Session X - Upper Extremity

Treatment of High-Energy Supracondylar/Intercondylar Fractures of the Distal Humerus

Lisa K. Cannada, MD, Mary B. Zadnik, OTR/L; Walter Andrew Eglseder, MD; University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA

Purpose: High-energy intraarticular fractures of the distal humerus seen at major trauma centers are often open, and the patients may have multiple injuries. The literature does not specifically address the long-term outcomes of the surgical decision-making protocol. Our technique involves the use of a staged capsulectomy, no routine transposition of the ulnar nerve, and olecranon osteotomy fixation with a 6.5 partially threaded cancellous screw and tension band wiring. The purpose of this study was to review the results of our protocol to provide trauma surgeons with guidelines to assist in the surgical decision making and treatment of these complex injuries to provide for an optimal functional outcome.

Methods: After obtaining IRB approval, the Trauma Registry was used to identify our study population. Between 1997 and 2001, 70 patients with 71 fractures were treated. There were 41 men and 29 women with an average age of 42 years (range, 16 to 85). Fifty-five percent of fractures were open (grade I, 6; II,19; IIIA, 9; IIIB, 5). Twenty-two patients had isolated injuries, and 25 (36%) had ipsilateral associated upper extremity trauma. Sixty-nine percent of patients had associated injuries, including 15 closed head injuries. The mechanism of injury was a motor vehicle accident (28), a fall >from a height (17), a pedestrian struck by an auto (8), a gun shot wound (5), industrial (4), and miscellaneous (8). According to the OTA classification, there were 28 13C-2 and 43 13C-3 fractures. The majority of operations were performed by a single surgeon through a posterior, triceps-sparing approach. The ulnar nerve was meticulously dissected and mobilized with the avoidance of traction or devascularization. Fracture fixation was with a combination of pelvic reconstruction plates or LCDC plates or both in addition to supplemental screw and K-wire fixation. Capsulectomy was completed in those patients with significant limitations (less than 60° of flexion/extension arc) of motion after an average of 10 months of follow-up. Clinical follow-up consisted of a physical examination, radiographs, and completion of the DASH.

Results: Sixteen patients were lost to follow-up. The average follow-up was 14 months (range, 3 to 67). Complications included five nonunions of the humerus, three nonunions of the olecranon, four ulnar nerve neurolyses, four superficial and three deep infections. Adapted Cassebaum ratings of results were 70% good to excellent, 20% fair, and 10% poor. Patients with isolated fractures had 81% good-to-excellent results; those who had polytrauma had 65% good-to-excellent results. Seventeen patients (25%) had capsulectomies, and 14 of them had good-to-excellent results, 2 had a fair result, and 1 was lost to follow-up. With use of our olecranon osteotomy fixation technique, there was only a 4% nonunion rate and two reports of painful hardware. Five patients had ulnar nerve symptoms at follow-up. The overall DASH score was 72.

Discussion: Supracondylar/intercondylar fractures of the distal humerus are among the most challenging fractures for the orthopaedic surgeon to treat. Our study population involved high-energy fractures; 55% of these were open injuries and 69% of patients had polytrauma. With these patients, operative stabilization can be of significant value in their care. However, early mobilization and rehabilitation may be difficult. The majority of capsulectomies were performed in this population, with 82% having a good-to-excellent result. We found only five patients (7%) with ulnar nerve symptoms at follow-up; therefore, we do not recommend routine transposition. Use of the long intramedullary screw for olecranon osteotomy fixation appears to minimize the risk of complications after osteotomy. In the largest series to date, our results demonstrate that our approach to the OTA C2 and C3 fractures of the distal humerus should help with the surgical decision-making and treatment of these fractures to provide for optimal functional outcome.