Session I - Upper Extremity

Assessment of Outcome following Intraarticular Distal Humerus Fractures Using the Dash Form

Rafael M. Williams, MD; David S. Ruch, MD; Lawrence X. Webb, MD; Charlie C. Yang, II, MS, Wake Forest University School of Medicine,Winston-Salem, NC

Purpose: To correlate radiographic findings with subjective assessment as measured by the AAOS DASH outcome form following intraarticular distal humerus fractures.

Methods: Retrospective review of patients treated at this institution for high-energy intraarticular distal humerus fractures was performed. Seventy-eight patients were selected. There were 44 type C3, 24 type C2 and 10 type Cl fracture patterns. The average age at the time of injury was 40 (range: 12-83). There were 30 open injuries and 41 were polytrauma. Associated neurovascular injuries occurred in 20 patients (26%) involving 11 ulnar nerves, 6 radial nerves, 2 median nerves and 1 brachial artery. Follow-up at a mean of 17.6 months (range of 1.3-119) consisted of chart review and radiographic follow-up. The patients were contacted at an average of 59.2 months (range of 23.1-114.7) postoperative and a DASH form was completed.

Results: Physical exam showed the average loss motion to be 27.3 degrees of flexion, 25.8 degrees of extension, 10.1 degrees of pronation and 10 degrees of supination. Radiographic assessment at an average of 14.1 months (range of 1.3-65.9) postoperative demonstrated healing in 94.7%, evidence of osteoarthritis in 8.8% and heterotopic ossification in 17.5%. Thirty-eight (48.7%) required secondary surgeries: 25 hardware removals, eight hardware exchange I revisions and four delayed bone grafts (ten initial bone grafts were performed). Two patients went on to require total elbow arthroplasties. Complications included fracture nonunion in 15.8% and olecranon osteotomy nonunion in 10.5%. Nine patients had delayed nerve injuries (seven ulnar and two radial nerves). Subjective assessment at an average of 59.2 months postoperative showed the mean overall raw DASH score to be 70.3 (range 30-150). Seventy percent of patients still had pain with 43% of these being mild and 53% being described as moderate. Eighty percent reported stiffness (25% mild, 37.5% moderate, 37.5% severe). With regards to activities of daily living, 80% had pain (25% mild, 37.5% moderate, 37.5% severe) when placing an object on a shelf above their heads, 70% had difficulty with heavy household chores, and 80% had difficulty carrying heavy (>10 lb) objects. Eighty percent of the patients returned to work at an average of 24 weeks and 37% had to change professions as a result of their injuries. Sixty percent reported limitations in their abilities at work.

Discussion: Several authors have shown that modern techniques of osteosynthesis for the distal humerus have significantly improved both union rates and overall radiographic parameters of healing. This paper reinforces these previous studies by demonstrating union rates of 94.7% and relatively low nonunion rates. It also documents the subjective and functional outcomes following these injuries. Seventy percent of the patients still reported pain, 80% noted stiffness and 60% reported limitations at work as evidenced by the DASH questionnaires. This study also reinforces the complication rate associated with these high energy injuries to the distal humerus.

Conclusions: Patient-directed subjective questionnaires at mean follow-up of 59.2 months following high-energy intraarticular fractures of the distal humerus reveal persistent pain and functional limitations despite a high rate of radiographically apparent union.