|Year : 2022 | Volume
| Issue : 3 | Page : 123-127
Surgical result of distal humerus fractures in adults: A consecutive series of 55 cases and review of the literature
Omar Lazrek1, Mehdi Omar Krimech1, Moncef Boufettal2, Bassir Rida Allah2, Moulay Omar Lamrani1, Mohammed Kharmaz1, Mohamed Salah Berrada1
1 Department of Traumatology and Orthopedic Surgery, Hospital IBN SINA, RABAT, Morocco
2 Department of Traumatology and Orthopedic Surgery, Hospital IBN SINA, RABAT; Department of Anatomy, Faculty of Medicine Rabat, University Med V Rabat, Morocco
|Date of Submission||05-Jan-2022|
|Date of Decision||05-Feb-2022|
|Date of Acceptance||15-Feb-2022|
|Date of Web Publication||1-Sep-2022|
Department of Traumatology and Orthopedic Surgery Hospital IBN SINA, Rabat
Source of Support: None, Conflict of Interest: None
Introduction: Fractures of the humeral pallet are more and more frequent; this is linked to the increase in road accidents and their violence. Methods: We have collected in our archives 55 cases of fracture of the humeral pallet at the Traumatology–Orthopedics Department of the IBN SINA CHU in RABAT from January 2015 to December 2019. Results: They mainly affect young adults with a clear predominance of men (73%). The trauma most often occurs by direct mechanism (65%). The main cause of these fractures is represented by road accidents (56%), followed by assaults and falls. Supra and intercondylar fractures are the most described anatomical form (65%). The treatment is surgical in all cases, with predominance of the posterior approach. Discussion: Considering the comminution often encountered, only a solid and stable osteosynthesis allows the anatomical restoration of the elbow, by adapting the indications to the types of fractures and by using a more codified technique, to allow an early rehabilitation, better guarantee of recovery of elbow function. The LECESTRE premolded plate is the most used in supra and intercondylar fractures; it seems to be a real progress in osteosynthesis (31.03% good results and 51.72% average results) for this type of fracture. Conclusion: The management of humeral paddle fractures is based on perfect anatomical reduction, by a solid assembly which must allow early rehabilitation ensuring good functionality. Level of Evidence: IV-retrospective study.
Keywords: Fracture, humeral pallet, osteosynthesis
|How to cite this article:|
Lazrek O, Krimech MO, Boufettal M, Allah BR, Lamrani MO, Kharmaz M, Berrada MS. Surgical result of distal humerus fractures in adults: A consecutive series of 55 cases and review of the literature. J Orthop Dis Traumatol 2022;5:123-7
|How to cite this URL:|
Lazrek O, Krimech MO, Boufettal M, Allah BR, Lamrani MO, Kharmaz M, Berrada MS. Surgical result of distal humerus fractures in adults: A consecutive series of 55 cases and review of the literature. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Jan 28];5:123-7. Available from: https://jodt.org/text.asp?2022/5/3/123/355234
| Introduction|| |
Fractures of the distal end of the humerus represent 1%–2% of adult fractures according to Morrey; they can be extra or intra-articular. In the latter case, they can be complex due to the fragmentation and/or the porous state of the bone. Their distribution is constantly bimodal, according to age and sex, with two frequency peaks: the age group 17–21 years with a majority of men in the context of a violent trauma (road accidents, fall from a high place) and the group ≥80 years with a majority of women (fall from his height). The clinical aspect comes down to a large painful elbow, which masks the palpation of the classic landmarks of the Hunter line and the isosceles triangle of Nelaton.
The treatment is most often surgical. Osteosynthesis by pin or isolated screw or a combination of the two has been gradually abandoned due to their precariousness, and since the consensus of the SOFCOT round table of 1979, screw-plate fixings are recognized as being the treatment of choice.
The use of a total elbow prosthesis for the treatment of these fractures was proposed by Cobb and Morrey in 1997 with satisfactory immediate results. The hypothesis of this study was that the total elbow prosthesis could represent a reliable therapeutic solution in the subjects of more than 65 years with articular fracture of the humeral pallet.
| Methods|| |
We report a prospective study of 55 cases of fractures of the distal end of the humerus treated surgically and followed by the Department of Orthopedic Surgery and Traumatology, CHU IBN SINA RABAT, Morocco, over a period of 5 years from January 2015 to December 2019. Patients were included in the study according to the following criteria: the occurrence of a fracture of the distal end of the humerus, on non-pathological bone, We excluded our study of fractures of the distal end of the humerus in patients under 16 years of age because the service only receives adults, people who have undergone orthopedic treatment and patients whose medical file is considered incomplete for the needs of the study. The operation was followed by a casuistic study on the distribution by age, sex, and mechanism of the trauma. As well as an anatomopathologic study according to the side of the lesion, the site and the fracture line. The aim of the study is to support the clinical and therapeutic peculiarities and complications presented below.
Follow-up included clinical and radiological evaluation. At the clinical level, the following data were sought: assessment of pain (visual analog scale [VAS] out of 10), active and passive mobility in flexion-extension and pronosupination, and mean time to return to work. On the radiological level, we looked for signs of acquired consolidation, complications such as secondary displacements and vicious calluses, and disassembly of the material and pseudarthrosis.
| Results|| |
In our series of 55 fractures of the humeral pallet, the mean follow-up when assessing the results was 18 months, with a minimum of one and a maximum of 5 years. The average age of the patients at the time of the accident was 42 years with extremes of 17 and 81 years. The sex ratio was 15 women and 40 men. The dominant limb was affected in 36 cases. The circumstances of the accident were dominated by road accidents 66%, assaults 23%, and falls 7%. Two patients were multiple traumas, i.e., 3.63% of cases. The time to treatment was <24 h in 35 cases, <48 h in 19 patients, and more than 48 h once. The fracture was open in 17 patients or in 30.9% of cases. Preoperative sensory motor damage to the radial nerve was observed in 3 (5.4%) patients and no ulnar nerve damage. An associated fracture of the same limb was found in 4 cases: fracture of the radial head associated with dislocation of the elbow in one case, a fracture of the lower end of the radius in one case and two patients presented with dislocation of the ipsilateral elbow, associated in the one of them has a fracture of the lower end of the radius.
The classification of fractures according to the association of osteosynthesis (AO) found a predominance of supra and intercondylar fractures [Figure 1] and [Figure 2], which represents 63.63% of cases in our series, followed by supracondylar fractures 29.09%, whereas fragmentary fractures are rarer, observed only in 7.27% of patients. The most frequently used approach was the posterior transtricipital inverted V approach (29 cases) [Figure 3], followed by the intra-articular transolecranon approach (19 cases) and the external approach (4 cases); the paratricipital route was more rarely preferred (3 cases). Olecranotomy was synthesized by pinning-guying in all patients. The osteosynthesis material mainly appealed to two mounting categories, either a premolded LECESTRE plate alone (25.45%) or in combination with other materials (69.09%): 1/3 tube plate and/or screws and/or plug-in [Figure 4]. Isolated triangulation screwing was performed in 3 (5.4%) patients. Immobilization with a brachio-antebrachial plaster splint maintained for an average of 3 weeks was performed in our patients until the pain and inflammatory phenomena subsided.
|Figure 4: Postoperative radiological control: Osteosynthesis by external Lecestre type plate associated with an internal 1/3 tube plate|
Click here to view
Postoperative pain was assessed by the VAS; it was absent in 37 patients (67.27%), between 2 and 5/10 in 14 patients (25.45%), and ≤5/10 in the rest of the patients.
In this study, the posterior transtricipital approach was the most used approach since it represents 52.72% of cases with results on the arch of mobility in flexion-extension better than the intra-articular transolecranon approach (34.5%), which was reserved mainly for comminuted fractures. Regarding mobility, the majority of patients, i.e., 44 cases (80%), have a flexion >120°, and in 6 cases (10.9%), it is <100°. The extension deficit is <15° in 31 cases (56.36%), between 15° and 45° in 13 patients (23.63%), and >45° in 11 patients (20%). The mobility in pronosupination was limited in 2 patients, one of whom was reoperated for radioulnar synostosis. The mean value of pronosupination was 150°. It exceeded 120° in 86.1% of cases, between 100° and 50° in 10.3% of cases, and <50° in 3.5% of cases. Disassembly of the reduction occurred in a patient who underwent revision surgery. Fracture pseudarthrosis was noted in 4 patients (1 case of septic pseudarthrosis). Elbow arthritis was observed in 10 cases (18.18%). Periarticular ossifications were rare, since only observed in 2 patients. Superficial infection was noted in 3 cases (9.09%). These infections required only local care, associated in two cases with the removal of the pins, which irritated the skin and one case of septic nonunion in a 29-year-old patient with no particular history requiring ablation of the plaque with pinning and 6-week antibiotic therapy. Statistically, there was a statistically significant difference between the approach used and the flexion-extension mobility arc results, but no statistically significant difference was found in the arc of mobility in flexion-extension between the two main categories of osteosynthesis (by LECESTRE plate alone and by two LECESTRE plates + 1/3 tube).
| Discussion|| |
The epidemiology of humeral pallet fractures has not changed over the past decades. It represents, on average, 1%–2% of fractures in adults and 30% of elbow fractures. The overall incidence of fractures of the humeral pallet is 5.7/100,000/1 year. This incidence is expected to increase in the elderly population by 2030 according to Kannus et al. However, all the series show two frequency peaks:,, One is between 12 and 19 years old, mostly male, and corresponds to a violent trauma: a road accident and a fall from a height, most often associated with preoperative complications important. The second peak concerns the population of elderly subjects with a clear predominance of women. The causal trauma often observed is the simple fall of these osteoporotic people with a field that combines many pathologies: inflammatory rheumatism and/or long-term corticosteroid therapy, unweaned alcoholism, unweaned smoking, neuropsychiatric field or elbow arthritis in 20%,, and 29% of cases.,
There is a discrepancy between the results of different authors regarding the predominance of the right or left side. For the circumstances of the trauma, we note the predominance of road accidents in our study, while the main etiology in the other series is represented by the fall.
The polymorphism of fractures of the humeral pallet has given rise to numerous classifications, none of which currently manages to synthesize anatomical, prognostic, and therapeutic criteria. They are mostly purely anatomical, depending on the type and level of the fracture line. The degree of fragmentation is the main criterion of the classifications commonly used: classification of Riseborough and Radin modified by the Orthopedic Trauma Association American Academy of Orthopedic Surgeons and classification of Muller and Allgower for AO., It can be seen that in all the series studied here above, supra and intercondylar fractures (type C) are the most frequent fractures of the humeral pallet, followed by supracondylar fractures (type A). Our results are in agreement with those described by the different series.
The anatomical complexity of the humeral paddle, the proximity of the nerves (radial and ulnar), and the great variety anatomopathological forms are so many difficulties, which have long-standing conservative treatment of the “bone bag” preferable surgical treatment, as surgical techniques seemed to have limited results. However, progress in osteosynthesis equipment and the results obtained have made it possible to propose surgical techniques allowing early rehabilitation, an essential therapeutic complement to obtain good results. The indications for the treatment of fractures of the humeral pallet depend on several factors linked to the type of fracture, the patient's terrain, and the osteosynthesis material. They are still debated between the authors. However, the consensus indicates systematic osteosynthesis for young patients and as a first-line choice for elderly subjects.,,,,,,,,, Several approaches have been described in the literature, each adapted to the type of fracture, including the lateral approach of Kocher, the medial. However, the posterior approach is the only one that allows, through a single incision, control of the two columns of the distal end of the humerus, respect for the subcutaneous nerves, and the possibility of all technical procedures, in particular after osteotomy of the olecranon, which earned it the qualification of the “universal approach”, Anglo-Saxon. In our series, the posterior trans-olecranon approach was performed in 34.5% of our patients. The trans-tricipital approach seems to be used more rarely nowadays. Nevertheless, Olson denounces the trans-olecranon approach as a source of complications (non-union, delayed consolidation, screw protruding under the skin, pin fractures) and recommends the medial trans-triccipital approach even in low fractures. Some authors have used the inverted V transtricipital approach, especially giving excellent exposure to the distal metaphysis. Thus, Merle-D 'Aubigné, using this approach first, reports 78% satisfactory results in a series of 19 bicondylar fractures. Sodergard obtains 65% of excellent and good results on a series of 61 bicondylar fractures osteosynthesized by the inverted V transtricipital route in 82% of cases, and in our series, it was used in 52.72% of our patients.
Regardless of the approach, it is impossible to reduce and synthesize all the fragments at the same time, with the exception of “simple” two-fragment fractures, for which it must be possible to obtain stable fixation by the lateral approach. This can be done either by screwing if the bone behaves well and if the fracture line lends itself to it, or by a side plate. In the event of fragmentation, the width of the trochlea should be reduced, since the congruence between the trochlea and the olecranon is responsible for 54% of the intrinsic stability of the elbow.
The instability of the fracture site is most often due to a failure to reconstruct the internal abutment with the risk of secondary displacement in medial rotation. The results are better when the initial setup is stable., Helfet has confirmed the better resistance and the best rigidity of a double-plate assembly. The OA and several authors recommend osteosynthesis by two posterior plates perpendicular., In the series, the results are compared according to the type of material used; our best results were obtained with two plates (LECESTRE and 1/3 of a tube). This observation was also made by Caja.
The fracture displacement rate with disassembly was 1.81% in our series; it involved a single patient. The most recent studies [Table 1], following the principles now known of stable osteosynthesis, show similar rates varying between 0% and 10%. Our series presents an infection rate of 7.27% comparable to that of the majority of the series studied, 5% in Raiss, and 8% in Lahdidi.[26-28] Stiffness was found in 23.63% of cases in Raiss, 16% in Roques, 20% in Obert and 8% in Lahdidi; the frequency of stiffness in most series remains high. Our series noted 11 cases of stiffness, with a frequency of 20%; Although this factor does not seem to us to be solely responsible, the fact remains that anatomical reconstruction and a stable assembly allowing early rehabilitation can avoid this pitfall.
| Conclusion|| |
Fractures of the humeral paddle are more and more frequent; this is linked to the frequency of road accidents in young active subjects. The trauma often occurs by a direct mechanism and the most described anatomical form is the type of supra and intercondylar fractures. The radiological diagnosis is based on standard images taken in the emergency room and images taken in traction in the operating room. Surgical treatment is systematic in young people and the first step in older people. Orthopedic treatment is interrupted by all orthopedic surgeons, with the exception of certain non-displaced fractures, as well as in patients with significant surgical risk. The goal of surgical treatment is to ensure stable osteosynthesis allowing early rehabilitation, the only guarantee of good functional results.
All the authors were fully involved in the study and in the preparation of the manuscript; the material within has not been and will not be submitted for publication elsewhere. No funds were received in support of this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
Financial support and sponsorship
Lack of specific funding.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kannus P, Niemi S, Parkkari J, Palvanen M, Heinonen A, Sievänen H, et al. Why is the age-standardized incidence of low-trauma fractures rising in many elderly populations? J Bone Miner Res. 2002;17:1363–7. [doi: 10.1359/jbmr.2002.17.8.1363].
Adolfsson L, Hammer R. Hémiarthroplastie du coude pour la reconstruction aiguë des fractures intra-articulaires distales de l'humérus: Un rapport préliminaire impliquant 4 patients. Acta Orthop 2006;77:785-7.
Robinson C, Hill RM, Jacobs N, Dall G, Court-Brown CM. Fractures métaphysaires humérales distales chez l'adulte: Épidémiologie et résultats du traitement. J Orthop Trauma 2003;17:38-47.
Cobb T, Morrey B. Arthroplastie totale du coude comme traitement principal des fractures distales de l'humérus chez les patients âgés*. J Bone Joint Surg 1997;79:826-32.
Kamineni S, Morrey B. Fractures distales de l'humérus traitées avec un remplacement total du coude non personnalisé. J Bone Joint Surg 2004;86:940-7.
Riseborough 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.
Lecestre P, Dupont JY, Lortat JA, Ramadier JO. Severe fractures of the lower end of the humerus in adults (author's transl). Journal of Orthopedic and Reconstructive Surgery 1979;65:11-23.
Limthongthang R, Jupiter JB. Distal humerus fractures. Operative Techniques in Orthopedics, 2013;23;178-87.
Manueddu CA, Hoffmeyer P, Haluzicky M, Blanc Y, Borst F. Humeral paddle fractures in adults: functional evaluation and isometric force measurements. Journal of orthopedic and restorative surgery of the motor apparatus, 1997;83:551-60.
Charissoux JL, Mabit C, Fourastier J, Beccari R, Emily S, Cappelli M, et al.
Comminuted intra-articular fractures of the distal humerus in elderly patients. Journal of Orthopedic and Restorative Surgery of the Motor Apparatus, 2008;94; Suppl, p. S36-62.
Hoppenfeld S, Deboer P, Buckley R. The forearm. Surgical exposures in orthopedics: the anatomic approach, 4th ed. Lippincott Williams and Wilkins, 2009;147-81.
Morrey BF, and KN, An. Morrey BF, Sanchez-Sotelo J. Functional evalution of the elbow. The Elbow and its Disorders 4th ed. Philadelphia: Saunders Elsevier, 2009;80-91.
Peach C, Stanley D. Elbow surgical approaches. Orthop Trauma 2012;26:297-302.
Olson SA, Hertel R, Jakob RP. The trans-tricipital approach for intra-articular fractures of the distal humerus: A report of two cases. Injury 1994;25:193-8.
Merledaubigne R, Carlioz J, Meary R. Recent supra- and intercondylar fractures in adults. Rev Chir Orthop Reparatrice Appar Mot 1964;50:279-88.
Södergård J, Sandelin J, Böstman O. Mechanical failures of internal fixation in T and Y fractures of the distal humerus. J Trauma 1992;33:687-90.
Morrey BF, O'Driscoll SW. Complex instability of the elbow. In: Morrey BF, editor. The Elbow and Its Disorders. 3rd ed. Philadelphia:Saunders;2000. p. 421-30.
Mansat P, Bonnel F, Canovas F, Captier G.Biomechanics of the elbow: Application to elbow prostheses. SOFCOT Teaching Notebooks. 2001;77:17-29.
Martin BF. The annular ligament of the superior radioulnar joint. J Anat 1958;92:473.
Duparc F. Elbow Stability and the Condyloradial Joint.” SOFCOT Teaching Notebooks 2001;77:30-7.
Poirier PJ, Charpy A, Amoëdo O, et al. Treaty of human anatomy: Arthrology. Masson et Cie, Publishers, Booksellers of the Academy of Medicine, 1926.
Mansat P, Akhavan H. Surgical approaches to the elbow. Surgical pathology of the elbow. 1991;49-62.
O'Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res 1992;280:186-97.
Kaiser T, Brunner A, Hohendorff B, Ulmar B, Babst R. Treatment of supra-and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: A 2-year follow-up. Journal of shoulder and elbow surgery, 2011;20:206-12.
Raiss M, Hrora A, Moughils S, Mahfoud M, Bardoum A, Oudghiri M, et al.
Humeral paddle fractures in adults: about 63 cases. Surgical Lyon Chir 1995;91:397-400.
Lahdidi S. Surgical treatment of humeral paddle fractures at the Mohamed V. Casablanca Hospital: Thesis in medicine,2006. No. 61.
Lecestre P, Aubanial JM, Claisse PR. Extremity fractures inferior humerus in adults. Round table of the SO.F.C.O.T. Rev Chir Orthop 1980;66:21-50.
Holdsworth BJ, Mossad MM. Fractures of the adult distal humerus. Elbow function after internal fixation. J Bone Joint Surg Br 1990;72:362-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]