|Year : 2015 | Volume
| Issue : 1 | Page : 68-73
Comparative study of different approaches for open reduction and internal fixation in fractures of distal humerus
Gautam Gupta1, Soumya Ghosh2, Arunima Chaudhuri3, Soma Datta4, Saumyadip Dutta1, Neeraj Dugar5
1 Department of Orthopedics, RG Kar Medical College, Kolkata, India
2 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, India
3 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, India
4 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, India
5 Department of Orthopedics, National Medical College, Kolkata, West Bengal, India
|Date of Web Publication||19-Jan-2015|
Krishnasayar South, Borehat, Burdwan 713 102, West Bengal
Background: Open reduction internal fixation (ORIF) of distal humerus fracture is the gold standard treatment but controversies exists regarding surgical approaches, type of implants, operative techniques, need for transposition of ulnar nerve, and type of rehabilitation after surgical treatment. Aims: To analyze the functional outcome of open reduction and internal fixation of distal humerus fracture using three different posterior approaches namely: olecranon osteotomy, Campbell's approach, Bryan Moorey approach. Materials and Methods: This prospective randomized observational study of 60 cases of intercondylar fracture of humerus was conducted in the Department of Orthopedic Surgery in a tertiary care hospital in West Bengal over a time span of two years after taking Institutional ethical clearance and informed consent of the patients. Out of 60 cases, olecranon osteotomy approach was used in 20 cases; Campbell's approach in 20 cases; and Bryan Moorey approach in 20 cases. Results: At final follow up, all patients were assessed by Mayo Elbow Performance Index (MEPI) scoring system. We found best results in patients operated by olecranon osteotomy approach (18 patients had excellent result) whereas only eight cases in Bryan Moore group and six cases in patients operated by Campbell's approach had excellent result. However, when statistically analyzed the mean results of three groups the results were statistically insignificant (P = 0.09). Conclusion: It can be concluded that among that three approaches being studied for intercondylar fracture humerus, the olecranon osteotomy approach provides adequate exposure to distal humerus facilitates accurate articular reduction even in complex type of fractures and early mobilization can be instituted, which is the crux for the final outcome.
دراسة مقارنة لطرق مختلفة للجبر المفتوح مع التثبيت الداخلي لكسور عظم العضد البعيدة
خلفية: تعد طريقة الجبر المفتوح مع التثبيت الداخلي المعيار الذهبي لعلاج الكسور، إلاّ أن اختلاف وجهات النظر ظهرت باعتبار الطرق الجراحية ، وزراعة العظام، والتقنيات الجراحية ، والحاجة إلى تغيير وضع العصب العضدي، و إعادة التأهيل بعد العلاج الجراحي.
الأهداف: كان هدف هذه الدراسة تحليل المردود الوظيفي لطريقة الرد المفتوح و التثبيت الداخلي لعلاج كسور عظم العضد البعيدة باستخدام ثلاثة طرق وهي: طريقة الزّج الزنديّ، وطريقة بريان موري، و طريقة كامبل.
المواد و منهج الدراسة: تم اختيار عينة عشوائية من 60 من حالات كسور العضد البعيدة ، وقد أجريت الدراسة في قسم جراحة العظام في مستشفى تعليمي للرعاية الصحية في ولاية البنغال الغربية على مدى عامين وبعد موافقة الوالدين . وقد استخدمت طريقة الزج في 20 حالة، و طريقة كامبل في 20 حالة، و طريقة بريان موري في 20 حالة .
النتائج: وبعد المتابعة النهائية خضع كل أفراد العينة للتقييم بواسطة مؤشر مايو لأداء الكوع . وقد كانت أحسن النتائج في المرضى الذين خضعوا لطريق الزج وحصل 18 منهم على نتيجة ممتازة، أما الذين حصلوا على نتيجة ممتازة في طربقة بايرن مور كانوا 8 و في طريقة كامبل كانوا 6. وبعد تحليل النتائج إحصائيا كانت نتائج للمجموعات الثلاث ذات أهمية إحصائية ( P= 0.09 )
الخلاصة: يمكن استنتاج أن من بين الطرق الثلاثة التي تدرّس لعلاج كسور عظم العضد البعيدة نجد ان طريقة الزج توفر التعرض الكافي لعظم العضد البعيدة ويسهل الرد المفتوح حتى في الكسور المعقدة والتحريك المبكر يمكن يؤدي إلى النتيجة النهائية.
Keywords: Bryan Moorey approach, Campbell′s approach, fractures of distal humerus, olecranon osteotomy, posterior approaches
|How to cite this article:|
Gupta G, Ghosh S, Chaudhuri A, Datta S, Dutta S, Dugar N. Comparative study of different approaches for open reduction and internal fixation in fractures of distal humerus. Saudi J Sports Med 2015;15:68-73
|How to cite this URL:|
Gupta G, Ghosh S, Chaudhuri A, Datta S, Dutta S, Dugar N. Comparative study of different approaches for open reduction and internal fixation in fractures of distal humerus. Saudi J Sports Med [serial online] 2015 [cited 2019 Aug 20];15:68-73. Available from: http://www.sjosm.org/text.asp?2015/15/1/68/149544
| Introduction|| |
The elbow joint is a unique mixture of the stability and motion of three separate articulations, namely humeroulnar, radiocapitellar, and proximal radioulnar joint. Fractures of the distal humerus may disrupt intra-articular anatomy, which has significant effects on the motion and functions of the elbow joints. These fractures are rare, comprising approximately 3% of all fractures.  Most fractures involve the joint surface and alter the complex three-dimensional geometry of distal humerus. Hence, restoration and reconstruction of normal anatomy poses a considerable challenge to surgeons.
Open reduction internal fixation (ORIF) of distal humerus fracture is the gold standard treatment but controversies exist regarding surgical approaches, type of implants, operative techniques, need for transposition of ulnar nerve, and type of rehabilitation after surgical treatment. ,,,
Medial, lateral, and anterior approaches can provide exposure to a single column; hence, anatomical reduction of articular fragments becomes immensely difficult. Posterior approaches provide proper exposure to articular surface. Therefore, it is said that "Front Door" to elbow is "From Back" as the extensor mechanism is interposed between the surgeon and fracture. These fractures are treated by posterior approach. , All these approaches have merits and demerits. This study was carried out to analyze the functional outcome of open reduction and internal fixation of distal humerus fracture using three different posterior approaches namely: Olecranon osteotomy (Muller MacAusland approach), triceps aponeurosis tongue approach (Campbell's approach), and triceps reflecting approach (Bryan Moorey approach).
| Materials and methods|| |
This prospective randomized observational study of 30 cases of intercondylar fracture of humerus was conducted in the Department of Orthopedic Surgery in a tertiary care hospital in West Bengal in a time span of two years after taking Institutional ethical clearance and informed consent of the patients. Out of 60 cases, olecranon osteotomy approach was used in 20 cases; Campbell's approach in 20 cases; Bryan Moorey approach in 20 cases.
Simple random sampling was carried. First case was operated by Bryan Moore approach, second case by olecranon osteotomy approach, and third case by Campbell's approach. This order was maintained in the rest of study. Inclusion criteria: Skeletally mature patient with intercondylar fracture humerus. Exclusion criteria: Open fractures. All cases were admitted. History was recorded, followed by clinical examination. The presence or absence of vascular or neurological deficit, open or close injury, and other complications were specifically noted. Routine investigations were done. The clinical diagnosis was confirmed by anteroposterior and lateral radiograph of the affected elbow joint. Assessment and grading of the fracture was based on AO classification.
Classification of fractures:
- Type 13A - Extra-articular fracture
- Type 13A 1 - Avulsion
- Type 13A 2 - Simple
- Type 13A 3 - Extra-articular multifragmentary
- Type 13B - Partial articular
- Type 13B 1 - Lateral sagittal
- Type 13B 2 - Medial sagittal
- Type 13B 3 - Frontal Type 13C - complete articular
- Type 13C 1 - Metaphyseal simple
- Type 13C 2 - Metaphyseal comminution
- Type 13C 3 - Multifragmentary.
After proper pre-anesthetic check up patients were planned for surgery. Regional anesthesia was administered.
Position of the patients: Patient were positioned in lateral decubitus with a bolster placed between arm and chest, and the entire upper extremity draped free. All cases were operated with pneumatic tourniquet applied over upper arm. If operative time exceeded more than 1 h 45 min tourniquet was deflated. Surgical Exposure: Posterior approach to distal humerus was followed. Incision: A posterior mid-line longitudinal incision was made over lower arm and extended distally beyond the elbow joint. Just above the tip of olecranon the incision was curved laterally. Superficial surgical dissection: Deep fascia was incised in the mid-line and aponeurosis of the triceps was exposed. Ulnar nerve was palpated on the back of medial epicondyle. Fascia over the ulnar nerve incised to expose the ulnar nerve. Ulnar nerve was fully dissected [Figure 1]. Articular branch of the ulnar nerve may be sacrificed. Olecranon osteotomy approach: , An apex distal chevron-shaped osteotomy was created 2 cm from the tip of olecranon [Figure 2]. A narrow oscillating saw was used to start the osteotomy. A small, straight osteotome was then used to complete it by levering the osteotome proximally and breaking the subchondral bone. This maneuver creates an uneven surface that facilitates repositioning and enhanced stability. The osteotomy must be proximal to the coronoid process, to provide a balance between an osteotomy that is too small, which may compromise the exposure of the articular surface, and one that is too large, which may cause an inadvertent osteotomy at the level of coronoid and destabilize the elbow. Osteotomized olecranon and attached triceps was reflected proximally to give excellent exposure of distal humerus. At the completion of surgery, the osteotomy secured using two K-wire and SS wire, and the tension band technique was followed.
Bryan moorey Approach
After superficial dissection and isolation of ulnar nerve further exposure Bryan Morey approach used and steps were: Medial aspect of the triceps was elevated from the humerus, along the intermuscular septum, to the level of posterior capsule. Superficial fascia was incised distally for about 6 cm to the periosteum of the medial aspect of olecranon. As a single unit, the periosteum and fascia medial to lateral was carefully reflected. The medial part of the junction between the triceps insertion and the superficial fascia and periosteum of the ulna is the weakest portion of the reflected tissue. Care was taken to maintain the continuity of triceps mechanism at this point. Careful dissection of the triceps tendon from olecranon was done with the elbow extended 20-30° to relieve tension on the tissue and then reflect the remaining portion of the triceps. During closure, triceps was returned to its anatomical position and sutured directly to the bone. Closure of the wound was done in layers and with a suction drain in the wound [Figure 3]a-c.
|Figure 3: (a) Bryan Moorey approach, (b) Open reduction and internal fixation, (c) Triceps sutured to ulna|
Click here to view
Deepened the dissection through the fascia, and exposed the aponeurosis of the triceps as far distally as it insertion on the olecranon. It freed the aponeurosis proximally to distally in a tongue-shaped flap and retracted distally to its insertion. We incised the remaining muscle fibers in mid-line and then elevated the periosteum together with triceps muscle from the posterior surface of the distal humerus for 5 cm. For wider exposure, the subperiosteal stripping on each side was continued, releasing the muscular and capsular attachment to the condyles and exposing the anterior surface [Figure 4]a-b. When the elbow was fixed in complete extension with a contracted triceps muscle it was flexed at right angle for closure of the wound. The distal part of the defect in the triceps tendon was filled with the inverted v-shaped part of the triceps fascia, and the proximal part was closed by suturing the remaining to margins of the triceps.
|Figure 4: (a) Triceps tongue aponeurosis exposed, (b) Exposure of fracture site|
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Techniques of fracture reduction
Articular fragments were reduced and provisionally fixed with guidewire. Definitive fixation of intra-articular part was performed using 4-mm cannulated cancellous screws. Care was be taken not to narrow the trochlea with a lag screw when there was bone loss. Once intra-articular part was fixed, intercondylar fracture was converted into supracondylar fracture. Further fixation was carried out with 3.5-mm reconstruction plate. Plate was bent to contour with pillars of distal humerus. Closure: The ulnar nerve was not anteriorly transposed in any case. Implants were covered with soft tissue to prevent ulnar neuritis. A negative suction drain was given.
Plaster-of-Paris (POP) backslab was applied, and drain was removed at 48 h. Out of 60 cases, 12 cases were operated under tourniquet control and in rest tourniquet had to be released intraoperatively as operative time exceeded more than 1 h 45 m. Blood loss in cases operated with tourniquet-measured by collected blood in suction drain. In 48 cases, tourniquet had to be removed intraoperatively. Blood loss in such cases was measured with numbers of mops required during surgery plus collection in drain (one wet mop = 200 ml of blood approximately) . Wound inspection was routinely done on 5 th postoperative day. Suture removal was done on 14 th postoperative day.
The patients were put through active elbow motion of flexion and extension, pronation and supination within limits of pain at the end of first week. Mobilization was delayed in patients with less rigid fixation.
Patients were reviewed every three weeks for first two months, every month for next six months and then every 3 rd month and were assessed on: Time taken for functional recovery; range of motion; any specific complaints; and time taken for fracture healing. Final follow up was done one month before the conclusion of the study, and various scoring systems and classifications were used to analyze the results. Mayo Elbow Performance Index (MEPI) score was used for grading of results [Table 1].
Results were analyzed statistically using SPSS software version 16. Annova was used and P < 0.05 was considered statistically significant and <0.01 as highly significant.
Results and analysis
A total of 32 males and 28 females were included in the present study. Out of 60 patients, right side was injured in 24 patients and left side was injured in 36 patients. Youngest patient was 15 years old and oldest was 62 years old. Average age of patients who were operated by Bryan Moore approach was 37.5 years, olecranon osteotomy approach was 37 years, Campbell's approach was 39.8 years. There was no statistical significance in age between the three groups. Most common mode of injury was fall from height (36 cases). In 16 cases, road traffic accident was the mode of injury, and in remaining eight patients, simple fall was the mode of injury. Average time gap between injury and operation was found to be 7 days (SD: 4.944) in olecranon osteotomy group whereas in Bryan Moore and Campbell's approach was 8.7 days (SD: 3.093) and 10.8 days (SD: 4.467), respectively. Applying ANOVA P value was found to be 0.153 (not significant). In our study group, the most common associated injury was found to be fracture distal radius. Out of 60 cases, six cases had distal radius fracture. Only two cases (Campbell's case no. 3 and 13) had preoperative radial nerve injury. No case had vascular injury. On analyzing the distribution of C1, C2, and C3, AO type of fracture it was found that most common type was C1 and least common was C3. On further observation, it was found that maximum number of C1 type (n = 12) of fracture was operated by Campbell's approach. Maximum number of C2 type (n = 12) of fracture were operated by olecranon osteotomy approach, and maximum number of C3 type (n = 6) of fracture were operated by Bryan Moore approach. Most of the complex fractures (n = 14; C2 = 12, C3 = 2) were operated by olecranon osteotomy approach, and most of the articular simple C1 type were operated by Campbell's approach. On analyzing the result of length of incision, it was found that that length of incision has no significance in three different posterior approaches. In 12 cases out of 60, operative time exceeded more than 2 h. Out of these 12 cases, olecranon osteotomy approach was used in six cases. Though most of the complex type of articular fractures in this study was operated by olecranon osteotomy approach, the average operative time was comparable in all three groups of patients. Visibility of fracture site in olecranon osteotomy approach was far better than Bryan Moore approach, which was better than Campbell's approach. Blood loss was comparable in all the three groups of patients and was statistically insignificant. When we compared the time required for functional recovery in three groups of patients, the mean value in Bryan Moore, olecranon osteotomy, and Campbell's approach were 90, 65, and 108 days, respectively. On applying ANOVA with post hoc analysis, we found significant difference between olecranon osteotomy and Campbell's approach (P = 0.007) group of patients, but we failed to find significant difference between the olecranon osteotomy and Bryan Moore approach groups of patients (P = 0.150). Patients in the olecranon osteotomy group had earliest functional recovery. Range of movement was graded using two grading systems viz. Cassebaum and Riseborough Radin method. Six patients had full range of motion; all these cases were operated by olecranon osteotomy approach. Minimum flexion extension arc of 60° (30-90°) was recorded in four patients (olecranon osteotomy case no.: 10, 20; Bryan Moore case no.: 7, 14). In both these patients, mobilization was delayed for more than four weeks due to inadequate fixation and soft tissue infection. On grading the result, we found comparable results in all three groups of patients. When we statistically analyzed mean flexion-extension arc of three groups of patients, we found no significant differences. Complete supination-pronation was achieved in 46 patients. Out of 14 patients, eight patients who failed to achieve complete supination-pronation arc were operated by Campbell's approach, four patients operated by Bryan Moore approach, and only two patients were operated by olecranon osteotomy approach. The maximum number of patients in whom the final range of motion was restricted was operated by Campbell's approach.
On analyzing the time taken from fracture healing in the three groups of patient, we found no statistical difference P = 0.056. The most common complication was superficial infection (12 cases), which was managed by antibiotic. Postoperative ulnar nerve neuropraxia developed in four cases (Bryan Moore case no.: 8, 16; Campbell's case no.: 9, 18) though ulnar nerve dissection was performed. Both patients had not recovered completely at final follow up. Only two patients had non-union (olecranon osteotomy case no.: 10, 20) of fracture site but the osteotomy site united in that case. Non-union of fracture was due to inadequate fixation of fracture. There was no incidence of non-union of osteotomy site. Only two patients had symptomatic tension band wiring but implant removal was not required. Fifty percent of the complication occurred in patients operated by Bryan's Moore approach. There was no statistical difference in complication rate among the three groups. The time required for functional recovery was least in patients operated by olecranon osteotomy approach and highest in patients operated by Campbell's approach. The difference in the three groups was statistically significant (P = 0.007). The least number of complications (n = 6) was in patients operated by olecranon osteotomy approach whereas maximum number of complications (n = 10) was found in patients operated by Bryan Moore approach. The MEPI score was highest in patients operated by olecranon osteotomy approach (18 patients had excellent result) but only two patients operated by Campbell's approach had excellent results.
At final follow up, all patients were assessed by MEPI scoring system. We found best results in patients operated by olecranon osteotomy approach (18 patients had excellent result) whereas only eight cases in Bryan Moore group and six cases in patients operated by Campbell's approach had excellent result. However, when the mean results of the three groups were statistically analyzed, the results were statistically insignificant (P = 0.09).
| Discussion|| |
The elbow is a complex vital joint for positioning the hand. Open reduction and internal fixation offers the best chance for return to function following intra-articular fractures of the distal humerus. Identification and protection of the ulnar nerve followed by transposition, broad exposure of the fracture utilizing an olecranon osteotomy, anatomic restoration of the articular surface with preservation of all osteochondral fragments, rigid fixation of both columns using pre-contoured plates and screws, and institution of early range of motion post-operatively provides better results.  At final follow up by MEPI scoring system, we found best results in patients operated by olecranon osteotomy approach (18 patients had excellent result) whereas only eight cases in Bryan Moore group and six cases in patients operated by Campbell's approach had excellent result. Similar results of olecranon osteotomy were observed in studies by Marsh M et al.  , Wang AA et al.  , and Meier et al.  in their studies.
Mohan et al.  described a posterolateral approach to the distal humerus for open reduction and internal fixation of displaced fractures of the lateral condyle. A total of 20 patients had open reduction and internal fixation over a four-year period using this approach, and at a mean follow-up of 12 months, had full union, range of movement, and no complications, either clinical or radiological. This approach is well-suited to the exact visualization and accurate reduction of this difficult fracture with minimal dissection of tissues. There were no intraoperative or postoperative complications. All fractures healed satisfactorily and were united at the time of radiological assessment at three months. There were no angular deformities at review. There were no cases of avascular necrosis, non-union, or epiphyseal overgrowth. The skin wounds healed well and the cosmetic appearance was acceptable. In all patients, there was a full range of movement.
Complications are common in the management of distal humerus fractures and include elbow stiffness, heterotopic ossification, non-unions, neuropathies, and infections. Post-traumatic elbow stiffness can arise from both intrinsic and extrinsic sources. Intrinsic causes of stiffness include joint adhesions, synovitis, articular incongruity, and intra-articular loose bodies. Extrinsic causes include capsular contractures and heterotopic ossification. Loss of some motion is expected after distal humerus fractures, particularly terminal extension. Loss of flexion is less tolerated than loss of extension. Post-traumatic elbow stiffness is best managed by avoidance and diligent post-operative rehabilitation. During the early post-operative period, motion should be instituted and edema minimized. 
| Conclusion|| |
It can be concluded that among the three approaches being studied for intercondylar fracture humerus, olecranon osteotomy approach provides adequate exposure to distal humerus, facilitates accurate articular reduction even in complex type of fractures, and early mobilization can be instituted, which is the crux for the final outcome.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]