outcomes following distal humeral fracture … following distal humeral fracture fixation with an...

Outcomes Following Distal Humeral FractureFixation with an Extensor Mechanism-On Approach

Jason M. Erpelding, MD, Adam Mailander, OTR/L, Robin High, MBA, MA,Matthew A. Mormino, MD, and Edward V. Fehringer, MD

Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska

Background: Distal humeral fractures have traditionally been managed with surgical approaches that disrupt the ex-tensor mechanism. We hypothesized that an extensor mechanism-on approach for operative fixation of distal humeralfractures with parallel or orthogonal plate constructs would allow excellent healing, a motion arc of the elbow exceeding100�, and maintenance of extensor mechanism strength.

Methods: Distal humeral open reduction and internal fixation (ORIF) was performed with either orthogonal or parallelplate constructs in seventy-nine elbows. Thirty-seven elbows were fixed via an extensor mechanism-on surgical approach,and twenty-four of them were available for additional evaluation. Radiographs as well as MEPI (Mayo Elbow PerformanceIndex), DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores were obtained.

Results: All thirty-seven fractures healed primarily. Three elbows underwent later release because of stiffness. Themedian arc of elbow motion was 126� (range, 60� to 141�). The mean MEPI was 91.5 points and the mean DASH scorewas 15.9 points, indicating excellent scores with mild impairment. The median percent loss of triceps strength was 10%(range, 0% to 49%) compared with the contralateral, normal elbow.

Conclusions: Open treatment of distal humeral fractures with an extensor mechanism-on approach results in excellenthealing, a mean elbow flexion-extension arc exceeding 100�, and maintenance of 90% of elbow extension strengthcompared with that of the contralateral, normal elbow.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intercondylar and low transcondylar distal humeral fracturesfrequently require operative exposure and stabilization of themedial and lateral columns as well as the articular surface1.

Traditionally, these fractures have been managed in an operativefashion with various extensor mechanism-disrupting surgicalapproaches2-8. These approaches are often associated with delayedunion or nonunion of the olecranon, triceps weakness, andosteotomy-related prominent implants9-11. To avoid these problems,various extensor mechanism-sparing approaches that providebicolumnar exposure of the distal part of the humerus have beendescribed, including triceps-splitting and reflecting techniques3,6-8.

The two-window approach to the distal part of the hu-merus was described in 1972 by Alonso-Llames for treatment ofpediatric supracondylar fractures for which closed reduction had

failed12. In 2003, Schildhauer et al. expanded on this approachfor treatment of distal humeral fractures with intra-articularextension7. They described an extensor mechanism-sparing,paratricipital, anconeus-preserving approach with bicolumnarvisualization through medial and lateral windows with thetriceps insertion on the olecranon kept intact.

To our knowledge, no prior report discusses the objectiveevaluation of elbow extension strength following distal hu-meral open reduction and internal fixation (ORIF) done withSchildhauer’s technique. Although Ali et al. reported functionaloutcomes following distal humeral fixation with this technique,dynamometric extension strength evaluation was not con-ducted13. We intended to determine whether this exposure wouldallow adequate visualization for anatomic reduction and lead to

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support ofany aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission ofthis work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, oneor more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential toinfluence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with theonline version of the article.

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COPYRIGHT � 2012 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2012;94:548-53 d http://dx.doi.org/10.2106/JBJS.J.01785

patient outcomes comparable with those after more invasiveexposures. We evaluated functional outcomes and elbow exten-sion strength following distal humeral fixation with Schildhauer’sparatricipital approach.

Materials and Methods

Our study was approved by the University of Nebraska Medical Center’sInstitutional Review Board for the Protection of Human Subjects (IRB#

542-08-FB).From January 2002 to January 2009, distal humeral ORIF was per-

formed with either orthogonal or parallel plate constructs in seventy-nine el-bows by the two senior authors (M.A.M. and E.V.F.). Thirty-seven of theseventy-nine elbows were fixed via the paratricipital posterior approach de-scribed by Schildhauer et al.

7. Forty-two patients were excluded from this study

for the following reasons: a surgical approach other than the one described bySchildhauer et al. (seven elbows), an associated olecranon fracture (six elbows),preoperative triceps avulsion (two elbows), an olecranon osteotomy (nineteenelbows), and previous elbow surgery (eight elbows). During the time periodstudied, three of the forty-two excluded elbows were converted to an olecranonosteotomy after an initial extensor mechanism-on approach was attemptedbecause visualization was inadequate to allow anatomic restoration of the fracturefragments with the extensor mechanism-on approach alone. These cases wereexcluded from the study. The decision to address the remaining thirty-seven withthe Schildhauer approach was made preoperatively by the treating surgeon afterreview of imaging studies.

At the time of this study, twenty-four of the thirty-seven patients treatedwith the Schildhauer technique returned for additional evaluation beyond thestandard clinical follow-up; they were evaluated by an orthopaedic surgery chief

resident other than the surgeon of record. Of the thirteen patients who did notreturn, one had died and twelve were either unable to or declined to return forthe additional evaluation.

The mean age at the time of surgery was forty-seven years (range,fourteen to eighty-five years). Thirteen injuries were in females and eleven werein males. The dominant extremity was involved in ten patients (42%). Themechanism of injury included fifteen ground-level falls, three falls from aheight, and six motor-vehicle accidents.

The fractures were classified according to the AO/ASIF classification. Sixpatients had a type-A fracture, one had a type-B fracture, and seventeen (71%)had a type-C fracture (Figs. 1-A and 1-B). Of the type-C fractures, eight were C1,six were C2, and three were C3. Six injuries (25%) were in extremities that hadassociated ipsilateral fractures. Five fractures (21%) were open: four of them weregrade 1 and one was grade 2 according to the Gustilo and Anderson open-fractureclassification

14. Osteosynthesis was performed with sixteen parallel and eight

orthogonal plate orientation constructs at the surgeon’s discretion.

Surgical TechniqueA consistent technique, except for plate configuration and ulnar nerve man-agement, was used in all patients. All patients were placed in the lateral decubitusposition on a beanbag with an axillary roll and with the affected arm allowed torest over a support. A slightly lateral to midline posterior incision was utilized.Full-thickness fasciocutaneous flaps were developed. The ulnar nerve was iden-tified and was dissected to the arcade of Struthers proximally and to the firstmotor branch in the flexor carpi ulnaris muscle belly distally (Fig. 2). The ulnarnerve was transposed to an anterior subcutaneous position in ten patients at thesurgeon’s discretion. The remaining fourteen patients had the ulnar nerve de-compressed in situ, and the nerve was allowed to rest in this position at the timeof closure. The medial and lateral borders of the triceps muscle were then elevated

Fig. 1-A Fig. 1-B

Initial injury anteroposterior (Fig. 1-A) and lateral (Fig. 1-B) radiographs of a twenty-two-year-old woman with a displaced AO/ASIF type-C2 distal humeral

fracture.

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 94-A d NU M B E R 6 d M A R C H 21, 2012OU T C O M E S F O L L OW I N G DI S TA L HU M E R A L F R AC T U R E

FI X AT I O N W I T H A N EX T E N S O R ME C H A N I S M -ON A P P R OAC H

from their respective intermuscular septae. The distal lateral dissection was con-tinued anterior to the anconeus muscle, allowing the muscle to be elevated alongwith the triceps and preserving its neurovascular supply (Fig. 3). Three closedfractures and all of the open fractures violated the triceps muscle. A figure-of-eightabsorbable suture was placed to approximate the muscle edges as needed. In thesecases, the triceps violation may have aided reduction and fixation. Otherwise,medial and lateral windows were connected with blunt dissection, freeing thetriceps muscle from the posterior aspect of the humerus in an extraperiostealfashion, and the intra-articular fat pad was excised. This provided visualization ofthe entire posterior articular surface, comprising roughly 50% of the overall ar-ticular surface of the distal part of the humerus.

The distal part of the humerus was anatomically reduced with directvisualization posteriorly and indirectly with fluoroscopy. The intact sigmoidnotch was used as a template for reduction. Fracture fragments were reduced

and provisionally fixed with smooth Kirschner wires, and the reduction wasverified with fluoroscopy. A sponge or 0.25-in (0.6-cm) Penrose drain wasplaced into the ulnohumeral joint to allow distraction of the joint by pullingdistally on the olecranon via the sigmoid notch to aid in visualization andfacilitate the reduction through ligamentotaxis. Extreme flexion can also behelpful to further visualize the posterior aspect of the distal part of the humerus.The reconstructed distal articular block was then approximated to the humeraldiaphysis. Kirschner-wire fixation was converted to definitive fixation with theapplication of either parallel or orthogonal plate constructs, depending on thesurgeon’s choice. One surgeon preferred parallel plating; the other preferredorthogonal plating. Fixation stability and motion arcs were assessed prior toclosure. A Hemovac drain was placed, the wound was closed, and a bulkydressing was applied with the elbow in full extension. The dressing was

Fig. 2

Fig. 2-A Medial dissection along the medial triceps border and intermus-

cular septum. The ulnar nerve is released from the arcade of Struthers

proximally and to the first motor branch in the flexor carpi ulnaris muscle

belly distally. The dotted line indicates the arthrotomy. Fig. 2-B Medial

dissection and arthrotomy posterior to the humeroulnar ligaments. A =

ulnar nerve, B = medial epicondyle, C = trochlea, and D = olecranon tip.

(Reproduced, with permission, from: 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.)

Fig. 3

Fig. 3-A Lateral dissection along the lateral triceps border and intermus-

cular septum. The dotted line indicates the arthrotomy anterior to the

anconeus. Fig. 3-B Lateral view with the reflected capsule and anconeus

muscle elevated with the triceps. A = radial nerve, B = lateral epicondyle,

C = reflected anconeus muscle and capsule, D = trochlea, and E = olec-

ranon tip. (Reproduced, with permission, from: 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.)

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removed on postoperative day two, and a full active-assisted elbow motion andgrip-strengthening therapy program was initiated. Radiographs were obtainedat regular follow-up intervals to assess for fracture union.

Once full institutional review board approval was obtained, all eligiblepatients were invited to return for evaluation beyond the standard clinicalfollow-up. The two senior authors were not involved in the questionnaireadministration, follow-up examination, or data collection. Functional resultswere assessed with the MEPI (Mayo Elbow Performance Index), DASH (Dis-abilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) ques-tionnaires

15-17. Elbow motion was assessed with a handheld goniometer.

Isometric elbow-extension strength was assessed with the elbow at the side, in90� of flexion, and with neutral forearm rotation with use of a CommanderPowerTrack II muscle dynamometer (JTECH Medical, Salt Lake City, Utah)and compared with that on the contralateral side. This has been shown to bethe optimal position for elbow strength assessment

18-20. The unaffected elbow

served as a control for each patient. The mean of three trials was utilized foreach side

10. Anteroposterior and lateral elbow radiographs were obtained at the

time of examination and assessed for reduction, alignment, fracture union,posttraumatic arthrosis, and heterotopic ossification (Figs. 4-A and 4-B).

Statistical AnalysisThe SAS/STATsoftware package, version 9.2 of the SAS System for Windows XP(copyright 2002-2008, SAS Institute, Cary, North Carolina), was utilized, anddescriptive summaries were performed. Nonparametric analysis of variance(ANOVA) and nonparametric Wilcoxon and Kruskal-Wallis tests were used toestablish whether there were any significant relationships between the plateorientation or fracture type and the range-of-motion values or loss of tricepsstrength. A value of p < 0.05 was considered to be significant. SF-36 scores foreach patient were compared with published age and sex-matched populationcontrol values

17.

Source of FundingAn intradepartmental grant was used to fund this study (radiographs only) anddid not play a role in the investigation. No external funding was utilized for thisstudy.

Results

All thirty-seven fractures healed primarily. The patients hadcompleted all postoperative physical therapy at the time of

the study and were determined to have achieved maximumfunction and elbow motion. The mean duration of follow-upwas twenty-seven months (range, five to eighty-two months).The median elbow flexion was 130� (range, 90� to 146�), me-dian supination was 90�(range, 0� to 90�), and median pro-nation was 90� (range, 0� to 90�). The median arc of motionwas 126� (range, 60� to 141�), with a mean motion arc of 115�(range, 60� to 141�) and a median fixed flexion deformity of9� (range, 0� to 48�). The median loss of range of motion, ascompared with that of the contralateral elbow, was 11� (range,0� to 83�). The median percent loss of triceps muscle strengthwas 10% (range, 0% to 49%). The plate construct orientation didnot significantly affect elbow motion (p = 0.586) or elbow ex-tension strength (p = 0.478). The effect of handedness on ex-tension strength loss was analyzed with nonparametric Wilcoxontesting, and no significant difference was found (p = 0.739)between the dominant and nondominant elbows.

Further analysis of the elbow motion arc (p = 0.009) andpercent extension strength loss (p = 0.049) with nonparametricone-way ANOVA and Kruskal-Wallis testing demonstrated sig-nificant differences across fracture types. The median motion

arcs for fracture types A, C1, and C2 were 118� (range, 70� to130�), 130� (range, 91� to 140�) , and 131� (range, 95� to 141�),respectively. The median percent losses of extension strengthfor fracture types A, C1, and C2 were 19.7%, 7.5%, and 0%,

Fig. 4-A

Fig. 4-B

Anteroposterior (Fig. 4-A) and lateral (Fig. 4-B) radiographs made seven-

teen months after fixation of the fracture shown in Figs.1-A and 1-B.

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respectively. Only one of the six patients with a type-C2 fracturepattern exhibited loss of extension strength (a loss of 23%). Thesingle type-B1 fracture in our series had a motion arc of 98� anda percent loss of extension strength of 13.8%. Type-C3 fracturesexhibited the greatest losses, with a median motion arc of 75�and a median extension strength loss of 29.7%.

The median time interval from the injury to surgery wasfour days (range, zero to ten days). Median quantile regressionanalysis showed no significant correlation between surgical delayand motion arc (b = 22.50, p = 0.5) or MEPI (b = 20.556, p =0.618). There was a significant positive correlation between sur-gical delay and percent extension strength loss (b = 2.97, p =0.011). DASH scores also showed a significant positive correlationwith increased surgical delay (b = 2.87, p = 0.034) and increasedage (b = 0.308, p = 0.009), indicating worse impairment. Ageshowed a significant positive correlation with percent extensionstrength loss (b = 20.498, p = 0.006). The MEPI showed nosignificant correlation with age (b = 20.125, p = 0.371).

The mean MEPI was 91.5 points (range, 65 to 100points), with fifteen excellent, seven good, and two fair grades.The mean DASH score was 15.9 points (range, 0 to 65 points),indicating mild impairment. SF-36 scores were not signifi-cantly different from known age and sex-matched populationmedians. There were no postoperative infections. Three elbowsunderwent a release because of stiffness. If an elbow had lessthan an approximately 70� arc of motion, the patient was of-fered a release. Of the three elbows that underwent a releasebecause of stiffness, one had had a type-C1 fracture and twohad had a type-C3 fracture.

Radiographic evidence of fracture union was noted in allpatients. No articular step-offs of >1 mm were seen. No mal-alignment of >5� in any plane was noted. However, we rec-ognize the inherent limitations of radiographs and that moreaccurate measurements of articular reduction would have beenprovided by follow-up computed tomography scans of theaffected elbows. One patient had evidence of posttraumaticarthritic changes at the time of final follow-up.

Two patients in our series experienced ulnar neuropathy.One case was noted preoperatively and resolved by the time ofthe latest follow-up. The second patient with ulnar nerve dys-function postoperatively had substantial comorbidities, includ-ing peripheral vascular disease and diabetes. The ulnar nervewas transposed subcutaneously to accommodate medial plateplacement and to eliminate nerve tension across the elbow. Thecomplete loss of ulnar nerve function is permanent.

Discussion

The optimal approach for ORIF of distal humeral fracturesthat provides the surgeon adequate visualization of the distal

part of the humerus and the articular surface but minimizesdisruption of the soft tissue and elbow extensor mechanism is stilla topic of investigation. Many surgical approaches have beendescribed, each with inherent advantages and complications2-6,11,17.Traditionally, an olecranon osteotomy approach has been the goldstandard for distal humeral exposure3,21,22. However, with in-creased exposure comes additional potential complications, in-

cluding delayed union or nonunion of the olecranon, additionalulnar nerve exposure, implant-related issues, and implant promi-nence requiring additional surgery3,22.

There is limited literature regarding elbow motion, func-tional outcomes, and objective strength assessment following theextensor mechanism-on approach utilized in this study6,7,21,23,24.We hypothesized that an extensor mechanism-on approach fordistal humeral fractures with parallel or orthogonal plate con-structs would allow excellent healing, an elbow motion arc ex-ceeding 100�, and maintenance of extensor mechanism strength.

Ali et al. reported that 82% of their patients had normaland 18% had good postoperative triceps muscle strength in theirstudy of elbows treated with an extensor mechanism-on ap-proach; however, objective measurement of triceps strength losswas not reported13. We utilized a dynamometer to quantify amedian 10% loss of triceps strength and utilized each patient’suninvolved upper extremity as a control for comparison. Tricepsstrength loss did not differ significantly between dominant andnondominant elbows. This provides a treating surgeon with atangible number when discussing postoperative function ex-pectations with patients. We recognize that additional studies areclearly needed to more accurately assess triceps muscle strengthloss with this technique and to compare this strength loss withthat associated with other triceps-sparing techniques.

In our series, the mean DASH score of 15.9 points in-dicates mild impairment, which is comparable with the DASHscores ranging from 12 to 20 points reported in other stud-ies10,22. Overall elbow function assessment revealed a meanMEPI of 91.5 points, with fifteen excellent, seven good, two fair,and no poor grades, which is consistent with the results in otherpublished studies2,21,22,25. There were no significant differencesbetween the SF-36 scores and age and sex-matched controls17.The median arc of elbow motion was 126�, which is a func-tional motion arc that is comparable with those in otherpublished studies21,22,25. Morrey et al. studied fifteen commonactivities of daily living and determined that a 100� arc of elbowmotion was necessary to accomplish those tasks26. The reportedrate of heterotopic ossification following posterior approachesto the distal part of the humerus has ranged from 0% to 49%27.We observed only one case of heterotopic ossification, in apatient who developed radioulnar synostosis following severeipsilateral forearm fractures in addition to the distal humeralfracture. No prophylaxis against heterotopic ossification wasutilized for patients in this study.

In our series, the patients with a type-C3 fracture had theworst elbow motion, with a median arc of 75� (range, 60� to100�) and a median extension strength loss of 29.7%. Becauseof the small numbers and many variables in our study, we areunable to clarify whether this lesser motion arc was due to thefracture severity or surgical technique.

During the time period in which we performed the sur-gical procedures, there were three cases in which we attemptedto perform an extensor mechanism-on approach but convertedit to an olecranon osteotomy approach to allow better exposureof a comminuted type-C3 fracture. Although the senior au-thors still perform olecranon osteotomies for patients with

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more intra-articular comminution, extra-articular or simpleintra-articular split fractures seem amenable to an extensormechanism-on approach. We do not claim that this approachcan be used for all distal humeral fractures. However, it can beused to achieve high healing rates and restoration of elbowfunction in some cases. The decision to use this approach formore complex fracture types with substantial intra-articularcomminution, such as type-C3 fractures, should be made on acase-by-case basis after careful review of imaging studies andconsideration of the surgeon’s familiarity with the approach.One of the advantages of this approach is the ease with which itcan be converted to an olecranon osteotomy without additionalsoft-tissue trauma if the reduction cannot be obtained or beadequately assessed intraoperatively.

Our study had limitations. First, it had the limitationsinherent in its retrospective nature. Second, our patient num-bers were small overall and across fracture types. The inabilityto reach conclusions regarding elbow motion arc and extensionstrength loss according to fracture type should be considereda limitation. Third, the patients in whom the approach wasconverted to an olecranon osteotomy were not included in thestudy. If this investigation had been a prospective, comparativestudy, this would have been an important problem. However,our goal was to establish a baseline for functional elbow out-comes and motion following a specific approach for whichfollow-up data have been very limited to date. Fourth, many of

these patients had simpler fracture patterns. It is important tokeep this in mind when comparing elbow motion findings withthose of previous studies that involved more aggressive expo-sures with or without more complicated fracture patterns. Fifth,a portion of our study population (six patients) had associatedfractures of the upper extremity involving the shoulder, forearm,or wrist that added confounding variables. These limitationsmay diminish the value of this study with regard to assessingfracture healing and functional outcomes following open re-duction and internal fixation of distal humeral fractures with anextensor mechanism-on approach. n

Jason M. Erpelding, MDRobin High, MBA, MAMatthew A. Mormino, MDEdward V. Fehringer, MDDepartment of Orthopaedic Surgery and Rehabilitation(J.M.E., M.A.M., and E.V.F.) and Department of Biostatistics (R.H.),University of Nebraska Medical Center,981080 Nebraska Medical Center, Omaha, NE 68198.E-mail address for J.M. Erpelding: [email protected]

Adam Mailander, OTR/L531 West Carrine Drive, Lincoln, NE 68521

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outcomes following distal humeral fracture … following distal humeral fracture fixation with an...

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