CASE SERIES


https://doi.org/10.5005/jojs-10079-1121
Journal of Orthopedics and Joint Surgery
Volume 5 | Issue 2 | Year 2023

Distal Humerus Intra-articular Fractures Fixed by 90–90 Plating and Functional Analysis: A Case Series


Thiyagaraj Chandramohan1https://orcid.org/0009-0001-0363-7758, Thirunarayanan Vasudevan2

1,2Department of Orthopedic Surgery, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India

Corresponding Author: Thiyagaraj Chandramohan, Department of Orthopedic Surgery, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India, Phone: +91 9445663115, e-mail: cthiya@gmail.com

Received on: 12 June 2023; Accepted on: 03 July 2023; Published on: 07 July 2023

ABSTRACT

Background: Young adults and the elderly frequently suffer from distal humerus fractures. Although internal fixation technology has advanced, treating these fractures still poses difficulties. Both orthogonal and parallel plating offer sufficient functional outcomes and mechanically stable structures that enable early mobilization and a wider range of motion.

Aim: The aim of the study is to assess the clinical as well as functional results of these fractures operated with orthogonal plating.

Study and design: Prospective study in Government Royapettah Hospital, Chennai, Tamil Nadu, India.

Materials and methods: A total of 25 patients with comminuted fractures of the distal humerus from January 2012 to 2017 in the age-group of 18–65 years were included in the study and were operated on with orthogonal plating. All the patients were followed at 3, 6, 12, and 24 weeks, and at 1 year. During follow-up, patients were assessed in terms of time for union, range of motion, Mayo score, disabilities of the arm, shoulder and hand (DASH) score, and complication rate.

Results: At the final follow-up, Mayo score was 96.32 ± 04.96 from 5.00 ± 01.26, and the DASH score was 31.42 ± 2.04, which dropped from 150 ± 05.34, range of motion improved from 21.38 to 116.1 with 100% union rate and complications <17%.

Conclusion: Orthogonal plating is an excellent method for fixing the distal humerus, which is biomechanically stable, providing an advantage of early mobilization with a fracture union rate comparable to other studies with good to excellent outcomes according to the Mayo and DASH scores with minimal complications. Olecranon osteotomy provides good exposure to the fracture, which aids in the anatomical reduction of the fracture.

How to cite this article: Chandramohan T, Vasudevan T. Distal Humerus Intra-articular Fractures Fixed By 90–90 Plating and Functional Analysis: A Case Series. J Orth Joint Surg 2023;5(2):86-91.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Distal humerus, Mayo elbow performance score, Olecranon osteotomy, Orthogonal, Unstable, 90–90.

INTRODUCTION

Of all the fractures, about 2–6% and about 30% of all elbow fractures are constituted by distal humerus fractures.1 Bimodal age distribution exists for the prevalence of distal humerus fractures. In younger age-groups, high-energy trauma is the cause, but low-energy falls are the main cause in the elderly. Mechanism of the injury, soft tissue condition, quality of bone, age of the patient, and physical demands should be taken into consideration on choosing the modality of management. Every orthopedic surgeon faces difficulty while treating distal humerus fractures due to the emergence of more modern fixing methods. It is challenging to get satisfactory outcomes because of the complicated architecture of the elbow and metaphyseal and articular comminution.2 Positive benefits are produced by an anatomical reduction, strong fixation, and an early range of mobility.3 With an intra-articular involvement and failure to achieve good control of the fracture fragments with closed treatment, distal humerus fractures should be treated surgically. In order to accomplish an anatomic reduction and a stable fixation of the broken fragments, distal humerus fractures are, therefore, surgically treated.4 In a comminuted intra-articular fracture of the distal humerus, both columns’ fixation of the distal humerus is required.5-7 In order to adequately stabilize the articular, metaphyseal, and diaphyseal areas of the distal humerus, several plates have been designed to match the specific structure of the distal humerus. A recon plate that is molded to the anatomy of the distal humerus, a Y-shaped plate, and precontoured plates with or without locking screw capabilities are some of the plates used to treat distal humerus fractures. The literature has discussed the anatomical placement of the plates on the distal humerus, with the majority of writers favoring two plates to offer appropriate stability and enable a sufficient restoration of the distal humerus morphology. Perpendicular plating or 90-90 plating other names for the orthogonal plating technique. Placing two plates includes placing one along the posterolateral column and the other on the medial column. A total of 25 participants who had just undergone the orthogonal plate fixation procedure for fresh distal humerus plating participated in our prospective research.

MATERIALS AND METHODS

This investigation included all newly reported communicated intra-articular distal humerus fractures (AO/OTA–13C3) in patients aged 18–65 who reported to us between January 2012 and January 2017. The permission of the institutional ethics committee was attained. All patients provided written consent after being fully informed. A total of 25 participants participated in this prospective trial. Patients who had a preexisting deformity, a disability, an infection, had undergone surgery on the elbow involved before, were deemed unfit for surgery, or failed to give their consent, were excluded.

Following the completion of necessary preoperative tests and confirmation of their eligibility for anesthesia, the patients were scheduled for surgery. After the regional or general anesthesia, they were placed on their side with their arm supported and hanging down, and the limb was covered, painted, and draped. The surgeon made an incision 5 cm below the tip of the elbow bone and 8 cm above it, using the standard midline posterior approach to expose the elbow. The ulnar nerve was then dissected and secured. And to improve the visibility of the joint surface, the surgeon performed an olecranon osteotomy in either a “V” or transverse shape.

The patients’ bone fragments were temporarily reduced and held in place using K-wires. To repair the fracture, an intercondylar screw was utilized, followed by two perpendicular plates covering the distal humerus’ medial and posterolateral columns. The elbow’s full range of motion was then tested after secure internal fixation. The olecranon osteotomy was minimized and secured using a figure of “8” tension band wire or a 6.5 mm cancellous screw. Stability was evaluated by testing the elbow’s range of motion once more. The wound was closed in layers and a negative suction drain was installed before a sterile pressure bandage was applied. The patient was given intravenous antibiotics 6 hours before surgery and continued till the 2nd postoperative day. Then, oral antibiotics were given for 5 more days. During the postoperative period, the limb was kept elevated, and active movement of fingers and the elbow joint was encouraged. The suction drain was removed on the 2nd postoperative day and the wound was inspected 3–4 days after the surgery. Analgesics were given until the sutures or staples were removed on the 12th postoperative day. Radiographs were obtained after the patient was comfortable. The elbow was moved through its full range of motion at least twice a day, with active physiotherapy activities performed. Follow-up evaluations were scheduled for the patient at 6, 12, and 24 weeks postsurgery. A thorough clinical examination was conducted, and the patient’s subjective pain, swelling, range of motion, and radiological union were evaluated. The patient’s functional status was evaluated using the disabilities of the arm, shoulder and hand (DASH) and Mayo elbow performance scores.

RESULTS

Patients were instructed to perform active physiotherapy of flexion and extension, pronation, and supination exercises. The elbow was mobilized through its full range of motion at least twice a day. Loading of the involved arm was avoided. Following surgery, the patients were reviewed and evaluated at the end of 6, 12, and 24 weeks. During the postoperative follow-up clinical evaluation, the patient’s subjective pain, swelling, range of motion, and radiological union were reviewed and recorded. The functional status of the patient was evaluated based on the scores of Mayo elbow performance and DASH protocol.

Road traffic accident in 16 patients (64%) was the cause of injury; in nine patients, fall from height was the cause of injury.

A total of 16 (69.6%) patients had a right-side involvement.

Patients in our study presented to us within 1 week of the injury. All patients in our study had no distal neurovascular involvement. There was an associated injury of pelvic fracture and femoral shaft fracture in one of our patients. According to the fracture morphology, a high T-type in nine patients, H-type in six patients, and a low T-type in eight patients was found, accounting for 36, 24, and 32%, respectively, and Y-type in two (8%) patients.

Surgery management duration ranged over from 150 to 180 minutes, with a mean of 157 minutes. All our patients in the study were followed up for 1 year. Two patients, after 6 months, were lost to follow-up. Minimal induration and edema along the suture line with a rise in local skin temperature were observed in four patients at 3 weeks of follow-up. This same was treated with oral antibiotics and nonsteroidal antiinflammatory drugs as it was taken as a sign of subclinical infection. Within 10 days of initiation of treatment, the induration and edema subsided. The initial Mayo score in the 1st-week postoperative was 5.00 ± 01.26. The scores increased gradually to 96.32 ± 04.96 at the end of the 1-year follow-up. In 1st week following surgery mean DASH score was 150 ± 05.34, which decreased to 31.42 ± 2.04 at the 1-year follow-up. The range of motion at the 1st week of postoperative follow-up of 21.38 ± 05.70 improved to 116.1 ± 7.92 by the end of 1-year follow-up (Table 1). The improvement of range of motion, Mayo, and DASH score and their statistical significance are shown in Table 1. At the final assessment, a full range of motion along with a united fracture without any angular or rotational deformity was seen in 17 patients. Around five patients had 5° short of full extension with fracture union and without any angular or rotational deformity, and the remaining patients had 15° short of full extension with united fracture and without any angular or rotational deformity (Figs 1 to 3).

Table 1: Showing comparative data of different clinical and functional parameters
Time interval Range of motion Mayo score DASH score
Mean Mean Mean
1st postoperative week (10–50) 21.38 (15–30) 18.8 (120–167) 150
3 weeks follow-up (10–95) 71.67 (60–75) 66.43 (70–80) 73.56
6 weeks follow-up (80–115) 98.33 (70–90) 82.6 (31–46) 38.16
3 months follow-up (95–120) 111.46 (85–100) 90.8 (30–37) 32.80
6 months follow-up (95–120) 115.0 (85–100) 93.8 (30–37) 31.64
1-year follow-up (95–120) 116.1 (85–100) 96.4 (30–37) 31.32

Figs 1A to C: Surgical illustration of 90-90 plate placement

Figs 2A to C: Case 1 preoperative, follow-up

Figs 3A to C: Case 2 preoperative, postoperative, and clinical photo

DISCUSSION

All 25 participants in our research received orthogonal plating as the surgical management for the intra-articular distal humerus fracture. Olecranon osteotomy was used in all 25 patients. Olecranon osteotomy helped to achieve an appropriate reduction and implant placement while providing great exposure to the fracture. We want to talk about and contrast our study with a few other comparable studies that have been published in the past.

Within 4 months, the union was achieved in all of our patients. According to the majority of research, nonunion or delayed union is not an issue with these fractures. In our series, the mean range of motion (116 ± 17.92) at the last follow-up is higher than that which has been reported by certain writers.6,10,14 However, some reports15-17 assert that patients have a complete or nearly complete range of motion after surgery. The range of Mayo scores in various research is between 72.3 and 96.32. Only one study has shown that Mayo scores higher than 90 can be obtained.8 Considerably younger age distribution of the study group may be responsible for higher Mayo scores in our study. This suggests that rigorous physical rehabilitation during the first 3 months following surgery might maximize benefit (Table 1). An anatomically stable fixation is essential for initiating early physical rehabilitation and betterment of the range of motion. In the literature, the rate of complication varies from 6 to 44.4%. Three superficial and one deep suture line infections, all of which were treated with antibiotics, were found in our investigation.

Only one researcher compared perpendicular and parallel plating in a single study.16 A comparison of the functional outcome of the current study with orthogonal plating studies in terms of union rate and functional outcome, range of motion, Mayo, DASH scores, and complication was done based on the findings presented in the literature (Table 2). When the results of our investigation and those from previous studies reporting functional outcomes following orthogonal plating were compared, no significant differences were identified with regard to union time, Mayo, and DASH scores (Table 2). The plates behave the same whether they are parallel or perpendicular. Based on this measure, complication rates might be noticed. With regard to the range of motion, our results are comparatively better. The Mayo scores further suggested a superior result in the current trial. Our findings concur with other researchers’ findings. Additionally, they found no discernible difference between the two techniques in terms of functional outcome.9,10,15 Excellent union rate, range of motion, and functional ratings were attained. Based on the outcomes of the current investigation, we support the orthogonal plating approach since the results are favorable.

Table 2: Showing functional outcome of the present study and perpendicular plating
S. no. Author Sample size Follow-up Union Range of motion Mayo elbow performance score DASH Complication
1 Sanchez-Sotelo et al.4 32 24 months 81.3% 99° 85 18.7%
2 Athwal et al.14 32 27 months 100% 97° 82 24 53%
3 Theivendran et al.7 16 35 months 100% 103° 72.3 46.1 12.5%
4 Atalar et al.18 31 28 months 100% 90.2° 86.1 7.6 29.0%
5 Rebuzzi et al.15 7 (a)
6 (c)
14.8 months
21.3 months
100%
100%
120°
113°
92.86
94.17
46.2%
6 Shin et al.16 18 100% full 44.4%
7 Lan et al.10 21 16 months 100% 101° 86.1
8 Lee et al.9 33 100% 6.0%
9 Flinkkilä et al.17 47 3.9 years 93.6% 123° 88 15%
10 Present study 25 12 months 100% 116° 96.32 31.42 17.0%

The idea of orthogonal plating emerged when parallel plating proved to be technically challenging and insufficiently fixative and stable in a significant portion of coronal fracture instances. On the basis of a few cadaver investigations, we would also want to explore whether orthogonal plating offers sufficient biomechanical strength and compare its strength to that of parallel plating in this study (Table 3).

Table 3: Showing outcomes in different studies assessing parallel plate fixation
S. no. Author Sample size Follow-up Union Range of motion Mayo elbow performance score DASH Complication
1 Aslam et al.13 20 35 months 100% 112° 15.0%
2 Shin et al.16 17 88.2% 35.3%
3 Tian et al.14 13 19.2 months 100% 120° 89.6 30.8%
4 Lan et al.10 24 16 months 100% 101° 85
5 Lee et al.9 34 100% 8.8%
6 Leigey et al.13 15 77 days 100% 105° 20%
7 Present study 25 12 months 100% 116° 96.32 31.42 17.0%

There have also been a number of cadaveric biomechanical studies that back the usage of either. Orthogonal and parallel plating were compared by Atalar et al. They discovered that there were no appreciable differences in stiffness values between the plating groups. In tests for posterior bending load to failure and plastic deformation values, there was no statistically significant difference between the two groups.18 Helfet and Hotchkiss, in their biomechanical comparison of methods of internal fixation of the distal humerus, concluded that the two plates applied in perpendicular planes provide the best fatigue performance in flexion and extension.19 The forces acting in the distal humerus are valgus and varus force, axial compression force, torsional, and anteroposterior (AP) bending force (Fig. 4). The forces are neutralized by both orthogonal and parallel plates but varying degrees, as given in Table 4.

Table 4: Neutralization of forces (in vitro)
No. Forces Plates
1 Valgus, varus Parallel plating > orthogonal plating
2 Axial compression Parallel plating > orthogonal plating
3 Torsional Parallel plating = orthogonal plating
4 AP bending Parallel plating < orthogonal plating

Fig. 4: Forces acting in distal humerus

In cadaveric biomechanical studies (Table 5), the mechanical load in AP bending was better withstood by the orthogonal plating. Parallel plating was better able to withstand mechanical stress in torsional, varus, and valgus forces. The axial compressive force of the parallel and orthogonal platings was equivalent. However, compared to the mechanical forces used in in vitro cadaver studies, the forces acting at the distal humerus in vivo are less. Thus, parallel plating or orthogonal plating in vivo can neutralize all forces and provide a stable and powerful fixation.

Table 5: Cadaveric studies showing stress and outcome of parallel and orthogonal plating
Author Materials Fracture classification Plate Load/stress Outcome
Schwartz et al.19 Epoxy composite humeri AO C3 LCP Flexion/extensionAxial torsion
Axial compressionVarus/valgus
No difference
Orthogonal > parallelOrthogonal < parallelNo difference
Got et al.20 10 cadaveric humeri AO C3 LCP Torque to failure
Torque to failure
Failure to torsion
Stiffness of fixation
Sensitivity to bone density
Orthogonal > parallel
No difference
No difference
No difference
No difference
Stoffel et al.21 24 cadaveric humeri AO C2 LCP Compression
External rotation
Axial deformation
Sensitivity to osteopenia
Orthogonal < parallel
Orthogonal < parallel
Orthogonal < parallel
Orthogonal > parallel
Penzkofer et al.22 Artificial bone model AO C2 and C3 LCP ExtensionFlexion Orthogonal < parallel
Orthogonal > parallel
Osteoporotic humeral model AO A RP
Y plate
Axial compression
Bending stress
Varus loading
Parallel > orthogonal > Y plate
Orthogonal < parallels < Y plate
Orthogonal < parallel < Y plate
Zalavras et al.23 14 cadaveric humeri AO C3 Nonlocking plate Cyclic varus
Varus to failure
Axial to failure
Orthogonal < parallel
Orthogonal < parallel
Orthogonal < parallel
28 cadaveric humeri AO type C LCP Axial torsion
Ultimate failure
Sagittal stiffness
Orthogonal < parallel
Orthogonal < parallel
No difference
Schuster et al.11 34 cadaveric humeri AO type C2 and C3 RP, LCP, and DHP Construct stiffness
Cyclic failure rate
No difference
DHP < RP < LCP
Arnander et al.6 Epoxy resin humeri AO type C RP Sagittal stiffness
Sagittal strength
Orthogonal < parallel
Orthogonal < parallel

AO, Arbeitsgemeinschaft für Osteosynthesefragen; DHP, Distal humerus plates LCP, locking compression plates; RP, Reconstruction plates

CONCLUSION

Orthogonal plating is an excellent method for fixing the distal humerus, which is biomechanically stable, providing an advantage of early mobilization with a fracture union rate comparable to other studies with good to excellent outcomes according to the Mayo and DASH scores with minimal complications. Olecranon osteotomy provides good exposure to the fracture, which aids in the anatomical reduction of the fracture.

DECLARATION

Ethical Approval

The study was conducted after approval of the Institutional Ethics Committee.

ORCID

Thiyagaraj Chandramohan https://orcid.org/0009-0001-0363-7758

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