|Year : 2021 | Volume
| Issue : 3 | Page : 85-90
Functional outcome of type 13 C2 distal humerus fractures treated with precontoured locking plates
SV Gowtam, Ravindra B Gunaki
Department of Orthopedics, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
|Date of Submission||01-Jul-2020|
|Date of Decision||04-Aug-2020|
|Date of Acceptance||30-Oct-2020|
|Date of Web Publication||12-Jun-2021|
Ravindra B Gunaki
Department of Orthopedics, Krishna Institute of Medical Sciences “Deemed to be University”, Karad - 415 110, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Distal humerus fractures pose the most challenging task in treatment, which can lead to poor functional outcomes. Anatomic reduction and internal fixation, along with early mobilization, are predicted to improve the functional outcomes. To evaluate the functional outcome, rate of malunion, and intercondylar fixation of distal humerus fractures treated with anatomically precontoured locking plates.
Methods: Thirty patients of either sex admitted with type 13 C2 distal humerus fractures, were included in this prospective study. All patients underwent open reduction and internal fixation with anatomically precontoured locking plates and screws using the modified triceps tongue flap approach. Postoperatively, patients were followed up for 6 months. During follow-up, they were evaluated clinically, radiologically, and functionally by mayo elbow performance score (MEPS). The results were analyzed using Chi-square test.
Results: A majority of the injuries were seen in males (66.7% vs. 33.3%). The mean age was 36.9 ± 14.7 years. The common mode of injury was through road traffic accident (66.7%). The right upper limb (76.7%) was the most common side involved. The overall excellent/good scores, according to the MEPS, were observed in 80% of the patients. The average time taken for the radiological union at the fracture site was 10.2 ± 2.1 weeks. The mean arc of extension-flexion at 6th weeks was 32.1°–104.1° and at 6th months was 11.5°–124.2°. The complications were early superficial infection (3.3%), ulnar neuropraxia (3.3%), delayed union (3.3%), malunion (3.3%), and chronic osteomyelitis (3.3%).
Conclusion: Distal humerus fractures treated with anatomically precontoured locking plates was effective in preserving the functional outcome of the elbow.
Keywords: Articular range of motion, bone plates, elbow joint, osteomyelitis
|How to cite this article:|
Gowtam S V, Gunaki RB. Functional outcome of type 13 C2 distal humerus fractures treated with precontoured locking plates. Formos J Surg 2021;54:85-90
|How to cite this URL:|
Gowtam S V, Gunaki RB. Functional outcome of type 13 C2 distal humerus fractures treated with precontoured locking plates. Formos J Surg [serial online] 2021 [cited 2021 Jul 24];54:85-90. Available from: https://www.e-fjs.org/text.asp?2021/54/3/85/318211
| Introduction|| |
Distal humerus fractures make up 30% of all fractures involving the elbow and up to only 0.5%–2% of all fractures. The complex structure of the elbow joint, the surrounding neurovascular system, and the sparse soft-tissue layer–all make it extremely difficult to manage such fractures. The key objective of treating distal humerus fractures is to maintain a good functional range of motion at the elbow with stability. Therefore, it is very important to determine if fracture fixation is effective in obtaining a stable mobile joint.
Throughout the last two decades, the treatment of these fractures has progressed from nonoperative procedure to anatomic reduction and internal fixation based on the Association for Osteosynthesis (AO)/Association for the Study of Internal Fixation principle of orthogonal plate fixation with early mobilization and better performance., The risks of functional impairment and deformity are very high following conservative treatment of these distal intra-articular fractures of the humerus, and stable internal repair may be challenging to attain due to the severity of the fractures and the resulting osteoporosis.
According to a study done by Schwartz et al. in Management of intraarticular fractures of the distal end of the humerus using a modification of triceps aponeurosis tongue flap approach, the surgical approach has the advantage of excellent exposure as well as a good functional outcome.
Several different types of plating are used in distal humerus fractures. The standard compression plate/locking compression plate does not provide sufficient stability when it comes to complicated fractures., Double plating in a parallel fashion or in an orthogonal manner is usually the accepted method of stable fixation in small-sized distal fragments. However, its advantage is limited with the risk of extensive soft tissue stripping, longer time of operation, and risk of infections and nonunion., Precontoured, anatomically shaped locking plates are expected to provide adequate stability, allow early range of movement of the elbow, and protect the soft tissue.
While many studies have reported good outcomes with standard plates and double plate methods, few studies have used these newer anatomically precontoured plates to directly investigate the effects of surgical fixations.,, These anatomically precontoured plates are thinner and less irritating to the soft tissue and have been shown to have greater stability in cadaveric studies., Due to the necessity of further research on these newer plates, this study was undertaken to evaluate the functional outcome of patients with distal humerus fractures (type 13 C2) treated with anatomically precontoured locking plates.
| Methods|| |
This was a prospective study of 30 patients admitted with type 13 C2 distal humerus fractures in the Department of Orthopedics in a tertiary care hospital in Maharashtra from October 2017 to April 2019. Ethical approval was obtained from the Institutional Ethical Committee before initiating the study (Ref No. KIMSDU/IEC/02/2017). Written informed consent was obtained from all the recruited patients before initiating the study. The sample size (n = 30) was calculated by considering an effect size of 0.67, significance level of 95%, and power of 92%.
All patients of either sex, irrespective of age, diagnosed with type 13 C2 distal humerus fractures were included in this study. Exclusion criteria included patients who were medically unfit or had pathological fractures or associated injuries of the same upper limb.
A predesigned structured pro forma was used to obtain a detailed history of the patient's age, gender, mode of injury, and the side involved along with associated injuries. The functional outcome was assessed using the mayo elbow performance score (MEPS), bony union, range of motion, and complications were observed during the course of the study. Findings at the 6th-week and 6th-month follow-up were documented.
Preoperative dose of tetanus toxoid was given and a day before surgery, parts preparation was done. For preoperative immobilization, the patient was given above elbow slab. The patient was positioned in a lateral position with the arm supported and the forearm hanging during the surgery. A modified triceps tongue flap approach was used for all the patients, wherein V-shaped triceps flap was taken and modified to an inverted V. A skin incision was marked posterior to the elbow in the midline, about 6–7 cm proximal to the elbow joint, curving it laterally near the olecranon tip and then extended distally 7–8 cm along the ulnar border.
The skin was incised superficially, fascia was separated and with further dissection, muscle was reached. An inverted V was marked over the triceps, and a tongue-shaped incision of 5–6 cm was made proximal to the tip of the olecranon over the triceps aponeurosis. The flap was raised from the proximal to the distal end of the triceps with the periosteum elevated and fracture site exposed. The ulnar nerve was dissected free from the medial edge of the triceps and medial epicondyle, and the nerve was retracted with a tape, safe from the injury.
The intercondylar reduction was maintained after the reduction of condyle with reduction clamp. A guide wire inserted from the medial epicondyle to the lateral epicondyle under C–ARM guidance. After confirming the position of the guide wire, drill inserted over the guidewire, and CC screw inserted, and intercondylar reduction was achieved. K (Kirschner) wires were used to maintain the reduction temporarily. The reduced medial and lateral pillars were reconstructed using anatomically precontoured locking plates and screws, and the type of locking plate was decided intra-operatively. Elbow flexion and extension was done to check the stability of fixation. For the surgical procedure, all implants of Genius Company were used.
During the postoperative period, all patients were given antibiotics and analgesics. Limb elevation and finger movement were advised, and the above-elbow slab was given for postoperative immobilization up to 15 days. The wound was inspected every 2 days postoperatively. On the postoperative day 11, suture and staples were removed. Patients were discharged with above-elbow slab and were advised to visit for follow-up on day 15 from the time of surgery, then every month for 6 months. On each follow-up, the patients were examined for pain, swelling, restriction of elbow movements, and the MEPS was also calculated. The bone union was examined by radiological examining the callus sign of fractures. Following 15 days of immobilization, passive assisted exercises were allowed for 15 days and followed by active exercises.
Data were entered in Microsoft Excel spreadsheets and analyzed using the software IBM® SPSS Statistics for Windows, Version 20.0 (SPSS, Chicago, USA). Descriptive statistics were expressed as frequencies, percentages, and mean ± standard deviation. Chi-square test was used to test the statistical association between age and gender in relation to the mode of injury. For all analyses, a P < 0.05 was considered statistically significant.
| Results|| |
The majority of the injuries were sustained by males (66.7%) than females (33.3%). The patients were aged between 10 and 70 years, with the mean age being 36.9 ± 14.7 years. Majority of the injuries (46.7%) were in the 21–30-year-old patients [Table 1].
The most common causes of injury encountered in the study were road traffic accident (RTA) (66.7%) and assault (13.3%). The right upper limb (76.7%) was the most common side involved. Out of 30 cases, 9 cases had distal humerus injury with associated injuries, the most common associated injury being fractures of the intertrochanteric femur [Table 2]. In addition, the type of implant used in the surgery is also mentioned in [Table 2].
Chi-square test was used to analyze the association between age and gender for the mode of injury. On analysis, it was noted that RTA was the major cause of injury in both male and female patients (P = 1) and majority of them were aged ≤40 years (P = 0.086); however, these findings were not statistically significant. There was no association observed between age and gender with respect to the mode of injury [Table 1].
The functional outcome of the study was determined by using the MEPS system. The mean MEP Scores at 6th week and 6th month were 67.5 ± 9.5 and 80.5 ± 9.7, respectively. The overall excellent/good scores were observed in 80% of the patients [Table 3].
The average time taken for the radiological union at the fractured site was 10.2 ± 2.1 weeks. The mean arc of extension-flexion was recorded at the 6th week and 6th month. There was a greater degree of extension and flexion in the 6th month [Table 4] and [Figure 1], [Figure 2], [Figure 3] out of the 30 cases, it was noted that the majority of the patients developed no complications (86.7%) in the postoperative period [Table 5]. The intercondylar reduction with CC screw was satisfactory as no loss of reduction, screw backout or failure was observed in any of the patients.
| Discussion|| |
Distal humerus fractures in adults are challenging to treat owing to the complex anatomy and structure of the elbow, tiny fracture fragments, and limited amount of subchondral bone that can sometimes be osteopenic. The primary aim of operative management is to preserve joint anatomy and stable fragment fixation as it is important to restore a full range of elbow movement.
In this study, the common causes of injury were RTA and fall. This is in accordance with the findings of Kulkarni et al. There was male predominance in this study, similar to the studies by Chouhan et al. and Shaik et al., In India, RTAs were more common among males than females. The fractures were commonly seen between the second and third decades of life, similar to Chouhan et al.'s study.
The surgical approach used in this study was modified triceps tongue flap approach with the advantage of the exposure of the distal part of humerus thereby allowing good reduction in Type 13 C 2 fractures. The approach allows the reduction of fractures, and stable fixation can be performed without osteotomy of the olecranon.
The functional outcome of the patient was based on the MEPS, which is a performance index that consists of the assessment of pain, stability, the arc of motion, and daily functionality of the patient. Our study had an 80% excellent/good score based on MEPS, which is comparable to a study by Reising et al., which reported 85%. The functional outcome of utilizing the locking plate was very good in both young and elderly patients. All patients had achieved radiological union at the site of fracture in 10.2 ± 2.1 weeks. The average time of union in our study is comparable to Sanchez-Sotelo et al.'s 12 weeks. The range of motion of the elbow was tested to assess the stability of the internal fixation. Early rehabilitation is the most important step in these fractures. Initially, patients were encouraged to start limb elevation and finger movement. By the end of 6 months, fixation and fracture reduction were sufficiently good.
The rate of complications observed in this study was 13.3%, which was evidently lower than that reported by Reising et al., which was 22%. There was a case of ulnar neuropraxia in the study, which was spontaneously resolved with appropriate treatment, similar to Ojha and Singh study, where in a patient had ulnar neuropraxia and recovered after 3 months. Many studies have reported superficial infection as one of the complications encountered during the postoperative period., One patient had delayed union, whereas another patient had chronic osteomyelitis with malunion. None of the complications required surgery and were resolved with appropriate care.
From the above results, it can be noted that the overall functional outcome was good, indicating that open reduction and internal fixation with anatomically precontoured locking plate is an efficient modality in the treatment of distal humerus fractures. Furthermore, the employment of additional implants like CC screws or k-wires can also be considered where locking alone will be useful. However, the usage of additional implants is always dependent on the different subgroups in AO/OTA type 13 C2 fractures.
A few limitations in this study were small sample size based on the hospital's inflow of patients and lack of objective testing of muscle strength to assess the functionality of the muscle. A definite conclusion cannot be drawn due to the small sample size. Large-scale randomized controlled trials are needed to make a better assessment of the functional outcomes of distal humerus fractures treated with locking plates.
| Conclusion|| |
The use of anatomically precontoured locking plates in distal humerus fractures was effective in preserving the functional outcome of the elbow with less fracture union time, good range of movement, and reduced associated complications with less rate of malunion. In addition, the study results also indicated a relatively less complication rate and its functional outcome of was dependent on the MEPS. Meanwhile, the intercondylar reduction with CC screw method employed in the study was satisfactory as no loss of reduction, screw backout, or failure was observed in any of the patients.
Research quality and ethics statement
We have obtained all appropriate written informed consent forms from all patients prior to investigation. The study was approved by the institutional review board. The manuscript was approved by all the authors and the draft was prepared free of plagiarism. The authors have no conflicts of interest and the study was not funded by any government and private organization.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg 2010;18:20-30.
Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am 2011;93:686-700.
O'Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005;14:186S-194S.
Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am 2000;31:103-13.
Schwartz A, Oka R, Odell T, Mahar A. Biomechanical comparison of two different periarticular plating systems for stabilization of complex distal humerus fractures. Clin Biomech (Bristol, Avon) 2006;21:950-5.
Korner J, Diederichs G, Arzdorf M, Lill H, Josten C, Schneider E, et al
. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma 2004;18:286-93.
Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation. J Bone Joint Surg Am 2006;88:2343-7.
Paris H, Tropiano P, Clouet D'orval B, Chaudet H, Poitout DG. Fractures of the shaft of the humerus: Systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot 2000;86:346-59.
Scolaro JA, Matzon JL, Mehta S. Tips and techniques-surgical fixation of extra-articular distal humerus fractures with a posterolateral locking compression plate. Univ PA Orthop J 2009;19:103-8.
Eralp L, Kocaoglu M, Sar C, Atalar AC. Surgical treatment of distal intraarticular humeral fractures in adults. Int Orthop 2001;25:46-50.
Celli A, Donini MT, Minervini C. The use of pre-contoured plates in the treatment of C2-C3 fractures of the distal humerus: Clinical experience. Chir Organi Mov 2008;91:57-64.
Greiner S, Haas NP, Bail HJ. Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: Preliminary results with the LCP distal humerus system. Arch Orthop Trauma Surg 2008;128:723-9.
Lee SK, Kim KJ, Park KH, Choy WS. A comparison between orthogonal and parallel plating methods for distal humerus fractures: A prospective randomized trial. Eur J Orthop Surg Traumatol 2014;24:1123-31.
Stoffel K, Cunneen S, Morgan R, Nicholls R, Stachowiak G. Comparative stability of perpendicular versus parallel double-locking plating systems in osteoporotic comminuted distal humerus fractures. J Orthop Res 2008;26:778-84.
Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: A critical analysis of 55 cases. Injury 2002;33:511-5.
Kulkarni VS, Saxena S, Kulkarni SG, Shah PB, Dixit P, Arora N, et al
. Management and functional outcome of closed intercondylar distal humerus fractures treated with dual plating in adults. J Trauma Orthop Surg 2016;11:24-9.
Chouhan S, Bhinde S, Shekhawat YS, Panwar N, Bajoria RS. A prospective study of functional outcome in intra articular distal humerus fracture treated with dual plating. Int J Orthop 2018;4:51-5.
Shaik RB, Reddy PV, Naidu KA. Study of clinical outcome in intra articular distal humerus fractures treated with dual plating. Int J Res Med Sci 2017;5:2438-41.
Gururaj G. Injuries in India: A national perspective. Background Papers: Burden of Disease in India Equitable Development-Healthy Future. New Delhi: National Commission on Macroeconomics and Health, Ministry of Health & Family Welfare, Government of India; 2005. p. 325-47.
Reising K, Hauschild O, Strohm PC, Suedkamp NP. Stabilisation of articular fractures of the distal humerus: Early experience with a novel perpendicular plate system. Injury 2009;40:611-7.
Sanchez-Sotelo J, Torchia ME, O'Driscoll SW. Complex distal humeral fractures: Internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am 2007;89:961-9.
Liu JJ, Ruan HJ, Wang JG, Fan CY, Zeng BF. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder Elbow Surg 2009;18:646-51.
Ojha A, Singh SK. A study of functional outcome after osteosynthesis of intercondylar fracture of distal humerus in adults with pre-contoured locking compression plate system. Int J Res Orthop 2019;5:1107-12.
Soon JL, Chan BK, Low CO. Surgical fixation of intra-articular fractures of the distal humerus in adults. Injury 2004;35:44-54.
Sapkota HP, Rokaya PK, Rawal M, Karki DB, Limbu D. Early versus late removal of internally fixated kirschner's wires for displaced lateral condyle fracture of humerus in children. Open Orthop J 2018;12:229-35.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]