Muller Journal of Medical Sciences and Research

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 10  |  Issue : 2  |  Page : 51--57

Distribution of AO13-C fractures and results of double plating using triceps V-shaped transection versus olecranon osteotomy approach


Tae-Song So, O Chang-Hwan, Gyong-Il Kim, Hyon-Ho Pak 
 Department of Trauma and Orthopaedic Surgery, Pyongyang Medical College, Kim Il Sung University, Pyongyang, Democratic People's Republic of Korea

Correspondence Address:
Dr. Tae-Song So
Department of Trauma and Orthopaedic Surgery, Pyongyang Medical College, Kim Il Sung University, Pyongyang
Democratic People's Republic of Korea

Abstract

Purpose: The purpose of this study is to investigate the distribution of AO13-C fracture and evaluate the surgical results of olecranon osteotomy approach and triceps V-shaped transection approach. Materials and Methods: Retrospective analysis of 86 patients with intraarticular fracture of distal humerus treated with double plating through olecranon osteotomy or triceps V-shaped transection approach between January 2007 and May 2015 was conducted. Distribution in relation to age, gender, side, injury mechanism, concomitant injury, fracture type, and soft-tissue injury was investigated and evaluation of surgical results was performed. Results: Most patients were female, totaling 60 (69.77%). Of 60 female patients, ones aged 40–49 years were 26 (approximately 43.3%). Regardless of gender, most cases, 64 (74.4%) in all, occured on the left arm. Injury mechanisms of fifty cases (58.1%) were simple fall. In 18 cases occured by fall from height ipsilateral distal radial fracture were revealed, totalling 6 (33.3%). According to AO classificaiton, 74 (86%) cases were AO13-C2. At the time of the latest follow-up, flexion arc was 118° ± 1.1° in the triceps transection whereas 100° ± 1.1° in the olecranon osteotomy (P < 0.05). Conclusion: AO13-C fractures were occurred most commonly in the middle-aged women of forties, mainly on the left arm, by simple fall, with the similar configuration to AO13-C2.2 or Riseborough and Radin type II. In the fall from height ipsilateral distal radial fracture must be examined closely. Final functional range of motion, interestingly, was better in triceps V-shaped transection than olecranon osteotomy, implying the importance of postoperative physical therapy and relatively good prognosis of elbow injury in general.



How to cite this article:
So TS, Chang-Hwan O, Kim GI, Pak HH. Distribution of AO13-C fractures and results of double plating using triceps V-shaped transection versus olecranon osteotomy approach.Muller J Med Sci Res 2019;10:51-57


How to cite this URL:
So TS, Chang-Hwan O, Kim GI, Pak HH. Distribution of AO13-C fractures and results of double plating using triceps V-shaped transection versus olecranon osteotomy approach. Muller J Med Sci Res [serial online] 2019 [cited 2020 Feb 23 ];10:51-57
Available from: http://www.mjmsr.net/text.asp?2019/10/2/51/276693


Full Text



 Introduction



A variety of classifications have been developed, and epidemiology and short-term/long-term surgical results of intraarticular fracture of distal humerus (AO13-C) have been well studied in the previous studies.[1],[2],[3],[4],[5],[6],[7],[8],[9] Some authors suggested that distal humerus fractures in adults are relatively uncommon, accounting for about 2%–6% of all fractures and for about 30% of all elbow fractures.[2],[8],[9] In an epidemiologic study, there was a bimodal distribution with respect to the patients'age and gender. Peaks of incidence were described in males age 12–19 years and in females age 80 and older.[8] Distribution of this fracture, however, is somewhat different according to regions or countries. Furthermore, double plating of distal humerus through the olecranon osteotomy has become the treatment of choice, resulting in good or excellent results,[1],[10] but comparative investigation of surgical results using triceps V-shaped transection versus olecranon osteotomy approach, to our knowledge, has been less done yet. The purpose of this study is to investigate the distribution of AO13-C fracture and comparatively evaluate the surgical results of olecranon osteotomy approach and triceps V-shaped transection approach.

 Materials and Methods



We retrospectively investigated 86 patients with AO13-C fracture operated in the Department of Trauma and Orthopaedic Surgery, Pyongyang Medical College Hospital from January 2007 to May 2015. Distribution in relation to age, gender, side, mechanism of injury, concomitant injury, fracture type, and soft-tissue injury was recorded and analysed, presenting tables, histograms, or illustrative figures.

Surgical treatment

All patients were operated with double plating technique, 36 cases of whom through olecranon osteotomy approach and others through triceps V-shaped transection approach [Figure 1]. In all cases orthogonal double plating usnig locking compression plates (LCPs), conventional plates, or 1/3 tubular plates were applied. Trochlea was fixed with a lag screw, either combined with a 2 mm Kirschner wire or not.{Figure 1}

Postoperative care

In case of olecranon osteotomy approach, early mobilization of the elbow was allowed immediately after removal of suction drain, while in the patients operated through triceps V-shaped transection approach, the elbow was immobilized in about 45° of flexion for 4 weeks, after which time rehabilitation for elbow stiffness was begun.

Comparison of short-term and long-term results

To compare short-term and long-term surgical results between olecranon osteotomy and triceps V-shaped transection approach, wound healing problem, days of immobilization, recovery of motion at 1 and 6 months, final range of motion (ROM) of elbow at the time of the latest follow-up, and functional outcome measures such as American Shoulder and Elbow Surgeons (ASES), Mayo Elbow Performance Index (MEPI), Disabilities of the Arm, Shoulder and Hand (DASH), and Visual Analog Scale (VAS) at average of 5 years (2–9 years after operation) were assessed.

T-test was performed to assess the siginificance of results. The mean follow-up period was 5 years (range, 2–9 years).

 Results



Distribution of cases

Distribution in relation to age, gender, and side

Most patients were female, totaling 60 (69.77%) among 86 patients with approximately 2.3:1 of ratio between female and male patients. Of 60 female patients, ones aged 40–49 years were 26 (approximately 43.3%). The mean age was 45.5 years (range 13–78 years) for female patients and 34.8 years (range 13–69 years) for male patients. In male patients (total 26), this fracture was usually seen in the group of age 30–39, occuring in 10 cases (38.5%).

Moreover, this fracture was more commonly occured on the left arm than on the right both in female and male patients, totaling 46 on the left, 14 on the right for female patients and 18 on the left, 8 on the right for male. Regardless of gender, 64 (74.4%) in all were occured on the left arm and 22 (25.6%) on the right, thus the ratio of left versus right was about 2.9:1 [Table 1] and [Figure 2].{Table 1}{Figure 2}

Distribution in relation to mechanism of injury, soft tissue injury, gender, age, fracture type, and concomitant injury

Of mechanisms of injury, simple fall was the most common in the occurence of intraarticular fracture of distal humerus; injury mechanisms of 50 cases (58.1%) were simple fall. Among 86 patients, 82 patients had closed injuries, accounting for about 95.3%. Patients (especially women) of ≥40 years (54 in all) were mainly injured by falling on the extended arm, counted as 50 cases (92.6%), while young adults younger than 40 (32 cases in all) were usually injured by high energy mechanism such as fall from height most commonly, counted as 18 cases (56.3%).

Concomitant injuries were rare, but in the cases occured by fall from height (total 18), ipsilateral distal radial fractures were revealed, totalling 6 (33.3%). According to AO classification, 4 cases (4.7%) were AO13-C1, 74 (86%) cases – AO13-C2, and 8 cases (9.3%) – AO13-C3. Actually, the frature type similar to AO13-C2.2, or Riseborough and Radin type II was most commonly occured [Figure 3], [Figure 4], [Figure 5] and [Table 2].{Figure 3}{Figure 4}{Figure 5}{Table 2}

Short-term postoperative results

Postoperative infection was mostly superficial, occuring in both olecranon ostetomy group and triceps V-shaped transection group, 5 cases (13.9%) and 8 cases (16%) respectively. Significant difference in infection rate was not revealed. Deep infection that required secondary procedure was occured in only one case operated through triecps V-shaped transection. In this case, because tip of the V-shaped transected triceps aponeurosis was necrosed, cleansing, irrigation and suction drain in place were performed so that delayd healing without removal of implants was achieved.

Postoperative immobilization was applied in the triceps transection group with splinting in flexion of 45° for 4 weeks, whereas early mobilization immediately (usually 24–48 h) after removal of drain was applied in the olecranon osteotomy group. At 1 month after operation, all patients operated with olecranon osteotomy returned to almost normal flexion angle (about 120° at average) and began more active exercises, but ones treated with triceps transection had stiffness of elbow because of splinting elbow for 4 weeks and began rehabilitation protocol from that time by removing splint [Figure 6] and [Figure 7]. In the group operated with triceps transection, recovery of functional ROM was taken 2.5 months at average (range 2–3.5 months after operation). At 6 months postoperatively, ROM was 100° ± 1.0° in the olecranon osteotomy group excluding one elbow salvaged with an arthrodesis and counted as a poor result, 110° ± 1.1° in the triceps transection group. In addition, all patients operated through triceps transection recovered the functional extension range more rapidly (recovered within 1 month of rehabilitation protocol) and better than flextion, while vice versa in ones operated through olecranon osteotomy [Table 3]. Final flextion degree in all patients was almost same, over 130°, showing no significant difference. Pronation and supination of forearm were not compromised in both groups, returning to almost normal range.{Figure 6}{Figure 7}{Table 3}

Long-term postoperative results

At average of 5 years (range 2–9 years) after operation, ASES, MEPI, DASH and VAS were not significantly different, althogh some patients operated through the triceps V-shaped transection approach, especially whose job required repeated elbow flexion and extenion (e.g., barber), complain of local fatigue. Excluding one case of arthrodesis, the average ASES score was 95 and 94 points, with an average satisfaction score of 8.9 and 9.0 points on a 0–10-point visual analog scale, in olecranon osteotomy and triceps transection group respectively. The average DASH score was 8 points in both group, and the average MEPI score was 93 and 94 points, respectively.

Final functional ROM, interestingly, was significantly bettter in the group of triceps transection than olecranon osteotomy although the patients operated through olecranon osteotomy began immediate motion of elbow; flexion-extension range was 118° ± 1.1° in the triceps transection while 100° ± 1.1° in the olecranon osteotomy (P< 0.05). Especially extenion loss was ranged from 20° to 35° in the olecranon osteotomy, but it was 10°–20° in the triceps transection.

 Discussion



Distal humerus fractures in adults are relatively uncommon. They account for about 2%–6% of all fractures[2],[9] and for about 30% of all elbow fractures.[8] There was a bimodal distribution with respect to the patients' age and gender in Edinburgh. Peaks of incidence were described in males age 12–19 years and in females age 80 and older.[8] In this investigation, however, as shown in [Table 1] and [Figure 2], most patients were female, totalling 60 (69.77%) among 86 patients with approximately 2.3:1 of ratio between female and male patients. Of 60 female patients, ones of age 40–49 years were 26 (approximately 43.3%). The mean age was 45.5 years (range 13–78 years) for female patients and for male patients 34.8 years (range 13–69 years). This implys indirectly that the bone mineral density (BMD) of the humerus of women begins decreasing from the age forty and this result is also consistent with the previous domestic study that showed the changes in BMD with age in the humerus of Korean women, in which the BMD significantly decreased from age forties.

In this study, most cases were middle-aged women of 40 years and older, usually injured by simple fall, indicating that the BMD of women older than forty is getting decreased. Of mechanisms of injury, simple fall was the commonest in occurence of intraarticular fracture of distal humerus; injury mechanisms of 50 cases (58.1%) were simple fall, [Table 2], which was consistent with the previous study.[8] Most patients (especially women of age forty and older) were mainly injured by falling on the extended arm, while young adults younger than 40 were usually injured by high energy mechanism such as fall from height or traffic accident most commonly.

Taking the findings of this study and the reports in the literature[1],[3],[4],[6],[9],[10] into account, we agree that the use of LCPs in a 90° configuration is more favorable. Therefore, female patients older than forties and old male patients with this fracture should be operated with LCP double plating placed in the orthogonal way, although conventional plates can be used in other cases.

Moreover, this fracture, interestingly, was more commonly occured on the left arm than on the right both in female and male patients, totalling 46 on the left, 14 on the right for female patients and 18 on the left, 8 on the right for male. Regardless of gender, the total number of cases was 64 (74.4%) on the left arm and 22 (25.6%) on the right, indicating the ratio of left versus right was about 2.9:1. Of course, this investigation was not a general demographic study. So the more detailed demographic study is needed. Among 86 patients, 82 patients had closed injuries, accounting for about 95.3%; open injuries were mostly seen in traffic accidents [Table 2]. Concomitant injuries were usually seen in the cases occured by fall from height; ipsilateral distal radial fractures were revealed, totalling 6 (33.3%) among 18 cases. Mehne and Matta described complex bicolumnar distal humeral fractures according to the configuration formed by the fracture lines: high or low T-fractures, Y-fractures, H-fractures, and medial and lateral Lambda-fractures.[10] When analyzing the distribution according to Mehne and Matta classification in this investigaton, typical T or Y fracture configuration of distal humerus were not seen and almost all fracture types were not pertained to this classification, showing the poor practicality of this classification. In this investigation AO classification was more practical and easier to use rather than any other classification. All cases could be classified according to AO classificaiton; 4 cases (4.7%) were AO13-C1, 74 (86%) cases, AO13-C2, and 8 cases (9.3%), AO13-C3. Actually the frature type similar to AO13-C2.2, or Riseborough and Radin type II was most commonly occured [Figure 3], [Figure 4], [Figure 5]. When the patient falls on his/her extended arm, an axial loading force is probably produced to allow trochlear notch of ulna to act as a hammer on the trochlea of the distal humerus, thus producing an impaction of the articular surface.

Short-term postoperative results

Distal humerus fractures in adults are treated by open reduction and internal fixation, which produces good results in the majority of patients. However, some complications still remain. In this study, we didn't find any difference in results according to internal fixation implants, but we believe that LCP should be applied due to its biomechanical, biological and surgical advantages. Most postoperative infections were just superficial ones that were revealed in both olecranon ostetomy group and triceps V-shaped transection group; 5 cases (13.9%) and 8 cases (16%), respectively. Significant difference in infection rate was not revealed. Deep infection that required secondary procedure was occured in only one case operated through triecps V-shaped transection. In this case, because tip of the trasected triceps aponeurosis was necrosed, cleansing, irrigation and suction drain in place were performed so that delayed healing was achieved without removal of implants.

Postoperative immobilization was applied in the triceps transection group with splint for 4 weeks, whereas early mobilization immediately (usually 24–48 h) after removal of drain was applied in the olecranon osteotomy. That is, eary mobilization in the case of triceps transection was impossible, which is a major pitfall. In the group treated with triceps transection, recovery of functional ROM was taken 2.5 months at average, requiring the help of professionfal physical therapists. Prolonged immobilization usually is believed to lead to persistent stiffness so that active motion is started early to produce the best possible result. At 6 months postoperatively, ROM, however, was 110° ± 1.1° in the triceps transection group and 100° ± 1.0° in the olecranon osteotomy group excluding one elbow salvaged with an arthrodesis and counted as a poor result.

Long-term postoperative results

Olcecranon osteotomy has many adavantages, so it has been commonly used. It provides the best exposure to the articular surface of distal humerus and allows the early motion of elbow without pain, which is impossible in case of triceps transection approach. Splinting of at least 4 weeks makes the patient's elbow stiff so that when resolving the stiffness, patients suffer a great.

It is usually recognized that recovery of flexion is usually rapid, whereas extension recovers more slowly and is more often incomplete, with a residual lag of 20°–30°. Final functional ROM, however, interestingly, was bettter in the group of triceps transection than olecranon osteotomy; flexion-extension range was 118° ± 1.1° in the triceps transection while 100° ± 1.1° in the olecranon osteotomy. Especially extenion loss was ranged from 20° to 35° in the olecranon osteotomy, but 10°–20° in the triceps transection. In addition, all patients operated through triceps transection have recovered the extension more rapidly and easily than flextion, while ones operated through olecranon osteotomy have recovered the flexion more rapidly and easily than extension. This is inconsistent with the previous data (showed that disabling stiffness develops if the elbow is immobilized for more than 3 weeks, thus early motion is necessary)[11] and presents the importance of postoperative physical therapy. Longer immobilization is known to negatively influence functional outcome; but, in the case of elbow (that is, perfectly reconstructed elbow), physical therapy can compensate that. Of course, this result doesn't mean triceps transection approach is superior than olecranon osteotomy. We agree that olecranon osteotomy approach should be the first choice, but this long-term result is kind of disappointing. 20°–30° of extension loss results in no problem when performing activities of daily living, some cases, however, showed undesirable extension loss over 30°. In case of olecranon osteotomy, we wonder if partial excision of olecranon osteotomy can be effective in recovering of elbow motion, which is further considered.

For all patients, most activities of daily living were performed with a pain-free functional arc of elbow movement. Other score indices such as ASES, MEPI, DASH and VAS were not significantly different at an average of 5 years (range 2–9 years).

 Conclusion



When analyzing the distribution of AO13-C fracture, it was occurred most commonly in the middle-aged women of forties, mainly on the left arm, by simple fall, with the similar fracture configuration to AO13-C2.2 or Riseborough and Radin type II. In the fall from height ipsilateral distal radial fracture must be examined closely. Short-term results were better in olecranon osteotomy than triceps V-shaped transection, but long-term results were vice versa in ROM. Elbow has a relatively good prognosis in general, approaches and postoperative care, however, should be improved further.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Thanks to the free medical care system in our country the state funds all the therapies, drugs, cesarean section and so on.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional and National Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflicts of interest

There are no conflicts of interest.

References

1Doornberg JN, van Duijn PJ, Linzel D, Ring DC, Zurakowski D, Marti RK, et al. Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years. J Bone Joint Surg Am 2007;89:1524-32.
2Jupiter JB, Morrey BF. Fractures of the distal humerus in the adult. In: Morrey BF, editor. The Elbow and its Disorders. 2nd ed. Philadelphia Pa: WB Saunders; 1993. p. 328-36.
3Korner J, Diederichs G, Arzdorf M, Lill H, Josten C, Schneider E, Linke B. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma 2004;18:286-93.
4Korner J, Lill H, Müller LP, Rommens PM, Schneider E, Linke B. The LCP-concept in the operative treatment of distal humerus fractures--biological, biomechanical and surgical aspects. Injury 2003;34 Suppl 2:B20-30.
5Pajarinen J, Björkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elbow Surg 2002;11:48-52.
6Palvanen M, Kannus P, Parkkari J, Pitkäjärvi T, Pasanen M, Vuori I, et al. The injury mechanisms of osteoporotic upper extremity fractures among older adults: A controlled study of 287 consecutive patients and their 108 controls. Osteoporos Int 2000;11:822-31.
7Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in twenty-nine cases. J Bone Joint Surg Am 1969;51:130-41.
8Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM. Adult distal humeral metaphyseal fractures: Epidemiology and results of treatment. J Orthop Trauma 2003;17:38-47.
9Rose SH, Melton LJ 3rd, Morrey BF, Ilstrup DM, Riggs BL. Epidemiologic features of humeral fractures. Clin Orthop Relat Res 1982;(168):24-30.
10Terry Canale S, Beaty J. Campbell's Operative Orthopaedics. 12th ed. Missouri: Mosby; 2012. p. 2862-3.
11Waddell JP, Hatch J, Richards R. Supracondylar fractures of the humerus–results of surgical treatment. J Trauma 1988;28:1615-21.