Distal Humeral Fractures In Adults Research Articles

Wound infection in elbow fractures: Incidence and new management protocol.

Wound infection in elbow fractures: Incidence and new management protocol.

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.

Study of functional outcome of surgical management of distal humerus fractures with bicolumnar plating

INTRODUCTION: Distal humerus fractures in adults comprise 2% of all fractures and 30% of all humeral fractures. Intra-articular distal humerus fractures account for 37% and involve both medial and lateral columns. Most of the distal humeral fractures in adults must be treated surgically to get better functional outcome. The aim of this study was to assess the efficacy, technical requirements, functional outcome, radiological and clinical union, and complications of distal humerus fractures treated with bicolumnar plating. MATERIALS AND METHODS: This was a prospective study of 35 cases of distal humerus fractures conducted at a tertiary care hospital, who were treated surgically with bicolumnar plating using posterior approach with transolecranon osteotomy between 2016 and 2018. The Mayo Elbow Performance Score was used for the assessment of functional outcome. RESULTS: Thirteen (37.14%) patients got excellent outcome, 17 (48.58%) got good outcome, 4 (11.42%) got fair outcome, and 1 (2.86%) got poor outcome, and the complications observed were infections, nonunion, implant failure, and elbow stiffness. Distal end radius fracture was the common association with distal humerus fracture in our study. CONCLUSION: Open reduction and internal fixation with bicolumnar plating is the treatment of choice for distal humerus fracture mainly in type B and C fractures. Fracture types, use of locking plates, stable fixation, and meticulous repair of soft tissues along with early elbow mobilization influence the final functional outcome. Bicolumnar plating provides better stability, allows early elbow range of motion, and prevents stiffness.

Distal humeral fractures in the adult

The management of distal humeral fractures in adults presents a unique set of challenges. Almost always they necessitate operative management, which might include complex intra-articular fracture fixation of very comminuted free fragments in an already complex joint, or, increasingly, novel arthroplasty techniques. Clinicians managing these injuries must be confident that they possess the requisite skills set, and, in the UK at least, this in itself is under scrutiny. This summary aims to acquaint the reader with the basic knowledge sufficient to begin to understand the approaches to managing these injuries, and some of the decision-making difficulties that are encountered.

Study on surgical management of distal humerus fractures in adults treated with bicolumnar plating

Background & Objectives: Distal humerus fractures in adults comprise 2% of all fractures and 30% of all humeral fractures. Intra-articular distal humerus fractures account for 37% and involve both medial and lateral columns. Most of the distal humeral fractures in adults must be treated surgically to get better functional outcome. The aim of this study was to assess the efficacy, technical requirements, functional outcome, radiological and clinical union, and complications of distal humerus fractures treated with bicolumnar plating. Aims and Objectives: The Aim of the present study is to evaluate the Functional Outcome of Surgical Management of distal Humerus fractures by Open Reduction and Internal using bicolumnar plating technique. Materials and Methods: A total of 30 distal humerus fractures admitted in teaching and general hospital were operated included in the study. Patients fitting in to inclusion criteria were selected. All the patients were operated with ORIF with precountered locking distal humerus plates in orthogonal fashion and outcome was measured by MEPS, rate of union, rate of complications and final range of motion. Results: In our series of 3 0 cases, there were 22 males and 8 females with average of 36.8 years. 17 cases were due to direct fall, 10 due to road traffic accident and 3 due to direct assault. There was a predominance of left side (24). Out of 30 cases, 6 (20%) were of 13C1 type, 21(70%) were of 13C2 type and 3 (10%) were of 13C3. Excellent results in 21, good in 6 and fair in 3 cases, according to MEPS. There were 3 (10%) cases each of superficial infection and 3 (10%) cases of ulnar neuropathy, treated accordingly. There were no cases of non-union, implant failure or heterotopic ossification. Conclusion: Operative treatment with rigid anatomical internal fixation, should be the line of treatment for fractures of distal humerus, as it gives best chance to achieve goodelbow function. During open reduction and internal fixation, anatomic reconstruction of articular surface should be given prime importance. Stable fixation allows early active and aggressive postoperative mobilization.

Surgical management of distal humeral fractures in adults

Introduction: The only reliable method for restoring the normal alignment and contour of the distal humerus is operative exposure and direct manipulation of fracture fragments. However, fixation of fracture fragments must be stable enough to allow motion while ensuring union Methodology: On admission of the patient, a careful history was elicited from the patient and/or attendants to reveal the mechanism of injury and the severity of trauma. The patients were then assessed clinically to evaluate their general condition and the local injury Results: In the present series there were no cases of type I fractures. There were 5 (25%) cases of type II fractures, 12 (60%) cases of type III fractures and 3 (15%) cases of type IV fractures. In this series 12 (60%) patients were fixed with double reconstruction plates of which supplementary K wires were used in 2 cases and 8 (40%) patients were fixed with Y plate Conclusion: During open reduction internal fixation, anatomic nature of articular surface should be given prime importance

Articular Fractures in the Elderly: to Fix or to Replace? - Distal Humerus

Distal humeral fractures in adults are rare. They are routinely treated by open reduction and internal fixation in an attempt to retain a painless, stable and functional joint. However, even with advances in plate technology, the results of fixation still depend on screw purchase and bone quality. Even if functional results appear to be favourable, complication rates remain quite high. This is particularly true in elderly patients, in whom multifragmentary intraarticular fractures are mostly associated with diminished bone quality. Recent results support the use of primary total elbow arthroplasty in patients with highly comminuted distal humeral fractures. This applies particularly to the elderly with low physical demands, or patients with marked joint destruction from significant preexisting inflammatory joint disease. Although short term results seem to be promising, the intermediate and long term data are still inadequate. There is indeed evidence for a dramatic increase in complications and revision rates over time. Lifelong weight restriction is a major drawback in total elbow arthroplasty. It is unclear whether the primary treatment of distal humeral fractures in the elderly should be open reduction and internal fixation or total elbow arthroplasty. The operation should be selected for the individual patient on the basis of the surgeon's experience and judgment as well possible contraindications. The surgeon should discuss the question openly with the patient.

A Study Of Comprehensive Management Of Distal End Humerus Fractures In Adults

In young adults, most distal humerus fractures occur from high-energy trauma like Sidesweep injuries, motor vehicle accidents, falls from height and gunshot wounds. In elderly persons with more osteoporotic bone; most of these injuries occur from falls. Evolution of management of these fractures have revolutionized over time. Management of distal end of humerus fractures pose a challenge to treating orthopedic surgeon. Choice of implant depends of fracture anatomy and circumstances. In the present study we evaluate modes of management of distal end of humerus fractures in adults. Thirty six cases of fracture of distal humerus in adults were treated both conservatively and surgically and fixed using various implants in Mamata General Hospital, Khammam from October 2010 to October 2012. The Objectives of the study are to analyze the various methods of management of distal humeral fractures in adults. Most of the cases were males with age ranging between 18 to 65 years. By mayo elbow performance scoring system out of 36 patients, 14 patients (38.9%) had excellent results, 11 patients (30.6%) had good results, 4 patients (11.1%) had fair results and 7 patients (19.4%) had poor results. Reconstruction plates and cannulated cancellous screws offer excellent results in distal humeral fractures in adults.Open reduction and internal fixation with reconstruction plate and cancellous screws can be considered as the treatment of choice. With this method, proper length of the distal humerus, opposition, articular congruency, axial alignment, rotational alignment and stability with good range of motion of elbow can be restored. Hence, Reconstruction plates and cannulated cancellous screws can be considered as first line of management.

English

Distal humerus fracture in adult is very difficult to treat. It is very difficult to achieve alignment, anatomical reduction, rigid fixation, immediate mobilization and fracture union in such patient MATERIAL AND METHOD-We operate 41 patient of close extra articular fracture of distal third of humerus, using posterior approach. 10 cases were fixed with single locking plate,6 cases by single distal multiple hole plate,12 cases by two reconstruction plate,6 cases by simple T plate,7cases by oblique metaphyseal locking plate. RESULT- Double plating with reconstruction plates provide a more rigid fixation than a single-locked plate. CONCLUSION- Fixation of extra articular distal humerus, diaphyseal fracture in adult are better with double plating than single plating, which provide more rigid fixation with early mobilization and higher mayo elbow score. INTRODUCTION : Fractures of distal humerus are rare injuries in adults (1). Distal humeral fractures make it difficult to use upper limb for activities of daily living such as eating, wearing clothes, maintaining body hygiene etc. To use elbow effectively, stable reduction and fixation of these fractures is necessary. Fractures of the distal humerus remain a challenging problem despite advances in technique and implants. Joint function often is compromised because of stiffness, pain, and weakness. Rarely is a normal elbow the outcome after these fractures, but outcomes have been improved with advances in implant technology, surgical approaches, and rehabilitation protocols. These fractures are difficult to manage because of poor bone quality in distal humerus. The appropriate treatment of extra-articular distal humerus fractures is controversial. Most distal humeral fractures in adults must be treated operatively, in contrast to fractures of the proximal humerus or humeral shaft. Nonoperative treatment with the bag of bones technique may be reasonable in an elderly patient with significant medical comorbidities. When operative fixation is indicated for humeral shaft fractures, plate osteosynthesis is the gold standard to which other

ACUMED self-orientated elbow plate instruments for type C distal humeral fractures in adults

Objective To investigate effects of ACUMED self-orientated elbow plate system in treatment of comminuted distal humeral fractures (type C) in adults.Methods Thirty-two adult cases of comminuted distal humeral fractures treated by open reduction and internal fixation with parallel dual plates from May 2009 to October 2010 were enrolled in the study.There were 17 males and 15 females,at average age of 60 years (range,21-85 years).All cases were subjected to closed fractures,involving left side in 15 cases and right side in 17.Besides,two cases had associated ulnar nerve injury.According to AO classification,there were 12 cases of type C1,12 of type C2 and eight of type C3 fractures.The time from injury to operation averaged 5.6 days.Distal humeri were exposed through posterior median incision of elbow and V shape osteotomy of olecroanon.Muscular contractile and relaxant functional exercise was taken within 24 hours postoperatively.Clinical results were assessed based on Mayo elbow performance score (MEPS) and X-ray films.Results X-ray films showed that all cases obtained primary bone healing in the follow-up (mean 12 months).Three cases of type C3 fractures had heterotopic ossification.All cases had no complications like infections or implant loosening postoperatively.Range of motion in elbow flexion and extension averaged 85° (range,8°-140°).MEPS was average 90 points (range,60-100 points),including excellent outcomes in 13 cases,good in 15,fair in one and poor in three,with excellence rate of 88％.Conclusion ACUMED parallel dual plate fixation technique based on stability theory of arch structure achieves solid fixation of adult comminuted distal humeral fractures,successfully reconstructs bone structure of distal humeri,and effectively restores elbow joint function in response to early rehabilitation exercise. Key words: Humeral fractures; Elbow joint; Internal fixators

The Cochrane Database of Systematic Reviews – issue 1 2013

The Cochrane Database of Systematic Reviews – issue 1 2013

Surgical interventions for treating distal humeral fractures in adults

Distal humeral fractures in adults are relatively uncommon injuries that require surgical intervention in most cases. There is a lack of consensus regarding the best management of distal humeral fractures in adults, including the role of conservative treatment, appropriate surgical approach, fixation strategies, the role of total elbow arthroplasty and handling of nerves such as the ulnar nerve. To assess the effects (benefits and harms) of surgical interventions for distal humeral fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 4), MEDLINE (1946 to April Week 4 2012), EMBASE (1980 to 2012 Week 17), Current Controlled Trials (1st May 2012), the WHO International Clinical Trials Registry Platform (1st May 2012) and the bibliographies of trial reports and relevant articles. All randomised and quasi-randomised controlled trials pertinent to the management of distal humeral fractures in adults were included. Two review authors independently performed study selection, assessed of risk of bias and extracted data. Pooling of data was impossible due to study heterogeneity. Three small randomised controlled trials, with a total of 109 participants with Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen (OTA/AO) type C distal humeral fractures, were included. Overall, the quality of the available evidence is limited. As well as the small sample sizes and detection bias from the lack of blinding of subjective outcomes, the methods and results of all three trials were incompletely reported.One trial, involving 42 participants, compared open reduction-internal fixation (ORIF) with total elbow arthroplasty (TEA) in patients aged over 65 years. Of the 40 participants followed up for two years, five allocated ORIF underwent intraoperative conversion to TEA. These participants were crossed-over to the TEA group in the analyses. The reported Mayo Elbow Performance Score (MEPS) results were consistently better in the TEA group at follow-up after 6, 12, and 24 months, whereas the Disability of the Arm, Shoulder, Hand (DASH) scores showed short term (after 6 months), but not longer term (after 12 and 24 months), superiority in the TEA group. The reoperation rate, complication rate and elbow range of motion results showed no statistically significant differences between the two groups. While an intention-to-treat analysis of treatment failure, where the five cross-over participants are placed in their original allocated group, is in favour of TEA, the result did not reach statistical significance (9/21 versus 3/21; RR 3.00, 95% CI 0.94 to 9.55).The second trial, involving 38 patients but reporting results for 35, compared perpendicular versus parallel double plate fixation strategies. There was a consistent finding of a lack of significant differences between the two treatment groups in terms of MEPS, re-operation for complications (3/17 versus 3/18; RR 1.06, 95% CI 0.25 to 4.54), complications and elbow joint range of motion.The third trial, which included 29 patients with preoperative ulnar nerve compression symptoms, compared anterior subfascial transposition with in situ decompression of the ulnar nerve. Although results for complete recovery of ulnar nerve function (12/15 versus 8/14; RR 1.4, 95% CI 0.83 to 2.35) and grades based on the Bishop rating system tended to favour the transposition group, none of the differences were statistically significant. Overall, this review found there is either no or insufficient evidence from randomised or quasi-randomised controlled trials to determine whether surgery is, and which surgical interventions are, the most appropriate for the management of different types of distal humerus fractures. Well designed and reported large and multi-centre randomised controlled trials testing current interventions, such as pre-contoured and locking plating systems, are needed.

Distal Humeral Fractures in Adults

Distal humeral fractures in adults are relatively uncommon injuries that require operative intervention in the majority of cases. Dual plate fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90° or 180° to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus. Acute total elbow arthroplasty is the preferred treatment for elderly patients with a displaced, comminuted, intra-articular distal humeral fracture that is not amenable to stable internal fixation. Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach.

Selection of approach and fixation in the treatment of type C fracture of distal humerus in adults

Objective To study the surgical treatment for distal humeral fractures in adults according to the follow-up results. Methods Twenty-one cases (16 males and 5 females) of distal humeral fracture were included in this study. The average age was 42.5 years (range: 37–52 years). Fractures were classified according to the AO classification system. Nine cases of C1, 8 C2 and 4 C3-type fractures were identified. Open reduction and internal fixation were performed in all cases. A tricep-reflecting approach was adopted, and either the AO orthogonal plating or parallel plating technique was chosen, based on the fracture type. The plaster cast was removed 3 weeks after operation. Rehabilitation was encouraged during this period and afterwards. The average follow-up time was 12.2 months (range: 8–28 months). The outcome was scored according to Aitken and Rorabeek system. Results No nerve injury, nonunion or failure of fixation was encountered during the operation and follow-up. However, ossifying myositis occurred in one case. Conclusion A triceps-reflecting approach can provide adequate exposure to the j oint. The us e of AO orthogonal plating or parallel plating techniques based on the type of fractures can provide rigid fixation for the fracture.

Internal fixation of complex distal humeral fractures in adults with parallel-plating: early experience

Objective To study the treatment of complex distal humeral fractures in adults with the parallel-plate technique. Methods From August 2007 to October 2008, 12 patients with complex distal humeral fractures were treated by open reduction and internal fixation using parallel plating. There were 8 males and 4 females, with an average age of 52. 3 years (range, 32 to 74 years). Five fractures occurred on the left extremity and 7 on the right. The fractures resulted from a traffic accident or falling in 11 and other trauma in one. According to AO/OTA classification, one case belonged to C1 type, 3 to C2 type, and 8 to C3 type. Two cases suffered from open fracture (Gustilo scale Ⅰ). Skin contusion occurred in 3 patients, multiple injuries in 8, and primary injury of ulnar never in 2. The function of elbow was assessed according to Mayo elbow performance score (MEPS) and plain X-ray films. Results The 12 patients were followed up for 3 to 16 months (mean, 9. 5 months). The mean fracture healing time was 11.5 weeks (range, 6 to 18 weeks). No nonunion, delayed union, displacement, avascular necrosis, or implant failure was observed. The range of motion of the elbow joint averaged 112.9° (40° to 145°) and the mean MEPS was 83.8 (45 to 100) points at the final follow-up. The clinical outcomes were excellent in 6 cases, good in 4, fair in one and poor in one. The overall excellent to good rate was 83.3%. Conclusion The parallel-plate technique can be used in the treatment of complex distal humeral fractures in adults to obtain stable internal fixation, early postoperative rehabilitation and satisfactory clinical effect. Key words: Humeral fractures; Elbow joint; Fracture fixation, internal; Treatment outcome

Distal Humeral Fractures of the Adult

Retrospective case series carried out to identify factors influencing the outcome of ORIF of distal humeral fractures in adults and to compare different elbow scoring systems. Twenty-eight consecutive distal humeral fractures sustained by 27 patients were treated by open reduction and internal fixation. Anatomical or near anatomical reduction was achieved in 25 cases. Fifty-six months (Range: 24–103) after surgery, 24 elbows were subjectively rated as good or excellent and 4 as fair or poor. The mean DASH Score was 24% and the mean Mayo Elbow Score 85%. The level of satisfaction significantly correlated with pain, stability, development of arthritis, heterotopic bone formation, range of motion, the condylar angle of alignment, as well as lack of further surgery. ORIF of distal humeral fractures lead to acceptable results even in elderly patients and in the event of complications.

Approaches to distal humeral fractures in adults and comparison of treatment results

We compared the results of surgical techniques used in the treatment of distal humeral fractures. The study included 22 patients (15 men, 7 women; mean age 52 years; range 21 to 80 years) who were treated for closed distal humeral fractures. The fractures were classified according to the Müller's classification (18 type 3, 4 type 4) and Mehne-Matta's classification of intraarticular fractures. Following open reduction, internal fixation was performed with the use of double reconstructive plates in seven patients (32%), multiple K-wires in eight patients (36%), and multiple screws in seven patients (32%). The mean follow-up period was 42 months (range 24 to 72 months). The results were assessed using the Mayo Elbow Performance Scoring system. The results were very good in five patients (22.7%), good in eight patients (36.4%), fair in five patients, and poor in four patients (18.2%). Valgus and varus deformities were found in six (27.3%) and three (13.6%) patients, respectively, and 12 patients (54.6%) had decreased muscle strength. Two patients (9.1%) in the K-wire group developed instability due to insufficient union. Heterotopic ossification was detected in five patients (22.7%). None of the patients had persistent or severe pain. Two patients (9.1%) were free of pain, while 11 patients (50%) had occasional and mild pain, and nine patients (40.9%) had moderate pain on activity. The mean Mayo Elbow Performance scores were 88, 72, and 55 with plate, screw, and K-wire applications, respectively. It was concluded that open reduction followed by internal fixation with double reconstructive plates was superior to K-wire and screw fixations in the treatment of distal humeral fractures.

Adult distal humeral metaphyseal fractures: epidemiology and results of treatment.

To examine the epidemiology and results of treatment of fractures of the distal humeral metaphysis. Observational cohort study. An orthopaedic trauma unit, which provides all the fracture care for a well-defined catchment population. A consecutive series of 320 patients with distal humeral fractures admitted to the unit between January 1988 and June 1997. We adopted a protocol of open reduction and fixation of all displaced fractures (greater than 5 mm of displacement in any plane) in patients who were medically fit for anesthesia. Postoperative immobilization was a cylinder cast for 6 weeks. Patients with undisplaced fractures or who were medically unfit were also treated nonoperatively in cylinder casts for 6 weeks. Epidemiological examination of patient subgroups and the incidence of complications of treatment. The overall incidence of distal humeral fractures in adults during this time was 5.7 cases per 100,000 in the population per year with an almost equal male to female ratio. There was a bimodal age distribution, simple falls were the most common overall cause of fracture, and the majority of the fractures were extra-articular (AO/OTA type A) or complete articular fractures (AO/OTA type C). The risk of complications during treatment was generally low in most patients, and the majority healed their fractures uneventfully. Overall, 90.6% of fractures united within 12 weeks and just under half of the remaining 9.4% patients with union complications healed without requiring further operative intervention by 24 weeks. The risk of union complications was higher following high-energy injuries, open fractures, and nonoperative treatment. Although the AO/OTA classification was not predictive of union complications, the "low" transcondylar (type A2.3 and A3) and simple intercondylar fracture (type C1.3) configuration had a greater risk of union complications than the "high" subtype. The rate of infection, myositis ossificans, and other implant-related complications were higher following operative treatment of type C fractures than type A and B fractures. The epidemiology of a consecutive unselected series of adult distal humeral fractures is defined in this study. The majority of these fractures are best treated surgically by rigid open reduction and internal fixation, except for "low" Type A and C fractures, which have a higher risk of union complications. The role of total elbow arthroplasty to treat these more complex injuries requires further evaluation.

Distal Humeral Fractures in Adults.

Distal humeral fractures in adults often pose a challenge to the orthopaedic surgeon. Preoperative planning, minimal devitalization of bone and soft tissue, and adherence to the prerequisites of biomechanical fixation are all important elements in effecting the desired end result. The chevron modification of the olecranon osteotomy affords excellent surgical exposure of the joint surface for fractures with an intra-articular component. When two plates are used to fix the lateral and medial distal humeral columns, it is best to orient them so that, when looked at in cross section, they are at right angles to each other. The achievement and maintenance of an anatomic reduction secure enough to permit early functional, pain-free motion of the elbow can be best ensured by open reduction and internal fixation with careful attention to detail.