Session V - Upper Extremity

Results of A Uniform Protocol for the Operative Treatment of Intraarticular Distal Humerus Fractures

Robert Trigg McClellan, MD, David Bradley, MD, H. Mostafavi, MD, Paul Tornetta, III, MD

Santa Clara Valley Medical Center, San Jose, California, USA; University Hospital, Brooklyn, New York, USA

Introduction: Intraarticular fractures of the distal humerus are uncommon injuries and present difficult problems in management due to the complex geometry of the distal humerus, comminution, and a poor tolerance for immobilization of the elbow joint. The goal of treatment consists of anatomic reconstruction of the articular surface with rigid fixation thereby permitting early range of motion. Rigid stabilization of the distal humerus is felt to be best obtained by the use of a two-plate construct. The purpose of this study is to examine the results of ORIF of intraarticular fractures of the distal humerus using a standard protocol.

Methods and Materials: We studied 42 patients with intraarticular fractures of the distal humerus treated by ORIF using a posterior approach through an olecranon osteotomy. Average followup was 48 months, range 6 months to 120 months. The average age was 35 years with a range of 14-81. There were 22 right elbows and 20 left elbows. The mechanism of injury consisted of 14 motor vehicle accidents, 4 bicycle accidents, 4 motorcycle accidents, 14 falls and 6 gunshot wounds. 25 were closed and 17 were open. Using the AO classification there were 18 type C3, 20 type C2 and 4 type Cl. Using the OTA classification there were 18 13-C3, 20 13-C2, and 4 13-Cl fractures. Six patients also sustained additional fractures in their ipsilateral extremity. One patient had a radial nerve palsy preoperatively which resolved. Operative reduction and fixation was performed through an olecranon osteotomy in all cases except 2 in which operative reduction was performed through a ipsilateral olecranon fracture. Standard techniques were utilized using lag screw fixation of the joint and double plating of the supracondylar portion of the fracture. All osteotomies were fixed using a standard tension band technique. There were 13 chevron and 27 transverse osteotomies. Submuscular transposition of the ulnar nerve was performed in 8 cases. Six fractures required bone grafting. Postoperatively patients were splinted for 2-5 days before initiating range of motion exercises.

Results: The articular reduction was anatomic in 40 of 42 fractures. The 2 nonanatomic reductions were in C3 type fractures. There were no supracondylar malreductions in the coronal or sagittal plane. All olecranon osteotomies were fixed anatomically. All fractures of the distal humerus except one united with a mean time to union of 10 weeks, range 6-22 weeks. There was one nonunion which required reoperation. Time to union of the olecranon osteotomy was specifically evaluated in 22 of the fractures, all having undergone a transverse osteotomy. The mean time to union was 22 weeks in this group with a range of 6-52 weeks. Complications consisted of 1 deep infection which resolved following 6 weeks of antibiotics. There were 3 superficial wound sloughs over the olecranon, 2 of which required eventual hardware removal. One patient required soft tissue coverage. None resulted in a deep infection. There were 3 cases of heterotopic ossification. One patient developed complete ankylosis of the elbow. There were 3 cases of hardware failure consisting of both plates breaking in two patients and a broken 3.5 mm Recon plate in another patient. Only one of these three cases went on to a nonunion requiring reoperation. There were 4 olecranon osteotomies which required greater than 6 months to unite and were therefore classified as delayed unions. All were transverse osteotomies and all 4 eventually healed without bone grafting. Four patients experienced minor symptoms of tingling or numbness in the ulnar nerve distribution. Twenty-five patients experienced no pain, 16 had mild pain and 1 complained of moderate pain. Mean extension was 18- (0-90) and mean flexion was 131- (95-145). Mean arc was 112- (5-140). Four patients had radiographic evidence of mild arthritis and 1 patient had radiographic evidence of moderate arthritis. Functional evaluation of the elbow was performed on all patients using the Mayo Elbow Performance Index. Results were rated as excellent or good in 37 patients, fair in 1 patient and poor in 4 patients. Three of the poor results were related to a restriction in elbow range of motion. One of these patients has undergone a capsular release and his result is now rated as excellent. The other poor result was in the patient with a nonunion.

Discussion: We studied 42 patients who underwent ORIF of bicolumn intraarticular distal humerus fractures via a transolecranon approach. The average follow-up in this series was over 4 years. There were 4 delayed unions of the transverse olecranon osteotomies. Bone grafting of the olecranon osteotomy is rarely indicated. Ulnar nerve transposition is unnecessary in the majority of cases. Poor results are usually related to a restriction in elbow range of motion. Nonunions are rare. Early rigid fixation and range of motion yields the best results. Using a standard protocol, excellent or good results were obtained in the majority of our cases.