European Journal of Cardiovascular Medicine

The elbow is a synovial joint featuring intricate hinges and plays a crucial role in hand positioning in space. In adults, distal humerus fractures account for 2% of all fractures and 30% of injuries around the elbow [1]. These fractures exhibit a bimodal distribution based on age. With the rise in vehicular traffic, there has been an increase in road traffic accidents, leading to a higher occurrence of distal humerus fractures, particularly among younger people. A study by Court-Brown and Caesar found that the growing average lifespan and higher rates of osteoporosis correlate with the rising incidence of osteoporotic distal humerus fractures in older adults [2].

Typically, these fractures result from axial loading on the joint when the elbow is bent at an angle greater than 90 degrees. The olecranon acts as a wedge, forcing itself between the two condyles of the humerus. Therefore, most distal humerus fractures in adults are intra-articular and affect both condyles [3].

The Association of the Study of Internal Fixation (AO/ASIF)4 categorizes distal humeral fractures into three distinct types: (1) Type A: an extra-articular fracture (supracondylar); Type B: partial intra-articular fractures (unicondylar); and Type C: complete intra-articular fractures (bicondylar).

Bicondylar intra-articular fractures (AO Type C) pose significant management challenges, as complications like malunion, stiffness, and osteoarthritis frequently occur. Desault stated in 1811 that these fractures are among the most challenging to treat.5 Treatment depends on the fracture pattern and the extent of comminution, often requiring complex and lengthy intervention. Approaches to management range from conservative methods such as plaster of Paris cast immobilization (also known as "bag of bones") to more invasive procedures like open reduction and internal fixation (ORIF).6

Typically, conservative treatment of these fractures leads to pseudo-arthrosis with significant instability or a painful, stiff elbow. Furthermore, achieving anatomical reduction of the articular surface can be challenging with closed methods. Consequently, many surgeons now support the idea of performing open anatomical reduction followed by stable fixation and early elbow mobilization to achieve satisfactory functional outcomes.7

Currently, the use of CT scans with three-dimensional reconstructions for complex articular fractures, a deeper understanding of the locking plate principle, and access to pre-contoured periarticular anatomical plates enhance the management of these injuries. The primary objective is to ensure uncomplicated soft tissue healing, the union between the distal fragment and shaft, restoration of the diaphyseal bone block, and a stable and mobile elbow joint. Hence the present study was planned to evaluate the outcome of surgical treatment of comminuted supracondylar fractures of humerus fixed with dual plating.

Aim: To assess the functional outcome of comminuted supracondylar fractures of the humerus treated with surgical management.

Objectives

• To achieve accurate anatomical reduction.
• To achieve stable fixation
• To assess the union of fracture after internal fixation.
• To study the role of surgical management and functional outcome in comminuted supracondylar humerus fractures.
• To assess a range of movements at the elbow joint postoperatively.

Study Design: Hospital-based prospective study.

Study area: The study was conducted in the Department of Orthopaedics, BGS Global Institute of medical sciences, Bangalore.

Study Period: 1 year.

Study population: Adult Patients sustained with comminuted supracondylar fractures of the humerus presenting at the Department of Orthopaedics were studied.

Sample size: The study consisted of a total of 20 subjects.

Sampling Technique:  Simple Random technique.

Inclusion Criteria:  

• Fracture lower end humerus with comminution, supracondylar or intercondylar /articular extension.
• Patients aged more than 18 years.

Exclusion criteria:  

• Patients with a history of any previous pathology leading to impairment of normal function in the ipsilateral elbow.
• Participant not consenting to participate in the study.

Ethical consideration: Institutional Ethical Committee permission was obtained before the commencement of the study.

Study tools and Data collection procedure:

The patients sustained with comminuted supracondylar or intercondylar unstable fractures of lower end humerus presenting at the Department of Orthopaedics were screened for eligibility. Those fulfilling the selection criteria were briefed about the nature of the study and written informed consent was obtained.

The information such as sex, age, occupation, history, details of injury, duration and progression were obtained through an interview. Patients were subjected to clinical and local examination. These findings were recorded on predesigned and pretested proforma.

Investigations: Investigations such as X-ray (Elbow with lower end humerus AP view and Elbow with lower end humerus lateral view), complete blood count, urine routine and microscopy were done. A computed tomography scan of the elbow was obtained if required.

PROCEDURE: Patients were treated with open reduction with internal fixation using dual plating. All the surgeries were performed in an orthopaedic theatre under antibiotic cover. General anaesthesia was administered to all the patients. All the surgeries were performed by registered orthopaedic consultants.

The incision was taken over the posterior aspect of the elbow. An olecranon osteotomy/triceps splitting/para tricipital approach was used. Ulnar Nerve transposition was done. All bony fragments were recognised and displaced fragments were mobilized. Reduction was done then held with bone-holding clamps. Temporary fixation was done with K-wires. Fixation was done with dual (contoured) reconstruction plates, pre-contoured plates or AO plates. When the trans olecranon approach was used, the customised olecranon was re-fixed with Tension Band wire or another reconstruction plate or a 6 mm lag screw. Two plates in either orthogonal or parallel configuration were used and fixed with screws to the lower end of the humerus. A drain was left and the wound was closed in layers.

Post-operative care:  Post-operative care started from day one, followed by drain removal on day two. Regular wound care was done. Mobilization started from day three, the nature of which was decided according to individual cases.

Follow-up: Follow-up of patients was done at six weeks, three and six months following the surgery. 

ASSESSMENT

For all subjects, radiographs were performed at the six-week third and sixth-month follow-up. Patients were evaluated based on the following parameters at the time of discharge and all three follow-ups;

• Complications
• Duration of hospital stay
• Range of motion – Shoulder, Elbow (Flexion, extension, supination and pronation) Wrist.
• Clinical union
• Radiological union
• outcome - Evaluated by QUICK DASH evaluation questionnaire and Functional Scoring System, Jupiter Criteria.

QUICK DASH evaluation questionnaire

The QuickDASH⁸ consists of 11 items to measure physical function and symptoms in people with any or multiple musculoskeletal disorders of the upper limb.

Each item has five response options

• 1 = no difficulty;
• 2 = mild difficulty;
• 3 = moderate difficulty;
• 4 = severe difficulty;
• 5 = unable

From the item scores, a summative score is calculated. The final score ranges between 0 (no disability) and 100 (the greatest possible disability). Only one missing item can be tolerated, and, if two or more items are missing, the score cannot be calculated.⁹ Based on the QuickDASH score the functional outcome among patients was graded as below. Excellent outcome – Score between 0 to 25 Good outcome – Score between 25.1 to 50.0 Fair outcome – Score between 50.1 to 75.0 Poor outcome – Score between ≥ 75 Functional Scoring System by Jupiter¹⁰ The functional outcome in patients was assessed based on Jupiter criteria at final follow up.

Functional Scoring System, Jupiter Criteria ¹¹

Statistical analysis:

The data obtained was coded and entered into a Microsoft Excel spreadsheet. The categorical data was expressed as rate, ratio and percentage. The continuous data was expressed as mean ± S.D. Fisher’s exact test was used to find the association between categorical data. A ‘p’ value of less than or equal to 0.05 was considered statistically significant.

In the present study, 55% of patients were males and 45% were females. The male-to-female ratio was 1.22:1. In this study 40% of patients were aged ≤ 30 years followed by 20% each with ages between 31 to 45 years, 46 to 60 years and > 60 years. The mean age in males was 40.9 ± 22.06 years and in females it was 40.6 ± 14.76 years. The mean age of the study population was 40.8 ± 18.65 years. In the present study, 40% of patients were in service while 20% of patients were housewives and labourers.

In this study, 90% of patients were right-handed while 10% were left-handed. In the present study 55% of patients present with right side fractures while 45% with left hand fractures.

Table 1. Nature of Trauma

In this study, the predominant nature of trauma was road traffic accidents seen in 90% of patients while 5% each had fallen on an outstretched hand and trivia. In the present study, open wound was noted in 10% of patients. In this study, neurovascular injury was seen in 10% of patients. In the present study history of associated injury was present in 25% of patients.

Table 2. Diagnosis

In this study 35% of patients each presented with C1/A3 and C3 type of fracture while C2 fracture was seen in 30% of patients. 

Table 3. Approach used

In this study orthogonal position of plates was applied in 75% of patients while 25% had parallel position of plates. In the present study olecranon osteotomy approach was used in 55% while the paratricipital and tricep splitting approach was used in 30% and 15% of patients respectively. In the present study, 55% of patients had a hospital stay between 8 to 14 days and 25% stayed ≤ 7 days.

Table 4. Movements

In the present study, tenderness was present in 50% of patients at one and half months follow-up while it was present in 5% of patients at three months follow-up.

Table 5. Complications

In this study, complications were present in 15% of patients at one and half month follow-up whereas at three three-month follow-up complications were seen in 10% of patients.

In this study, the radiological union was achieved in 65% of patients at one and half month intervals whereas 35% of patients had radiological union during the third month.

Table 6. Comparison of outcome based on Quick DASH score with the type of plate used

It was observed that orthogonal-type plates resulted in a significantly higher number of patients with excellent outcomes (86.7%) compared to parallel plates (20%). Similarly, no statistically significant difference was noted (p>0.050) about the type of approach used with outcome based on the Quick DASH score at all three follow-ups.

Table 7. Functional Outcome Based on Jupiter Criteria

In the present study based on the Jupiter criteria, the functional outcome was found to be excellent in 25%, good in 35% and fair in 40%.

Comminuted supracondylar fractures of the humerus can pose significant challenges for orthopaedic surgeons. In recent years, the approach to treating distal humeral fractures has changed considerably. Key developments in treatment include the increased use of CT scans with three-dimensional reconstructions, better identification of complex articular shear fractures12, awareness of the advantages offered by the parallel-plate technique13, the introduction of pre-contoured periarticular plates, and the judicious application of total elbow arthroplasty.14

In this study, the commonest age group was (40%) ≤ 30 years followed by 31 to 45 years, 46 to 60 years and > 60 years (20% each) and the mean age of the study population was 40.8 ± 18.65 years. The distribution of distal humerus fractures follows a bimodal age distribution.15,16 In contrast, Palvanen et al. identified more than a 2-fold increase in the age-adjusted incidence of distal humerus fractures in Finnish women older than 60 between 1970 and 1995 and predicted a 3-fold increase by the year 2030.17 In another study, the frequency varied by age with a higher incidence in middle-aged and elderly females.18

In this study, the orthogonal position of plates was applied in 75% of patients while 25% had parallel position of plates. The olecranon osteotomy approach was used in 55% and the participial and tricep splitting approach was used in 30% and 15% of patients respectively. Intraoperative complications such as difficulty in reduction were noted in 55% of patients while infection and nerve injury were seen in 10% of patients postoperatively.

In the present study, tenderness was present in 50% of patients at one and half months follow-up while it was present in 5% of patients at three months follow-up. The complications were seen in 15% of patients at one and half month follow-ups up whereas at three-month follow-up complications were seen in 10% of patients. Complications are common in the management of distal humerus fractures and include elbow stiffness, heterotopic ossification, nonunions, neuropathies, and infections. Post-traumatic elbow stiffness can arise from both intrinsic and extrinsic sources. Intrinsic causes of stiffness include joint adhesions, synovitis, articular incongruity, and intra-articular loose bodies. Extrinsic causes include capsular contractures and heterotopic ossification. Loss of some motion is expected after distal humerus fractures, particularly terminal extension. Loss of flexion is less tolerated than loss of extension. Although functional range of motion has been defined as 30 to 130 degrees of flexion, even small decreases in motion can cause functional impairment depending upon the patient's needs.19 Wang and colleagues20 in their study of 20 patients reported, 4 complications viz. 1 nonunion, 1 malunion, 1 deep infection, and 1 brachial artery laceration.

In this study, the radiological union was achieved in 65% of patients at one and half month intervals whereas 35% of patients had radiological union during the third month. Nonunion occurs in 2 to 10% of distal humerus fractures treated with open reduction internal fixation.21 Risk factors include comminution, bone loss, and inadequate fixation. Treatment options include revision open reduction internal fixation with bone graft or total elbow arthroplasty in older low-demand patients with poor bone stock.21-23 Helfet et al reported their series of 52 patients with delayed union or nonunion of the distal humerus that were treated with revision open reduction internal fixation.21 They achieved a 98% union rate after re-operation (with autogenous bone graft used in 88% of cases).

In this study, two patients with open fractures (One Gustillo Anderson Type IIIb and one with Type III c injury). The patient with vascular injury (at the level of the brachial artery) was managed by emergent bony fixation followed by vascular repair. The patient’s soft tissue and bony healing were uneventful and he had an excellent outcome. The second patient with an open fracture (Type IIIb) had an extremely contaminated wound on initial presentation and his wounds were contaminated with grease, mud and other vegetative dust. He was emergently taken for thorough debridement, clean out and external fixator application. He was taken for definitive fixation after 2 weeks and the rest of his follow-up period was uneventful.

In the present study, about functional outcome based and type of plates, orthogonal plates resulted in a significantly higher number of patients with excellent outcomes (86.7%) compared to parallel plates (20%). However, no statistically significant difference was noted about the type of approach used with outcome based on the Quick DASH score at all three follow-ups (p>0.050).

Sanchez-Sotelo et al.24 discussed their retrospective results of thirty-two patients treated with parallel plating over ten years when they described the surgical technique. Thirty-one of the thirty-two patients went on to union without requiring additional surgery and none of the patients had failure of their hardware or fracture displacement.24 The average flexion-extension arc at the latest follow-up was 99 degrees but five patients did require excision of heterotopic ossification secondary to elbow stiffness. The mean MEPS was 85 points with twenty-seven patients having a good or excellent result and five patients having a fair or poor result.24

Muller et al.25 studied 49 elderly patients to achieve stability and pain-free function for osteoporotic intraarticular multifragmentary fractures of the distal humerus by primary total elbow replacement (TER). The authors reported that 32 of the 49 elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Ten additional operative procedures, including five revision arthroplasties, were required. Similarly, Egol  KA et al.26 in a retrospective study evaluated functional outcomes for distal humeral fractures treated with TEA or ORIF in a non-arthritic elderly population with osteoporosis among 20 patients. Of the 20 patients, 9 had undergone cemented, semi-constrained TEA as initial treatment, and 11 had undergone ORIF. The study concluded that implant selection must be based on bone quality, expected outcome, and surgeon experience. For these injuries, good outcomes may be obtained with either TEA or ORIF.

Overall the present study showed excellent outcomes in 70% of patients and 25% of with good outcomes in patients with comminuted unstable fractures of lower-end humerus treated with surgical management with dual plating. The limitation of the study was the smaller sample size which limited us to finding the association between outcomes and other dependent and independent variables.

The surgical treatment of comminuted supracondylar humerus fractures using dual plating led to excellent outcomes in 70% of the patients, while 25% experienced good outcomes as assessed by the Quick DASH score. Additionally, patients who received surgical treatment with orthogonal plates exhibited significantly better outcomes, but there was no statistically significant difference observed concerning the type of surgical approach utilized.

1.       Webb LX. Rockwood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott Williams & Williams; 2001. Fractures of the distal humerus; pp. 953–972. 

2.       Epidemiology of adult fractures: a review. Court-Brown CM, Caesar B. Injury. 2006;37:691–697.  

3.       Fractures of the distal humerus. Jupiter JB, Mehne DK. Orthopedics. 1992;15:825–833. 

4.       Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. Muller M, Nazarian J, Koch P. https://pubmed.ncbi.nlm.nih.gov/8814583/ J Orthop Trauma. 1996;10 Suppl 1:1–154. 

5.       Desault PJ. Conrad. Philadelphia, PA: Kimber and Conrad; 1811. A Treatise on Fractures, Luxations and Other Affections of the Bones; p. 1811. 

6.       Intercondylar fractures of the humerus. An operative approach. Jupiter JB, Neff U, Holzach P, Allgöwer M. https://pubmed.ncbi.nlm.nih.gov/3968114/ J Bone Joint Surg Am. 1985;67:226–239. 

7.       Fractures of the elbow. Kuntz DG Jr, Baratz ME. Orthop Clin North Am. 1999;30:37–61.

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11.    Knirk JL, Jupiter JB. Intraarticular fractures of the distal end of the radius in young adults. J Bone Joint Surg. 1986;68A:647-59.

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17.    Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Europ J Epidemiol 1998;14:159-64.

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25.    Müller LP, Kamineni S, Rommens PM, Morrey BF. Primary total elbow replacement for fractures of the distal humerus. Oper Orthop Traumatol 2005;17(2):119-42.

26.    Egol KA, Tsai P, Vazques O, Tejwani NC. Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbows. Am J Orthop (Belle Mead NJ) 2011;40(2):67-71.