Distal Articular Fractures of the Humerus: Surgical Approach with Dynamic Elbow external Fixator

Abstract

Purpose To measure clinical and radiographic outcomes using external fixation in distal humeral fractures.

Methods A total of 10 elderly patients, with a mean age of 71 (range 64–84 years) years old, with unstable distal humeral fractures were treated by percutaneous reduction and fixation with an articulated external fixator. The patients were assessed on range of elbow motion, patient disabilities of the arm, shoulder, and hand (DASH), and pain visual analog scale (VAS) and radiographic evaluation at 12 months.

Results The mean range of motion was 134° of flexion, extension was of - 5°. All of the elbows were clinically stable. The mean VAS was 2.2, and the mean DASH score was 14.3. Radiographic analysis showed satisfactory reduction and consolidation. All of the patients showed congruence of concentric humerus-ulnar and radius and no patient had joint stiffness or posttraumatic arthritis of the elbow. Regarding complications, we observed a patient who presented with pain in the location of the ulnar pin, which was resolved with the removal of the pin. After two months, another patient had pneumonia and died. The follow-up was of 15.44 months.

Conclusions A radiographic analysis of the patients showed fracture healing with joint congruity. In the functional clinical aspect, it was noted that patients had functional range of motion

Type of study/level of evidence Therapeutic IV

Keywords

elbow - fractures - distal humerus fractures - instability - elderly - external fixation

Introduction

The incidence of distal humeral fractures corresponds to ∼ 2% of all adult elbow fractures.[1] [2] [3] [4] [5] [6] [7] [8] The mechanisms of injury are bimodal, and includes low-energy trauma, usually associated with osteoporotic bone in elderly patients, and high-energy, more frequent in young patients with higher incidence of complications such as soft tissue, nerves[3] and vascular injuries.

In elderly patients, surgical treatment with open reduction and internal fixation using plates and screws remains the choice of treatment,[9] [10] [11] [12] [13] [14] even with high complication rates, as reduction loss, articular stiffness and soft tissue damage. According to Korner et al[15] and Hausman et al[16], the internal fixation is justified by the improvements in osteosynthesis techniques and implants with locking screws.

Elbow arthroplasty may be indicated in selected patients with fractures of the severely fragmented distal humerus, or in patients with osteoporosis or rheumatoid arthritis.[17] [18] [19]

Gausepohl et al[9] applied the dynamic external elbow fixator associated with internal fixation in the surgical treatment of complex fractures of the distal humerus in patients with osteoporosis, to protect the internal fixation and decrease complication rates.

The hypothesis of the present study is that distal humeral fractures in elderly patients treated with percutaneous reduction and fixation with an articulated external fixator would avoid complications of the open management, reducing the risk of infection and soft tissues damage.

The objective of the present study is to measure the radiographic, clinical, and functional outcomes of patients with complete articular fractures of the distal humerus treated with an articulated external fixator.

Methods

The study design is a prospective cohort. Inclusion criteria were elderly patients (> 60 years old), with distal humeral fractures (closed or open), classified as AO 13C, comminution below the olecranon fossa, observed in radiographs and computed tomography (CT) scan ([Figs. 1] [2] [3]). The study was approved by the Ethics Committee (CAAE: 50927715.3.0000.5484).

Fig. 1 Radiographic/Tomographic aspects (preoperative): distal humerus fracture (13C3).

Fig. 2 Radiographic aspects (preoperative): distal humerus fracture (13C3).

Fig. 3 Tomographic 3D aspects (preoperative): distal humerus fracture (13C3).

The patients were positioned in the supine position and submitted to general anesthesia or regional brachial plexus block. Closed maneuvers and indirect fracture reduction with longitudinal traction and percutaneous bone reduction clamps, aiming satisfactory articular surface reduction and the distal humerus alignment, were performed. The stabilization was performed with Kirschnner wires and/or lag screws near the joint line of the distal humerus ([Fig. 4]), to fix the joint surface fragments, the medial epicondyle and the lateral cross into the metaphysis.

Fig. 4 Intraoperative fluoroscopic aspects. Kirschner wires and or lag screws near the joint line of the distal humerus.

With the reduced fracture, we positioned the elbow at 90° flexion and the forearm at 90° pronation, conducted the examination with fluoroscopy in this elbow to identify its rotation axis (imaginary line that cuts through the center of the capitellum) and passed a Kirschner wire guide (2 mm) in the center of rotation in the parallel direction to the articular surface of the distal humerus, from lateral to medial direction.

The central body of the external fixator (Elbow external fixator, Amsterdam, Fixus^®, Netherlands, and Galaxy elbow external fixator, Bussolengo, Orthofix^®, Italy) was properly seated in the guide wire. Two Schantz pins (5 mm) were introduced in the humerus, and two other pins (4 mm) into the ulna and connected to the clamps. Those were fixed to the rods passing through the central body. The principle of arthrodiastasis (increased joint space) can be promoted by external fixator to help reduce the articular fragments. An occlusive dressing was applied, and the final tightening of the components of the external fixator was checked.

After the procedure, patients remained in hospital for a period of 24 hours. Subsequently, they performed rehabilitation in the occupational therapy sector of the institution, with the specific protocol already established, which recommends elbow mobility from the 1^st day after the surgery ([Fig. 5]).

Fig. 5 Postoperative clinical and radiographic aspects showed the range of motion of the elbow.

When patients were discharged, they were followed-up weekly in the first month. Then, the returns occurred at 2 months, 3 months, 6 months and 1 year after the surgery.

The parameters chosen for analysis were X-rays to assess articular congruence, reduction and consolidation; range of motion compared with the normal side; pain by visual analogue scale (VAS) after 1 year; the quality of life by the disabilities of the arm, shoulder and hand (DASH) questionnaire and any complications and new operations if they had occurred.

For statistical analysis we adopted the significance level of 5% (0.050) to the testing. The comparison between the variables was due to the application of the test of Wilcoxon Signed Posts, to investigate possible differences between the normal ROM (opposite side) and ROM after 1 year (affected side)

Results

We evaluated a total of 10 patients, 4 men and 6 women. The mean age was ∼ 71 years old, ranging from 64 to 84 years old. The follow-up time was 15.44 months (minimum of 12 and maximum of 21 months).

The average range of motion of the fracture side was 134° of flexion, and - 5° of extension. All of the elbows were clinically stable. The mean VAS was 2.2 and the mean DASH was 14.3.

Radiographic analysis showed satisfactory reduction and consolidation. All of the patients showed congruence of concentric humerus-ulnar and radius: ([Fig. 6]) and no patient had joint stiffness or post-traumatic arthritis of the elbow.

Fig. 6 Postoperative radiographic aspects – articular congruence radius-capitellum and humerus-ulnar.

A patient with pain in the ulnar pin path location was observed, which was solved with the removal of the pin, and another patient had pneumonia and came to die 2 months after the fracture. They were assessed at 12 months (see [Table 1]).

Table 1

Identification	Age	Follow-up	Gender	Side	ROM normal	ROM1 year	DASH normal	DASH 1 year	VAS 1 year	Complications	AO Classification
I	64	21	F	R	140	130	1	12	3	——————-	13C2
II	85	21	F	L	140	140	1	12	1	——————	13C1
III	67	2	F	R	135	130	1	1	1	death	13C3
IV	66	18	M	R	140	140	1	1	1	ulnar pins release	13C1
V	64	16	M	R	140	120	1	30	3	——————	13C3
VI	84	14	F	R	140	125	1	30	4	——————	13C3
VII	65	13	F	L	130	125	1	18	3	——————	13C2
VIII	75	12	F	R	140	132	1	15	2	——————	13C3
IX	71	12	M	R	135	128	1	18	3	——————	13C3
X	73	12	M	R	135	130	1	6	1	——————	13C2

It was noted that the three comparisons showed 'statistical similarity' between the two time points, for the variables of interest. It was interpreted that the parameters DASH and VAS do not tend to statistical differences, suggesting quality of life and pain improvements in the patients after the treatment (see [Table 2]).

Table 2

Variabilities	n	Mean	Standard deviation	Minimum	Maximum	Percentile 25	Percentile 50 (mediana)	Percentile 75	Significance (p-value)
ROM normal	10	139.17	2.04	135.00	140.00	138.75	140.00	140.00	0.068
ROM 1 year	10	130.83	8.01	120.00	140.00	123.75	130.00	140.00
DASH normal	10	1.00	0.00	1.00	1.00	1.00	1.00	1.00	0.063
DASH 1 year	10	14.3	13.09	1.00	30.00	1.00	12.00	30.00
VAS normal	10	1.00	0.00	1.00	1.00	1.00	1.00	1.00	0.102
VAS 1 year	10	2.2	1.33	1.00	4.00	1.00	2.00	3.25

Discussion

The surgical approach to these elbow fractures is challenging and highly difficult.[13] All of the current methods of internal stabilization require broad access, with triceps handling with or without osteotomy of the olecranon, which can result in stiffness and nonunion.[10] [11] [12] [13] [14] [15] [16] Searching the stability, the mobility restoration, and the reduction of perioperative complications, we proposed the use of an articular external fixator.[3] [4] [5] [6] Those patients “supported” early mobilization of the elbow.

Currently, there are several case studies using primary elbow arthroplasty[17] [18] [19] [20] as a possible method of treatment of those fractures, with promising results: elbow mobility turns out to be a functional and safe method for those geriatric patients. But the choice of that method is still an exception in our midst.

The external fixator used in the present study ([Fig. 7]) promoted stability and early mobility of the elbows, which influenced directly in the clinical and functional outcome of those patients who have endured such pain during the early handling of the elbow since the 1^st day after surgery, with the help of physiotherapists, while hospitalized. Association between physical therapy activities and the use of analgesics was reported by most patients in the 1^st month after surgery.

Fig. 7 Radiographic and clinical aspects (immediate postoperative).

The average value of the flexion-extension of the elbow in our study was 129°, while for Orbay¹ (internal fixator) it was 115°, for Sorensen et al[19] (arthroplasty) it was 114°, for McKee et al[12] it was 105°, and for Sørensen et al[7] (external fixation) it was 95°. Although the sample is small, our results are superior when compared with the aforementioned studies ([Fig. 8])

Fig. 8 Clinical aspects (postoperative): right elbow and functional ROM.

All of our patients had consolidation and maintenance of fracture reduction (articular congruence radius-capitellum and humerus-ulna) and stability of the elbow. (see [Fig. 9])

Fig. 9 Postoperative radiographic aspects after 6 months: elbow articular congruence.

Orbay[1] didn't have complications, McKee et al[12] presented in their series of 16 patients, a case of recurrent elbow instability; Sørensen et al[7] reported a patient with elbow dislocation. In the study of Sorensen et al, 4 out of 20 patients undergoing elbow arthroplasty presented complications (2 with infection, and 2 with ulnar nerve injury). In the present study, a patient was observed with pain in the location of the ulnar pin path, which was solved with the removal of the pin.

The present research had the disadvantage of the need for a new procedure to remove the implant. It is a prospective cohort study and these results need to be confirmed in larger quantitative and qualitative studies.

This technique restores stability, the anatomy, and allows early mobility of the elbows of the patients. It is believed that it is a promising method for the treatment of geriatric patients with distal and articular fractures of the humerus.

It is suggested new scientific research, with greater level of evidence to validate this method. Thus, the articulated external fixator elbow can be part of the orthopedic surgeon toolbox.

Conclusion

Radiographic analysis of the patients showed fracture healing with joint congruity. In the functional clinical aspect, it was noted that patients had functional range of motion.

Conflict of Interests

The authors have no conflict of interests to declare.

Acknowledgments

Translation service provided by Edith Nicole Laniado – Rua Albuquerque Lins, 1238–2b, Santa Cecília, São Paulo, State of São Paulo, Brazil.

Phone: + 55 11 3368–4600 / 55 11 99904–3418

[e-mail] | www.ibttranslations.com

Ethical Approval

The research presented here was approved by and was in accordance with the ethical standards of the Faculdade de Medicina do ABC Ethics Committee on human experimentation under the CAAE number: 50927715.3.0000.5484.

Informed Consent

An informed consent document was provided to all research participants, who read and signed it according to their will.

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