Fixation Of Distal Humeral Fractures Research Articles

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

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. 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. 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. 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 4, retrospective study.

Functional outcome of internal fixation of complex intraarticular fractures of the distal humerus (OTA-AO type-C) in focus of O’Driscoll criteria for optimized stability

Introduction Internal fixation of distal humeral fractures is challenging because of complex anatomy and articular or metaphyseal comminution. Bi-columnar locked plating (orthogonal or parallel) is the standard method of fixation the success of which requires a rigid stable construct to optimize stability. The aim of this retrospective study was to evaluate the outcome of fixation of type-C distal humeral fractures by orthogonal locked plates and to determine the causes of early mechanical failure according to O’Driscoll criteria of optimized fixation stability. Settings and design A retrospective study conducted in Benha University Hospital. Patients and methods A review of 34 patients with type-C distal humeral fractures fixed with orthogonal anatomical locking plates through the period from 2014 to 2019, and evaluation of their outcome after 24–36 months. Radiographic images were reviewed for O’Driscoll criteria of optimized fixation, and complications were recorded. Results Functional outcome was assessed with Mayo elbow performance score. Twenty patients had an excellent outcome, seven patients good and seven fair in whom, O’Driscoll criteria for optimized fixation stability were not met and fixation was revised. All patients showed radiological union of fractures after about 3 months from definitive fixation. Multivariate analysis of the collected data was done by SPSS software to determine the cumulative percent of its factors and its relation with the final outcome. Conclusion Internal fixation of type-C distal humeral fractures by anatomically precontoured locking plates must be optimized according to O’Driscoll criteria to avoid early mechanical failure, revision surgery, and to achieve satisfactory functional outcome.

Advanced Imaging of Pediatric Radial and Axillary Nerve Anatomy for Intraoperative Use

Abstract Introduction: Lateral percutaneous pin placement, intramedullary screw placement, and plate placement during surgical fixation of distal humeral fractures all risk iatrogenic injury to the radial nerve as it crosses from the posterior to anterior compartment at the level of the mid-humeral shaft. Current literature describing the "safe zone" to avoid damaging the radial nerve at this location focuses on adult vascular anatomy. Radial nerve anatomy changes throughout childhood, and determination of age specific safe zones will help minimize iatrogenic nerve palsy in the pediatric population. Axillary nerve anatomy was also assessed. Methods: Electronic medical records were queried for humeral and shoulder MRIs that included the proximal humeral physis and the lateral epicondyle to assess the radial nerve or the lateral edge of the acromion and the upper 1/3 of the humeral diaphysis to assess the axillary nerve. Results/Discussion: Our study suggests the axillary nerve reaches its adult location around 14 years of age while the radial nerve does not reach its approximate adult location until 16 years of age. Before these ages extra precaution should be taken during surgical dissection and fracture fixation.

Technique for Arthroscopic-Assisted Reduction and Cannulated Screw Fixation for Coronal Shear Fractures of the Distal Humerus

Several articles have described arthroscopic fixation of coronal shear fractures of the distal humerus. However, not all of them have used purely arthroscopic techniques. In this Technical Note we describe another technique for intra-articular distal humeral fracture fixation using arthroscopy alone. Standard proximal anteromedial, proximal anterolateral, and posterolateral viewing portals are established with soft spot portal for reduction. During intra-articular examination, the fragment involving the capitellum and the trochlea as 1 piece is detected. Closed manipulative reduction under anesthesia is conducted with distraction, varus force, and gradual elbow extension. After closed reduction, reduction of the fragment more precisely under arthroscopic visualization using probe and elevator is performed. The fragment is temporarily fixed using 2 Kirschner wires from posterior direction. Anatomic reduction is confirmed with an image intensifier. Screw guide pin is inserted posteroanteriorly under image intensification, and a headless compression screw is placed over each wire. We describe a safe, reproducible, and minimal invasive technique for the arthroscopic treatment of coronal shear fractures of the distal humerus.

Functional outcome following elbow release and hardware removal after bicolumnar fixation of distal humeral fractures

IntroductionIntra-articular fractures of the distal humerus are typically treated with bicolumnar plate fixation. Despite prompt and accurate reduction and fixation, there is a high rate of complications post-surgical fixation. The purpose of this study was to determine the indications, technique, and outcomes of patients who had undergone an elbow release and hardware removal following bicolumnar plate fixation for an intra-articular fracture of the distal humerus. MethodsPatients who had undergone an elbow release and hardware removal by a single surgeon following bicolumnar fixation of an intra-articular fracture of the distal humerus were identified. Patients were contacted to participate in a chart review and to return to clinic for a follow-up visit. Patients who returned for a follow-up visit completed the DASH (Disabilities of the Arm, Shoulder and Hand), the MEPS (Mayo Elbow Performance Score), and the SF-36. ResultsForty-two patients were included in the final analysis. The average time from the original injury to the elbow release procedure was 17.5 months. There was an improvement of 33° in the mean flexion-extension arc following the procedure (p<0.001). The mean DASH score was 21 (SD=19) and the mean MEPS score was 82 (SD=16). There was a high rate of post-traumatic osteoarthritis (n=30). Two patients underwent a total elbow arthroplasty (TEA). One patient sustained a re-fracture of the distal humerus, and subsequently underwent repeat bicolumnar fixation. There were four reoperations (10%): two patients had a revision release of contracture and two patients underwent a closed manipulation. ConclusionsIt appears safe to remove both plates and to re-intervene relatively early. There is a modest but consistent improvement in flexion-extension arc, and the re-operation rate is low. Although there is a high rate of post-traumatic arthritic change radiographically, TEA was rare, and elbow-based outcome scores were good, although not normal.

Outcomes Following Distal Humeral Fracture Fixation with an Extensor Mechanism-On Approach

Distal humeral fractures have traditionally been managed with surgical approaches that disrupt the extensor mechanism. We hypothesized that an extensor mechanism-on approach for operative fixation of distal humeral fractures with parallel or orthogonal plate constructs would allow excellent healing, a motion arc of the elbow exceeding 100°, and maintenance of extensor mechanism strength. Distal humeral open reduction and internal fixation (ORIF) was performed with either orthogonal or parallel plate constructs in seventy-nine elbows. Thirty-seven elbows were fixed via an extensor mechanism-on surgical approach, and twenty-four of them were available for additional evaluation. Radiographs as well as MEPI (Mayo Elbow Performance Index), DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores were obtained. All thirty-seven fractures healed primarily. Three elbows underwent later release because of stiffness. The median arc of elbow motion was 126° (range, 60° to 141°). The mean MEPI was 91.5 points and the mean DASH score was 15.9 points, indicating excellent scores with mild impairment. The median percent loss of triceps strength was 10% (range, 0% to 49%) compared with the contralateral, normal elbow. Open treatment of distal humeral fractures with an extensor mechanism-on approach results in excellent healing, a mean elbow flexion-extension arc exceeding 100°, and maintenance of 90% of elbow extension strength compared with that of the contralateral, normal elbow.

Paper # 119: Distal Humeral Fracture Fixation – Results From General Orthopedic Surgeons

Paper # 119: Distal Humeral Fracture Fixation – Results From General Orthopedic Surgeons

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

The LCP Distal Humerus Plate (DHP) system represents an angular stable fixation system consisting of 2 anatomically pre-shaped orthogonal plates intended for the treatment of fractures of the distal humerus. The purpose of this retrospective study was to evaluate the clinical and radiologic outcome after a minimum follow-up of 2 years after open reduction and fixation of distal humeral fractures with this device. Twenty-two consecutive patients with distal humeral fractures were treated with the DHP system between January 2004 and June 2006. Of these, 16 could be clinically and radiologically evaluated after a mean follow-up of 30.5 months. Follow-up included anteroposterior and lateral radiographs; assessment of range of motion; pain according to a VAS; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score. All fractures showed satisfactory articular reduction. One patient showed preoperative sensory ulnar neuropathy, which recovered incompletely, and two patients showed sensory ulnar neuropathy postoperatively, requiring revision surgery in one patient. Mean range of motion was as follows: flexion, 129°; extension, -16°; pronation, 82°; and supination, 71°. The mean visual analog scale score was 1 point; the mean Disabilities of the Arm, Shoulder and Hand score, 23.3 points; and the mean Mayo Elbow Performance Score, 84.7 points. The DHP system represents a valuable tool to perform internal fixation of complex fractures of the distal humerus. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, even in elderly patients with potentially reduced bone mass. The multiple angular stable point fixation also of small distal fragments seems to be effective in the application of this system.

Distal Humeral Fracture With Associated Triceps Tendon Avulsion in a Renal Transplant Recipient

Although distal humeral fractures are well described in the literature, concomitant distal triceps avulsion has not previously been reported. One population that warrants a high index of suspicion for tendon injury after trauma is patients with renal disease. Clinical tests on such patients may yield equivocal results, and in that setting, magnetic resonance imaging may be useful in the diagnosis of concomitant tendon injury. Postoperative rehabilitation is a challenge considering that the old standard of care for isolated triceps avulsions is several weeks of immobilization and that early motion is recommended for open reduction and internal fixation of distal humeral fractures. More recent literature supports early active-assisted range-of-motion (ROM) elbow exercises after triceps tendon repair, and our case supports those recommendations.A 48-year-old, right-hand-dominant man, who was a living-related kidney transplant recipient 3 years previously, presented with radiographic evidence of an intra-articular distal humeral fracture. The patient was rejecting his kidney at the time of injury and was receiving 50 mg of prednisone daily. The patient underwent open reduction and internal fixation of the distal humeral fracture and concomitant triceps repair. Postoperatively, active-assisted and passive ROM elbow exercises were begun. At 3-year follow-up, the patient had 10 degrees to 120 degrees of motion at the elbow, with full supination and pronation.

Surgical treatment of complex distal humeral fractures: Functional outcome after internal fixation using precontoured anatomic plates

Several studies have shown good results with internal fixation of distal humeral fractures; however, few have focused specifically on anatomic parallel plate fixation using the same implant and postoperative regimen. The purpose of this study was to determine the functional outcome after open reduction and internal fixation of these complex fractures using parallel precontoured anatomic plates. This was a retrospective single-surgeon series involving 16 patients (12 women, 4 men) treated with a double-column parallel plating technique. Clinical assessment included the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand Score (DASH). Mean age was 43 years (range, 20-78 years). Average follow-up was 35 months. Four fractures were AO type A and 12 were AO type C. Union was achieved in all patients. There was no superficial or deep infection or hardware failure. Two patients required removal of plates for pain and prominence but not all screws could be completely removed. The mean flexion was 132 degrees and extension was 29 degrees . The mean DASH score was 46.1. Grip strength was 56% of the uninjured side. Mean flexion and extension force was 72% and 70%, respectively, of the uninjured elbow. The mean MEPS score was 72.3. Anatomically precontoured parallel plates are effective in achieving bony union with low implant failure with acceptable functional outcomes. However, screw extraction can be difficult when the implant is removed.

Management of distal humeral fractures in the elderly

Although relatively uncommon, fractures of the distal humerus in the elderly patient population are significant injuries of which optimal management is a subject of debate in orthopaedic literature. The combination of complex anatomy, poor bone quality and extensive comminution often seen with these fractures makes successful treatment difficult. Currently, most surgeons support surgical fixation of distal humeral fractures with the belief that restoration of the patient's native elbow joint provides the best opportunity for a good functional outcome. Others have proposed the use of total elbow arthroplasty as a primary treatment method for geriatric distal humeral fractures based on the difficulties associated with ORIF and the relatively low demands of this patient population. To date, there have been no prospective randomised trials comparing these two treatment alternatives, and a comparison of available outcome data shows good functional outcome for both forms of fracture management. With the aging of the population and an associated increase in the incidence of distal humeral fractures, the debate over the optimal treatment regime will undoubtedly continue.

Optimizing stability in distal humeral fracture fixation

Restoration of painless and satisfactory elbow function after a fracture of the distal humerus requires anatomic reconstruction of the articular surface, restitution of the overall geometry of the distal humerus, and stable fixation of the fracture fragments to allow early and full rehabilitation. Although these goals are now widely accepted by the orthopaedic community, they may be technically difficult to achieve, especially in the presence of substantial osteoporosis or comminution. Failure, when it occurs, typically occurs at the supracondylar level through loss of fixation in the distal fragments. To prevent such failure and thereby maximize the potential for union and full elbow mobility after a severely fractured distal humerus, 2 principles must be satisfied: (1) fixation in the distal fragment must be maximized and (2) all fixation in distal fragments should contribute to stability between the distal fragments and the shaft. There are 8 technical objectives by which these principles are met: (1) every screw in the distal fragments should pass through a plate; (2) engage a fragment on the opposite side that is also fixed to a plate; (3) as many screws as possible should be placed in the distal fragments; (4) each screw should be as long as possible; (5) each screw should engage as many articular fragments as possible; (6) the screws in the distal fragments should lock together by interdigitation, creating a fixed-angle structure; (7) plates should be applied such that compression is achieved at the supracondylar level for both columns; and (8) the plates must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level. These can be achieved with parallel plating. Severe metaphyseal comminution and bone loss are managed by supracondylar shortening. From the biomechanical data in the literature, 3 conclusions can be reached concerning fixation of distal humeral fractures. First, the concept that plates need to be placed perpendicular (90 degrees /90 degrees orientation) is unsubstantiated and incorrect. Second, parallel placement of 2 plates in the sagittal plane is as strong or stronger than the 90 degrees /90 degrees orientation. Finally, linking the plates together through the bone, thereby creating the architectural equivalent of an arch, offers the greatest biomechanical stability for comminuted distal humeral fractures. This can be done by interdigitating and locking the screws together as they pass through the distal fragments from the medial and lateral plates placed in the sagittal plane.

Internal Fixation of the Distal Humerus: A Biomechanical Comparison of Methods

Three commonly used configurations of various implants used for fixation of distal humeral fractures were quantitatively compared. The double plate construct, irrespective of plate type (1/3 tubular and/or 3.5 mm reconstruction plate), was significantly stronger, both in rigidity and fatigue testing, than cross screws or the single "Y" plate. If rigid stabilization of supracondylar or bicondylar distal humeral fractures is desired, then two plate constructs, at right angles (the ulna plate medially, the lateral plate posteriorly), are biomechanically optimal.