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VOLUME 17 , ISSUE 1 ( January-April, 2022 ) > List of Articles

Original Article

Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome

Efstratios D Athanaselis, Georgios Komnos, Dimitrios Deligeorgis, Michael Hantes, Theofilos Karachalios, Konstantinos N Malizos, Sokratis Varitimidis

Keywords : Distal humeral fractures, Double plating technique, Heterotopic ossification, Olecranon osteotomy, Tension band osteosynthesis, Two-column theory, Ulnar nerve management

Citation Information : Athanaselis ED, Komnos G, Deligeorgis D, Hantes M, Karachalios T, Malizos KN, Varitimidis S. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. 2022; 17 (1):7-13.

DOI: 10.5005/jp-journals-10080-1546

License: CC BY-NC-SA 4.0

Published Online: 24-05-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Purpose: This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options. Materials and methods: Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus. Results: The mean follow-up time was 8.7 years [range 2–15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6–10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0–49) and 83.3 (range 25–100), respectively. Conclusion: In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function.


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  1. Morrey BF. Fractures and dislocations. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders; 1993. p. 293–329.
  2. McCarty LP, Ring D, Jupiter JB. Management of distal humerus fractures. Am J Orthop 2005;34(9):430–438. PMID: 16250484.
  3. Bégué T. Articular fractures of the distal humerus. Orthop Traumatol Surg Res 2014;100(1 Suppl):S55–S63. DOI: 10.1016/j.otsr.2013.11.002.
  4. Hotchkiss RN, Green DP. Fractures and dislocations of the elbow. In: Rockwood CA Jr, Green DP, Bucholz RW, editors. Fractures in adults. Philadelphia: J.B. Lippincott; 1991. p. 739–841.
  5. Min W, Anwar A, Ding BC, et al. Open distal humerus fractures-review of the literature. Bull NYU Hosp Jt Dis 2010;68(4):257–261. PMID: 21162702.
  6. Ruan HJ, Liu JJ, Fan CY, et al. Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus. J Trauma 2009;67(6):1397–1401. DOI: 10.1097/TA.0b013e3181968176.
  7. Burczak JR. Median nerve palsy after operative treatment of intra-articular distal humerus fracture with intact supracondylar process. J Orthop Trauma 1994;8(3):252–254. PMID: 8027897.
  8. Chen RC, Harris DJ, Leduc S, et al. Is ulnar nerve transposition beneficial duringopen reduction internal fixation of distal humerus fractures? J Orthop Trauma 2010;24(7):391–394. DOI: 10.1097/BOT.0b013e3181c99246.
  9. Vazquez O, Rutgers M, Ring DC, et al. Fate of the ulnar nerve after operative fixation of distal humerus fractures. J Orthop Trauma 2010;24(7):395–399. DOI: 10.1097/BOT.0b013e3181e3e273.
  10. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10): S1–S133. DOI: 10.1097/00005131-200711101-00001.
  11. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics 1992;15(7):825–833. DOI: 10.3928/0147-7447-19920701-07.
  12. Eastwood WJ. The T-shaped fractures of the lower end of the humerus. J Bone Joint Surg 1937;19(2):364–369.
  13. Horne G. Supracondylar fractures of the humerus in adults. J Trauma 1980;20(1):71–74. PMID: 7351683.
  14. Zagorski JB, Jennings JJ, Burkhalter WE, et al. Comminuted intraarticular fractures of the distal humeral condyles. Surgical vs. nonsurgical treatment. Clin Orthop Relat Res 1986;202:197–204. PMID: 3955949.
  15. Ul Islam S, Glover AW, Waseem M. Challenges and solutions in management of distal humerus fractures. Open Orthop J 2017;11:1292–1307. DOI: 10.2174/1874325001711011292.
  16. Miller AN, Beingessner DM. Intra-articular distal humerus fractures. Orthop Clin North Am 2013;44(1):35–45. DOI: 10.1016/j.ocl.2012.08.010.
  17. Hausman M, Panozzo A. Treatment of distal humerus fractures in the elderly. Clin Orthop Relat Res 2004;425:55–63. DOI: 10.1097/01.blo.0000131485.47685.8c.
  18. Jupiter JB, Neff U, Holzach P, et al. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am 1985;67(2):226–239. PMID: 3968114.
  19. Pajarinen J, Björkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elbow Surg 2002;11(1):48–52. DOI: 10.1067/mse.2002.119390.
  20. Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am 2000;31(1):103–113. DOI: 10.1016/s0030-5898(05)70131-0.
  21. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003;85(2):232–238. DOI: 10.2106/00004623-200302000-00008.
  22. Greiner S, Haas NP, Bail HJ. Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system. Arch Orthop Trauma Surg 2008;128(7):723–729. DOI: 10.1007/s00402-007-0428-2.
  23. Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg 1999;8(1):85–97. DOI: 10.1016/s1058-2746(99)90063-0.
  24. Longo UG, Francheschi F, Loppini M, et al. Rating systems for evaluation of the elbow. Br Med Bull 2008;87:131–161. DOI: 10.1093/bmb/ldn023.
  25. Vincent J, Macdermid J, King GJW, et al. Validity and sensitivity to change of patient-reported pain and disability measures for elbow pathologies. J Orthop Sports Phys Ther 2013;43(4):263–274. DOI: 10.2519/jospt.2013.4029.
  26. Frankle MA, Herscovici D Jr, DiPasquale TG, et al. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003;17(7):473–480. DOI: 10.1097/00005131-200308000-00001.
  27. Sanchez-Sotelo J, Torchia ME, O'driscoll SW. Principle-based internal fixation of distal humerus fractures. Tech Hand Up Extrem Surg 2001;5(4):179–187. DOI: 10.1097/00130911-200112000-00001.
  28. Wajnsztejn A, de Albuquerque DD, Espinola I, et al. Submuscular double bridge plating for complex distal fractures of the humerus: an alternative, safe, and efficient treatment method. Eur J Orthop Surg Traumatol 2017;27(8):1069–1074. DOI: 10.1007/s00590-017-1987-8.
  29. Schildhauer TA, Nork SE, Mills WJ, et al. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma 2003;17(5):374–378. DOI: 10.1097/00005131-200305000-00009.
  30. Zalavras CG, McAllister ET, Singh A, et al. Operative treatment of intra-articular distal humerus fractures. Am J Orthop (Belle Mead NJ) 2007;36(12 Suppl 2):8–12. PMID: 18264557.
  31. McKee MD, Wilson TL, Winston L, et al. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82(12):1701–1707. DOI: 10.2106/00004623-200012000-00003.
  32. Mejía Silva D, Morales de los Santos R, Ciénega Ramos MA, et al. Functional results of two different surgical approaches in patients with distal humerus fractures type C (AO). Acta Ortop Mex 2008;22(1):26–30. PMID: 18672749.
  33. Henley MB, Bone LB, Parker B. Operative management of intra-articular fractures of the distal humerus. J Orthop Trauma 1987;1(1):24–35. DOI: 10.1097/00005131-198701010-00004.
  34. Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma 2004;18(7):446–449. DOI: 10.1097/00005131-200408000-00010.
  35. Coles CP, Barei DP, Nork SE, et al. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma 2006;20(3):164–171. DOI: 10.1097/00005131-200603000-00002.
  36. Hewins EA, Gofton WT, Dubberly J, et al. Plate fixation of olecranon osteotomies. J Orthop Trauma 2007;21(1):58–62. DOI: 10.1097/01.bot.0000246467.32574.fe.
  37. Jupiter JB, Morrey B. Fractures of the distal humerus in the adult. In: Morrey B, editor. The elbow and its disorders. Philadelphia: W.B. Sauders Ed; 1993. p. 328–366.
  38. Lecestre P, Dupont JY, Lortat Jacob A, et al. Les fractures complexes de l'extrémité inférieure de l'humérus chez l'adulte. A propos de 66 cas, dont 55 opérés [Severe fractures of the lower end of the humerus in adults (author's transl)]. Rev Chir Orthop Reparatrice Appar Mot 1979;65(1):11–23. PMID: 156383.
  39. O'driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005;14(1 Suppl S):186S–194S. DOI: 10.1016/j.jse.2004.09.033.
  40. Gupta RK, Gupta V, Marak DR. Locking plates in distal humerus fractures: study of 43 patients. Chin J Traumatol 2013;16(4):207–211. PMID: 23910671.
  41. Schuster I, Korner J, Arzdorf M, et al. Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma 2008;22(2):113–120. DOI: 10.1097/BOT.0b013e3181632cf8.
  42. O'driscoll SW, Sanchez-Sotelo J, Torchia ME. Management of the smashed distal humerus. Orthop Clin North Am 2002;33(1):19–33. DOI: 10.1016/s0030-5898(03)00070-1.
  43. Zalavras CG, Vercillo MT, Jun BJ, et al. Biomechanical evaluation of parallel versus orthogonal plate fixation of intra-articular distal humerus fractures. J Shoulder Elbow Surg 2011;20(1):12–20. DOI: 10.1016/j.jse.2010.08.005.
  44. Vennettilli M, Athwal GS. Parallel versus orthogonal plating for distal humerus fractures. J Hand Surg Am 2012;37(4):819–820. DOI: 10.1016/j.jhsa.2011.10.025.
  45. Kaiser T, Brunner A, Hohendorff B, et al. Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up. J Shoulder Elbow Surg 2011;20(2):206–212. DOI: 10.1016/j.jse.2010.06.010.
  46. Kimball JP, Glowczewskie F, Wright TW. Intraosseous blood supply to the distal humerus. J Hand Surg Am 2007;32(5):642–646. DOI: 10.1016/j.jhsa.2007.02.019.
  47. Charissoux JL, Mabit C, Fourastier J, et al. Fractures articulaires complexes de l'extrémité distale de l'humérus chez le sujet âgé [Comminuted intra-articular fractures of the distal humerus in elderly patients]. Rev Chir Orthop Reparatrice Appar Mot 2008; 94(4 Suppl):S36–S62. DOI: 10.1016/j.rco.2008.03.005.
  48. Lindenhovius AL, Jupiter JB. The post-traumatic stiff elbow: a review of the literature. J Hand Surg Am 2007;32(10):1605–1623. DOI: 10.1016/j.jhsa.2007.09.015.
  49. Sanchez-Sotelo J, Torchia ME, O'driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am 2007;89(5):961–969. DOI: 10.2106/JBJS.E.01311.
  50. Aslam N, Willett K. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta Orthop Belg 2004;70(2):118–122. PMID: 15165012.
  51. Robinson CM, Hill RM, Jacobs N, et al. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma 2003;17(1):38–47. DOI: 10.1097/00005131-200301000-00006.
  52. Ali A, Douglas H, Stanley D. Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus. J Bone Joint Surg Br 2005;87(8):1107–1110. DOI: 10.1302/0301- 620X.87B8.15610.
  53. Ring D, Gulotta L, Jupiter JB. Unstable nonunions of the distal part of the humerus. J Bone Joint Surg Am 2003;85(6):1040–1046. DOI: 10.2106/00004623-200306000-00008.
  54. Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma 1990;4(3):260–264. DOI: 10.1097/00005131-199004030-00004.
  55. Tak SR, Dar GN, Halwai MA, et al. Outcome of olecranon osteotomy in the trans-olecranon approach of intra-articular fractures of the distal humerus. Ulus Travma Acil Cerrahi Derg 2009;15(6):565–570. PMID: 20037874.
  56. Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elbow Surg 2010;19(1):2–9. DOI: 10.1016/j.jse.2009.05.003.
  57. Wang KC, Shih HN, Hsu KY, et al. Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach. J Trauma 1994;36(6):770–773. PMID: 8014996.
  58. Athwal GS, Hoxie SC, Rispoli DM, et al. Precontoured parallel plate fixation of AO/OTA type C distal humerus fractures. J Orthop Trauma 2009;23(8):575–580. DOI: 10.1097/BOT.0b013e3181aa5402.
  59. McKee MD, Kim J, Kebaish K, et al. Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. J Bone Joint Surg Br 2000;82(5):646–651. DOI: 10.1302/0301-620x.82b5.10423.
  60. Yamaguchi K, Sweet FA, Bindra R, et al. The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am 1997;79(11):1653–1662. DOI: 10.2106/00004623-199711000-00007.
  61. Limthongthang R, Jupiter JB. Distal humerus fractures. Oper Tech Orthop 2013;23(4):178–187. DOI: 10.1016/j.ocl.2007.12.002.
  62. Stoffel K, Cunneen S, Morgan R, et al. Comparative stability of perpendicular versus parallel double-locking plating systems in osteoporotic comminuted distal humerus fractures. J Orthop Res 2008;26(6):778–784. DOI: 10.1002/jor.20528.
  63. McKee MD, Jupiter JB, Bosse G, et al. Outcome of ulnar neurolysis during post-traumatic reconstruction of the elbow. J Bone Joint Surg Br 1998;80(1):100–105. DOI: 10.1302/0301-620x.80b1.7822.
  64. Srinivasan K, Agarwal M, Matthews SJ, et al. Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice? Clin Orthop Relat Res 2005;(434):222–230. DOI: 10.1097/01.blo.0000154010.43568.5b.
  65. Theivendran K, Duggan PJ, Deshmukh SC. Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates. J Shoulder Elbow Surg 2010;19(4):524–532. DOI: 10.1016/j.jse.2009.09.011.
  66. Liu JJ, Ruan HJ, Wang JG, et al. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder Elbow Surg 2009;18(4):646–651. DOI: 10.1016/j.jse.2008.12.012.
  67. Chen G, Liao Q, Luo W, et al. Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus. Injury 2011;42(4):366–370. DOI: 10.1016/j.injury.2010.09.004.
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