Keywords
elbow - fractures - distal humerus fractures - instability - elderly - external fixation
Introduction
The incidence of distal humeral fractures corresponds to ∼ 2% of all adult elbow fractures.[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8] The mechanisms of injury are bimodal, and includes low-energy trauma, usually associated
with osteoporotic bone in elderly patients, and high-energy, more frequent in young
patients with higher incidence of complications such as soft tissue, nerves[3] and vascular injuries.
In elderly patients, surgical treatment with open reduction and internal fixation
using plates and screws remains the choice of treatment,[9]
[10]
[11]
[12]
[13]
[14] even with high complication rates, as reduction loss, articular stiffness and soft
tissue damage. According to Korner et al[15] and Hausman et al[16], the internal fixation is justified by the improvements in osteosynthesis techniques
and implants with locking screws.
Elbow arthroplasty may be indicated in selected patients with fractures of the severely
fragmented distal humerus, or in patients with osteoporosis or rheumatoid arthritis.[17]
[18]
[19]
Gausepohl et al[9] applied the dynamic external elbow fixator associated with internal fixation in
the surgical treatment of complex fractures of the distal humerus in patients with
osteoporosis, to protect the internal fixation and decrease complication rates.
The hypothesis of the present study is that distal humeral fractures in elderly patients
treated with percutaneous reduction and fixation with an articulated external fixator
would avoid complications of the open management, reducing the risk of infection and
soft tissues damage.
The objective of the present study is to measure the radiographic, clinical, and functional
outcomes of patients with complete articular fractures of the distal humerus treated
with an articulated external fixator.
Methods
The study design is a prospective cohort. Inclusion criteria were elderly patients
(> 60 years old), with distal humeral fractures (closed or open), classified as AO
13C, comminution below the olecranon fossa, observed in radiographs and computed tomography
(CT) scan ([Figs. 1]
[2]
[3]). The study was approved by the Ethics Committee (CAAE: 50927715.3.0000.5484).
Fig. 1 Radiographic/Tomographic aspects (preoperative): distal humerus fracture (13C3).
Fig. 2 Radiographic aspects (preoperative): distal humerus fracture (13C3).
Fig. 3 Tomographic 3D aspects (preoperative): distal humerus fracture (13C3).
The patients were positioned in the supine position and submitted to general anesthesia
or regional brachial plexus block. Closed maneuvers and indirect fracture reduction
with longitudinal traction and percutaneous bone reduction clamps, aiming satisfactory
articular surface reduction and the distal humerus alignment, were performed. The
stabilization was performed with Kirschnner wires and/or lag screws near the joint
line of the distal humerus ([Fig. 4]), to fix the joint surface fragments, the medial epicondyle and the lateral cross
into the metaphysis.
Fig. 4 Intraoperative fluoroscopic aspects. Kirschner wires and or lag screws near the joint
line of the distal humerus.
With the reduced fracture, we positioned the elbow at 90° flexion and the forearm
at 90° pronation, conducted the examination with fluoroscopy in this elbow to identify
its rotation axis (imaginary line that cuts through the center of the capitellum)
and passed a Kirschner wire guide (2 mm) in the center of rotation in the parallel
direction to the articular surface of the distal humerus, from lateral to medial direction.
The central body of the external fixator (Elbow external fixator, Amsterdam, Fixus®, Netherlands, and Galaxy elbow external fixator, Bussolengo, Orthofix®, Italy) was properly seated in the guide wire. Two Schantz pins (5 mm) were introduced
in the humerus, and two other pins (4 mm) into the ulna and connected to the clamps.
Those were fixed to the rods passing through the central body. The principle of arthrodiastasis
(increased joint space) can be promoted by external fixator to help reduce the articular
fragments. An occlusive dressing was applied, and the final tightening of the components
of the external fixator was checked.
After the procedure, patients remained in hospital for a period of 24 hours. Subsequently,
they performed rehabilitation in the occupational therapy sector of the institution,
with the specific protocol already established, which recommends elbow mobility from
the 1st day after the surgery ([Fig. 5]).
Fig. 5 Postoperative clinical and radiographic aspects showed the range of motion of the
elbow.
When patients were discharged, they were followed-up weekly in the first month. Then,
the returns occurred at 2 months, 3 months, 6 months and 1 year after the surgery.
The parameters chosen for analysis were X-rays to assess articular congruence, reduction
and consolidation; range of motion compared with the normal side; pain by visual analogue
scale (VAS) after 1 year; the quality of life by the disabilities of the arm, shoulder
and hand (DASH) questionnaire and any complications and new operations if they had
occurred.
For statistical analysis we adopted the significance level of 5% (0.050) to the testing.
The comparison between the variables was due to the application of the test of Wilcoxon
Signed Posts, to investigate possible differences between the normal ROM (opposite
side) and ROM after 1 year (affected side)
Results
We evaluated a total of 10 patients, 4 men and 6 women. The mean age was ∼ 71 years
old, ranging from 64 to 84 years old. The follow-up time was 15.44 months (minimum
of 12 and maximum of 21 months).
The average range of motion of the fracture side was 134° of flexion, and - 5° of
extension. All of the elbows were clinically stable. The mean VAS was 2.2 and the
mean DASH was 14.3.
Radiographic analysis showed satisfactory reduction and consolidation. All of the
patients showed congruence of concentric humerus-ulnar and radius: ([Fig. 6]) and no patient had joint stiffness or post-traumatic arthritis of the elbow.
Fig. 6 Postoperative radiographic aspects – articular congruence radius-capitellum and humerus-ulnar.
A patient with pain in the ulnar pin path location was observed, which was solved
with the removal of the pin, and another patient had pneumonia and came to die 2 months
after the fracture. They were assessed at 12 months (see [Table 1]).
Table 1
|
Identification
|
Age
|
Follow-up
|
Gender
|
Side
|
ROM
normal
|
ROM1
year
|
DASH
normal
|
DASH
1 year
|
VAS
1 year
|
Complications
|
AO Classification
|
|
I
|
64
|
21
|
F
|
R
|
140
|
130
|
1
|
12
|
3
|
——————-
|
13C2
|
|
II
|
85
|
21
|
F
|
L
|
140
|
140
|
1
|
12
|
1
|
——————
|
13C1
|
|
III
|
67
|
2
|
F
|
R
|
135
|
130
|
1
|
1
|
1
|
death
|
13C3
|
|
IV
|
66
|
18
|
M
|
R
|
140
|
140
|
1
|
1
|
1
|
ulnar pins release
|
13C1
|
|
V
|
64
|
16
|
M
|
R
|
140
|
120
|
1
|
30
|
3
|
——————
|
13C3
|
|
VI
|
84
|
14
|
F
|
R
|
140
|
125
|
1
|
30
|
4
|
——————
|
13C3
|
|
VII
|
65
|
13
|
F
|
L
|
130
|
125
|
1
|
18
|
3
|
——————
|
13C2
|
|
VIII
|
75
|
12
|
F
|
R
|
140
|
132
|
1
|
15
|
2
|
——————
|
13C3
|
|
IX
|
71
|
12
|
M
|
R
|
135
|
128
|
1
|
18
|
3
|
——————
|
13C3
|
|
X
|
73
|
12
|
M
|
R
|
135
|
130
|
1
|
6
|
1
|
——————
|
13C2
|
It was noted that the three comparisons showed 'statistical similarity' between the
two time points, for the variables of interest. It was interpreted that the parameters
DASH and VAS do not tend to statistical differences, suggesting quality of life and
pain improvements in the patients after the treatment (see [Table 2]).
Table 2
|
Variabilities
|
n
|
Mean
|
Standard deviation
|
Minimum
|
Maximum
|
Percentile 25
|
Percentile 50 (mediana)
|
Percentile 75
|
Significance (p-value)
|
|
ROM normal
|
10
|
139.17
|
2.04
|
135.00
|
140.00
|
138.75
|
140.00
|
140.00
|
0.068
|
|
ROM 1 year
|
10
|
130.83
|
8.01
|
120.00
|
140.00
|
123.75
|
130.00
|
140.00
|
|
DASH normal
|
10
|
1.00
|
0.00
|
1.00
|
1.00
|
1.00
|
1.00
|
1.00
|
0.063
|
|
DASH 1 year
|
10
|
14.3
|
13.09
|
1.00
|
30.00
|
1.00
|
12.00
|
30.00
|
|
VAS normal
|
10
|
1.00
|
0.00
|
1.00
|
1.00
|
1.00
|
1.00
|
1.00
|
0.102
|
|
VAS 1 year
|
10
|
2.2
|
1.33
|
1.00
|
4.00
|
1.00
|
2.00
|
3.25
|
Discussion
The surgical approach to these elbow fractures is challenging and highly difficult.[13] All of the current methods of internal stabilization require broad access, with
triceps handling with or without osteotomy of the olecranon, which can result in stiffness
and nonunion.[10]
[11]
[12]
[13]
[14]
[15]
[16] Searching the stability, the mobility restoration, and the reduction of perioperative
complications, we proposed the use of an articular external fixator.[3]
[4]
[5]
[6] Those patients “supported” early mobilization of the elbow.
Currently, there are several case studies using primary elbow arthroplasty[17]
[18]
[19]
[20] as a possible method of treatment of those fractures, with promising results: elbow
mobility turns out to be a functional and safe method for those geriatric patients.
But the choice of that method is still an exception in our midst.
The external fixator used in the present study ([Fig. 7]) promoted stability and early mobility of the elbows, which influenced directly
in the clinical and functional outcome of those patients who have endured such pain
during the early handling of the elbow since the 1st day after surgery, with the help of physiotherapists, while hospitalized. Association
between physical therapy activities and the use of analgesics was reported by most
patients in the 1st month after surgery.
Fig. 7 Radiographic and clinical aspects (immediate postoperative).
The average value of the flexion-extension of the elbow in our study was 129°, while
for Orbay1 (internal fixator) it was 115°, for Sorensen et al[19] (arthroplasty) it was 114°, for McKee et al[12] it was 105°, and for Sørensen et al[7] (external fixation) it was 95°. Although the sample is small, our results are superior
when compared with the aforementioned studies ([Fig. 8])
Fig. 8 Clinical aspects (postoperative): right elbow and functional ROM.
All of our patients had consolidation and maintenance of fracture reduction (articular
congruence radius-capitellum and humerus-ulna) and stability of the elbow. (see [Fig. 9])
Fig. 9 Postoperative radiographic aspects after 6 months: elbow articular congruence.
Orbay[1] didn't have complications, McKee et al[12] presented in their series of 16 patients, a case of recurrent elbow instability;
Sørensen et al[7] reported a patient with elbow dislocation. In the study of Sorensen et al, 4 out
of 20 patients undergoing elbow arthroplasty presented complications (2 with infection,
and 2 with ulnar nerve injury). In the present study, a patient was observed with
pain in the location of the ulnar pin path, which was solved with the removal of the
pin.
The present research had the disadvantage of the need for a new procedure to remove
the implant. It is a prospective cohort study and these results need to be confirmed
in larger quantitative and qualitative studies.
This technique restores stability, the anatomy, and allows early mobility of the elbows
of the patients. It is believed that it is a promising method for the treatment of
geriatric patients with distal and articular fractures of the humerus.
It is suggested new scientific research, with greater level of evidence to validate
this method. Thus, the articulated external fixator elbow can be part of the orthopedic
surgeon toolbox.
Conclusion
Radiographic analysis of the patients showed fracture healing with joint congruity.
In the functional clinical aspect, it was noted that patients had functional range
of motion.
