Introduction
One of the most challenging injuries to repair is a distal humerus fracture. They account for 2-6 percent of all fractures and 30 percent of all elbow fractures.1 RTA being the most common cause in young population.2, 3 The majority of distal humerus fractures feature a complicated pattern that includes both the medial and lateral columns as well as the articular surface (AO type C injury).4 The treatment of these fractures has always been a contentious issue. For these intra-articular fractures, ORIF is the treatment of choice. The goal of treatment is to achieva a painless and functional joint. Bryan-Morrey in their study revealed the permissible range of motion should be at least 30 to 130 degrees.5 In order to obtain desirable functional outcome following distal humerus fracture, adequate reduction and restoration of fracture must be done for early rehabilitation.6 The AO/ASIF group has recommended a number of treatment methods for distal humerus fractures. Bicolumnar dual plating or orthogonal/90-90 plating is the gold standard procedure.7 Double-plate osteosynthesis procedures in various configurations have been the treatment of choice in recent years. Few studies on locking compression plates based on clinical and biomechanical functions suggest that LCPs can help with primary stability in distal humerus fracture osteosynthesis.8 The aim of present study is to evaluate the functional outcome of intraarticular distal humerus fractures treated with locking compression plates applied in orthogonal 90-90° pattern.
Aims
The aim of the study is to evaluate the functional outcome of intra-articular distal humerus fractures treated with locking compression plates.
Results
Age distribution, Sex distribution, Side of Injury, Mode of Injury, Fracture type according to AO Classification, Fracture union and Complications in Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7.
Table 1
Comparison of mean time of fracture union with AO fracture type
|
Fracture Type |
C1 |
C2 |
C3 |
F |
p - value |
|
Mean (SD) |
Mean (SD) |
Mean (SD) |
|||
|
Fracture Union |
12.44 (0.88) |
13.27 (1.01) |
16.80 (4.15) |
8.923 |
0.002 |
Statistically significant difference was noted in the fracture union time with regard to AO fracture type signifies, less severe the fracture type earlier the fracture union as depicted in Table 1.
Functional outcome
Elbow range of motion
Among the study population the mean arc of flexion at 6 month follow up was 111.20 ± 14.53 degree and mean extension deficit was 10 ± 4.56 degree.
Progressive significant improvement was observed in the range of motion from initial mean ROM of 89.20 ± 12.56 degree at 6 weeks to 111.2 ± 14.53 degree at 6 month follow up (p=0.001).
Mayo Elbow Performance score
Among the study population Mayo Elbow Performance score at 6 weeks, 3 months and 6 months as depicted in Figure 8.
The mean MEPS of the study population at the end of 6 month follow up was 87.80 ± 8.67.
Table 2
Comparison of MEPS score with AO fracture types
|
AO Type |
C1 |
C2 |
C3 |
P value |
|
MEPS 6 Wks |
56.67 |
62.0 |
52.86 |
0.4 |
|
MEPS 3 M |
70.83 |
76.0 |
70.0 |
0.3 |
|
MEPS 6 M |
94.0 |
87.50 |
87.71 |
0.1 |
On comparison of MEPS score with AO fracture type, improvement was seen in final score with insignificant p values as depicted in Table 2.
Discussion
Distal humerus fractures in adults remain one of the most challenging fractures to reduce and fix.
An adequate return of the elbow range of motion to allow proper and a good functional outcome is major aim for restoration of a distal humerus fractures, especially in cases of intra-articular fracture of distal humerus.
These fractures warrant restoration of the articular surface as well as the geometry of the distal humerus along with stable fixation to allow for early healing and quick rehabilitation which are often difficult to achieve.9
In our study, most of fractures were AO type 13C2 constituting 44% of the fracture pattern. Followed by 13C1 (36%) and 13C3 (20%) of cases. The results were comparable with studies conducted by Pereles et al10 and RE Hughes et al.11
Mean duration for fracture union in our study population was 13.40 ± 1.83 weeks ranging from 12 to 20 weeks.
The average mean time taken by C1 type of fracture for union was 12.44 ± 0.88 weeks which is significantly less when compared with mean time of C2 type fracture i.e. 13.27 ± 1.01 weeks and of C3 type of fracture was 16.80 ± 4.15 (p=0.002). Our study was in concurrence with studies conducted by Kiran GU et al12 and Singh V et al.13
The mean arc of flexion at 6 month follow up was 111.20 ± 14.53 degree, with mean extension deficit was 10 ± 4.56 degree. The similar results found by Gofton et al,14 Kundel et al15 and Aslam et al16 in their study.
The mean MEPS at the end of 6 month follow up was 87.80 ± 8.67.
At 6 months excellent results were found in 64% patients, good results in 24% patients, fair results in 12% patients. Our study is closely comparable with CD Deepak et al,17 Imran Mang et al18 and Singh V. et al.13
Out of 25 operated cases, majority of cases (72%) had no complications. Three patients (12%) reported joint stiffness with decreased range of elbow motion being 20-80º, 20-75º and 20-80º respectively. Two patients (8%) had superficial skin infection, which was managed by regular dressing and antibiotic coverage. Two patients reported hardware irritation. Out of which one patient required k-wire removal at osteotomy site under local anaesthesia. Singh V et al13 reported a complication rate 22.23%
Conclusion
Distal humerus fractures are complex fractures and represent 2% of all fractures. Despite being uncommon, distal humerus fractures pose the greatest challenge in terms of surgical fixation and absolute anatomical reduction. Anatomic restoration of the articular surface should be a priority during open reduction internal fixation. Good functional outcomes are expected with articular surface restoration, reconstruction of elbow joint and early rehabilitation.
In our study we treated 25 patients of distal humerus intra articular fracture with open reduction and internal fixation using 3.5mm distal humerus locking compression plates and functional outcome was good to excellent in 88% patients.
To conclude distal humerus locking compression plate is a stable and safe implant in management of intraarticular fractures of the distal humerus.
However, a more comprehensive study with longer follow-up periods and larger sample size is essential to throw more light into the advantages, complications and possible disadvantages of the use of locking compression plate with special attention to the long-term outcomes.