In Situ Placement Versus Anterior Transposition of the Ulnar Nerve for Distal Humerus Fractures Treated With Plate Fixation: A Multicenter Randomized Controlled Trial

Intraoperative Subperiosteal Elevation of the Ulnar Nerve Is a Safe and Effective Way to Minimize Postoperative Ulnar Neuritis in Distal Humerus Fractures

OBJECTIVES

To describe subperiosteal elevation of the ulnar nerve and compare to anterior transposition and in situ decompression techniques.

METHODS

DESIGN

Retrospective comparative study.

SETTING

Urban Level 1 trauma center.

PATIENT SELECTION CRITERIA

Distal humerus fractures (Orthopaedic Trauma Association/AO 13) treated with open reduction internal fixation between 2014 and 2022.

OUTCOME MEASURES AND COMPARISONS

Rate of preoperative and postoperative neuritis grouped by the management of the ulnar nerve. During subperiosteal elevation, the ulnar nerve was identified and raised off the ulna subperiosteally and mobilized submuscularly anterior to the medial epicondyle to protect the nerve. The nerve was released only laterally off the triceps, and the medial soft tissue attachment is maintained. The main outcome measurements was rate of neuritis documented within physical examination.

RESULTS

Within the 125 patients, 35 underwent subperiosteal elevation (mean age of 56 ± 21 years, 57% female), 63 in situ decompression (mean age of 60 ± 18 years, 46% female), and 27 anterior transposition (mean age of 55 ± 20 years, 59% female). Preoperative ulnar neuritis was present in 34%, 21%, and 33% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively ( P = 0.26). At postoperative evaluation, symptom resolution occurred in 100%, 69%, and 33% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively ( P = 0.003). New cases of postoperative ulnar neuritis occurred in 6%, 8%, and 26% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively ( P = 0.054). Subperiosteal elevation outperformed anterior transposition regarding postoperative ulnar neuritis ( P = 0.019) and symptom resolution ( P = 0.002) and performed similarly to in situ decompression ( P > 0.05). On multiple regression analysis, anterior transposition was an independent risk factor for postoperative neuritis (OR = 5.2, P = 0.023).

CONCLUSIONS

Subperiosteal elevation is an effective way to minimize postoperative neuritis and similar to an in situ decompression during distal humerus fracture fixation. Based on the results of this cohort, authors recommended that anterior transposition of the ulnar nerve be used with caution due to its association with postoperative ulnar neuritis.

LEVEL OF EVIDENCE

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

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.

The Novel Ulnar Nerve Coverage Method Which Has the Potential to Prevent the Postoperative Ulnar Neuropathy after Plate Fixation of Distal Humerus Fractures: Three Case Reports

Introduction

Postoperative ulnar neuropathy is still an unresolved complication in patients undergoing plate fixation of distal humerus fractures. We hypothesized that decreased blood flow to the ulnar nerve due to intraoperative procedures is an important factor in the development of postoperative ulnar neuropathy. We herein report three cases of distal humerus fractures in which the soft tissues surrounding the ulnar nerve were preserved as much as possible and finally not transferred anteriorly. Case Presentation. A 76-year-old woman, 82-year-old woman, and 34-year-old woman underwent plate fixation for distal humerus fractures. None of the patients developed postoperative ulnar neuropathy, and there were no complaints of numbness after postoperative day 1. Nerve conduction studies were performed after 3 months postoperatively and revealed that the motor nerve conduction velocities and compound motor nerve action potentials of the ulnar nerve in two of the three patients were higher than those of the noninjured side. In one of the three patients, these values were slightly lower than those of the noninjured side. All three patients achieved bony union after several months postoperatively.

Conclusions

We obtained good outcomes with the ulnar nerve coverage method for preventing postoperative ulnar neuropathy in patients with distal humerus fractures. Preservation of blood flow to the ulnar nerve was considered important, and anatomical repositioning of the ulnar nerve after plate fixation has the potential to prevent adhesion between the ulnar nerve and the plate.

Ulnar Nerve Neuropathy After Surgery for Intraarticular Distal Humerus Fractures: An Analysis of 116 Patients

PURPOSE

To identify the incidence and the factors associated with a postoperative ulnar nerve neuropathy in patients who had undergone open reduction and internal fixation for intraarticular distal humerus fractures.

METHODS

We retrospectively reviewed 116 patients who had undergone surgery between January 2011 and December 2020. Age, sex, BMI, mechanism of injury, open or closed fracture, operation time, tourniquet time, and nerve injury at the final examination were collected from medical charts. We essentially used the paratricipital approach. In cases in which the reduction of intraarticular bone fragments was difficult, olecranon osteotomy was used. Ulnar nerve function was graded according to a modified system of McGowan. We conducted logistic regression analysis to investigate factors of neuropathy using items identified as statistically significant in univariate analysis as explanatory variables.

RESULTS

Thirty-four patients (29.3%) had persistent neuropathy at the final follow-up. In the modified McGowan classification, 28 patients had grade 1 and 6 patients had grade 2 neuropathy. Olecranon osteotomy emerged as a distinct explanatory variable for the prophylaxis of ulnar nerve neuropathy in the multivariate analysis (odds ratio, 0.30; 95% confidence interval, 0.12-0.73). Anterior transposition, however, was not a statistically significant factor (odds ratio, 1.91; 95% confidence interval, 0.81-4.56).

CONCLUSIONS

Olecranon osteotomy was the only independent factor associated with preventing the occurrence of ulnar nerve neuropathy. Ulnar nerve transposition might not be associated with prevention of ulnar nerve neuropathy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Ulnar Nerve Management in Distal Humerus Fracture Surgery: A Case of Developing Ulnar Neuropathy After Open Reduction and Internal Fixation

In this case report, we want to show how a patient who underwent surgery for a distal humerus fracture developed postoperative ulnar neuropathy symptoms, how nonunion persisted even at the ninth month of follow-up, and whether the nonunion was connected to the ulnar neuropathy that developed. Due to this, we used this case to explore ulnar nerve care and whether ulnar nerve transposition, manipulation, or decompression should be carried out during surgery on patients with distal humerus fractures. A 52-year-old man with a bi-columnar distal humerus fracture from a fall on his right elbow underwent open reduction and internal fixation at an external center one year before. Elbow restriction, discomfort, numbness, and weakness in the fourth and fifth digits of the right hand were all symptoms the patient experienced eight months following the surgery. We discovered the distal right humerus' nonunion during the radiological exams. It became apparent that the patient had no signs of ulnar neuropathy before the injury. In the eighth month following the injury, the patient had implant removal, open reduction internal fixation with autograft, and ulnar nerve transposition. We discovered during follow-up that the patient's ulnar neuropathy symptoms had subsided. The surgeon's familiarity with the procedure and command of the anatomy of the elbow has a role in managing the ulnar nerve in distal humerus fractures. We concluded that more study is required to determine the connection between the onset of ulnar neuropathy and nonunion while treating distal humerus fractures.

Modern Treatment of Cubital Tunnel Syndrome: Evidence and Controversy

Cubital tunnel syndrome is the second most common peripheral mononeuropathy in the upper extremity. However, the diagnosis and treatment of cubital tunnel syndrome remains controversial without a standard algorithm. Although diagnosis can often be made from the patient's history and physical examination alone, electrodiagnostic studies, ultrasound, computed tomography (CT), and magnetic resonance image (MRI) can also be useful in diagnosing the disease and selecting the most appropriate treatment option. Treatment options include conservative nonoperative techniques as well as various surgical options, including in situ decompression with or without transposition, medial epicondylectomy, and nerve transfer in advanced disease. The purpose of this review is to summarize the most up-to-date literature regarding cubital tunnel syndrome and propose a treatment algorithm to provide clarity about the challenges of treating this complex patient population.

Diagnostic Considerations in Compressive Neuropathies

Peripheral nerve compression of the upper extremity is a common pathology often necessitating surgical intervention, much is known, but much more is left to understand. For the more common pathologies, carpal tunnel syndrome, cubital tunnel syndrome, and ulnar tunnel syndrome, research and clinical efforts directed toward standardization and reduction of resource use have been attempted with varied success. Diagnosis of many of these syndromes is largely based on a proper history and physical examination. Electrodiagnostic studies continue to have value, but proportionally less than previous decades. In addition, emerging technologies, including magnetic resonance neurography, novel ultrasound evaluation techniques, and ultrasound-guided diagnostic injections, are beginning to demonstrate their ability to add value to the diagnostic algorithm, particularly when less common compressive neuropathies are present and/or the diagnosis is in question.

Controversies in the Management of Bicolumnar Fractures of the Distal Humerus

Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

Efficacy and safety of anterior transposition of the ulnar nerve for distal humerus fractures: A systematic review and meta-analysis

Background

This systematic review and meta-analysis was performed to summarize available evidence of anterior transposition of the ulnar nerve for patients with distal humerus fractures.

Materials and Methods

The databases were searched from PubMed, Cochrane, Embase, Scopus, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database up to June 2022. The clinical outcome included operation time, fracture healing time, hospital stays, elbow joint function, and ulnar neuritis rate. Statistical analysis was performed with Review Manager 5.3 (Cochrane Collaboration).

Results

A total of 17 studies were included (8 RCTs and 9 retrospective studies), and 1280 patients were analyzed. The results of this meta-analysis showed anterior transposition group had longer operation time (MD = 20.35 min, 95%CI: 12.56-28.14, P < 0.00001). There was no significant difference in fracture healing time (SMD = -0.50, 95%CI: -1.50-0.50, P = 0.33), hospital stays (MD = -1.23 days, 95%CI: -2.72--0.27, P = 0.11), blood loss (MD = 2.66 ml, 95%CI: -2.45-7.76, P = 0.31), and ulnar neuritis rate (OR = 1.23, 95%CI: 0.63-2.42, P = 0.54) between two groups. Finally, elbow joint motion, elbow joint function, fracture nonunion, and post-operative infection (P > 0.05) between two groups were not significantly statistic difference.

Conclusion

This meta-analysis showed that anterior transposition group is not superior to non-transposition group for patients with distal humerus fractures without ulnar nerve injury. On the contrary, non-transposition group have shorter operation time than that of anterior transposition group. Non-transposition group did not increase the post-operative ulnar neuritis rate. Therefore, both anterior transposition group and non- transposition group are the treatment options for patients with distal humerus fractures without ulnar nerve injury. Besides, these findings need to be further verified by multi-center, double-blind, and large sample RCTs.

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.

Bi-columnar locking plate fixation through a combined medial and lateral approach for the treatment of low transcondylar fractures of the distal humerus in the elderly

Background

Low transcondylar fractures (LTFs) of the distal humerus are relatively uncommon elbow injuries in elderly patients after low-energy injuries. Although there is still debate regarding the method of fixation, several surgeons prefer bi-columnar fixation using pre-contoured locking plates. However, posterior approaches, which are usually used to perform the above procedure, have disadvantages, such as ulnar nerve neuropathy, damage to the extensor mechanism, and the need for general anesthesia. To solve these problems, the authors designed a combined medial and lateral approach. The purpose of this study was to present the outcomes of bi-columnar internal fixation through a combined medial and lateral approach for the treatment of LTFs of the distal humerus in the elderly. 

Methods

A total of 46 patients diagnosed with distal humeral fractures between May 2017 and April 2020 were included. Thirty patients were excluded, and 16 patients who underwent open reduction and internal fixation by the medial and lateral approach were selected. We carried out all the surgeries under brachial plexus anesthesia. The clinical outcomes were assessed based on the visual analog scale (VAS) score, Mayo elbow performance score (MEPS), disabilities of the arm, shoulder, and hand (DASH) score, and range of motion (ROM) of the elbow joint. Standardized radiographs were obtained at 3, 6, and 12 months after surgery and at the last follow-up visit to evaluate for bony union and to check for complications, such as ulnar nerve neuropathy and heterotopic ossification.

Results

The mean age was 81 years (range, 65–91 years). Bony union was achieved in 15 out of 16 patients. The mean VAS score was 2.1 (range, 0–6), the mean MEPS was 84.4 (range, 70–100), and the mean DASH score was 20.6 (range, 9.5–33.6). There were three complications including reduction loss, skin necrosis, and stiffness of the elbow. There was no ulnar nerve neuropathy. The post-operative ROM was 100 degrees or higher in all cases, which did not cause any impairment in daily life.

Conclusion

LTFs of the distal humerus in the elderly can yield satisfactory results with bi-columnar internal fixation through a combined medial and lateral approach.

Cubital Tunnel Syndrome: Review of Diagnosis and Management

Cubital tunnel syndrome is one of the most common upper extremity nerve entrapment conditions. Clinical examination and electrodiagnostic studies assist in the diagnosis. Mild cases can be successfully treated conservatively, aiming to reduce traction and compression on the nerve. Surgical management of cubital tunnel syndrome is increasing in frequency. Multiple surgical options exist ranging from simple decompression to decompression and anterior transposition of the nerve. There is no preferred surgical technique. It is critical to reduce the risk of recurrent cubital tunnel syndrome. Revision surgical procedures have worse outcomes than primary surgical procedures.

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.