International Journal of Orthopaedics Sciences 2017; 3(2): 186-190

ISSN: 2395-1958
IJOS 2017; 3(2): 186-190
© 2017 IJOS Stabilization of Distal Humerus fractures by
www.orthopaper.com
Received: 29-02-2017 precontoured bi-condylar plating in a 90-90 pattern
Accepted: 30-03-2017

Dr. Prateek Jain Dr. Prateek Jain, Dr. Ankur Gupta, Dr. Ravikant Thakur and Dr.
MS Ortho, Deptt. of Orthopedics
IGMC Shimla, India. Shashikant Sharma
Dr. Ankur Gupta DOI: http://dx.doi.org/10.22271/ortho.2017.v3.i2c.29
MS Ortho, Deptt. of Orthopedics
IGMC Shimla, India.
Abstract
Introduction:
Dr. Ravikant Thakur
MS Ortho, Deptt. of Orthopedics
The treatment of fractures of the distal humerus is difficult and involves the risk of bad functional results,
IGMC Shimla, India. particularly with articular fractures or impaired bone quality. Anatomical reconstruction and rigid
fixation allowing early mobilization of the elbow are the basic prerequisites for good clinical outcomes.
Dr. Shashikant Sharma The aim of our study was to evaluate outcome of intercondylar fractures of distal humerus.
MS Ortho Deptt. of Orthopedics Patients and methods: The study included prospective or retrospective analysis of 28 cases of
IGMC Shimla, India. intercondylar fracture of distal humerus. There were 3 C1, 15C2 and 10 C3 type of fractures as per AO
classification in our study. Patients were operated by 90-90 plating using olecranon osteotomy or
Campbell’s approach. Results were evaluated by post-operative X-rays, mayo elbow performance score
and range of motion measurements.
Results: Male to female ratio in our study was 1.15:1. Mean age in study was 41.3±17.0 yrs. Most
common mode of injury was fall from height followed by road traffic accident. Mean duration of interval
between injury and surgery was 7.1±7.3 days and mean duration of hospital stay was 10.3±6.1 days.
85.72% of patients in had excellent to good results. Mean range of motion in our study was 100.6±20.0
degrees. Complications included 1 case of transient ulnar nerve neuropathy, one case of deep infection,
one case of malunion, and one case of delayed union.
Conclusions: Open reduction and internal fixation with 90-90 plating provides reliable, rigid fixation
allowing early functional mobilization of the elbow joint. Distal humeral locking plates proved to be
useful in C3 type of fractures and in elderly osteoporotic bones. Complication rates in the study were low
and comparable to studies in literature.

Keywords: Intercondylar fracture distal humerus, 90-90 plating.

1. Introduction
Intercondylar fractures of the distal humerus are uncommon injuries and present the most
difficult challenge out of fractures of lower end of humerus. The complex shape of the elbow
joint, the adjacent neurovascular structures, and the sparse soft tissue envelope combine to
make these fractures difficult to treat [1].
Improved surgical approaches and better fixation techniques allow early return to active
motion, which decreases the rate of soft tissue complications. An understanding of distal
humeral anatomy is helpful in the treatment of elbow fractures. In addition, biomechanical
studies have helped define the optimal implant characteristics and placement [1].
Distal humeral fractures have an estimated incidence in adults of 5.7 per 100,000 persons per
year. They constitute 30% of humerus fractures and 2% of all the fractures. These injuries
occur in a bimodal distribution, with an early peak in young males, twelve to nineteen years of
age, and a second peak in elderly women, with osteoporotic bone [2, 3].
The majority of distal humerus fractures occur in one of two ways: low energy falls or high
energy trauma. The most common cause is a simple fall in the forward direction. In general,
70% of patient that sustain an elbow fracture fall directly on to the elbow because they are
Correspondence unable to break their fall with an outstretched hand. High energy injuries are the cause of most
Dr. Prateek Jain distal humerus fractures in younger adults which include motor vehicle accidents, sports, fall
MS Ortho Deptt of Orthopedics from height, and industrial accidents [2, 3]. The common signs and symptoms of distal humerus
IGMC Shimla, India. fractures are pain, swelling, deformity, and, sometimes, instability of the elbow after a fall.
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A complete neurovascular examination of the radial, median, rule out intraarticular impingement of the implant. Ulnar
ulnar, and anterior and posterior interosseous nerves should nerve was embedded in the soft tissue and a fat pad harvested
be completed both before and after any manipulation [4]. locally was placed between the nerve and the medial plate if
AP and lateral radiographs of the elbow and humerus should required. The triceps V-Y flap was reattached to the triceps
be standard images. Traction radiographs can help define muscle in case of the triceps turndown approach. We used 90-
fragments that may be impacted or collapsed. CT scans with 90 plating using reconstruction plates or distal humerus
two dimensional views can be helpful. Three-dimensional precontoured plates as standard procedure.
reconstructions images help to know the exact geometry of Post operatively limb was immobilized in plaster of Paris slab
fracture and often allow for subtraction of the radius and ulna. for a period of 2 weeks. After 2 weeks sutures were removed
This technique can further illustrate fracture level, area and and split age was discontinued and patients were put on
degree of comminution, articular incongruity, and column physiotherapy.
involvement. All of these factors can affect the surgical Patients were followed up every 6 weeks for a period of 6
approach and ultimate treatment [4]. months. The results were assessed 6 months after the
Since the introduction of AO techniques open reduction and procedure using Rise borough and Radin grading system and
internal fixation has been the gold standard making Mayo elbow performance score system.
conservative management almost obsolete. It is well accepted The collected data was tabulated on a computer using
fact that plates are to be applied on both the columns in type Windows 7 operating system on Microsoft office 2013, Excel
C fractures, however, there is still no consensus regarding the package and the statistical analysis unpaired, two tailed
orientation of plates on both the columns [5]. Student’s t-test and ANOVA (Analysis of variance) for
The introduction of angular stable implants has revolutionized qualitative variables was done on the same software and Epi
the operative treatment of these fractures, particularly in Info TM version 7.
multifragmentory and osteopenia fractures. Now, Chi square test, Fischer’s exact test were used for univariate
anatomically precontoured plates with extensive distal screw analysis of categorical variables in different subgroups. A p-
options are available for distal humerus, promising enhanced value < 0.05 was considered statistically significant.
stability and an ease in application [6].
The aim of the present prospective-retrospective study was to 3. Results
evaluate the functional outcomes and complications in 28 There were 15 males and 13 females in our study. Mean age
patients of fracture intercondylar humerus operated in our in our study was 41.35±17.05 yrs.
institute using 90-90 plating. Majority of the patients (75%) sustained injury due fall while
25% of the patients sustained injury due to road traffic
2. Patients and Methods accidents.
The study included 28 cases of intercondylar fracture of distal In our study maximum number of patients had 13C2 type of
humerus admitted in Indira Gandhi Medical College, Shimla, fracture of the distal humerus (53.57%) followed by 13C3
between June 2013 to November 2014 or those patients who type which constituted 35.71% of all the fractures. 13C1 type
had been operated before June 2013. In the retrospective constituted only 10.71% of all the fractures. (Table 1)
group, records of patient were taken from record section. 60.71% of patients were operated by olecranon osteotomy
These patients were called for follow up, evaluated and approach, while 39.29% of patients were operated using
assessed radiologically and functionally. Campbell’s approach (triceps splitting). Olecranon osteotomy
Upon arrival in the department of casualty, thorough clinical was more favourable in fractures with intraarticular
examination of patients were done including neurovascular comminution. However, relationship between fracture type
examination. Radiography in form of X- rays and CT scans and approach of surgery was statistically insignificant.
with 3D reconstruction were done to know the exact geometry We observed comorbid conditions in 32.14% of our patients.
of fracture. Patients were taken up for surgery after battery of 14.29% patients each had diabetes, 10.71% had epilepsy and
blood investigations and detailed pre-anaesthetic examination. 7.14% of patients had both diabetes and hypertension.
All the patients were operated in lateral position using either Maximum number of patients were operated within first week
Campbell’s approach or Chevron olecranon osteotomy of injury. Delay occurred either due to delayed presentation to
approach, which was decided on preoperative planning and the institution or in the management of comorbid conditions
intraoperative visualization of fracture geometry. Ulnar nerve which was statistically insignificant. Mean duration between
was identified and dissected on routinely basis. The injury and surgery was 7.71±7.38 days and mean duration of
intercondylar articular surface was visualized and the articular hospital stay was 10.38±6.15 days.
surface was reconstructed anatomically. The intraarticular 42.86% patients had excellent results according to Mayo
reduction was stabilized with help of a 4.5 mm partially elbow performance score, 42.86% had good results, while
threaded cancellous screw passed over a guide wire. On 14.28% of the patients had fair and poor results.
attainment of a satisfactory articular reduction, the 46.43% of the patients had range of motion of more than100
supracondylar ridges were examined and the shaft was degrees. 39.29% of the patients had range of motion more
reduced to the condyles and maintaining the medial and between 80-100 degrees. Only 14.29% of the patients had
lateral ridges. The reduction was held with help of bone range of motion less than 80 degrees.
holding forceps and an interfragmentary screw was used to Mean range of motion was 100.6±20.03 degrees. (Table 1)
attain reduction if required. Precontoured distal humerus We observed that complexity of fracture increased with
locking plates or reconstruction plates were applied over the increasing age which was statistically significant with p value
lateral and medial ridges in a 90–90 fashion. Before definitive of 0.03. Patients with road traffic accidents had relatively
plate fixation, the elbow was placed through a range of complex fractures as compared with fall. However, this was
motion to ensure there is no hardware impingement. The statistically insignificant.
olecranon osteotomy was stabilized with tension band wiring No statistical significant relationship was found while
principle. The elbow range of motion was again reassessed to comparing various fracture subtypes with parameters like
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interval between injury and surgery, duration of hospital stay of deep infection, 1 case of malunion, 1 case of delayed
and post-operative complications. union, and 1 case of transient ulnar neuropathy.
Younger patients tend to have better range of motion, mayo
elbow performance score and relatively less pain at final Table 1: Data stratification according to AO classification
follow up as compared to older individuals. These AO Classification
observations were statistically insignificant. C1 C2 C3 P value
No statistical significant relationship was found between No. of Patients 3 15 10 0.43
interval between injury and surgery, duration of hospital stay, Mean Age in years 36.0±25.3 35.0±14.6 52.4±13.5 0.03
comorbid conditions and pain, range of motion and mayo Sex
elbow performance score at final follow up. Male 2 10 3
0.17
Female 1 5 7
No statistical significant relationship was found between
approach of surgery, post-operative complications and pain, Duration of hospital
range of motion and mayo elbow performance score at final 9.6±1.1 8.2±3.9 13.6±8.8 0.1
stay
follow up.
As the complexity of fractures increased, range of motion at Range of Motion 123.3±5.7 108.0±12.1 82.8±18.6 0.0001
final follow up decreased (p value – 0.0001).
Prolonged immobilization for a period of 4-6 weeks had Mayo Elbow Performance Score
relatively poorer outcome in terms of pain, range of motion, Excellent 3 9 0
Good 0 6 6
and mayo elbow performance score at final follow up. 0.01
Fair 0 0 2
Complication rate in our study was 14.28%. There was 1 case Poor 0 0 2

Fig 1: Pre-operative imaging

Fig 2: Post-operative X rays Fig 3.6: week follow up

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Fig 4.3: month follow-up with full range of motion

4. Discussion intercondylar fractures. We felt that fractures with larger

24 out of 28 patients had excellent to good results in our distal fragments could be fixed with reconstruction plates,
study. There was tendency towards better results among while fractures with smaller distal fragments or osteoporotic
younger individuals. However, we could not found bone required precontoured locking plates due to greater
statistically significant association. distal screw options.
There was tendency towards relatively complex fractures in Another area of controversy is regarding the positioning of
older individuals, which may be on account of decreased bone plates. In biomechanical studies, Korner et14 al found greater
quality and increased incidence of osteoporosis among older stability for perpendicular plate system while Stoffel et al.[13]
individuals. Patients with C3 type of fractures had relatively found greater rotational stability for parallel plating system
poorer outcome in terms of MEPS, ROM, and post-operative while comparing parallel arrangement of mayo elbow system
pain at final follow up, consistent with other studies [7, 8]. to perpendicular distal humerus plating system. We were able
These correlations were statistically significant. to achieve rigid fixation in all cases by using 4.5 mm partially
The selection of a surgical approach for the management of threaded cancellous screw for intercondylar fragments in
distal humerus fractures is dependent on several factors. addition to perpendicular plating.
These include the surgeon’s experience and preferences, We observed that prolonged immobilization for a period of 4-
fracture pattern, degree of articular involvement9. We used 6 weeks led to detrimental effect on post-operative pain, range
Campbell’s approach in 11 patients and olecranon osteotomy of motion and mayo elbow performance score at final follow
in 17 patients. We felt that C1 and some C2 type of fractures up which was statistically significant. These observations
(without much rotation of fragments) did not require were similar to Korner et al. [8] and Gupta et al. [7].
olecranon osteotomy and could easily be operated by We encountered only 1 case of ulnar neuropathy, which
Campbell’s approach. However, C2 type of fractures with recovered completely. This may be due to routine
significant rotational component and C3 type of fractures intraoperative identification and protection of ulnar nerve.
were better operated upon with olecranon osteotomy due to There was 1 case of deep infection which required
better visualization of articular surface as observed by debridement and removal of implant. Infection subsided and
Wilkinson et al. [10]. patient could return to his routine activities. 1 case of delayed
The use of locking plates for distal humeral fractures remains union was treated with bone grafting at later stage and union
controversial, and the indications for their use are unclear. could be achieved. There was 1 case of malunion in our study.
The high cost of these implants requires that their use be Overall complication rates in our study were comparable to
justified by sufficient clinical evidence prior to their other studies [16-20].
application. Two clinical case series on the results of locked There were many limitations in our study. Sample size in our
plate fixation of distal humeral fractures have been reported study was relatively small. Study was a prospective –
by Greiner et al and Reising et al. [11, 12]. Pooled analysis retrospective study. We used only orthogonal plating in our
showed good/excellent results in 79% of the patients, with study. So comparison with other plating techniques like
only a single case of implant failure. parallel or dorsal plating could not be done.
Biomechanical studies have shown that locking plates
provided somewhat improved fixation in models of 5. Conclusions
osteoporotic or comminuted distal humeral fractures [13-15]. In the end, we conclude that from literature and from the
Despite the lack of available evidence in support of locking experience of our study early open reduction and rigid
plates, many experts believe that their use may be internal fixation with dual plates in orthogonal fashion
advantageous in the management of comminuted, followed by early post-operative mobilization are to be
osteoporotic fractures. recommended for the management of intercondylar fractures
We used reconstruction plates as well as distal humerus of the distal humerus. Precontored distal humeral locking
precontoured locking plates in the management of plates is a good option for fractures with intraarticular
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