Injury, Int. J.

Care Injured 33 (2002) 511–515

Intercondylar fractures of the distal humerus in adults:

a critical analysis of 55 cases
Rakesh Gupta∗ , Prakash Khanchandani
Department of Orthopaedics, Postgraduate Institute of Medical Sciences, 42/9 J Medical Enclave, Rohtak 124001, India

Accepted 20 September 2001

Abstract
Intercondylar fractures of the distal humerus in adults are difficult management problems on account of the complex anatomy of the elbow,
small sized fracture fragments and the limited amount of sub-chondral bone, which is often osteopenic. The results of managing these frac-
tures non-operatively are compromised by the failure to get anatomical reduction and early mobilization. This often results in a painful stiff
elbow and/or pseudarthrosis, thereby making an operative approach for these fractures, desirable. Fifty-five such fractures, operated on by the
author during the last 9 years, were reviewed. All the fractures were managed by open reduction and internal fixation followed by early mobi-
lization. The outcome in 51 of these cases was graded as excellent or good using the evaluation criteria of Aitken and Rorabeck. Thirty-three
of these cases achieved a range of flexion of more than 130◦ . There was minimal incidence of complications like ulnar nerve neuropraxia or
heterotopic bone formation. Anterior transposition of the ulnar nerve was performed in only one of the patients. Dorsal application of both
the plates instead of the commonly advocated supracondylar crest placement resulted in a stable configuration requiring less extensive dis-
section and retraction of the ulnar nerve and resulting in a low incidence of complications. © 2002 Elsevier Science Ltd. All rights reserved.

1. Introduction 2. Material and methods

Intercondylar fractures of the distal humerus in adults con- Fifty-five patients with intercondylar fractures of the distal
stitute a small percentage of fractures. These fractures are humerus in adults operated on by the first author during
often difficult to treat with an uncertain outcome. Recom- 1992–2000 and available for follow up, were reviewed. The
mended management in the literature varies considerably, series included long term follow up of 20 such cases reported
ranging from plaster of Paris (POP) cast immobilization or earlier by the author [13].
treatment as a bag of bones, to fully invasive open reduction Fall on the point of the elbow was the most common
and internal fixation [1–8]. Non-operative management of mode of trauma followed by road traffic crashes. Twelve
these fractures may lead to either a pseudarthrosis with gross of the patients had associated injuries elsewhere, including
instability or a painful stiff elbow [7–9]. Moreover, accurate additional ipsilateral upper limb trauma (five patients). There
reconstruction of the articular surface is not always possible were 37 males and 18 females and the average age of the
by closed methods. As a result, many now favor open re- patients was 39 years (range 18–65 years). Six of the patients
duction and internal fixation, although to obtain acceptable had compound injuries of Gustilo type 1 (three patients) or
results, it has to be followed by early mobilization of the type 2 (three patients) [14].
elbow [1–3,5,6,9,10]. Authors recommending an operative As per Muller et al. [15] classification, 18 fractures were
approach differ widely in respect to the extent and type of of C1 type, 23 of C2 and the remaining 14 of C3 type. Two
internal fixation. In addition most of the authors advocating of the patients had an additional dislocation of the medial
internal fixation propose placement of plates on the supra- condyle from the olecranon notch of ulna. All but six of
condylar crest and have reported a significant incidence of the patients were operated on within 7 days of injury. De-
hetrotopic ossification and ulnar nerve involvement [10–12]. lay in surgery usually resulted from late presentation of the
The present study analyses the long term results of the patients though in some of the cases it was due to associ-
author’s experience of operative management of these frac- ated injuries. One patient presented 8 months after injury,
tures and attempts to address these problems. with pseudarthrosis and gross instability at the fracture site,
demonstrating failed conservative treatment.
∗ Corresponding author. Tel.: +91-1262-44799. All the patients were operated on, in the lateral decubitus
E-mail address: [email protected] (R. Gupta). position with the forearm hanging by the side over a sand

0020-1383/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 0 9 - 8
512 R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515

olecranon fossa. Stability of the reconstruction was con-

firmed per-operatively by looking for any movement in
between the fragments. The olecranon osteotomy was stabi-
lized with a tension band wire supplemented with K-wires
(seven cases) or a 6.5 mm cancellous lag screw (six cases).
A suction drain and a POP back slab were used in all the
patients.
Active mobilization of the elbow was permitted from the
first post-operative day, after breaking the POP slab at the
elbow. The slab was discarded after 2–3 weeks depending
upon the fracture anatomy, the stability of fixation and the
clinical progress of the patient. Subsequently, the patients
were subjected to extensive active physiotherapy of the el-
bow. Patients were examined clinically and radiologically
Fig. 1. Pre-operative radiograph. with regard to pain, activities of daily living, range of motion
and fracture union. In addition, any deficit of ulnar nerve
function, whether early or late and evidence of secondary
bag, placed against the patient’s chest. A posterior midline osteoarthritis, were specifically looked into. Maximum fol-
approach to the elbow was used and the ulnar nerve was low up was 9 years with an average of 4 years.
exposed in all the cases. In 42 of the patients, an inverted
“v” shaped triceps aponeurosis flap was reflected distally to
expose the fracture site. In the remaining 13, a transverse or
chevron osteotomy of the olecranon was performed to reflect 3. Results
triceps proximally. Holes were drilled in the ulna, prior to
the osteotomy, for subsequent tension band wiring. All the fractures including osteotomies of the olecranon
A five hole 3.5 mm DCP/reconstruction plate was con- healed by 10–12 weeks. Full extension could be achieved
toured in both planes to fit the posterior flat surface of the in 15 of the patients, though loss of the last 5◦ of flexion
distal humerus and was used as a basic implant. It was used was observed in 20 other patients (Table 1). No limitation
to stabilize the larger of the articular fragments to the cor- of supination or pronation of the forearm was observed in
responding pillar. The remaining articular fragments were any patient. Regaining elbow function was observed to be
either fixed to the other pillar or to the already reconstructed related to the stability of the fixation and to the extent of
pillar or both, as determined by the assessment of stability. physiotherapy performed by the patients. The final outcome
This was achieved by either an additional 3.5 mm plate (46 was observed to be better in younger patients, although it
cases) on the posterior flat surface of distal humerus or was probably more on account of their better physiotherapy
screw fixation (8 cases). Fixation was supplemented with an record rather than their chronological age.
additional transcondylar screw to enhance stability, partic- The results were evaluated using the criteria of Aitken
ularly in the C3 type of fractures (Figs. 1 and 2). In one of and Rorabeck [9] (Table 2). The final result was graded as
the patients, the fracture was stabilized by multiple screws excellent in 41 patients with an arc of flexion >110◦ and no
only. Special attention was paid to ensure proper reconstruc- pain or disability. In 10 of the patients, it was graded as good.
tion of the trochlear component and the adequacy of the Four patients had an unacceptable (fair or poor) outcome
with an arc of flexion at elbow being <60◦ in two and >60◦
in the other two. The range of motion of the elbow movement
was observed to improve up to 2 years following injury, but
the majority of this occurred in the first 12 months. One
patient with significant heterotopic ossification was graded
as fair with a limited range of motion at the elbow (<75◦ ).

Table 1
Range of motion at elbow
Range of Number Extension Number
flexion (◦ ) of cases loss (◦ ) of cases
>130 33 Nil 15
110–130 9 <5 20
75–110 9 5–10 15
60–75 2 10–15 2
<60 2 >15 3
Fig. 2. Final radiograph showing consolidation.
 R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515 513

Table 2 good reconstruction of the articular surface nor permit early

Evaluation criteria (Aitken and Rorabeck [9]) mobilization of the elbow, key factors in achieving good
Arc of Activity Pain function. Operative management of these fractures has been
flexion (◦ ) criticized in literature for additional surgical trauma and in-
Acceptable herent difficulty in securing stable fixation of small frag-
Excellent 110 No limitation None ments. Consensus, though, is gradually building for surgical
Good 75 Activities of daily Minimal
stabilization of these fractures, largely as a consequence of
living
significant advances in surgical technique and implants dur-
Unacceptable ing the last decade ensuring a stable osteosynthesis of small
Fair >60 Activities of daily Mild occasional
living analgesic
intra-articular fragments.
Poor <60 Arm used as a prop Constant Lateral position of the patient with his arm hanging by the
side not only gives convenient patient access to the anaes-
thetist but is also comfortable for the surgeon. Moreover,
flexion of the elbow in this position was observed to give a
He was able to perform most of his activities of daily living. good view of the articular surface of the distal humerus. This
One of the two patients with poor grading had pre-operative is confirmed by the fact that the intercondylar screws could
pseudarthrosis while the other one had post-operative deep be easily passed, in a number of patients in the present se-
infection, though both had no pain and some useful function ries, without olecranon osteotomy. It may possibly also de-
could be performed by the limb. crease the need for an olecranon osteotomy for stabilization
The complications included ulnar nerve paraesthesias in of these fractures. An intact olecranon can act as a mould
three patients, in the immediate post-operative period, which over which reconstruction of distal humerus is easy with
disappeared spontaneously by the third week. However, no the additional advantage of avoiding the creation of an ad-
late ulnar nerve paraesthesias/deficit was observed in any ditional intra-articular fracture. However, the authors are in
of the patients. None of the patients had any clinical or ra- agreement with Jupiter et al., that the trans-olecranon ap-
diological evidence of secondary osteoarthritis in spite of proach offers excellent exposure for reconstruction of the ar-
long term follow up of the majority of cases. Two patients ticular surface especially in type C3 fractures [5]. Proximal
had early deep infection requiring the removal of implants migration of K-wires was observed in four of the patients,
after healing of the fracture. One of these had a grade 2 where they were used for the stabilization of the osteotomy.
compound fracture while the other one had associated frac- The study reinforces the views expressed by Henley regard-
tures of the ipsilateral shaft of the humerus and ulna which ing the desirability of the use of 6.5 mm cancellous screws
were operated on simultaneously. Another patient had late instead of K-wires for stabilization of the osteotomy, wher-
local superficial infection due to scar breakdown at the site ever it is performed [1].
of tension band wiring of olecranon, which healed after re- Early active mobilization of the elbow has been univer-
moval of the implants. Proximal migration of the K-wires sally accepted as a ground rule to ensure an acceptable out-
was seen in four of the patients and this necessitated their come [1–3,5,9]. It is reaffirmed by the present study, as an
removal. Failure of fixation was not observed in any of the excellent range of motion was achieved in all patients where
patients, though one of the patients had late implant failure early mobilization was possible due to stable internal fixa-
in the form of a broken one-third tubular plate which had tion. In fact, all patients with a lesser range of motion were
been used as a second plate in one of the cases instead of either old patients or with a poor post-operative physiother-
the usual 3.5 mm reconstruction plate. Three patients devel- apy record, quite often on account of associated injuries.
oped heterotopic ossification around the elbow. In two of Some loss of extension at the elbow was observed in 40 of
these patients, it was clinically not significant in view of our patients, which is similar to that reported by Sanders
the fact that it did not interfere markedly with the range of et al. [6]. The authors are of the opinion that an accurate re-
motion. The only patient with significant heterotopic ossi- construction with special emphasis on adequacy of the ole-
fication was an elderly male with a severely comminuted cranon fossa is desirable to ensure minimal loss of extension.
fracture and significant soft tissue trauma. One patient had a A general perusal of literature regarding internal fixation
clinically apparent cubitus varus deformity but without any of these fractures indicates a reasonably high incidence of
interference in elbow function. No significant loss of power ulnar nerve neuropraxia [10–12], so much so that Ring and
in the triceps was observed in any of our patients. Jupiter [2] and Wang et al. [16] have advocated routine an-
terior transposition of ulnar nerve in such cases. In addi-
tion some of the authors have also indicated an incidence
4. Discussion of heterotopic ossification ranging from 4 to 49%, though
most of these reports have not commented upon the extent
Intercondylar fractures of the distal humerus in adults of heterotopic ossification encountered or its clinical signif-
are difficult to treat because of the nature of injury. The icance [1,3,10,17]. The majority of these authors have ad-
non-operative approach to these fractures can neither ensure vocated the posterior midline approach with supracondylar
514 R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515

Our only experience of implant failure was with a

one-third tubular plate and it corroborates the views ex-
pressed by Henley [1] and Holdsworth and Mossad [18] that
these plates are not strong enough and should be replaced
with 3.5 mm reconstruction/DC plate for stabilization of
these fractures.
The rating system of Aitken and Rorabeck was used in
this study for the final outcome as it takes into consideration
additional features like pain and the activity level with the
range of motion at the elbow [9]. Overall 93% of the pa-
tients had acceptable results (41 excellent, 10 good) which
reinforces the desirability of an operative approach to these
fractures and compares favorably with the reports in the
literature [1,5,6]. A high percentage of acceptable results
can probably be attributed to early open reduction, stable
internal fixation and early post-operative mobilization of
the elbow. The age group in the present series was relatively
younger, with a good bone stock and this may have been the
reason for a lack of fixation failures and the higher percent-
age of acceptable results. Kinik et al. [12] and Holdsworth
and Mossad [18] have also indicated that old age is no
contraindication for surgical management of these fractures
and the final outcome is more dependent on the quality
Fig. 3. Illustration showing exposure and placement of plates on posterior of bone rather than the chronological age of the patient.
surface of humerus. The authors are in agreement with Sodegard et al. [11] and
Kuntz Jr. and Baratz [17] that the results are likely to be
crest placement of plates, ostensibly for more secure fixation less gratifying if only elderly patients with poor bone stock
[6,8,10,12,16,18]. However, it is apparent that the combina- are considered.
tion of this approach and anatomical location of plates on The present study therefore reaffirms that early open
supracondylar crests, requires an extensive dissection and reduction and stable internal fixation followed by early
retraction of the triceps and brachialis muscles besides sig- mobilization of elbow is the treatment of choice for these
nificant retraction of the ulnar nerve. The placement of both complex fractures. Posterior placement of both the plates
plates on the posterior flat surface of the humerus, which is provides an adequately stable fixation and requires less ex-
directly under vision by a posterior approach neither requires tensive dissection or retraction of the ulnar nerve, thereby,
extensive dissection nor significant retraction of the ulnar decreasing the incidence of two of the most commonly
nerve (Fig. 3), thereby, decreasing the incidence of both ul- reported complication namely ulnar nerve neuropraxia and
nar nerve neuropraxia or heterotopic ossification, as was ob- heterotopic ossification.
served in the present series. The only instance of significant
heterotopic ossification observed in the present series was
more on account of the severe nature of the pre-operative References
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