability was assessed for all measurements.

RESULTS

Specific optimal ranges of value were identified for mTCI-HA (0.750-0.875), mTCI-LHL (0.640-1.060), and mTCI-MHL (0.740-0.900), beyond which the likelihood of elbow stiffness significantly increased (P < .001). By multivariate analysis, mTCI-HA (odds ratio [OR] 26.22, 95% confidence interval [CI] 3.39-203.07, P = .002), mTCI-LHL (OR 5.37, 95% CI 2.17-13.28, P < .001), and mTCI-MHL (OR 5.95, 95% CI 1.91-18.56, P = .002) values beyond the optimal ranges were identified as the independent risk factors for elbow stiffness. The interrater reliability of mTCI-HA, mTCI-LHL, and mTCI-MHL was 0.986, 0.983, and 0.987, respectively.

CONCLUSION

The mTCI measurement method is reliable. Either too small or too large mTCI values were associated with post-traumatic elbow stiffness among adult patients with type C2-3 distal humeral fractures. The mTCI-HA showed a better predictive value than mTCI-LHL and mTCI-MHL.

Locking versus non-locking plates in fixation of extra-articular distal humerus fracture: a randomized controlled study

INTRODUCTION

Studies have shown that the use of nonlocking (reconstruction) plates in fixing distal humerus fractures may not yield stable fixation which therefore requires long immobilization and suboptimal functional results. There are reports showing that locking plates are biomechanically superior to nonlocking plates. The aim of this study was to compare elbow functional outcomes between locking and nonlocking plates in fixation of distal humerus fractures.

METHODS

A single-centre, randomized control study was conducted at an academic level 1 trauma centre. A total of 60 patients with type 13-A fracture (AO/OTA classification) were randomized into two equal groups, locking plates group, and nonlocking plates group. The primary outcome measure was the Mayo elbow performance score (MEPS) at one year. Secondary outcomes measures were elbow flexion/extension arc, union, operative time, and complications (e.g., infection, heterotrophic ossification).

RESULTS

The Mayo Elbow Performance Score (MEPS) at one year was 88 ± 10.1 in locking plates group and 75.8 ± 12.8 in nonlocking plates group. The difference was found to be statically significant (P value = 0.01). Elbow flexion/extension arc of motion at one year was 116° ± 15° in locking plates group and 113° ± 28° in nonlocking plates. The difference was not found to be statistically significant (P value = 0.17).

CONCLUSION

Both implants yield similar results, with locking plates showing slightly better clinical scores.

ORIF of Distal Humerus Fractures with Modern Pre-contoured Implants is Still Associated with a High Rate of Complications

BACKGROUND

The purpose of this study was to identify complications after operative treatment of distal humerus fractures with anatomic, pre-contoured, locking distal humeral plates. We hypothesized that these fractures have high complication rates despite the use of these modern implants.

MATERIALS AND METHODS

Between 2010 and 2018, 43 adult patients with a distal humerus fracture underwent open reduction and internal fixation (ORIF) at a Level I trauma center. Pre-operative variables, including medical comorbidities, mechanism of injury, open or closed fracture, AO/OTA fracture classification (Type A, B, or C), and nerve palsy, were recorded. Intra-operative variables including surgical approach, ulnar nerve transposition, and plate configuration were recorded. Anatomic, pre-contoured, locking distal humeral plates were used in all patients. Various plating systems were used based on surgeon preference and fracture pattern. Post-operative complications including infection, nonunion, malunion, painful implants, nerve palsy, heterotopic ossification, stiffness, and post-traumatic arthritis were recorded.

RESULTS

Most fractures were Type C (53%). The posterior olecranon osteotomy approach (51%) and parallel plate configuration (42%) were used in most cases. At a mean follow-up of 15 months, the complication rate was 61% (26/43 patients). Among all patients, 49% (21/43 patients) required a reoperation. Elbow stiffness (19%) was the most common complication followed by nerve palsy (16%). There were four fracture nonunions (9%), deep infections (9%), painful implants (9%), post-traumatic arthritis (9%), and heterotopic ossification (9%).

CONCLUSIONS

Distal humerus fractures treated with ORIF utilizing anatomic, pre-contoured, locking distal humeral plates have a high complication rate, with many requiring reoperation.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Outcome after surgical treatment of complex elbow fractures: a single-center follow-up study

INTRODUCTION

Elbow injuries present particular challenges for the treating surgeons. The aim of the present study was to evaluate the postoperative outcome after surgical treatment of complex elbow fractures.

PATIENTS AND METHODS

Retrospective analysis with subsequent clinical follow-up examination of all patients with complex elbow fractures admitted to our level I trauma center over a 6-year period. The patients were stratified into three groups: single fractures of the proximal forearm (olecranon fractures type Mayo IIB, radial head fractures type Mason II-IV), distal humerus fractures (AO type C1-3), and combined injures. The clinical examination included the range of motion, grip strength measured with a Jamar dynamometer, DASH and MEP score.

RESULTS

Overall, 39 patients with complex elbow fractures were included in the study. Twelve patients presented with a distal, intra-articular humerus fracture, 16 patients had an isolated proximal forearm fracture and 11 patients suffered multiple fractures. The functional scores showed good overall results, with a median DASH score of 6.7 points and median MEP score of 85.0 points. The median extension deficit in the elbow joint was 15.0° (mean 16.2° ± 12.8°), the median flexion deficit was 5.0° (9.8° ± 12.3°) and the median pronation/supination (overall rotation) deficit was 5.0° (16.7° ± 23.6°). Patients with intra-articular distal humerus fractures showed a significantly increased extension and flexion deficit compared to the other groups.

CONCLUSION

The surgical treatment of complex elbow fractures was associated with good to excellent clinical results. However, distal intra-articular humerus fractures presented the most prominent loss of elbow motion in the follow-up examination.

Biomechanical analysis of a novel plating for intra-articular distal humerus fractures: combined anteromedial and anterolateral plating

Purpose

The traditional strategy for fixing intra-articular distal humerus fractures is double plating placed in an orthogonal or parallel configuration, based on posterior approach. With a combined medial and lateral approach, a novel configuration of plating (combined anteromedial and anterolateral plating) has been used. In this study, we investigated the biomechanical properties of the novel plating by comparing it with orthogonal plating.

Methods

Based on the 3D morphology of a healthy subject’s humerus, the models of simple intra-articular distal humerus fractures were simulated. Two configurations of plating were applied to fix the models: the novel plating (with one plate anteromedially and the other anterolaterally on distal humerus), and orthogonal plating. Stresses, displacement, and stiffness were simulated and calculated under the conditions of axial compression, rotation torsion, bending torsion, and valgus torsion by using finite element analysis.

Results

In all the conditions, the maximal von Mises stresses of the novel plating are similar to those of orthogonal plating, and the patterns of stress distribution are similar between these two configurations. However, the impact of high stresses was weaker on the novel plating. The maximal displacement of the novel plating is smaller than that of orthogonal plating. The stiffness of the novel plating is superior to that of orthogonal plating, with the improvements of 19.4%, 122.7%, 25.0%, and 54.2% in axial compression, rotation torsion, bending torsion, and valgus torsion, respectively.

Conclusions

The novel plating is stronger than orthogonal plating without increasing stress magnitude when fixing simple intra-articular distal humerus fractures, which makes it a feasible alternative. Further biomechanical and clinical studies are needed for a decisive conclusion.

Posttraumatic elbow agility and reduction of muscle force after intra-articular distal fractures of the humerus in adults

BACKGROUND

Treatment of distal intra-articular humerus fractures is still a technical challenge. Until now, little is known about the regain of strength and elbow agility after surgical treatment of these fractures. Due to small collectives there is only limited data.

OBJECTIVE

Investigation of regained strength and elbow agility in patients with intra-articular distal humerus fractures.

METHODS

A total of 28 patients were treated with distal intra-articular humerus fractures followed up for an average period of 62.3 months. The following parameters were examined: Arthrosis, heterotopic ossification, functional outcome (MEPS, DASH score, LES) and isometric strength of the elbow in extension and flexion was tested in 30∘, 60∘ and 90∘ in a custom-made positioning device.

RESULTS

There was a high complication rate with 32%. At the 60th month post injury, range of motion (ROM) of the elbow was 114∘ with a reduction of 32∘ compared to the contralateral uninjured side (p< 0.001). The highest reduction was seen in extension with an average loss of 16∘ (p< 0.001). Loss of motion correlated with the fracture severity regarding the AO-classification (r= 0.54, p< 0.01). The average regained muscle force was 81.5% in flexion and 92% in extension in comparison to the contralateral healthy side. Patients over 60 years had less range of motion and inferior results in the DASH score compared to younger patients.

CONCLUSIONS

Functional impairment in terms of reduced ROM and muscle force is a common complication after distal intra-articular humerus fracture. Patients over 60 years have a higher deficit of motion in the injured elbow joint and an inferior clinical outcome. Superiority of modern angle-stable implants could yet not be shown.

Complications of open reduction and internal fixation of distal humerus fractures

Treatment of distal humerus fractures is demanding. Surgery is the optimal treatment and preoperative planning is based on fracture type and degree of comminution.

Fixation with two precontoured anatomical locking plates at 90^o:90^o orthogonal or 180^o parallel is the optimal treatment.

The main goal of surgical treatment is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness.

Despite evolution of plates and surgical techniques, complications such as mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, infection, and complications from olecranon osteotomy are quite common.

Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Cite this article: EFORT Open Rev 2018;3:558-567. DOI: 10.1302/2058-5241.3.180009

[Effectiveness comparison between the paratricipital approach and the chevron olecranon V osteotomy approach in the treatment of type C3 distal humeral fractures]

Objective

To compare the effectiveness between paratricipital approach and chevron olecranon V osteotomy approach for the treatment of type C3 (AO/OTA) distal humeral fractures and investigate the details of operation.

Methods

Between April 2010 and September 2016, 36 type C3 (AO/OTA) distal humeral fractures were treated with open reduction and bicolumnar orthogonal locking plating fixation by paratricipital approach and chevron olecranon V osteotomy approach respectively. The patients were divided into 2 groups by approach, there were 17 cases in paratricipital group (group A) and the bicolumns and distal humeral joint surface were exposed by traction of triceps and olecranon, and the distal humeral joint surface of the 19 cases in chevron olecranon V osteotomy group (group B) were exposed by osteotomy of the olecranon and reversing of triceps. There was no significant difference in gender, age, dominant side, interval between injury and surgery, causes of injury between 2 groups ( P>0.05). Patients were followed up, the postoperative range of motion of elbow joint, strength, pain, and stability in 2 groups were documented and compared; the elbow joint function was evaluated according to Mayo elbow performance score (MEPS).

Results

The operation time of group A [(115.0±10.4) minutes] was less than that of group B [(121.0±12.3) minutes], but there was no significant difference ( t=–1.580, P=0.123). All patients in 2 groups got over 1 year follow-up and there was no significant difference of the follow-up time between 2 groups ( t=–0.843, P=0.405). There was 1 case of heterotopic ossification in each group; 1 case of incision infection in group A and 1 case of incision superficial infection in group B, and were cured after 2 weeks of intravenous antibiotics administration. There was no other operative complications in the 2 groups. At 3 months after operation, all the distal humerus healed. At last follow-up, the elbow flexion extension range of groups A and B were (102.0±12.6)° and (99.5±10.1)° respectively, showing no significant difference ( t=–0.681, P=0.501). The MEPS scores of groups A and B were 82.9±7.3 and 81.3±7.2 respectively, showing no significant difference ( t=0.670, P=0.507); and the evaluation grade also showed no significant difference between 2 groups ( Z=–0.442, P=0.659).

Conclusion

By paratricipital approach and proper traction of the olecranon, the distal humeral articular surface can be exposed in the operation of type C3 distal humeral fractures, followed with same stable fixation after reduction, the effectiveness is equal to by chevron olecranon V osteotomy approach.

Internal Fixation of Osteoporotic Bone

Osteoporosis is one of the costliest conditions managed by orthopaedic surgeons. This condition, which is characterized by decreased bone density and thinning of cortical bone, is strongly influenced by complex signaling in both the hormonal and mechanical environments. Osteoporosis cannot be cured; instead, it can only be managed to decrease patient morbidity. Current pharmacologic treatments are aimed at minimizing bone turnover and have substantial side effects. Therefore, much work remains to find safer and more effective agents to restore bone density. In addition to the high incidence of fracture in elderly patients, many of the traditional fixation constructs used for repair of these fractures are not suitable for use in osteoporotic bone. Increased use of fixed-angle locking plates, intramedullary devices, and bone substitutes has greatly improved outcomes in these patients.

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

Intra-articular fractures of the distal humerus are complex injuries that can considerably limit elbow function if not treated appropriately. Surgical management is indicated for most intra-articular distal humerus fractures with the goal of restoring elbow range of motion and function. Open reduction and internal fixation (ORIF) with plates and screws has been the preferred surgical option. Double plating is recommended for bicolumnar fractures and plates can be applied either parallel or orthogonal to each other. Surgical approach for ORIF of the distal humerus can be performed through an olecranon osteotomy, but other approaches that preserve the olecranon are also in use, such as the triceps-reflecting, triceps-splitting, paratricipital, and triceps-reflecting anconeus pedicle approach. The ulnar nerve is identified during the approach, followed by either in situ decompression or anterior transposition. Elbow arthroplasty has also emerged as a viable alternative to ORIF for fixation of these fractures in elderly patients with poor bone quality.

Challenges and Solutions in Management of Distal Humerus Fractures

Background

Management of distal humerus fractures remains a challenge for trauma surgeons and advancements in treatment options continue to be made to achieve the best results for patients presenting with these complex fractures. Our aim in this article is to provide the surgeons with a detailed review of current literature to help them make an evidence based decision when faced with managing such complex injuries in their surgical practice.

Methods

This is a comprehensive review of the current literature that details various aspects of distal distal humerus fractures such as classification, surgical anatomy, surgical approaches, treatment options, choices of devices, outcomes and complications.

Results

With the advancements in techniques and equipment, there has been improvement in patients' outcomes following surgical management of these fractures and a large proportion of these patients are able to achieve pre-injury level of function. The contoured locking plates have enabled successful fixation of many of these fractures that were previously considered unfixable. For those not amenable to surgical fixation, total elbow arthroplasty and elbow hemiarthroplasty are considered as good alternatives.

Conclusion

Since the days where the 'bag of bones' technique was the preferred method of treating these complex injuries, techniques and outcomes have advanced greatly. However, they still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

First-line management of distal humerus fracture by total elbow arthroplasty in geriatric traumatology: Results in a 21-patient series at a minimum 2years' follow-up

INTRODUCTION

Total elbow arthroplasty (TEA) is one option in distal humerus fracture in elderly osteoporotic patients.

HYPOTHESIS

The study hypothesis was that, in patients aged 70years or more, TEA provides functional results and ranges of motion compatible with everyday activity, with a complications rate equal to or lower than with internal fixation, and no loss of autonomy or cognitive impairment.

MATERIAL AND METHODS

In this retrospective study, 21 patients receiving TEA for distal humerus fracture were included. Mean follow-up was 3.2years, with functional (Quick DASH and MEPS), cognitive (MMSE), autonomy-related (ADL) and radiological assessment (Morrey).

RESULTS

Mean MEPS was 84 and QuickDASH 32.4. Mean extension deficit was 22°, and mean flexion 125°. There was no loss of autonomy or cognitive impairment. The complications rate was 9.5%. There were no revision surgeries.

DISCUSSION

TEA proved reliable in comminuted distal humerus fracture in elderly patients. Functional results were comparable to those in the literature, and the complications rate was lower. Long-term implant survival needs confirmation to validate this option as a treatment of choice in these indications in geriatric traumatology.

TYPE OF STUDY

Retrospective non-comparative, single-center.

LEVEL OF EVIDENCE

4.

[Surgical treatment of the humeral pallet fractures in adults]

Le traitement des fractures de la palette humérale repose principalement sur la chirurgie de reconstruction par ostéosynthèse. On a colligé dans nos archives 40 cas de fracture de la palette humérale au service de traumatologie-orthopédie de CHU IBN SINA de RABAT du mois JANVIER 2012 au mois de DECEMBRE 2014, dont le but est de montrer les particularités cliniques, thérapeutiques et évolutives de ces fractures; ainsi que les difficultés de prise en charge de ces fractures complexes et d’évaluer les résultats. On a noté une nette prédominance masculine (75 % des cas) avec un âge moyen de 35 ans. Les étiologies sont dominées par accidents de la voie publique (56 %). Tous nos patients ont été hospitalisés par le biais des urgences puis opérés. Le type C selon la classification de MÜLLER et ALLGOWER(A.O) est le plus fréquent : 62,5% des cas. les lésions associées sont assez fréquents (52,5%) dans le cadre d’un poly-traumatisme. Tous nos patients ont été opérés (100% des cas) via un bord postérieur dans 70 % des cas. Ce geste comprenait une réduction puis ostéosynthèse par plaque de LECESTRE dans 82,5% des cas. Nos résultats sont de 85,5 % de bons et moyens résultats, conformément aux données de la littérature. La prise en charge de ce type de fracture est basée sur une réduction anatomique parfaite, par un montage solide qui doit permettre une rééducation précoce garante d’un bon résultat fonctionnel.

Distal humerus fractures: a review of current therapy concepts

Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment.

Triangular Fixation Technique for Bicolumn Restoration in Treatment of Distal Humerus Intercondylar Fracture

BACKGROUND

Distal humerus intercondylar fractures are intra-articular and comminuted fractures involving soft tissue injury. As distal humerus is triangle-shaped, parallel plating coupled with articular fixation would be suitable for bicolumn restoration in treatment of distal humerus intercondylar fracture.

METHODS

This study included 38 patients (15 males and 23 females) who underwent olecranon osteotomy, open reduction and internal fixation with the triangle-shaped cannulated screw and parallel locking plates (triangular fixation technique). Functional results were assessed with the visual analog scale (VAS) scores, Mayo elbow performance (MEP) scores and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. Anteroposterior and lateral elbow radiographs were assessed for reduction, alignment, fracture union, posttraumatic arthrosis, and heterotopic ossification, and computed tomography (CT) scans were used to obtain more accurate measurements of articular discrepancy.

RESULTS

All fractures healed primarily with no loss of reduction. The mean VAS, MEP, and DASH scores of the affected elbow were not significantly different from those of the unaffected elbow (p = 0.140, p = 0.090, and p = 0.262, respectively). The mean degree of flexion was significantly lower in the affected elbow than in the unaffected elbow, but was still considered as functional (p = 0.001, > 100° in 33 of 38 patients). Two cases of articular step-offs (> 2 mm) were seen on follow-up CT scans, but not significantly higher in the affected elbow than in the unaffected elbow (p = 0.657). Binary logistic regression analysis revealed that only Association for Osteosynthesis (AO) type C3 fractures correlated with good/excellent functional outcome (p = 0.012). Complications occurred in 12 of the 38 patients, and the overall reoperation rate for complications was 10.5% (4 of 38 patients).

CONCLUSIONS

Triangular fixation technique for bicolumn restoration was an effective and reliable method in treatment of distal humerus intercondylar fracture. This technique maintained articular congruency and restored both medial and lateral columns, resulting in good elbow function.

Total Elbow Arthroplasty for Distal Humerus Fractures

Total elbow arthroplasty is a good treatment alternative for selected patients with distal humerus fractures. Its attractiveness is related to several factors, including the possibility of performing the procedure; leaving the extensor mechanism intact; faster, easier rehabilitation compared with internal fixation; and overall good outcomes reported in terms of both pain relief and function. Implant failure leading to revision surgery does happen, and patients must comply with certain limitations to extend the longevity of their implant. Development of high-performance implants may allow expanding the indications of elbow arthroplasty for fractures.

Crisscross-type screw fixation for transcondylar fractures of distal humerus in elderly patients

INTRODUCTION

This study presents the outcomes of low transcondylar fractures of the distal humerus treated by closed reduction and internal fixation with two screws in a crisscross orientation.

MATERIALS AND METHODS

Between 2003 and 2009, ten consecutive elderly patients (1 man and 9 women) with transcondylar fractures of distal humerus (AO 13A2.3) were included in this study. The average age at the time of injury was 72 years (range 63-82). All were closed injuries without nerve injury. The mechanism of the injuries was low-energy fall or slip. Six patients had medical or other systemic diseases.

SURGICAL TECHNIQUE

After a closed reduction of the fracture fragments, two guide wires were inserted in a crisscross orientation; one from the lower lateral edge of the capitellum to the medial cortex of the distal humerus, and the other from the lower medial edge of the trochlea to the lateral cortex of the distal humerus. After drilling, fully threaded cannulated screws (4.5 mm in diameter) were inserted along the each guide wire. Functional outcome was assessed with Mayo Elbow Performance scores.

RESULTS

The mean operation time was 55 min (range 40-100 min). The average follow-up duration was 26.8 months (range 24-35 months). The mean Mayo Elbow Performance scores were 93.8 (range 90-99). The elbow extension-flexion arc was 12(o)-125(o). The mean pronation-supination angle was 74(o)-72(o).

CONCLUSION

In geriatric patients with transcondylar fractures of the distal humerus, a crisscross fixation with two cannulated screws provides satisfactory results that allow a nearly full range of elbow motion with minimal surgical morbidity.

Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: six years clinical experience with both the triceps-sparing approach and olecranon osteotomy

BACKGROUND

Although open reduction and internal fixation (ORIF) is a standard fracture treatment method, the optimal way to expose a fracture prior to ORIF is debated. We compared the effects of two exposure methods, the triceps-sparing approach and olecranon osteotomy, on the functional outcomes of ORIF-treated type C distal humerus fractures in elderly people.

METHODS

From January 2006 to January 2011, 75 elderly patients with type C distal humerus fractures were treated with ORIF, and we retrospectively reviewed their medical records, radiographs, and follow-up charts to identify any complications. Patients' Mayo Elbow Performance Score (MEPS) and range of motion were determined at their final clinic visit.

RESULTS

Sixty-seven patients (89 %) attended the final visit. Of these patients, 36 received olecranon osteotomy and 31 received the triceps-sparing approach. For patients with type C1 and C2 fractures, we observed reductions in procedure times, blood loss, complication rates, and MEPS outcomes (all P < 0.01) with the triceps-sparing approach compared with olecranon osteotomy. Except for MEPS outcomes, all of these approach-related improvements were also statistically significantly for type C3 fractures (all P < 0.01). Overall, we did not observe any cases of fracture nonunion, implantation breakage or loosening, or elbow stiffening in our series.

CONCLUSIONS

In our study, we found better functional outcomes for type C1 and C2 distal humerus fractures that were exposed using the triceps-sparing approach rather than olecranon osteotomy. Even for the most complex type of fracture, C3 fractures, similar recoveries in elbow function were achieved using either approach.

LEVEL OF EVIDENCE

Level III.

Results of parallel plate fixation of comminuted intra-articular distal humeral fractures

BACKGROUND

This study investigated the results of parallel plate fixation of comminuted distal humeral fractures in a consecutive series of patients.

METHODS

Parallel plate fixation was used in 47 patients (30 women), mean age 60 years (range 18-98 years), with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C distal humeral fractures during 2007 to 2011. Medical records and radiographs were retrospectively assessed. Thirty-five patients completed Disabilities of Arm, Shoulder and Hand (DASH) outcome measure and the RAND Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey. Twenty-seven patients underwent clinical examination, Mayo Elbow Performance Score (MEPS) rating, and radiography after 3.9 years (range, 1.6-7.9 years) of follow-up.

RESULTS

The mean flexion arc was lower on the affected side vs the unaffected elbow (123° vs 140°, P = .03). The mean MEPS was 88; the result was excellent in 14, good in 8, fair in 3, and poor in 2 patients. DASH results indicated slight impairment of upper extremity function compared with the reference value (26 vs 10, P = .001). RAND SF-36 scores indicated normal quality of life compared with reference values from the Finnish population. Forty-four fractures united uneventfully. One case each of nonunion and malunion occurred. One olecranon osteotomy failed to unite. There were 3 cases of infection. Prominent hardware was a common late problem, and plates often required removal. The complication rate was 7 of 47 (15%); 4 of these patients (9%) required reoperation. The hardware removal rate was 13 of 47 (28%).

CONCLUSION

Parallel plate fixation is an effective method to treat comminuted distal humeral fractures. Good elbow function can be restored in most cases with minor impairments that do not worsen quality of life.

Low transcondylar fractures of the distal humerus: results of open reduction and internal fixation

BACKGROUND

This study presents the outcomes of low transcondylar fractures of the distal humerus treated by open reduction and internal fixation.

METHODS

Between 1996 and 2010, 263 distal humeral fractures were managed at our institution. Patients with a true low transcondylar fracture treated by open reduction and internal fixation were included. Fourteen patients form the basis of this study. Fracture fixation was achieved through a triceps-sparing approach, a triceps tongue, or an olecranon osteotomy. Internal fixation was performed with parallel plates, orthogonal plates, a single lateral plate, or a single medial plate. The clinical outcome was measured with pain levels, range of motion, and the Mayo Elbow Performance Score. Radiographs at latest follow-up were assessed for union, delayed union, nonunion, and hardware failure.

RESULTS

At most recent follow-up, 11 patients had no pain, 2 had mild pain, and 1 had moderate pain. The mean Mayo Elbow Performance Score was 85. The mean arch of motion was 95°. Complications included nonunion, delayed union, wound complications, deep infection, and heterotopic ossification.

DISCUSSION

Stable internal fixation of low transcondylar fractures is perceived as difficult to achieve because of the very small size of the distal fragment. However, the results of our study indicate that internal fixation of low transcondylar fractures of the distal humerus is associated with a high union rate and satisfactory clinical results. Elbow arthroplasty does not need to be considered for most patients with a low transcondylar distal humeral fracture.

Articular fractures of the distal humerus

Distal humeral fractures represent 2% of all adult elbow fractures. Injury mechanisms include high-energy trauma with skin involvement, and low energy trauma in osteoporotic bone. Treatment goals are anatomical restoration in young, high-demand patients and quick recovery of activities of daily living in the elderly. Complete fractures are relatively easy to diagnose, but partial intra-articular fractures are not. The clinical diagnosis must take into account potential complications such as open injuries and ulnar nerve trauma. Standard X-rays with additional distraction series in the operating room are sufficient in complete articular fracture cases. Partial intra-articular fractures will need CT scan and 3D reconstruction to fully evaluate the involved fragments. SOFCOT, AO/OTA and Dubberley classifications are the most useful for describing fractures and selecting treatment. Surgery is the optimal treatment and planning is based on fracture type. Complete fractures are treated using a posterior approach. Triceps management is a function of fracture lines and type of fixation planned. Constructs using two plates at 90° or 180° are the most stable, with additional frontal screw for intercondylar fractures. Elbow arthroplasty may be indicated in selected patients, having severely communited distal humerus fractures and osteoporotic bone. Open fractures make fixation and wound management more challenging and unfortunately have poorer outcomes. Other complications are elbow stiffness, non-union, malunion and heterotopic ossification.

Distal humerus fractures in patients over 65: complications

INTRODUCTION

Fractures of the distal humerus in patients over the age of 65 remain a therapeutic challenge. Treatment options include conservative treatment, internal fixation or total elbow arthroplasty. The complications of these different treatment options were evaluated in a multicentre study.

MATERIALS AND METHODS

Four hundred and ninety-seven medical records were evaluated. A retrospective study was performed in 410 cases: 34 received conservative treatment, 289 internal fixation and 87 underwent total elbow arthroplasty. A prospective study was performed in 87 cases: 22 received conservative treatment, 53 internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated after at least 6 months follow-up.

RESULTS

The rate of complications was 30% in the retrospective study and 29% in the prospective study. The rate of complications in the conservative treatment group was 60%, and the main complication was essentially malunion. The rate of complications was 44% in the internal fixation group and included neuropathies, mechanical failure or wound dehiscence. Although complications only developed in 23% of total elbow arthroplasties, they were often more severe than those following other treatments.

DISCUSSION

Complications develop in one out of three patients over 65 with distal humerus fractures. Three main types of complications were identified. Neuropathies especially of the ulnar nerve, especially during arthroplasty, must always be identified, the nerve requiring isolation and transposition. Bone complications, due principally to mechanical failure, were found following internal fixation. Despite technical progress, care must be taken not to favor excessive utilization of this treatment option in complex fractures on fragile bone. Although there were relatively fewer complications with total elbow arthroplasty they were more difficult to treat. Ossifications were frequent whatever the surgical option and can jeopardize the functional outcome.

Outcomes of distal humerus fractures in patients above 65 years of age treated by plate fixation

INTRODUCTION

Distal humerus fractures in elderly patients are often complex fractures that are difficult to treat. The goal of this study was to report on the results of a multicentre series of internal fixation of AO type A, B and C distal humerus fractures in elderly patients and to identify the pros and cons of various fixation constructs.

PATIENTS AND METHODS

Two studies were performed. One was a prospective multicentre study with 53 patients and the other was a retrospective multicentre study with 289 patients, all above 65 years of age and with a recent distal humerus fracture. Patients were evaluated based on clinical criteria (history, health condition, joint range of motion, Mayo Elbow Performance Score) and radiological criteria (fracture type, union of fracture, presence of malunion, hardware condition).

RESULTS

Based on the MEPS, the clinical and functional results were relatively satisfactory: average of 92 points for type A, 82 points for type B and 88 points for type C. In both series, type B fractures were the most difficult to treat and had less good clinical, functional and radiological outcomes. Most of the complications occurred with type C fractures; these consisted mainly of nerve injuries and fixation failure/non-union.

DISCUSSION

Although these fractures are difficult to treat and have an appreciable number of complications, the functional recovery was fairly satisfactory. One of the most challenging aspects of surgical treatment is the existence of osteoporosis in these patients. This must be carefully analysed to determine if an indication exists for total elbow arthroplasty.

LEVEL OF EVIDENCE

IV.

Promising results after the treatment of simple and complex distal humerus type C fractures by angular-stable double-plate osteosynthesis

INTRODUCTION

The aim of this study was to evaluate the functional results and complications following open reduction and internal fixation of distal humerus type C fractures (AO classification) using an anatomically precontoured, angular-stable double-plate system.

PATIENTS AND METHODS

The study is a retrospective analysis of 45 patients with 46 type C fractures. There was one C1, eight C2 and 31 C3 fractures. Twelve fractures were open (Gustilo classification). Follow-up was performed on 38 patients with 39 fractures (84%) after 14 months (range, 12-22). The mean age was 50 years (range, 14-87). Functional results were evaluated using the Mayo Elbow Performance Score (MEPS); the Disabilities of the Arm, Shoulder and Hand score (DASH); and range-of motion (ROM) measurements. Complications were classified as minor or major, and the postoperative and follow-up X-rays were analyzed.

RESULTS

Thirty-four fractures were considered stable to allow early physical therapy. With a mean MEPS of 85 points, 36 results (36/39 [92%]) were rated as excellent or good. The mean DASH was 22.5 points, and the ROM for extension-flexion was 105° (range, 50-145). Sixteen major complications (eventually coexistent: 6 × implant failure, 3 × non-union, 6 × stiffness, 2 × necrosis capitulum, 4 × failure olecranon osteotomy refixation) and two minor complications were recorded in 17 patients. These adverse events led to 14 revision surgeries (14/39 [36%]). Except for extension deficit, no statistically significant differences were found between the articular simple and articular complex fractures and when comparing the results between patients with and without a major complication.

CONCLUSION

The anatomically precontoured and angular-stable double-plate system provides sufficient immediate postoperative stability to allow early physiotherapy, even in C3-type fractures. Excellent or good results could be achieved in the vast majority of patients, independent on having suffered a complication or not. Complication rates were remarkably high, emphasizing the difficulties associated with this rare type of fracture.

LEVEL OF EVIDENCE

Level IV Retrospective study.

Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years

INTRODUCTION

Fractures of the distal humerus are often complex and therefore challenging to treat. In elderly patients with decreased bone strength due to osteoporosis, strong fixation is crucial to allow resuming early motion that guarantees a good functional outcome as well as minimising mechanical complications. Locked implants meet these requirements. Here, we report outcomes in a uniform series of patients older than 65 years with distal humerus fractures managed with LCP DHP(®) (Synthès) fixation. Our objective was to evaluate the efficacy and limitations of this technique.

HYPOTHESIS

LCP DHP provides strong fixation of osteoporotic bone and leads to good clinical and radiological outcomes.

MATERIALS AND METHODS

We retrospectively studied 46 consecutive patients (2004-2010) with a mean age of 80 years including 15 with extra-articular and 31 with articular distal humerus fractures. At presentation, 11 complications were noted in nine patients (compound fractures and trauma-related nerve injuries). The transolecranon approach was used in 31 patients. Mean duration of immobilisation was 2.7 weeks in 33 patients.

RESULTS

Forty-three patients were re-evaluated after a mean follow-up of 25 months (range, 10-64 months); two patients died and one was lost to follow-up. Flexion was 127° and loss of extension was 23°, producing an average range of motion of 104°. Functional recovery was highly satisfactory with a Mayo Clinic Performance Score of 87 (70-100) and 95% of good and very good results. Postoperative complications consisted of infection (n=3), metaphyseal non-union (n=2), ulnar nerve injury (n=6), transient radial nerve palsy (n=1), and peri-articular ossification (n=4). Compound fracture and worse AO fracture type were associated with worse functional outcomes.

DISCUSSION

Despite the high complication rate, functional recovery was similar to that reported in previous case series, including after arthroplasty. Furthermore, the rate of mechanical complications was lower. Thus, our working hypothesis was confirmed.

LEVEL OF EVIDENCE

Level IV retrospective non-comparative study.

Complex fractures of the distal humerus in the elderly: is primary total elbow arthroplasty a valid treatment alternative? A series of 20 cases

INTRODUCTION

Distal humerus fractures are fairly rare. But as our population ages, these fractures become more complex and the choice of treatment more delicate. Poor bone quality results in many technical problems and the fixation hardware stability remains at risk. The goal of this study was to evaluate the functional recovery and morbidity of complex distal humerus fractures in elderly patients when treated with elbow prosthesis.

HYPOTHESIS

Good functional recovery can be achieved with a total joint replacement.

PATIENTS AND METHODS

This series consisted of 20 patients (18 women and two men) having an average age of 80years (range 65-93, median 80). Based on the AO classification, there were two Type A2 fractures, two Type B fractures, 15 Type C fractures and one fracture that could not be classified because of previous rheumatoid disease history at this elbow. Two fractures were open. In two cases, the olecranon was also fractured. Treatment consisted of the implantation of a Coonrad-Morrey, hinge-type total elbow prosthesis (Zimmer(®), Warsaw, IN, USA). The Mayo Clinic surgical approach was used 17 times and the transolecranon approach was used three times. Primary arthroplasty was performed in 19 cases and the surgery was performed after six weeks of conservative treatment (diagnostic delay) in one case. Unrestricted motion was allowed after surgery, but a maximum of 0.5kg could be carried during the first 3months; this was subsequently increased to 2.5kg.

RESULTS

Fifteen of the 20 patients were available for reevaluation with an average follow-up of 3.6years (range 1.7-5.5, median 3.4). Four patients had died and one was lost to follow-up. The average range of motion was 97° (range 60-130°), comprising an average flexion of 130° (range 110-140°) and average loss of extension of 33° (range 0-80°). Pronation and supination were normal. The average Mayo Elbow Performance Score (MEPS) was 83 (range 60-100, median 80). X-rays revealed seven cases of radiolucent lines, with two being progressive. There was no visible wear of the polyethylene bushings at the hinge. Six patients had moderate periarticular heterotopic ossification. The two cases of olecranon osteotomy and one case of olecranon fracture had healed. There were no surgical site infections but two cases of ulnar compression, one of which required neurolysis. There was one case of humeral component loosening after 6years, but the implant was not changed.

DISCUSSION

The clinical range of motion results were comparable to published data. The functional scores were slightly lower, mainly because of the pain factor. The initial results were encouraging and consistent with published data as long as the indications were well-chosen. Based on this retrospective study, total elbow arthroplasty can be a valid alternative in the surgeon's treatment armamentarium for complex distal humerus fractures in elderly patients who have moderate functional demands. Our results support our hypothesis, since we found good functional recovery without associated morbidity.

LEVEL OF EVIDENCE

Level IV retrospective study without comparator.

Distal humerus fractures in the elderly: osteosynthesis or endoprosthesis? Review of the literature

Fractures of the distal humerus in adults are rare but challenging for the orthopaedic trauma surgeon. The bimodal distribution reflects the trauma mechanism. While distal humerus fractures are caused by high-energy traumata in young male adults, a fall from a standing height is the most common reason for humerus fractures among elderly females. As a rule, fractures of the distal humerus are treated surgically. In young patients, open reduction and internal fixation (ORIF) with anatomic locking plates are the gold standard. In elderly patients, reconstruction is not always possible, and total elbow arthroplasty (TEA) becomes necessary. The present article provides an overview of the current diagnostic and treatment recommendations. The current literature is reviewed and the results discussed.

Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol

INTRODUCTION

This study determined outcomes after temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures.

MATERIALS AND METHODS

A retrospective case analysis was done of all patients who were treated between 2000 and 2008 in 3 level I trauma centers with temporary joint-spanning external fixation before internal fixation of an open intra-articular distal humeral fracture. Healing rates, complications, Disabilities of Arm, Shoulder and Hand (DASH), and Smith and Cooney outcome scores were documented.

RESULTS

The study included 16 patients. Mean follow-up was 35.2 months. Fractures united after an average of 5.2 months. No complications specifically related to the external fixation occurred. The DASH outcome score averaged 15.1. Although complications occurred in 12 patients (9 patients requiring surgery), 10 of 16 had an excellent/good outcome score.

CONCLUSIONS

Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct.

Fragility fractures of the distal humerus

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.