Fixation Of Distal Humerus Fractures Research Articles

Intra-operative subperiosteal elevation of the ulnar nerve is a safe and effective way to minimize post-operative ulnar neuritis in distal humerus fractures.

To describe subperiosteal elevation of the ulnar nerve and compare to anterior transposition and in situ decompression techniques. Design: Retrospective comparative study. Urban Level 1 trauma center. Distal humerus fractures (OTA/AO 13) treated with open reduction internal fixation between 2014-2022. Rate of pre- and post-operative neuritis grouped by 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 outcomes measurements was rate of neuritis documented within physical exam. 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). Pre-operative 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 post-operative 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 post-operative 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 post-operative 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 post-operative neuritis (OR=5.2, p=0.023). Subperiosteal elevation is an effective way to minimize post-operative 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 association with post-operative ulnar neuritis. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for dysfunctional elbow stiffness following operative fixation of distal humerus fractures

BackgroundElbow stiffness is one of the most common complications after operative fixation of distal humerus fractures; however, there is relatively limited literature assessing which factors are associated with this problem. The purpose of this study is to identify risk factors associated with dysfunctional elbow stiffness in distal humerus fractures after operative fixation. MethodsA retrospective review of all distal humerus fractures that underwent operative fixation (AO/OTA 13A-C) at a single level 1 trauma center from November 2014 to October 2021. A minimum six-month follow-up was required for inclusion or the outcome of interest. Dysfunctional elbow stiffness was defined as a flexion-extension arc of less than 100° at latest follow-up or any patient requiring surgical treatment for limited elbow range of motion. ResultsA total of 110 patients with distal humerus fractures were included in the study: 54 patients comprised the elbow stiffness group and 56 patients were in the control group. Average follow-up of 343 (59 to 2,079) days. Multiple logistic regression showed that orthogonal plate configuration (aOR: 5.70, 95% CI: 1.91-16.99, p=0.002), and longer operative time (aOR: 1.86, 95% CI: 1.11-3.10, p=0.017) were independently associated with an increased odds of elbow stiffness. OTA/AO 13A type fractures were significantly associated with a decreased odds of stiffness (aOR: 0.16, 95% CI: 0.03-0.80, p=0.026). Among 13C fractures, olecranon osteotomy (aOR: 5.48, 95% CI: 1.08-27.73, p=0.040) was also associated with an increased odds of elbow stiffness. There were no significant differences in injury mechanism, Gustilo-Anderson classification, reduction quality, days to surgery from admission, type of fixation, as well as rates of ipsilateral upper extremity fracture, neurovascular injury, nonunion, or infection between the two groups. ConclusionDysfunctional elbow stiffness was observed in 49.1% of patients who underwent operative fixation of distal humerus fractures in the present study. Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with an increased odds of dysfunctional elbow stiffness; however, 13A type fractures were associated with decreased odds of stiffness. Patients with these injuries should be counseled on their risk of stiffness following surgery, and modifiable risk factors like plate positioning and performing an olecranon osteotomy should be considered by surgeons.

Clinical outcomes for linked fixation of distal humerus fractures: a multicenter study

BackgroundO’Driscoll popularized the principle of linked column fixation for distal humerus fractures. Despite the linked column concept being widely accepted, there are few reported techniques to accomplish this goal. A novel device was designed based on the principles of linked columns. An interlocking beam is used to connect the medial and lateral plates, creating a unified fixed angle construct. Our primary objective was to report clinical outcomes across multiple institutions for a linking beam used in distal humerus fracture fixation. MethodsA retrospective series was collected from five institutions for the TiBeam (Skeletal Dynamics, Miami, FL, USA) with a minimum follow-up of six months. Acute and chronic treatment of distal humerus fracture patterns, and all plate configurations were included for analysis. ResultsA total of 36 cases were collected at a mean age of 52 years and a mean follow-up of 19.3 months. AO C-type fractures were 56% of the series. The median MEPS was 85 (IQR 76.3 to 90), the median DASH was 21.4 (IQR 15.9 to 30), and the median VASa was 3.5 (IQR 2 to 5). An olecranon osteotomy was used in 86% of cases and an anatomic plate was used for fixation of the osteotomy in 94% of those cases. There were three cases of olecranon plate removal for a rate across the series of 13.7%. DiscussionOur short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fracture fixed with a linking beam. Further, the rate of removal for the olecranon osteotomy plate was lower than historical reports for aggregate methods of osteotomy fixation.

To Compare the Fixation of Distal Humerus Fracture by Orthogonal (90°–90°) Plating Versus Parallel Plating in Adults

Abstract Introduction: A distal humerus fracture is defined as a fracture within a square of the lower end of the humerus where the base is the distance between the epicondyles of the humerus on an anteroposterior view of the radiograph. The most distal humerus fractures are due to high-energy trauma, such as road traffic accidents in adults, and in the elderly due to low-energy injuries, such as trivial falls. The purpose of this study was to analyze and evaluate the comparison of fixation of distal humerus fracture by orthogonal and parallel plating in adults. Materials and Methods: A prospective study was done among 30 patients having distal humerus fractures. The distal humerus fractures were managed with anatomical locking plates by orthogonal and parallel plating techniques through posterior approach and reduction, stable fixation, and functional outcome were assessed by using Mayo Elbow Performance Score (MEPS). Results: The results revealed that all patients were followed up by using MEPS scoring and X-ray of the elbow in anteroposterior and lateral view. In our study, road traffic accidents were the most common mode of injury and the mean age was 43 years. By using the MEPS score, the results were excellent for 9 patients, good for 13 patients, fair for 3 patients, and poor for 5 patients. After comparison between orthogonal and parallel plating groups, there was no significant difference in the total range of flexion and extension, MEPS, and flexion–extension arc. Conclusion: The results conclude that in the management of distal humerus fracture, the plates applied orthogonally have no significant difference compared with the parallel plating technique. The plates applied in the orthogonal and parallel configuration by using appropriate surgical techniques provided stable fixation and anatomical reduction of distal humerus fractures.

Iatrogenic "overshoot" nerve injuries: imaging features.

Describe features of iatrogenic "overshoot" nerve injuries on ultrasound and MRI, which occur when an instrument passes through the bone and injures the nerve after it penetrates the opposite cortex. After a keyword search of the radiology database at a tertiary care orthopedic hospital from January 2016 to December 2022, those fulfilling the inclusion criteria of (1) instrumentation through the bone during surgery, (2) acute neuropathy immediately after surgery, (3) nerve injury confirmed on electrodiagnostics, and (4) imaging consistent with overshoot nerve injury were included. Imaging studies were retrospectively evaluated to determine primary and secondary signs of an overshoot nerve injury. Six patients (3 females, mean age 26.7 (range 10-49) years) had nerve injury fitting the mechanism of injury: 3 injuries to the radial nerve during fixation of distal humerus fractures, 1 tibial nerve and 1 superficial peroneal nerve injury during fixation of tibial fractures, and 1 posterior interosseous nerve injury during biceps tendon repair. Ultrasounds were performed in all while 4 also had MRI. Secondary signs included (1) cortical defect adjacent to injured nerve (n=2); (2) scar extending from bone to injured nerve (n=2); (3) screw tip pointing to injured nerve (n=1, 4) tract in bone on MRI from previous instrumentation pointing to injured nerve (n=2). In addition to primary signs such as laceration or neuroma, secondary signs of "overshoot" nerve injury include cortical defect, scar extending to nerve, screw tip pointing to nerve, and linear tract in the bone on MRI.

Predictors of Adverse Events in the Surgical Treatment of Adult Distal Humerus Fractures.

The purpose of this study was to identify surgical complications after distal humerus fracture fixation as well as correlations between these complications and patient variables. A total of 132 patients underwent open reduction and internal fixation of traumatic distal humerus fractures between October 2011 and June 2018. Included were adult patients who underwent surgical fixation and had more than 6 months of follow-up. Excluded were patients with inadequate radiographic imaging, less than 6 months of follow-up, and previous distal humerus surgery. Multivariate logistic regression models controlling for age and body mass index were used to determine preoperative factors predictive of postoperative complications. A total of 73 patients were included in this analysis. Surgical complications were reported for 17 patients. Reoperation was required for 13 patients. Open injury at presentation was predictive of delayed union. Predictors of subsequent elbow surgery included younger age, polytrauma, open fracture, and ulnar nerve injury at the time of injury. Radial nerve injury at the time of presentation was also a risk factor for postoperative radial nerve symptoms. Predictors of postoperative heterotopic ossification included older age. Thirty-one patients had an olecranon osteotomy during their open reduction and internal fixation and none went on to nonunion. There were 13 patients with ulnar nerve complications. Of these patients, 3 had undergone an ulnar nerve transposition. None of the other studied variables were predictors of complications, malunion, or nonunion at latest follow-up. Although open reduction and internal fixation is effective in treating distal humerus fractures, its complications cannot be overlooked. Open fractures are more likely to go on to delayed union. Ulnar nerve injury, open fracture, and polytrauma were predictive for reoperation. Older patients were less likely to have subsequent surgery but more likely to develop heterotopic ossification. By identifying at-risk patients, managing physicians can better prognosticate and counsel patients on their recovery. [Orthopedics. 2023;46(6):352-357.].

Risk factors for hardware-related complications after extra-articular distal humerus fracture fixation using an anatomical locking plate.

We aimed to identify the incidence and risk factors of hardware-related complications in patients treated with anatomical locking plate fixation for extra-articular distal humerus fractures. From 2013 to 2020, patients with extra-articular distal humerus fractures who underwent open reduction and internal fixation with an extra-articular distal humerus locking plate (EADHP) were retrospectively reviewed and categorized according to the presence/absence of hardware-related complications. Hardware-related complications were defined as the occurrence of skin prominence on the plate and discomfort in activities of daily living. Patient demographics, the lateral condylar angle, lateral body length, shaft-condylar angle of the humerus, and plate length were analyzed. Of the 29 patients, 10 (34%) did not develop hardware-related complications (group A), whereas 19 (66%) did (group B). Patient demographics did not differ between the groups. However, the number of patients who underwent hardware removal was significantly greater in group B (16/19) than in group A (4/10; p = 0.032). Radiologic assessment revealed no significant difference in the lateral condylar or shaft-condylar angle. However, the lateral body length was greater in group A than in group B (44.5 ± 4.8 vs. 39.5 ± 3.7, p = 0.007). The plate length significantly differed between the groups. Twelve of 19 (63%) patients in group B received short-hole plates (six holes), while nine of ten (90%) patients in group A received long-hole plates (eight holes). In the multivariable analysis, the lateral body length of the distal humerus (p = 0.047, odds ratio = 0.734, 95% confidence interval: 0.542-0.996) and plate length (p = 0.036, odds ratio = 0.076, 95% confidence interval: 0.542-0.996) were associated with hardware-related complications. Most patients developed hardware-related complications, particularly with short plates, mainly because of the narrow lateral body length of the distal humerus. Surgeons should be careful to secure EADHP in the appropriate position, especially when short plates are used in patients with narrow lateral body length.

Efficacy of utilizing 3D printed models for preoperative surgical planning of open reduction, internal fixation of distal humerus fractures

Introduction3D printing in distal humerus fracture surgery has not been evaluated despite increasing popularity. MethodsA retrospective study comparing distal humerus fracture surgery pre-operative plans to actual surgical plans and constructs was conducted using radiographs, CTs, 3D CT reconstructions, and 3D printed models. ResultsNo difference existed among imaging modalities for approach or plate size. 3D CT reconstructions best predicted lateral plate size. 3D printed models best predicted medial plate size. 3D printed models elicited higher confidence in pre-operative plan. Discussion3D printed models were an equivalent tool for pre-operative planning compared to other modalities in our study.

Low-Cost Method for Fixation of Distal Humerus Fracture in Elderly Osteoporotic Individuals: Experience from a Resource-Limited, Tertiary-Care Setting in North India

Introduction: About 7% of adult fractures involve elbow and around 2% involve distal humerus. Conventionally, these are managed by ORIF with plates and screws. Often osteoporosis and communition of fracture fragments is observed in elderly presenting with this pattern of injury. This further complicates the situation for reconstruction and stable fixation which is critical for early mobilisation. We present our fixation method of Joshi’s External Stabilizing System resulting in satisfactory outcome Methods: During study period (August 2017-Oct 2019), total of 19 patients (male=8) were treated at Dr Rajendra Government Medical College, Tanda, Himachal Pradesh, India. Seventeen of them were elderly osteoporotic individuals. Closed reduction was achieved in 7 cases who had displaced supracondylar humerus fracture. Open reduction through triceps splitting approach extending longitudinally up to fascial sleeve of forearm was done in one case of one year old neglected supracondylar humerus fracture and all cases of intercondylar humerus fracture (N=9). Articular visualisation and reduction were achieved after flexing to about 110 degrees and applying longitudinal traction through trochlear notch with the help of ribbon gauge, obviating the need of olecranon osteotomy. Results: Union was achieved in 15 cases; one case was lost to follow-up after 8 weeks. Another case is within 4 weeks follow-up. Elbow movements were initiated on first post-operative day in all. Fracture was classified on basis of A.O classification. Mayo elbow performance score system was done to evaluate the final functional outcome (Table 1). Conclusion: Complications encountered include minor pin-tract infections in 6 patients. In one patient, fracture was noted on 5th post-operative day at proximal level of construct. This was the patient with one year old neglected supracondylar humerus fracture. One patient was lost to follow-up. Others are doing well after a follow-up duration of 218 patient-months.

Evaluation of outcome of distal humerus fracture fixation by two-locked plates

Objective: The objective of the study was to evaluate the results of operative management of distal humerus fracture fixation by two-locked plates. Materials and method: This was a retrospective study involving 72 patients with distal humeral fractures who were managed surgically by fixation with two-locked parallel plates at Al- Gamhoria Teaching Hospital, and two private hospitals, in Aden, Yemen, between January 2018 and December 2020. The data was entered into a computer and analyzed using SPSS program version 17. For variables difference, chi-square tests, and P values were calculated. A p- value of < 0.05 was considered statistically significant. Results: The total study patients were 72 and they were (79.2%) males and (20.8%) with a ratio of male to female of 3.8:1. The mean age of the patients was 37.8 ± 15.3 years and the age ranged between 11 and 75 years. Most of the patients (69.4%) were of age 40 years, while more than 40 years old represented (30.6%). Causes of fractures were gunshots (56.9%) followed by road traffic accidents (37.5%). Left side was predominant with (62.5%). Type of injuries were open with (73.6%) and closed with (26.4%). Partially articular fractures were in (86.1%) of cases and complete articular fractures were in (13.9%) cases. Transpositions of ulnar nerve were found in (65.3%) cases. Ulnar nerve neuropraxia was found in (5.6%) cases and the Range of Motion (ROM) was limited (pron. – sup 30-45/flex – exten 30 – 130) in (29.2%) cases and no range of motion in (9.7%) cases. Non-union was found in (4.2%) cases while superficial infection was in (5.6%) cases. Stiffness was found in (9.7%) cases. Conclusion: This study revealed that managing the distal humeral fractures by internal fixation of two Parallel-Plates gives satisfactory results. Key words: distal humerus, fracture, internal fixation, locking plate, outcome

Triceps Tenotomy as an Alternative Exposure for Fixation of OTA/AO 13-C Fractures: A Technical Trick.

Intra-articular fractures of the distal humerus present challenges to treating physician and patient alike. The olecranon osteotomy is accepted as the standard exposure for intra-articular distal humerus fractures; nevertheless, complications such as nonunion and implant prominence are common. In this article, we describe the clinical outcomes and anatomic features of the triceps tenotomy as an alternative method of exposure for internal fixation of intra-articular distal humerus fractures. The olecranon osteotomy approach affords greater exposure of the distal humerus articular surface; however, there was no difference in quality of fracture reduction, progression to fracture union, posttraumatic arthrosis, or implant failure between approaches in our series. The osteotomy approach resulted in a greater need for reoperation (15% vs. 46%, respectively); largely as a result of olecranon implant-related complications. In summary, the triceps tenotomy offers an alternative exposure for intra-articular distal humerus fracture fixation with comparable clinical outcomes to the olecranon osteotomy technique.

Length of Plates and Number of Screws for the Fixation of Distal Humerus Fractures: A Finite Element Biomechanical Study

We performed a biomechanical analysis using the finite element method to assess the effects of plate length and the number of screws on construct stiffness, stress distribution, and fracture displacement in the fixation of type A2 distal humerus fractures. A 3-dimensional humerus model was constructed using computed tomography of a healthy man. After creating a 2-mm extra-articular fracture gap, orthogonal double-plate fixation was performed with an incremental increase in plate length and the number of screws, creating 17 fixation models. Four screws were placed in each plate's distal segment, and the number of screws was increased incrementally in the segment proximal to the fracture, starting from 2 in the medial (M) and 2 in the lateral (L) plate (M2∗L2). The fifth screw proximal to the fracture in the lateral plate (L5) played an essential role in increasing stiffness under bending, axial, and torsional forces surpassing the intact bone, which may have been due to the bypassing of the stress riser area. Minimum construct stiffness was created when 5 (M3∗L2) screws were inserted into the proximal segment. For bending forces, the M4∗L2 construct was stronger than M3∗L3 (total 6 proximal screws), and M5∗L3 was stronger than M4∗L4 (total 8 proximal screws), showing higher stiffness when the plates ended at different levels. The M4∗L2 construct (6 screws) had stiffness comparable with M4∗L3, M4∗L4, and M5∗L4 during bending, showing comparable stiffness with the least instrumentation density. Our findings suggested M3∗L5 as the optimum and M3∗L2 as the minimum construct to resist all bending, axial and torsional forces. Applying the results may improve surgical techniques, decrease the rate of complications, including fixation failure and nerve injury, and optimize the time of surgery. Moreover, hardware removal is less cumbersome with fewer screws.

Functional outcome of type 13 C2 distal humerus fractures treated with precontoured locking plates

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.

Functional outcome of the treatment of AO-ASIF type C distal humerus fracture using Lambda plate

Introduction: Although the use of two plates for the treatment of type-C distal humerus fracture is popular, site of plate placement still is under debate. Use of Lambda plate for the fracture treatment can be easier and settle the dispute. This study aims to evaluate the functional outcome of the surgery using Lambda Plate. This can be a reference for surgeons and helps them make the decision about choice of implant for type C distal humerus fracture treatment among Nepalese people.
 Methods: This interventional study used Lambda plate for the treatment of type C fracture of distal humerus. Patients were examined at 4, 12, and 24 weeks respectively for the measurement of the outcome. Visual analogous scale was used for assessment of pain, range of motion for functional recovery and Mayo Elbow Performance Score was used for the assessment of functional outcome. Paired-samples t-test and linear regression was used to for data analysis.
 Results: Functional outcome at the last follow-up was excellent in 24(53.33%) patients, good in 18(40%) patients and fair in 3(6.67%) patients. Range of motion of elbow increased significantly with every follow-up (p-value <0.001). Average angle of flexion at last follow-up was 117.53°±11.74 while loss of extension was 7.53°±4.86. Average number of patients had their fracture union at 19.84±2.38 weeks. There was no association of age, sex and union weeks with functional outcome when measured with MEPS.
 Conclusion: Fixation of distal humerus fracture by using Lambda plate gave excellent and satisfying outcome in terms of pain, range of motion and objective functional outcome.

Comparison of outcome of distal humerus fracture: Single extra articular humerus plating versus bipillar plating

Introduction: Distal humerus fractures are complex injuries as their management requires stable fixation and properly working adjoining joints. Management includes open reduction and internal fixation of distal humerus fractures with the use of available implants and their modification. Dual lock plating still has disadvantages of less hardware availability, their cost and also long surgical time wiht extensive soft tissue damage. The mainstay objective of this study is to evaluate the effectiveness and benefits of distal humerus fractures operated by using a single extra articular humerus plating versus bipillar plating. Aims and Objectives: 1: Evaluation of Clinical and radiological Outcome of single extra articular humerus plating planned for distal humerus fractures. 2: Comparison of clinical outcome of single extra articular humerus plating than the bipillar plating planned for distal humerus fractures. Materials and Methods: A retrospective clinical study was done on 40 patients with distal humerus fractures treated with single extra articular humerus plating and bipillar plating by trained single surgeon at a tertiary trauma care centre in the Department of Orthopaedics, BJ medical college, Civil hospital Ahmedabad between August 2016 and march 2018. The mean follow-up study time was approximately 13 months. Observation and Results: All the operated patients were followed up for a mean time of about 13 months (range from 06 to 20 months). Clinical, physiological and ortho-radiological assessment was performed to observe and evaluate fracture stabilization and reduction and fracture healing and callus formation and range of movements. The Mayo Elbow Performance Score and visual analogue scale were used to asses functional outcome. Conclusion: Proper Reduction with internal fixation still being considered the gold standard for treatment of distal humerus fractures. Extra articular plating however has better good prognostic results than bipillar plating. Early p

Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications.

To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13). Retrospective comparative cohort study. Level 1 trauma center. Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy). Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy. Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI). Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001). Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Olecranon Osteotomy Implant Removal Rates and Associated Complications.

This study reports on olecranon osteotomy implant removal rates, fixation types, and associated complications. Multicentre case series. Patients were identified through an electronic medical database at one Level 1 trauma center and three Level 2 trauma centers. Two hundred thirty-five patients were identified through the database, of which 92 patients met inclusion criteria. Patients underwent olecranon osteotomy for fixation of distal humerus fractures and the implant used was at the surgeon's discretion. Implant removal rate. Thirty-four of 92 (37.0%) patients underwent removal of implant from their olecranon osteotomy. Implant removal rates were as follows: 28 of the 63 patients for tension band wiring (TBW) (44.4%), 6 of the 18 patients for plates (33.3%), 0 of the 1 patient for cable-pin, and 0 of the 10 patients for osteotomies fixed with a screw fixation. Screw fixation was removed less frequently than TBW (P = 0.01). Screws were less commonly removed than all other fixation types (P = 0.01). TBWs (28/63) were more commonly removed than all other implants (6/29) (P < 0.05). The nonunion rate for olecranon osteotomies was 3.3%. TBWs (18/18) are more likely to be removed for implant irritation than plates. TBWs had an odds ratio of 3.29 for requiring implant removal if they were left >1 mm off of the olecranon tip. In this study, 34 of the 92 (37%) patients undergoing an olecranon osteotomy for treatment of a distal humerus fracture required removal of olecranon implant. Screw fixation (0/10) was found to be removed less frequently than TBW fixation 28 of the 63 patients (44.4%). Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The role of ulnar nerve subcutaneous anterior transposition during open reduction and internal fixation of distal humerus fractures: a retrospective cohort study

PurposeTo compare the rates of ulnar nerve neuropathy following ulnar nerve subcutaneous anterior transposition versus no transposition during open reduction and internal fixation (ORIF) of distal humerus fractures.MethodsThis was a retrospective cohort study at an academic level I trauma centre. A total of 97 consecutive patients with distal humerus fractures underwent ORIF between 2011 and 2018. All included patients were treated with plates (isolated lateral plates excluded) and had no pre-operative ulnar neuropathy. Subcutaneous ulnar nerve anterior transposition was compared versus no transposition at the time of ORIF. The main outcome measure was the rate of ulnar nerve neuropathy. The secondary outcomes were the severity of the ulnar nerve neuropathy and the rate of ulnar nerve recovery.ResultsTwenty-eight patients underwent subcutaneous ulnar nerve anterior transposition during ORIF, whereas 69 patients had no transposition. Transposition was associated with significantly higher rates of ulnar nerve neuropathy (10/28 versus 10/69; P = 0.027). An adjusted logistic regression model demonstrated an odds ratio of 4.8 (1.3, 17.5; 95% CI) when transposition was performed. Ulnar nerve neuropathy was classified as McGowan grades 1 and 2 in all neuropathy cases in both groups (P = 0.66). Three out of ten cases recovered in the transposition group, and five out of ten cases recovered in the no transposition group over a mean follow-up of 11.2 months (P = 1.00).ConclusionWe do not recommend performing routine subcutaneous ulnar nerve anterior transposition during ORIF of distal humerus fracture as it was associated with a significant 5-fold increase in ulnar nerve neuropathy.

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

Studies have shown that the use of nonlocking (reconstruction) plates in fixing distal humerus fractures may not yield stable fixation whichtherefore requires long immobilization and suboptimal functional results. There are reports showing that locking plates are biomechanically superior to nonlocking plates. The aim of this study was to compare elbow functional outcomes between locking and nonlocking plates in fixation of distal humerus fractures. A single-centre, randomized control study was conducted at an academic level 1 trauma centre. A total of 60 patients with type 13-A fracture (AO/OTA classification) were randomized into two equal groups, locking plates group, and nonlocking plates group. The primary outcome measure was the Mayo elbow performance score (MEPS) at one year. Secondary outcomes measures were elbow flexion/extension arc, union, operative time, and complications (e.g., infection, heterotrophic ossification). The Mayo Elbow Performance Score (MEPS) at one year was 88 ± 10.1 in locking plates group and 75.8 ± 12.8 in nonlocking plates group. The difference was found to be statically significant (P value = 0.01). Elbow flexion/extension arc of motion at one year was116° ± 15° in locking plates group and113° ± 28° in nonlocking plates. The difference was not found to be statistically significant (P value = 0.17). Both implants yield similar results, withlocking plates showing slightly better clinical scores.

Evaluating the 5-Factor Modified Frailty Index (mFI-5) for Associations with 30-Day Postoperative Adverse Outcomes after Surgical Fixation of Distal Humerus Fractures in the Elderly

Evaluating the 5-Factor Modified Frailty Index (mFI-5) for Associations with 30-Day Postoperative Adverse Outcomes after Surgical Fixation of Distal Humerus Fractures in the Elderly