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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1483-1487  

Functional and radiological outcome in distal third humerus fracture treated with extra-articular locking plate: A multicentric retrospective study


1 Department of Orthopaedics, PRM Medical College and Hospital, Baripada, Odisha, India
2 Department of Orthopaedics, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India

Date of Submission27-Mar-2021
Date of Decision16-Apr-2021
Date of Acceptance09-May-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
Ashis Kumar Gupta
Assistant Professor, Department of Orthopaedics, PRM Medical College and Hospital, Baripada, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.jpbs_263_21

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   Abstract 


Introduction: The optimal method for fixation of extra-articular distal humerus fractures poses a management dilemma. Although various plate configurations have been proposed, anatomic shaped extra-articular distal humerus locking plates (EADHPs) have emerged as a viable solution for these complex injuries. We assessed functional and radiologic outcomes in our retrospective case series of extra-articular distal humerus fractures managed with these plates at different centers in Cuttack, Odisha. Materials and Methods: One hundred and ten patients of extra-articular distal humerus fractures, who were operated at various trauma centers between January 2012 and December 2020, were identified. After exclusion, 100 patients were available for the final assessment. All patients were operated with the triceps-reflecting modified posterior approach. Regular functional–radiologic follow-up was done evaluating elbow functionality, fracture union, secondary displacement, nonunion, implant failure, and any complications; Mayo Elbow Performance Score (MEPS) was used for the final functional assessment. Results: Sixty-seven percent of male and 33% of female patients constituted the study group, who had an average follow-up of 18 months. Preoperatively three patients and postoperatively one patient had radial nerve palsy; all had neurapraxia and recovered completely. Overall, 95% of patients were adjudged to have complete radiological union within 3 months; 6% of patients developed nonunion. The mean flexion achieved was 123 + 22, and the mean extension was 4.031 + 6.50; five patients with head injury developed flexion deformity of 45. The average MEPS at the final follow-up was 91 + 9.8. Conclusion: Stable reconstruction and early initiation of physiotherapy are utilitarian to envision optimal outcome; the use of precontoured EADHPs has yielded satisfactory results with minimal complications in our hands.

Keywords: Distal humerus, extra-articular, fracture, locking plate, outcome


How to cite this article:
Gupta AK, Samal BP, Dalei TR. Functional and radiological outcome in distal third humerus fracture treated with extra-articular locking plate: A multicentric retrospective study. J Pharm Bioall Sci 2021;13, Suppl S2:1483-7

How to cite this URL:
Gupta AK, Samal BP, Dalei TR. Functional and radiological outcome in distal third humerus fracture treated with extra-articular locking plate: A multicentric retrospective study. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Aug 12];13, Suppl S2:1483-7. Available from: https://www.jpbsonline.org/text.asp?2021/13/6/1483/330049




   Introduction Top


Extra-articular distal humerus fracture accounts for approximately 16% of humerus fracture and 3% of all fractures in adults.[1] These fractures are difficult to manage in view of its periarticular location, small size of distal fragment, associated comminution, and moreover, the osteoporotic nature of bone in older individuals. Numerous methods are described for its management, and there are proponents for both conservative and operative interventions. The main goal of treatment is to achieve stable fixation with correct alignment and to allow early range of movement of elbow and shoulder.[2],[3] Operative management of these fractures is favored as it is quite difficult to control and maintain acceptable fracture alignment with the functional brace, and also, long duration of immobilization in brace is cumbersome and may lead to elbow stiffness.[4],[5]

Standard plates available, that is, 4.5-mm dynamic compression plate/locking compression plate (LCP), fail to provide adequate stability in such fracture pattern.[6],[7],[8] Dual plating either in an orthogonal or in a parallel fashion is generally accepted for management of such fracture pattern, as it confers multiple points of fixation into small size distal fragment. This ensures stable fixation and, therefore, allows early range of motion (ROM) of the elbow; but its application is fraught with dangers of extensive soft-tissue stripping and long operating time, which may risk the development of nonunion and infections.[8],[9] To minimize the surgical duration and soft-tissue devitalization, a single conventional posterolateral distal humerus plate has been proposed for fixation; however, these plates also do not provide adequate stability to allow early range of movement.[5],[8],[10] The extra-articular distal humerus locking plate (EADHP) is a precontoured, anatomical shaped, angular stable locking plate crafted for extra-articular distal humerus fracture. By even fixing one column of bone, it is purported to provide adequate construct stability and, therefore, can allow early range of movement. We conducted this retrospective study to analyze the functional and radiological outcomes, complication rates, and the need of reoperation in the patients with extra-articular distal humerus fracture of distal third of diaphysis and metaphysis managed by EADHP.


   Materials and Methods Top


One hundred patients with extra-articular distal humerus fracture involving distal third of diaphysis and/or metaphysis ((Arbeitsgemeinschaft für Osteosynthesefragen) or the Association of the Study of Internal Fixation (ASIF) type 12A/B/C and 13A), treated at various trauma centers at Cuttack, Odisha, between January 2012 and December 2020, were evaluated retrospectively after obtaining ethics clearance. Clinical and radiological data were obtained from hospital charts, patients' file, office records, and hospital's electronic and radiological database.

Exclusion criteria were pathological fractures, associated vascular injury, frank compartment syndrome, age <15 years, and Grade II and III open fractures. Demographics, mechanism of injury, associated injuries, and hospitalization details, along with operation description, were collected from the hospital records. Patients with a minimum follow-up of 1 year were called telephonically or by letter for clinical and radiological assessment. All patients with extra-articular distal humerus fracture were evaluated preoperatively for skin condition, associated injuries, and neurovascular status. Depending upon the skin condition, U-slab was applied in traction and maintained until operation. All patients were operated in lateral decubitus position under general anesthesia and/or brachial block; fracture was approached through the midline posterior incision and triceps-reflecting approach. Radial nerve was identified and protected both at lateral intermuscular septum and at spiral groove; status of radial nerve was documented in every case. Triceps was lifted from lateral intermuscular septum, and fracture site was exposed. Fracture was reduced under vision and provisionally held with Kirschner's wire or bone holding clamps; depending upon the fracture configuration, fragments were lagged, whenever appropriate. Appropriate length of plate was chosen and slid under the radial nerve, its proximal end was centered on diaphysis of humerus, and the distal end of the plate was placed over posterolateral aspect of distal humerus just lateral to olecranon fossa and inferior to it up to the capitellum. Final position was checked under C-arm and fixation was done accordingly.

Closure was done in layer over Romo Vac drain. A supervised physiotherapy regime of active-assisted and passive exercises was started for all patients from the first postoperative day. All patients were subjected to regular clinical and radiological follow-up in the outpatient department. At the latest follow-up visit, patients were evaluated clinically for ROM, activity level. Radiological assessment was done to look for union of fracture, secondary displacement, nonunion, implant failure, or any other implant-related complications. Final functional evaluation was done using Mayo Elbow Performance Score (MEPS). ROM of elbow was measured using a goniometer. Union was assessed radiologically; bone was assumed to be united when three cortex unions were seen on orthogonal roentgenograms.


   Results Top


A total of 100 patients were included in the study. The average duration of follow-up was 15 months (range: 12–36 months). Our study group comprised 67% of male and 33% of female patients, of which 62% had left limb involvement and 3% had bilateral involvement. The average age at the time of surgical procedure was 32 years, 38.9% had associated injuries, and 5 patients had Grade 1 open fracture.

Surgical fixation was performed within a mean delay of 3 days from the date of injury utilizing the triceps-reflecting modified posterior approach by EADHP. No intraoperative complications were noted in relation to implant application. Clinical and radiographic data were available for all 100 patients. Eight percent had preoperative radial nerve palsy, and postoperatively 3% developed radial nerve palsy; all had neurapraxia and recovered completely within 3 months as evident by nerve conduction tests. Intraoperatively, continuity of radial nerve was found in all patients.

Of the 100 patients, 95% were adjudged to have complete radiological union within 3 months. The mean flexion achieved was 122.90 + 23 (range: 45–135), and the mean extension was 4.031 + 6.5 (range: 0–20). One patient, who developed elbow stiffness and flexion deformity of 45, had associated head injury. Elbow arthrolysis was performed one and half years after index operation, and the final elbow ROM attained was 20–90. Six patients had nonunion; one of them showed breakage of the second proximal locking screw; however, intact plate was providing adequate stability. Even so, they were satisfied with their elbow functionality, resumed their preinjury occupation with minimal discomfort, and therefore, refused for further operative intervention. Implant prominence over posterolateral aspect of distal humerus was noted in majority of the patients (n ¼ 22), especially in thin built individuals, because of which they complained of pain in that area when their elbow hit some hard object. However, only one patient had undergone implant removal so far. The average MEPS at the latest follow-up was 90.80 + 9.91. No superficial or deep infection was reported. There were no cases of redisplacement of fracture, implant failure, or any other implant-related complication in follow-up.


   Discussion Top


Extra-articular distal humerus fractures are difficult injuries and pose management challenge in view of its periarticular location, associated comminution, and small size distal fragment; still, there is no definite consensus as to the optimal choice of implant. The goal of treatment is to achieve proper alignment with stable reconstruction so as to commence early elbow ROM. Hence, surgical intervention is favored over conservative treatment.[8] Small size of distal fragment and strong torsional forces at this junction does not allow optimal stable fixation with the standard plates available. To overcome this difficulty, a number of modifications in plate designs have been suggested, and some authors have recommended using the plates that are meant for different locations. Levy et al.[11] had used the lateral proximal tibial head buttress locking plate of the same side with few modifications to fix these difficult fractures. They reported on 15 patients with good clinicoradiologic outcome without any implant failure, but they argued that this needs elaborate modification in existing designs of plate and in bulk production of the same for general use. Similarly, Spitzer et al.[12] had demonstrated encouraging results with a “hybrid” metaphyseal LCP for proximal or distal metaphyseal humerus fractures and nonunions; it comprised 4.5-mm locking holes at one end and 3.5-mm locking holes at the other end which was postulated to be advantageous to afford increased purchase by virtue of its small caliber screws at short bone fragments. They reported healing of all 21 fractures or nonunion at a mean time of 4.5 months without any adverse event of infection or implant failure. Saragaglia et al.[13] developed a “lambda” plate, which is an inverted Y-shaped plate with a stem and two sectile arms that can be easily remodeled to fit properly according to the type of fracture in distal humerus. However, there is no denying the fact that it is a compression plate without locking holes, which is fraught with risk of inadequate fixation, particularly in the presence of comminution and in osteoporotic bone.

We have been using EADHP for treating these difficult fractures since 2012 at our level 1 trauma center; it is a precontoured, anatomical-shaped distal humerus metaphyseal plate with lateral curvature to accommodate at least five locking screws in small distal fragment of humerus which ensures rigid fixation in such fracture pattern. Although a dual-plate construct is postulated to confer greater stiffness than single locking plate construct in the presence of severe comminution,[14] a recent in vitro study by Scolaro et al.[15] has concurred favorable biomechanical properties of single precontoured posterolateral extra-articular LCP. This implant was found to have significantly greater bending, torsional, and yield strength than standard 3.5-mm LCP for fixation of distal humerus fracture, which was simulated by saw bone osteotomy 80 mm above the trochlea. However, the authors were pragmatic in their approach and cautioned that extrapolation of these data to be done carefully, which is because of the fact that this study was done on the saw bone model without taking into account the surrounding soft tissues, which could potentially stabilize or destabilize fracture fragments. Different approaches have been defined to fix this fracture, the posterior approach being the most common.

We have used triceps sparing, a modified posterior approach proposed by Gerwin et al.[16] This allows excellent visualization but causes minimum devascularization of bone, spares extensor mechanism to allow early movements, with added advantage of exploration of radial nerve both at lateral intermuscular septum and spiral groove. The main problem with posterior approach, what was observed in our patients, was hypertrophic scar, which was not appreciated cosmetically by patients, in 15 (41.6%) of our cases. Recently, Meloy et al.,[17] in a comparative study, contended that single-column plating with precontoured posterolateral locking plate results in comparable union rate and alignment in comparison to dual-column plating for extra-articular distal humerus fracture but with significantly fewer complications and better elbow ROM. Favorable results have emanated from our study; union was achieved in 34 patients within 3 months, the mean arc of elbow movement was found to be 118.8 + 24.7; the mean MEPS score was 90.8. Our results fare favorably with other published studies.[18],[19],[20],[21]

We feel that nonunion in our two cases (5.5%) was because of failure to achieve sufficient compression in anterior cortex, which may be partly due to plate configuration. The problem noted during application of plate on flat posterior aspect was offset of plate away from bone in proximal aspect; an attempt to approximate the plate close to the bone with the help of cortical screw leads to anterior opening of fracture site. This phenomenon was particularly noticeable in transverse fracture pattern, which we encountered in our initial two cases that subsequently developed nonunion. Zhou et al.[22] in their study showed that mismatch was found between proximal portion of plate and posterior surface of humerus shaft due to the existence of forward flexion angulation of humerus shaft. An attempt to bring the plate close to the bone surface leads to opening of opposite cortex, so prebending of plate to approximately 8 between the fourth and fifth dynamic compression portions of combination hole in the distal-to-proximal direction is recommended, and for an obvious reason, preoperative planning with evaluation of contralateral uninjured humeral anatomy could make it an effective way to combat this potential problem. Learning from our initial experience, we strive to avoid untoward distraction and keep a low threshold for prebending the plate whenever deemed necessary. The other problem encountered was the prominence of hardware at lateral aspect of elbow in most of the patients. Thin built patients were more vulnerable, and almost all patients complained of pain on lateral aspect of elbow when they hit by some object. However, only one patient has asked for removal of implant so far.


   Conclusion Top


We take cognizance of the fact that retrospective nature of the study and lack of control cohort are the potential drawbacks of our study. However, judicious management of extra-articular distal humerus fractures with extra-articular plates has yielded encouraging results in our hands. We reiterate the importance of stable anatomic reconstruction and early initiation of ROM. We suggest to use EADHP in extra-articular distal humerus fracture involving distal third of diaphysis and/or metaphysis. However, surgeons should use a pragmatic approach; judicious preoperative planning is pivotal to choose appropriate implant and thereby optimize the outcome. Patients might need to be counseled about future implant removal due to untoward prominence when using EADHP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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