Operative Management Of Intercondylar Fractures Of The Distal End Humerus In Adults
V GUPTA, N KALSOTRA, R GUPTA, T MOTTEN, M SINGH, Y Kamal
Keywords
intercondylar fracture, one third tubular plate, reconstruction plates, trans-olecranon approach.
Citation
V GUPTA, N KALSOTRA, R GUPTA, T MOTTEN, M SINGH, Y Kamal. Operative Management Of Intercondylar Fractures Of The Distal End Humerus In Adults. The Internet Journal of Orthopedic Surgery. 2009 Volume 17 Number 1.
Abstract
This is a prospective study which includes 26 adult patients of intercondylar fracture of distal humerus, both male (20 patients) and female (6 patients) of different age group treated with open reduction and internal fixation with 4.5 mm malleolar screw or 6.5 cancellous screw and reconstructed condyles of the humerus were fixed to the diaphysis with either dual reconstruction plates or one third tubular plates or small fragment DCPs preferably via trans-olecranon approach. Immediate post operative mobilization was started as patient was pain free. Most of the patients (50%) were between age group of 21-40 years. Mode of injury in 18 (70%) cases was road traffic accident and rest cases were due to fall from height. 20 cases (77%) belong to AO/ASIF classification C1 and14 case (54%) belong to Riseborough and Radin’s classification type III. 22 (85%) of 26 cases showed timely union at 18 weeks. Pain and stiffness in 3 (11.5%) patients, implant loosening in 3 (11.5%) patients were the common complications of this study. In our study 13 (50%) patients had range of motion (ROM) between 100 and 120 degrees. Based on Jupitar et al system 20 patients (77%) had ‘Excellent’ to ‘Good’ results and 6 patients (23%) had fair to poor results.
Introduction
Intercondylar fractures of the distal humerus are relatively rare and difficult to manage. Since the original description by
Mechanism of Injury
Material and Methods
This is a prospective study which includes 26 adult patients of intercondylar fracture of distal humerus, both male and female of different age group treated in the Department of Orthopaedics, Government Medical College Jammu. Once the General Condition stabilized, patients were sent for X-rays and fracture was classified according to AO/ASIF as well as Riseborough and Radins’s classifications. However compound fractures were thoroughly irrigated with Normal saline, antiseptic dressing done, limb splinted and then sent for x-rays.
Operative Technique
Anaesthesia and Position
General anaesthesia was given and then patient was turned in either lateral or prone position with elbow flexed at 900 and supported on one side of the table. Tourniquet was applied; whole of upper limb was painted with iodine solution and draped with sterile sheets. Tourniquet was inflated and time noted.
Approach
About 20 cm long incision was given extending about 10 cm proximal and 10 cm distal to the elbow joint on the posterior aspect. Subcutaneous tissue and fascia was incised in the line of skin incision. Ulnar nerve is identified first and is retracted medially with a finger of gloves.
Fracture site was exposed either through a trans-olecranon approach or campbell’s posterior approach.
Assembling of fragments of distal humerus:
Both the condyles were reduced and held together with the help of bone holding clamps. Condyles are temporarily fixed with K-wires and then with 4.5 mm malleolar screw or 6.5 mm cancellous screws of adequate length. K-wire is now removed and stability as well as congruity of joint surface was assessed.
After the reduction of condyles to the humerus metaphysis, fixation is done with either single or dual (contoured) reconstruction plates or one third tubular plates or sometimes small fragment DCP and cortical screws. K-wires, malleolar screws or cancellous screws can be used in addition.
When transolecranon approach was used, the osteomised olecranon was re-fixed with Tension Band wire.
Post-operatively
Bulky dressing was done and above elbow POP slab applied. Limb was elevated and broad spectrum antibiotics and analgesics continued. Active finger movements were started immediately once the patient was conscious.
Post operative elbow mobilization is started as soon as pain subsided or as and when patient was comfortable or sometimes delayed if fixation was not reliable or if there is gross osteoporosis or if fracture was severely comminuted. Drain was removed after 24-48 hrs.
Follow up
Physiotherapy was continued and in some cases under the supervision of physiotherapist. At each follow up the parameters like pain, swelling, ROM, Disability, complication and rate of union were assessed. Time of clinical and radiological union was recorded.
The results were graded according to Jupiter et al system as excellent, good, fair and poor.
Observations
Majority of patients 22 (85%) were in the age group of third to sixth decade (Table 1). There were 20 males (80%) and 6 females (20%) (Table 2). RTA was the commonest mode of injury (70%) and the next common mode was fall in 8 patients (30%) (Table 3). 20 cases (77%) belong to AO/ASIF classification C1 (Table 4) and14 case (54%) belong to Riseborough and Radin’s classification type III (Table 5). 22 (85%) of 26 cases showed timely union at 18 weeks (Table 6).In 14 (54%) the radiological union time was 6-12 weeks (Table 7). Pain and stiffness in 3 (11.5%) patients, implant loosening in 3 (11.5%) patients were the common complications of this study (Table 8). In our study 13 (50%) patients had range of motion (ROM) between 100 and 120 degrees (Table 9). Based on Jupitar et al system 20 patients (77%) had ‘Excellent’ to ‘Good’ results and 6 patients (23%) had fair to poor results (Table 10).
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Discussion
Intercondylar fracture of distal humerus is a relatively rare injury and is one of the most difficult fractures to manage with its inherent complications. The rarity of the fracture and intricate anatomy of the region makes this fracture among one of the difficult fractures to treat. The recent literature shows that operative treatment has better results than closed methods. If this injury is not managed appropriately, it can result in prolonged morbidity and even permanent stiffness of Elbow causing lot of disability.
The results were graded according to Jupiter et al system.
20 (77%) patients had ‘good’ to ‘excellent’ results. 6 patients (23%) had “poor” to “fair” results.
Poor or fair results were seen in 2 cases of extensive comminution, 2 cases of type II, III compound fractures, 1 case of implant loosening and 1 case of floating elbow.
Although this is a small study with a short follow up but we conclude that attainment of congruous articular surface is possible with open reduction only. This principle of congruous articulation combined with biological stable reconstruction of medial and lateral pillar supports while respecting the soft tissue attachments and early postoperative mobilization seems to be the goal of the study to achieve excellent functional result.
Conclusion
Keeping in view the results of other authors as well as the results of our series, we finally concluded that the treatment of the Intercondylar fracture of the distal end of the humerus in adults with open reduction and rigid internal fixation has much better functional and anatomical results as compared to conservative treatment. And we recommend operative treatment of these fractures for good to excellent results in experienced hands when all other factors are favorable.