Comminuted intra-articular fractures of the distal humerus

A comparison between perpendicular and parallel plating methods for distal humerus fractures: A meta-analysis of randomized controlled trials

OBJECTIVE

To compare the clinical outcomes of perpendicular and parallel plating for the treatment of distal humerus fractures.

METHODS

Two investigators independently searched PubMed, OVID, and ScienceDirect databases prior to April 2019, without any limitations on language or publication status. The outcomes were union time, range of motion of elbow, Mayo Elbow Performance Score, and postoperative complications. Two authors independently performed a methodological quality and risk of bias assessment using Cochrane collaboration's tool. Data analysis was performed with STATA version 13.0.

RESULTS

Six randomized controlled trials with 305 participants were included. The present meta-analysis indicated that orthogonal plating was associated with a longer union time compared with parallel plating. There were no significant differences between the 2 groups regarding Elbow function, Mayo Elbow Performance Score, operation time, reduction quality, or postoperative complications.

CONCLUSION

Both parallel plating and orthogonal plating are considered to be effective methods when treating distal humerus fractures. The results of this study found that parallel plating is superior to orthogonal plating in humerus fracture healing.

The influence of mini-fragment plates on the mechanical properties of long-bone plate fixation

Objective:

Mini-fragment plates (MFPs) are increasingly used in fracture surgery to provide provisional fixation. After definitive fixation, the surgeon decides whether to remove the plates or leave them in place as additional fixation, based on the perceived biomechanical influence of the MFP. However, there are no current biomechanical studies to guide this decision. Therefore, the purpose of this study was to evaluate the influence of MFPs on the four-point bending and torsional stiffness of long bone transverse and simple wedge fracture fixation constructs.

Methods:

Fourth-generation composite bone cylinders were cut to produce transverse (AO-OTA classification 12-A3) and simple wedge (AO-OTA classification 12-B2) fracture models. The specimens were fixed using a low-contact dynamic compression plate (LC-DCP) and MFPs. Specimens were tested in four-point bending and torsion utilizing 3 different MFP orientations.

Results:

No statistically significant differences in bending stiffness were found between control and MFP groups for transverse fracture constructs. MFPs significantly increased the bending stiffness for wedge fracture constructs under certain loading conditions. This increase was observed when MFPs were positioned both orthogonal (85.1% increase, P = .034) and opposite (848.2% increase, P < .001) to the LC-DCP. MFPs significantly increased the torsional stiffness for both transverse and wedge fracture constructs when MFPs were positioned both orthogonal (transverse: 27.7% increase, wedge: 16.7% increase) and opposite (transverse: 28.4%, wedge: 24.2% increase) to the LC-DCP.

Conclusions:

Our results indicate that including MFPs in definitive fixation can increase the bending and torsional stiffness of a long-bone fracture fixation construct. This suggests that the biomechanical influence of MFPs should be considered. However, clinical studies will be required to test the applicability of these findings to the clinical setting.

Stabilisation of articular fractures of the distal humerus: early experience with a novel perpendicular plate system

INTRODUCTION

The treatment of fractures of the distal humerus is difficult and involves the risk of bad functional results, particularly with articular fractures or impaired bone quality. Anatomical reconstruction and stable fixation allowing early mobilisation of the elbow are the basic prerequisites for good clinical outcomes. The aim of our study was to evaluate whether the Distal Humerus Plate (DHP, Synthes), a novel, perpendicular, fixed-angle plate system, fulfils the requirements for this treatment goal.

METHODS

From 2004 to 2007, 46 consecutive patients (19 men and 21 women; mean age of 60.5 years) underwent open reduction and internal fixation with the new DHP system. Six patients were lost to follow up. The remaining 40 patients were followed up for 11 months (range 4-24 months). Follow up involved assessment of functional outcome using the Mayo Elbow Performance Score (MEPS) and Liverpool Elbow Score (LES), reduction results and complication rates. Subgroup analyses involved comparisons of younger (<60 years) to elderly (> or =60 years) patients and type C3 injuries versus other fracture patterns.

RESULTS

Only six cases received primary internal fixation, whilst 31 patients were temporarily stabilised by either external fixation or cast before ORIF could be performed. Three patients were treated for implant failure (systems other than DHP) after surgery in other hospitals. The mean time from injury to internal fixation was 7 days. Open fractures were present in 10 cases. Olecranon osteotomy was required for reduction in 35 cases. Mean operation time was 215 min. 'Good' or 'excellent' results were observed in 29/40 patients. Median MEPS and LES were 84 and 8.1 points, respectively. Mean ROM was 100 degrees. We found no significant differences in the subgroup analyses; however, there was a tendency towards better functional results in younger patients and injuries without comminution of the articular surface. Complications comprised two superficial wound infections, two cases of heterotopic ossification, one case of delayed union and five cases of transient ulnar neuropathy. Implant failure was observed twice in one patient.

CONCLUSION

Open reduction and internal fixation with the DHP system provides reliable, stable fixation allowing early functional mobilisation of the elbow joint, even in complex fractures and impaired bone quality, resulting in good outcomes for the majority of patients. The complication rate reported here is comparable to that of other implants, but the low number of implant failures is promising and warrants further investigation.

[Intra-articular fracture of the distal humerus: outcome after osteosynthesis in patients over 60]

PURPOSE OF THE STUDY

This is a retrospective analysis of patients aged over 60 years treated in a single center for intra-articular fractures of the distal humerus. Outcomes were compared with published results for osteosynthesis and arthroplasty.

MATERIAL AND METHODS

The cohort included 34 patients (36 fractures) reviewed at mean 35 months. Mean age was 77.6 years. Fracture types were: C1: 8, C2: 10, C3: 18. The transtricipital posteromedial approach was used in the majority of patients. Fixation was achieved with a prebent lateral plate (n=11 fractures), a Y-plate (n=9), two plates (n=4), pins or screws (n=9) and an external fixator (n=3). Outcome was assessed with the Mayo elbow score, the Bröberg radiographic score and patient satisfaction. The social impact was also noted.

RESULTS

The mean Mayo elbow score was 73.3; outcome was excellent (n=13), good (n=8), fair (n=5) and poor (n=10). Pain persisted in 23 patients. The mean range of movement was 80 degrees . Patient satisfaction remained good. Ten patients did not recover their preoperative level of autonomy. Radiological signs of osteoarthritis were noted for 75% of patients and nonunion of the humeral fracture in 32%. There were three superficial infections and four neurological lesions.

DISCUSSION

Good and very good outcome was noted for 59% of the osteosyntheses in this series, compared with 71% in the literature. The rate for arthroplasty is 95%. The mean range of motion is 101 degrees , 17% of patients with a prosthesis complain of pain, 5% develop a superficial infection and 6.5% suffer neurological injury. The estimated rate of revision for arthroplasty is 11% at 7 years.

CONCLUSION

Beyond the age of 65 years and based on evidence reported in the literature, it would be advisable to prefer another mode of treatment for these intra-articular fractures, for example elbow arthroplasty, particularly for comminutive fractures on osteoporotic bone.

Distal humerus fractures

Fractures of the distal humerus in adults have traditionally presented a treatment challenge for the orthopedic surgeon. The combination of anatomic complexity, multifragmentary comminution, and a short distal segment, often in the setting of osteoporotic bone, renders these fractures difficult to treat successfully and often make a full restoration of function uncertain. Multiple methods of treatment for these fractures have been described, including bracing, internal fixation, hemiarthroplasty, and total elbow arthroplasty. This article reviews the epidemiology and classification of these injuries and the numerous described fixation and arthroplasty techniques. The current treatment algorithm and authors' preferred method of internal fixation are also illustrated. Additionally, the treatment of these injuries in the elderly population and the complications of surgical treatment are reviewed.

The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: a critical analysis of the results

BACKGROUND

We would like to define the results of treatment of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus.

METHODS

Between 1988 and 1998, 19 consecutive aged patients (older than 65 years old) with displaced comminuted articular fractures of the distal humerus were treated by open reduction and internal fixation with AO reconstruction plate. The age at the time of injury was 71.9 (65-79) years old. According to the AO classification, 15 patients had type C2 and four had type C3 injury. No patient had inflammatory arthritis of the elbow. The period of follow up is 97.2 (60-174) months.

RESULTS

All fractures united with union time of 14.6 (11-20) weeks. No implant failure was found. In final follow up, the average flexion contracture was 16.8 degrees with a range of 0-40 degrees , the average active flexion was 128.4 degrees with a range of 115-140 degrees , the average pronation was 80 degrees with a range of 60-90 degrees , and the average supination was 78 degrees with a range of 60-90 degrees . According to the elbow motion classification of Cassebaum, eight (42.1%) patients were graded as very good elbow motion, eight (42.1%) as good, three (15.8%) as fair, and none as poor. The functional results showed that 15 (79%) patients had excellent results, four (21%) had good results, and none had fair or poor results, according to Mayo elbow performance score. The radiographic evaluation in final follow up showed that four patients (21%) had no osteoarthritic (OA) change, 11 (58%) had grade 1 OA, four (21%) had grade 2 OA, and none had grade 3 OA (the scale of Knirk and Jupiter). Fifteen (79%) patients reported no pain and four (21%) had mild pain. All patients were satisfied with their results. However, There were two early post-operative complications, including one (5.3%) superficial wound infection and one (5.3%) iatrogenic ulnar nerve injury.

CONCLUSIONS

Open reduction and internal fixation with appropriate surgical technique is effective in the treatment of displaced fractures of the distal humerus in elderly patients.

Surgical treatment of acute displaced fractures of adult distal humerus with reconstruction plate

We evaluated the results of the use of AO reconstruction plates in the open reduction and internal fixation of acute displaced fractures of the adult distal humerus. This was a retrospective study of such patients where the main surgical strategy was open reduction and internal fixation with AO reconstruction plates. From 1992 to 1998, 40 patients were included. Average follow-up was 98 (60-127) months. All the fractures united with the union time of 11.7 (9-16) weeks. Early post-operative complications developed in four patients (10%), including wound infection in two (5%) and iatrogenic ulnar neuropathy in another two (5%). At follow-up, 24 (60%) patients developed grade 1 osteoarthritis and eight (20%) developed grade 2 osteoarthritis. Thirty-five patients (87.5%) got good to excellent functional results and 35 cases (87.5%) were satisfied with their surgical results. In conclusion, open reduction and internal fixation with AO reconstruction plate is very useful and effective in the treatment of displaced fractures of the adult distal humerus.

Total elbow anthroplasty and distal humerus elbow fractures

Palvanen et al in 2003 collected data on osteoporotic fractures of the distal humerus fractures from the Finnish National Hospital Discharge Register. They defined an osteoporotic fracture of the distal humerus as a fracture occurring in persons 60 years of age or older following moderate or minimal trauma. The annual rate of incidence of these types of fractures has increased significantly, with 42 fractures reported in 1970 and 208 fractures in 2000(395% increase). The age-specific incidence rates showed a ninefold increase for women 80 years of age or older (8 in 1970 versus 75 in 2000). In the 60-69-year and 70-79-year age groups, the age adjusted increases were twofold. This presents great challenges for future orthopedists, reinforcing the ongoing need to critically analyze results of treatment for this difficult problem. Many patients over the age of 60 years can do well with traditional open reduction and internal fixation of distal humerus fractures. When patients have poor bone quality, however, preventing stable internal fixation or significant medical comorbidities, TEA should be considered. Encouraging results have been reported using TEA as a primary mode of treatment for carefully selected comminuted distal humerus fractures in elderly patients, particularly if the patient also has significant rheumatoid arthritic changes. A triceps-sparing approach is recommended so that patients may be mobilized early following surgery.