Distal humerus extraarticular fractures with large butterfly fragment: How we deal with it

Rajesh Kar; Sanjay Kumar; Anant Kumar Garg

doi:10.4103/ijors.ijors_4_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 30 | Issue : 1 | Page : 3-7

Distal humerus extraarticular fractures with large butterfly fragment: How we deal with it

Rajesh Kar¹, Sanjay Kumar², Anant Kumar Garg³
¹ Department of Orthopaedic Surgery, Debra Superspeciality Hospital, Debra, India
² Department of Orthopaedic Surgery, R G Kar Medical College & Hospital, Kolkata, India
³ Department of Orthopaedic Surgery, Murshidabad Medical College & Hospital, Berhampore, West Bengal, India

Date of Submission	16-May-2022
Date of Acceptance	08-Jun-2022
Date of Web Publication	30-Jun-2022

Correspondence Address:
Rajesh Kar
Department of Orthopaedic Surgery, Debra Superspeciality Hospital, Debra, West Bengal
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ijors.ijors_4_22

Abstract

Background: The treatment of distal-third extra-articular fracture of the humerus with large butterfly fragment is challenging and often controversial. The aim of this study is to see the result of open reduction and internal fixation of such fractures fixed with pre-contoured extra-articular anatomical locking plate in context to percentage of union, time of union and functional capability. Materials and Methods: This is a prospective study comprising of 28 cases from 2016 to 2019 with average follow-up of 19 months. In this study, all the cases included were extra-articular fractures of distal humerus having large butterfly fragments and were comminuted. The simple distal humeral extra-articular fractures without comminution were excluded from study. All the patients were operated on with posterior triceps reflecting approach and fixing the fractures with 3.5 mm pre-contoured extra-articular locking plate. Results: Out of 28 cases, there were 17 males and 11 females with mean age of 34.8 years. 4 patients were having post injury radial nerve palsy. None of the patients in our series were treated conservatively. The average time of operation after injury was 7 days and the average time of union was 20 weeks. 3 of the patients post operatively developed radial nerve palsy which completely recovered within 5 months. The results were evaluated with Mayo elbow performance score. Conclusion: Distal humeral comminuted extra-articular fractures are complex and difficult to manage. A pre-contoured distal humeral plate is a good option and gives adequate purchase for distal fixation. Moreover, the triceps sparing approach is good and chances of nerve injury and stiffness are less. We are happy with this plate and type of fixation.

Keywords: Comminution, distal humerus, extra-articular fracture, locking plate, pre-contoured

How to cite this article:
Kar R, Kumar S, Garg AK. Distal humerus extraarticular fractures with large butterfly fragment: How we deal with it. Int J Orthop Surg 2022;30:3-7

How to cite this URL:
Kar R, Kumar S, Garg AK. Distal humerus extraarticular fractures with large butterfly fragment: How we deal with it. Int J Orthop Surg [serial online] 2022 [cited 2023 Mar 26];30:3-7. Available from: https://www.ijos.in/text.asp?2022/30/1/3/348189

Introduction

Extra-articular fracture of distal humerus is not an uncommon injury and it accounts for approximately 16% of all humerus fractures.^[1] The treatment of distal-third diaphyseal fractures of the humerus is challenging and often controversial. These types of fractures are so variably treated from the nonoperative treatment in terms of cast and braces to open reduction and internal fixation with different variety of plates, that they seem to be a field of predilection and misconceptions. Though these fractures mostly heal with cast and brace management, the distal end being small, it is very hard to prevent the varus deformity and posterior angulation. Fracture bracing for several weeks is also unsuitable for few aspects - elderly parents/incapacitated family members, single parents and people who cannot manage long time off from their duty.

Operative management is also not an untroubled option because there is often a butterfly fragment with associated comminution. That leads to proximal extension of the plate which increases the iatrogenic radial nerve injury risk. Besides one needs to extend the plate down to the non-articular part of the lateral column posteriorly for getting a stable fixation, which makes it tough to use a straight plate especially 4.5 DCP with potential complication of hardware prominence, infection, heterotrophic ossification and stiffness.^[2],[3]

So before making final decision, one should always consider all these factors like patient factors, fracture pattern, comminution and surgical proficiency. Among all options, plate fixation is familiar to most surgeons, maintains alignment and makes patients early use of the affected arm by stabilizing the fracture while it is in the healing process.^[4] So in our view, operative intervention for the treatment of distal-third extra-articular comminuted diaphyseal humerus fractures is cost effective. On review of the literature, we find no published randomized trial comparing the surgical and nonsurgical treatment of distal third diaphyseal humerus fractures, but there is a study that shows no superiority of operative fixation.^[5] So, the aim of this study is to evaluate the operative management of extra-articular comminuted fracture with butterfly fragments of distal humerus using pre-contoured extra articular posterior locking plate and compare it with published literature.

Materials and Methods

After getting approval from the ethical committee, this study was conducted at tertiary teaching hospital from March, 2016 to Jan, 2019 with average of 19 months (Range: 12–30 months) follow-up.

Inclusion and Exclusion Criteria: Patients were selected as per inclusion criteria

Inclusion criteria:

Extra-articular distal humeral fracture having large butterfly fragment with comminution (AO/OTA 13-A3) [Figure 1]

Closed injury

Age >18 years

Figure 1: AO/OTA classification of dista third humerus fracture

Click here to view

Exclusion criteria:

The non-comminuted extra-articular distal humerus fractures

Old fracture (>3 weeks) as it could affect the range of motion of elbow joint

Open fractures

Intra-articular extension of fractures

All patients were thoroughly assessed on arrival by ATLS protocol and Plaster of Paris (POP) back slabs were applied primarily to splint the fractures after detailed clinical examination. 30 patients were qualified for this study among which two patients were lost to follow-up. All 28 patients were operated by a single senior professor and evaluated radiologically by doing x-rays and clinically using Mayo Elbow Performance Score (MEPS).

Surgical steps

All the patients, after proper investigations, were put for pre-anesthetic check up. Received proper informed consent and patients were put for operation. Among 28 patients, 24 patients were given brachial anesthesia whereas in 4 patients general anesthesia was administered. All patients were operated on in lateral decubitus position with affected limb upwards, supported by arm support. After proper draping, adequate midline incision was made and a thick lateral flap was developed up to lateral intermuscular septum. The posterior antecubital cutaneous nerve was identified and separated in the posterior part of lateral intramuscular septum. Then radial nerve was identified, exposed and separated gently. As the dissection continues, the triceps is elevated from the lateral side and reflected to the medial side. The whole of the fracture site is then exposed, freshened, manipulated and reduced under direct vision and temporarily fixed with Kirschner wires. In most of our cases, the large butterfly fragments were fixed first with the distal fragments with intra-fragmentary lag screw, helping us to get anatomical reduction. Once the pre-contoured extra-articular plate fixation is achieved, intra-operatively ROM of elbow is checked to exclude any olecranon impingement. We did not put any other additional plate fixation in our study. We did not use primary bone graft or bone graft substitute to any cases. Then the wound is closed in layers over a suction drain and bulky soft dressing is applied.

Implant

This is a pre-contoured anatomical plate (LCP) designed for lateral pillar and is side specific. They are designed to accommodate 3.5 mm screws. The proximal holes are combi holes that can accommodate dynamic screws to allow axial compression or the locking screws through the threaded portion which gives a fixed angle construct and gives a robust fixation, even in osteoporotic bones. The distal portion of the plate is low profile, tapered smooth and contoured in a fashion to sit well in the lateral condyle. The distal portion of the plate contains five locking holes which are directed medially for screw purchases. The distal most two screws are designed to get purchase of trochlea and capitellum. This type of construct makes the fractures very stable.

Post-op physiotherapy

Passive elbow movements were started from day 1. Active movements were started as soon as patient starts tolerating pain. Stitches were removed after 14 days of surgery. All patients were advised to follow a home based physiotherapy program with a regular follow-up at 6th wk, 3rd month, 6th month, 12th month, 24th month (max up to 30 months). Patients with radial nerve palsy were put on dynamic cock up splint additionally along with physiotherapy protocol.

Results

30 patients were qualified for this study among which two patients were lost to follow-up. Among remaining 28 patients, 17 were male and 11 were female. The incidence of associated injuries was 28.6% (8/28). The mean age of the patients was 34.8 (±10.9) years (maximum 68 yrs- minimum 20 yrs). Patient’s characteristics are depicted in table [Table 1].

Table 1: Patients’ characteristics

Click here to view

All fractures except one, got united with the average time of union was 20 weeks. In one patient we noticed non union who was grafted at 12^th month which later united. In 3 of our post operative patients, we noticed radial nerve neurapraxia which completely recovered within 5 months (range 3–5 months). The perioperative data is summarized in table [Table 2]. All the 4 patients with pre-operative radial nerve injury recovered well within 4 months (range 3–4 month). We didn’t have any incidence of deep infection. We noticed one superficial infection which subsided with aseptic dressing. All patients were evaluated with the Mayo elbow performance index. Out of 28 patients, 11 patients had excellent, 14 patients had good, 2 patients had fair and one patient had poor results at final follow-up. At the 6^th month and at final follow-up, the mean Mayo Elbow Performance Score were 82.68 ± 9.88 was 89.82 ± 8.01 respectively [Figure 2]. The mean elbow range of motion was 120.7 ± 14.18 and the mean metaphyseal-diaphyseal angle was 83.7˚ ± 1.9˚ at final follow-up. None of the patient had an extensor lag at elbow joint. A detailed clinic-radiological follow-up of one of our patient have been depicted in figure [Figure 3].

Table 2: Perioperative data

Click here to view

Figure 2: Showing mean (with standard deviation) Mayo Elbow Performance Score at sixth month of follow-up and at final follow-up.

Click here to view

Figure 3: (A and B) preoperative radiograph: Anteroposterior and lateral views. (C) Intraoperative image. (D) Postoperative radiograph. (E and F) Clinical images at final follow-up

Click here to view

Discussion

Distal third humerus regional anatomy and acting forces in this region makes its management tricky to have a good functional result. These may be due to change in anatomic region where the humerus become rounding to flat, the forces provided by the action of various muscles, the shorter fractured segment of the distal part with limited area for bracing, or osteosynthesis.

Goel et al.^[4] found that patients undergoing surgical management achieves more predictable alignment and potentially quicker functional return. But it risks iatrogenic nerve injury, infection and the need for repeated operation.^[6] In this study, 4 of our patients had pre-operative nerve palsy whereas 3 of our patients got iatrogenic post-operative nerve weakness. All the nerve injuries (both pre and post operation) improved with an average period of 3.7 months (range 3–5 months). One patient developed a superficial wound infection which was healed subsequently on aseptic dressing and one patient had non union which subsequently healed on re-fixation with bone grafting.

The fracture brace ends at or just below the level of the fracture. Though this is adequate for healing, it cannot prevent varus deformity. With brace and sling, the pain and instability of the fracture make the arm relatively purposeless for many weeks as the fracture starts to heal. Even simple daily tasks are difficult on one’s own. Eventually, it takes several weeks to months of uncomfortable stretching exercises to return shoulder and elbow motion, but stiffness follows. Skin problems are also not an uncommon complication - especially in hot, humid environment. This leads to extended sick leave or disability leave which harms the socio-economic aspect of life. In contrast, after plate fixation, the fracture is stable and one can carry out light functional tasks immediately as the surgical pain rapidly improves most of the cases. This uprises operative indications day by day.^[4],[7],[8] Sarmiento et al. in his series showed 92% union rate with 9 degree of varus angulation in 81% of case with good functional result through conservative brace management.^[9] However, Jawa et al., Kharbanda et al., and Aitken and Rorabeck suggest operative management as a preferable option for distal third humerus fractures.^[3],[6],[7]

Only few studies have mentioned of the incidence of comminuted extra-articular fracture of distal humerus. Chowdhary et al., Nadeem et al., Kharbanda et al., and Jain et al. have mentioned in their paper about incidence of comminution with large butterfly fragments. The first two authors in their study of extra-articular distal humerus fracture have found comminution with large butterfly fragments in 60% of cases.^{[7],[8],[10],[11]} Kharbanda et al. and Jain et al. have found comminution and wedge shaped butterfly fragments in 75% and 84.6% of their cases, respectively.^[7],[8]

In our study, out of 28 patients 11 patients had excellent, 14 patients had good, 2 patients had fair and one patient had poor results at final follow-up. Only one patient required revision due to non union. This makes union rate of 96.4% in our study. Literature quotes in nonoperative management, non union rate of 5% to 24% with few patients have deformity more than 30˚ in any direction.^[6] The mean metaphyseal-diaphyseal angle and elbow range of motion were 83.7˚ ± 1.9˚ (normal value = 82˚–84˚) and 120.7 ± 14.18, respectively. This high rate of union without deformity was probably due to wide surface area of the fracture, lesser amount of soft tissue stripping, no/minimal joint impingement by the plate and most importantly stable lateral column fixation. These findings of our study support the findings of available literature by O’Driscoll, Sabalic et al., and Capo et al. which indicate the paramount importance of lateral column fixation for overall stability of the whole construct.^[12],[13]

The limitations of this study include lack of non-operative control group, lesser sample size and lack of long term follow-up. This study also lacks comparison with that of dual plating construct. Though Meloy et al. in their study supported the use of a single plating system compared to dual plating, quoting improved elbow function and fewer surgical complications, this field needs more comparative studies to establish overall superiority over dual plating system.^[14]

Conclusion

Management of extra-articular fractures of distal third of humerus is relatively tough. The presence of comminuted butterfly wedge fragments makes it more difficult to treat. For comminuted extra-articular distal humerus fractures, operative fixation has become the treatment of choice nowadays as the reduction is anatomical, return to activity is early with less pain and joint stiffness as compared to functional bracing, but with a higher risk of infection and neuropraxia. Compared to dual plating system, single pre-contoured anatomical plating demands less soft tissue damage without compromising the stability, which respects the AO principle of fracture fixation. Though our sample size is less and relatively shorter follow-up period, this study indicates that, pre-contoured anatomical single plating for this type of fracture is a very good option in terms of union, deformity and overall functional outcome.

Acknowledgement

This research work is done at Murshidabad Medical College and Hospital, Berhampore, India. Author(s) of this article thank the administration of the Institute for kind support.

Conflict of interest

All the authors declared that there is no conflict of interest.

Statement from authors

This manuscript represents the honest work performed at Murshidabad Medical College & Hospital, Berhampore, India. All the authors have approved this final manuscript and agreed to submit to the International Journal of Orthopaedic Surgery.

Contributions of authors

Dr. Rajesh Kar: Research work, Study design, Analysis of Data, Preparation of manuscript and Reviewed the manuscript for final preparation.

Prof. (Dr.) Sanjay Kumar: Supervised the research work and Reviewed the manuscript for final preparation.

Dr. Anant Kumar Garg: Supervised the research work, Study design and Reviewed the manuscript for final preparation.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

References

1.	Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br 2006;88:1469-73.
2.	Douglas K, Cannada LK, Archer KR, Dean D, Lee S, Obremskey W. Incidence and risk factor for heterotopic ossification after major elbow trauma. Orthopaedics 2012;35:e815-822.
3.	Aitken GK, Rorabeck CH. Distal humeral fractures in the adult. Clin Orthop Relat Res 1986;207:191-7.
4.	Goel DP, Pike JM, Athwal GS. Open reduction and internal fixation of distal humerus fractures. Oper Tech Orthop 2010;20:24-33.
5.	Horne G. Supracondylar fractures of the humerus in adults. J Trauma 1980;20:71-4.
6.	Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation. J Bone Joint Surg Am 2006;88:2343-7.
7.	Kharbanda Y, Tanwar YS, Srivastava V, Birla V, Rajput A, Pandit R. Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach. Strategies Trauma Limb Reconstr 2017;12:1-9.
8.	Jain D, Goyal GS, Garg R, Mahindra P, Yamin M, Selhi HS. Outcome of anatomic locking plate in extraarticular distal humeral shaft fractures. Indian J Orthop 2017;51:86-92. [PUBMED] [Full text]
9.	Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT Jr. Functional bracing of communited extra articular fractures of distal third of humerus. J. Bone Joint Surgery Br 1990;72: 283-87.
10.	Chowdary L, Yaligon V, Nagendra S, Rudrappa GH. Management of distal diaphysiometaphyseal junction humerus fractures with single coloumn posterolateral LCP- Our results, J Evol Med Dent Sci 2015;4:3427-32.
11.	Ali N, Nasser MA, Taheer DA, Mohamad RN, Wajahat MA, Senin S, et al. Outcome of extra articular distal humerus fractures fixed by single coloumn distal humerus LCP using triceps sparing postero lateral approach. Bull Emerg Trauma 2018;6: 306-12.
12.	O’Driscoll SW. Optimizing stability in distal humerus fractures. J Elbow Joint Surg 2005;14: S186-94.
13.	Capo JT, Debkowska MP, Liporace F, Beutel BG, Melamed E. Outcomes of distal humerus diaphyseal injuries fixed with a single-column anatomic plate. Int Orthop 2014;38:1037-43.
14.	Meloy GM, Mormino MA, Siska PA, Tarkin IS. A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: Single-column plating. Injury 2013;44:1620-4.