ISSN: 2320-5407 Int. J. Adv. Res.

10(05), 1288-1294

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Article DOI: 10.21474/IJAR01/14848

DOI URL: http://dx.doi.org/10.21474/IJAR01/14848

RESEARCH ARTICLE
INTRA-ARTICULAR FRACTURES OF DISTAL HUMERUS MANAGED WITH ANATOMIC PRE-
CONTOURED PLATES VIA OLECRANON OSTEOTOMY APPROACH

Dr. Rahul Mahajan1, Dr. Nitin Choudhary1, Dr. Sanjeev Gupta2 and Dr. Neeraj Mahajan3
1. Senior Resident, Deptt. Of Orthopaedics, Govt Medical College, Jammu.
2. Prof and Head, Deptt. Of Orthopaedics, Govt Medical College, Jammu.
3. Lectures, Deptt. Of Orthopaedics, Govt Medical College, Jammu.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History The treatment for displaced intra-articular fractures of the distal
Received: 31 March 2022 humerus is open reduction and internal fixation with early
Final Accepted: 30 April 2022 rehabilitation. Best exposure of both columns and articular surface of
Published: May 2022 the distal humerus is achieved through olecranon osteotomy approach
and fixation of two columns of distal humeruswith orthogonal plate
Key words:-
Distal Humerus Fracture, Olecranon construct which will allow absolute stability and early rehabilitation to
Osteotomy, Two-Column Fixation restore early elbow joint function. 16 cases of intra-articular fractures
of distal humerus were treated by open reduction and internal fixation
(ORIF) with orthogonal plate construct via olecranon osteotomy
approach. Chevron type olecranon osteotomy was performed and fixed
with tension band wiring using 6mm CCS and SS wires in all cases.
Radiological evaluationand regular clinical examination were done as
per Mayo elbow Performance score. All fractures united within average
duration of 3 months. More than 1000 range of motion is attained in 14
of cases. The mean Mayo Elbow Performance Score was 90.01
indicating excellent results. The factors for a successful outcome of
intra-articular fractures of the distal humerus depends upon anatomic
reduction, surgical technique, stable internal fixation, and early
rehabilitation. ORIF with orthogonal plate construct securing both
humeral columns via olecranon osteotomy approach results in excellent
healing and functional outcomes.

Copy Right, IJAR, 2022,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Distal humerus fractures comprise 2-6% of all fractures.They are commonly comminuted and occur in osteopenic
bone with limited options for internal fixation. Treatment outcomes are often associated with elbow stiffness,
weakness, hardware symptoms and pain. A painless, stable and mobile elbow joint is desired as it allows to conduct
the activities of daily living. Therefore, distal humerus intra-articular fractures require anatomic intraarticular
reduction, and early mobilisation[1-2]. Traditionally, these fractures had been managed in an operative fashion with
various extensor mechanism-disrupting surgical approaches[3-10]. Various extensor mechanism-sparing approaches
that provide bi-columnar exposure of the distal part of the humerus have been described, including triceps-splitting
and reflecting techniques [5,8-10].The principles set out by the Association for the Study of Internal Fixation,
AOASIFgroup, including anatomic articular reduction and rigid internal fixation and early postoperative range of
motion. Recent advances in the understanding of elbow anatomy, improvements in surgical approaches, new

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Corresponding Author:- Dr. Rahul Mahajan
Address:- Senior Resident, Deptt. Of Orthopaedics, Govt Medical College, Jammu.
ISSN: 2320-5407 Int. J. Adv. Res. 10(05), 1288-1294

innovative fixation devices led to improved outcomes in intra-articular distal humerus fractures. Pre-contoured
locking plates for lateral and medial columns and for fixation of olecranon osteotomy by AO group is new and
effective method of fixation in distal humeral fractures and more effective in osteoporotic bone [1-2] So, in younger
patients, open reduction and internal fixation of distal humerus fractures using modern fixation principles should be
considered. Hence, the present study is undertaken to evaluate the management and outcome of two column fixation
of intra-articular fracture of distal humerus in adults by orthogonal anatomic plates construct via olecranon
osteotomy (using 6mm CCS and SS wires) approach.

Materials And Methods:-

This was a retrospective interventional study which included 16 consecutively cases of intra-articular fractures of
distal humerus carried out in Department of Orthopaedics, Govt. Medical College, Jammu from January 2019 to
August 2021 after getting the approval from ethical committee and complete informed written consent from all
patients. Fractures were classified as per AO fracture classification system.

Inclusion criteria:-
AO Type C fractures in adults (18-65 years). Most of the fractures were of C1 type in 7 cases, C2 in 5 and C3 in 4
cases.

All the patients underwent ORIF of distal Humeral fractures with orthogonal anatomic plate construct via olecranon
osteotomy approach after general anaesthesia or supra-clavicular block. Olecranon osteotomy posterior approach
was used for reduction and fixation.

In our study we used 6mm CCS and stainless steel wires for tension band wiring of osteotomised olecranon and pre-
contoured anatomic plates for medial an lateral columns.

Surgical Technique:-
Patient was placed in a lateral decubitus position. A midline posterior incision was made over the distal humerus.
The Ulnar Nerve was identified, explored and protected. An olecranon chevron osteotomy was performed for the
exposure of the joint surface. Later on osteotomy was fixed with tension band wiring using 6mm CCS and stainless
steel wires in all cases.The articular fragments were reduced and held with a partially threaded K-wires
(temporarily), cancellous screw or cortical screws. In all cases two pre-contoured anatomical plates (3.5mm) were
used to the distal humerus. Plates applied on distal humerus at right angle to each other. Plates ended at different
levels on humeral shaft to minimize the stress riser. Each plate should have at least 2-3 bi-cortical screws proximal
to metaphyseal comminution[1-2]. After fixation, ulnar nerve was secured in soft tissue or anteriorly trans-positioned
in cases of tension on the nerve, wound closed in layers under suction drain. Post operatively a hinged brace was
applied over dressing and gentle active or active-assisted exercises were carried out on 2nd post-operative day or as
soon as possible as pain allows. All patients were followed up at twice a month for 3 months and monthly intervals
for next 3 months then quarterly. During this period patient was motivated for physiotherapy and gradual normal use
of the affected limb, fracture union was assessed clinically and radiologically (Fig.4) and elbow function on the
operated side was evaluated and compared with the normal side as per Mayo elbow score [11] by the same observer.
Mayo Elbow Performance Score [11]which is based on 100-point scale with maximum of 45 points for Pain, 25
points for Function, 20 points for Range of Motion and 10 points for stability.

Results:-
Among the patients, 10 were males and 6 were males. The mean patient age was 48 years. The right side was
involved in 12 cases. All fractures were closed and open fractures were excluded from the study. The mechanism of
injury was fall (9 cases) in most of cases followed by RTA (7 cases). Any patient with other associated injuries on
the same limb were excluded. Co-morbid conditions were also encountered in 6 cases like Diabetes mellitus,
Hypertension and Hypothyroidism. All the patients were operated within 48 hours of injury. The mean duration of
follow up was 12 months, ranging from 8 to 16 months. The duration of fracture healing was 3 months, ranging
from 10 weeks to16 weeks. The flexion at the elbow joint ranged from 50 0 to 1400 with an average of 1200 (Fig. 5).
14 patients had a flexion beyond 1100 . And average loss of extension ranged from 00 to 200 with an average of 140 .
More than 1000 of range of movement is obtained in 14 (87.5%) of cases. The mean motion of arc was 115 0. In most
the cases functional arc of motion (300 to 1100 ) is preserved(Fig. 5). Scoring of range of motion is done as per
Mayo Elbow Performance Score [11]which was calculated as 90.01 (Table-3). The final functional outcome was

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excellent in 10(62.5%), good in 5(31.25%), 1 fair (6.25%)results(Table-4). All of the fixations were stable. No
patient suffered from iatrogenic neuro or vascular injury. Painful hardware in 4, superficial infection in 2, non-union
of olecranon osteotomy in 0, elbow stiffness in 2.

Discussion:-
Final outcome of painless, functional range of motion at elbow causing no disability is more important. At the
average follow up of 16 months, the average flexion achieved was 120 0 degrees and the average loss of extension
was 140. The mean Mayo Elbow Performance score was 90.01comparable with other studies and signifies excellent
results by maintaining functional arc of motion (30 0 to 1100 )[3,19-21] . Within the last two decades, a two-column
theory of the distal humerus anatomy has been advocated whereby the coronal plane of the distal humerus is in the
shape of a triangle, with the coronoid fossa and olecranon fossa accounting for the majority of the central area, and
the medial and lateral condyles forming two strong columns by proximal extension [8,12]. The articular segment
functions architecturally as a tie arch [1-2] . There are several options for fixation between the condyle and humeral
metaphysis. These include the use of J-shaped plates, single plates, double K-wire, and K-wire together with tension
band wiring [13,14]. The aim is to facilitate biomechanical reconstruction of the two column structure. We found that
plates applied in orthogonal fashion overcome the bending forces and securing the two columns [3,22]. Rigid fixation
and early rehabilitation are the most important goals in treatment of type C elbow fracture. In our study, posterior
approach with olecranon osteotomy was used in distal humerus fracture. This approach gives the better exposure of
articular surface[3,15,16] and both columns as well as it provides easy access toulnar nerveand negates the risk of
compromising extensor mechanism. Good exposure is mandatory for the fixation of Type C3 fractures and to
provide good fixation.Wefound the operative field to be extensive, fracture reduction satisfactory and the
implementation of early functional exercises easily possible. The most important step in these fractures is the early
rehabilitation[22].We started gentle active or activeassisted exercises immediately after surgery and active exercise
around the third week. In each case, fracture reduction was satisfactory, fixation was strong and durable, fracture site
was stable and early post-surgical functional exercise was possible. In our series, any patient with associated neuro-
vascular injuries or injury at other site on same limbs were not included. Post-operatively, 2 patients had superficial
infection which got better with antibiotics and dressings. More than 15 degree of stiffness is seen in 2 patients. Other
complications encountered in our series were, 4 patients had mild pain and hardware symptoms and 10 patients had
no pain at all.There was no case of heterotopic ossification. Sodegard et al (1992) [18] in his series of 96 patients
encountered 6 post-operative infections. 12 neural injuries and 16 fixation failures. Thus the complications in our
study were comparable studies.Manjit S. Daroch et al (2016) [23] in his series of 40 cases encountered, 2 patients had
transient ulnar nerve Neuropraxia, 3 patients had superficial infection, more than 20 degree of stiffness is seen in 3
patients, mild varus deformity in 2 patients, hardware failure in 1, non-union of olecranon osteotomy in 1 patient, 15
patients had mild pain.Almost the complications like pain an ROM loss in our study was comparable to other
studies.

Fig 1:- Antero-posterior and lateral radiographs of 40 years old patient immediately after injury showing AO Type
C fracture.

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Fig 2:- Intra-op pic showing reduction and provisional fixation with K-wires.

Fig 3:- Antero-posterior and lateral radiographs immediately after surgery (1 st post-op day).

Fig 4:- Antero-posterior and lateral radiographs showing fracture union at 12 weeks after surgery.

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Fig 5:- Clinical picture showing functional outcome at 12 weeks after surgery.

Table 1:- Technical Objectives for Fixation of Distal Humeral Fractures.

Every screw should pass through a plate.
Each screw should engage a fragment on the opposite side that is also fixed to a plate.
As many screws as possible should be placed in the distal fragments.
Each screw should be as long as possible.
Each screw should engage as many articular fragments as possible.
Plates should be applied such that compression is achieved at the supracondylar level for both columns.
Plates used must be strong enough and stiff enough to resist breaking or bending before union occurs at the
supracondylar level
From Sanchez-Sotelo J, Torchia ME, O'Driscoll SW: Principle-based internal fixation of distal humerus fractures,
Tech Hand Upper Extremity Surg 5:179, 2001

Table 2:- Mayo Elbow Performance Score.

FUNCTION MEAN SCORE (POINTS)
Pain(Max 45 points)
None(45) Mild(30) Moderate(15) Severe(0)
ROM(Max 20 points)
>1000 (20), 500 to 1000 (15),<500(5)
Stability (Max 10 points)
Stable(10) Moderately Stable (5) Unstable(0)
Function (Max 25 points)
Comb(5) Feed(5) Personal(5) Shirt(5) Shoes(5)
Mean Total (maximum 100 points)
Interpreting the Mayo Elbow Performance Score: Score
Excellent 90
Good 75-89
Fair 60-74
Poor Below 60

Table 3:- Mayo Elbow Performance Score.

Function No. of Patients Percentage Mean score
Pain (Max points 45) None(45) 10 62.5 37.5
Mild(30) 4 25
Moderate(15) 2 12.5
Severe(0)
ROM (Max 20 >100 (20) 14 87.5 19.38
points) 50-1000 (15) 2 12.5
<50 (5)
Stability (Max 10 Stable (10) 14 87.5 9.38
points) Moderately (5) 2 12.5
Unstable (0)

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Function (Max 25 Comb (5) 13 81.25 23.75

points) Feed (5) 16 100
Personal (5) 16 100
Shirt (5) 16 100
Shoes(5) 15 93.75
Mean Total (Max 100 points) 90.01

Table 4:- Final Functional Outcome.

Grading No. of Patients Percentage

Excellent 10 62.5
Good 5 31.25
Fair 1 6.25
Poor 0 0

Limitations:-
In our study sample size was small and inadequate follow-up in some cases.

There is limited literature regarding objective extensor mechanism strength assessment in our study.

In summary, we found that use of a olecranon osteotomy approach gives adequate view to intra articular distal
humeral fractures. Anatomic reduction and stable rigid fixation is important in Type C intra-articular distal humerus
fractures for early post-operative rehabilitation. Complications were minimal and healing satisfactory. We advocate
the use of this approach for repair of type C distal humerus fractures with pre-contoured anatomic plates an fix the
osteotomy site with 6m CCS and stainless steel wires for better functional outcomes.

References:-
1. Athwal GS. Distal Humerus Fractures. In: Rockwood & Green’s FRACTURES IN ADULTS. 7th ed.
Philadelphia:Lippincott Williams & Wilkins 2010;1:945-972.
2. Crenshaw AH, Perez EA. Fractures of the shoulder, arm & forearm In: Cambell’s Operative Orthopaedics. 11th
ed. USA:Mosby 2008;3:3405.
3. Jason M. Erpelding, Adam Mailander, Robin High, Matthew A. Mormino and Edward V. Fehringer. J Bone
Joint Surg Am. 2012;94:548-53.
4. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. ClinOrthopRelat
Res. 1982;166:188-92.
5. Canale ST, Beaty JH, editors. Campbell’s operative orthopaedics. 11th ed.Philadelphia: Mosby; 2008.
6. Cassebaum WH. Operative treatment of T and Y fractures of the lower end of the humerus. Am J Surg.
1952;83:265-70.
7. Rosenwasser MP. Paratricipital-triceps splitting two windows-approach to the posterior elbow for distal
humerus fractures. Presented at the 24th Annual American Shoulder and Elbow Surgeons closed meeting;
Dallas, TX; 2007 Oct 10-12.
8. Schildhauer TA, Nork SE, Mills WJ, Henley MB. Extensor mechanism-sparing paratricipital posterior approach
to the distal humerus. J Orthop Trauma. 2003;17:374-8.
9. Zlotolow DA, Catalano LW 3rd, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am AcadOrthop
Surg. 2006;14:754-65.
10. Coles CP, Barei DP, Nork SE, Taitsman LA, Hanel DP, Bradford Henley M. The olecranon osteotomy: a
sixyear experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma.
2006;20:164-71.
11. Dawson J, Fitzpatrick R, Car A, Murray D. Cambridge Shoulder Group Revised. British Journal of Bone and
Joint Surgery March 1996;78-B(2):185-190.
12. Manueddu CA, Hoffmeyer P, Haluzicky M, Blanc Y, Borst F. [Distal humeral fracture in adults: functional
evaluation and measurement of isometric strength].RevChirOrthopReparatriceAppar Mot. 1997;83:551-60.
French.

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13. McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical
treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am.
2000;82:1701-7.
14. Pereles TR, Koval KJ, Gallagher M, Rosen H. Open reduction and internal fixation of the distal humerus:
functional outcome in the elderly. J Trauma. 1997;43:578-84.
15. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open
fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453-8.
16. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH
(disabilities of the arm, shoulder and hand) [corrected].The Upper Extremity Collaborative Group (UECG). Am
J Ind Med. 1996;29:602-8.
17. Henley MB. lntraarticular distal Humeral fractures in adults. Orthop. Clin North Am 18(1):11-23,1987.
18. Sodergard J, Sandelin J, Bostman D. Mechanical failures of internal fixation in T & Y fractures of the distal
Humerus. J Trauma 33(5):687-690,1992.
19. Dasheng Tian, Juehua Jing, Jun Qian, Jianming Li. Comparison of two different double-plate fixation methods
with olecranon osteotomy for intercondylar fractures of the distal humeri of young adults In: ExpTher Med July
2013;6(1):147-151.
20. Kilicarslan K, Bektaser B, Ucguder A, Dogan M, Ugurlu M, Yildirim H. Results of early surgical treatment of
intra-articular complex fractures of the humerus in adults In: BratislLekListy 2011;112(9):501-505.
21. SudhirBabhulkar et al. Controversies in the management of intra articular fractures of distal humerus in adults.
Indian Journal of Orthopaedics. May 2011; vol. 45 issue 3 :216-225
22. Liu JJ, Ruan HJ, Wang JG, Fan CY, Zeng BF. Double column fixation for type C fractures of distal in the
elderly In: Journal of Shoulder and Elbow Surgery ; July 2009;18(4):646-651.
23. Manjit S. Daroch et al Management of intra-articular fractures of distal humerus with two column fixation with
orthogonal plate construct In: Int J Med Res Health Sci. 2016, 5(10):159-165.

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