“COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL

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“COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL

PLATING AND PARALLEL PLATING

Dissertation Submitted to

THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY

in partial fulfillment for the requirement for the award of the degree of

M.S DEGREE IN

ORTHOPAEDIC SURGERY BRANCH II Reg.No : 221712352

DEPARTMENT OF ORTHOPAEDICS

GOVT MOHAN KUMARAMANGALAM MEDICAL COLLEGE THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY

CHENNAI, INDIA MAY 2020

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CERTIFICATE

This is to certify that this dissertation “COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL PLATING AND PARALLEL PLATING^”is a bonafide record of work done by Dr. S.ARAVINDAN, during the period of his Post graduate study from Nov 2017 to Oct 2019 under guidance and supervision in the Department of Orthopaedics, Govt.

Mohan Kumaramangalam Medical College, Salem 636001, in partial fulfilment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr. M.G.R.Medical University to be held in May 2020.

Prof. Dr. K. THIRUMAL BABU, M.D D.M

Dean

Govt Mohan Kumaramangalam medical college Salem.

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CERTIFICATE

This is to certify that this dissertation titled, which is being submitted for M.S., Orthopaedics, is a bonafide work done by Dr. S.ARAVINDAN, Post graduate student of the Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College Hospital, Salem.

He has completed the necessary period of stay in the department and has fulfilled the condition required for submission of this thesis according to university regulations. The study was undertaken by the candidate himself and the observations recorded have been periodically checked by us.

Recommended and Forwarded

Prof. DR.C. KAMALANATHAN. M.S.ORTHO, D.ORTHO, DNB., Professor and Head of the Department,

Department of Orthopaedics,

Govt Mohan Kumaramangalam Medical College Hospital, Salem.

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CERTIFICATE

This is to certify that this dissertation “COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL PLATING AND PARALLEL PLATING” which is being submitted for M.S. Orthopaedics, is done by Dr.S.ARAVINDAN, Post graduate student of the Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College Hospital, Salem under my guidance.

Prof.DR.T.M.MANOHAR, M.S Ortho., Professor of Orthopaedics,

Govt Mohan Kumaramangalam Medical College, Salem.

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DECLARATION

I, Dr.S.ARAVINDAN, solemnly declare that this dissertation titled

“COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL PLATING AND PARALLEL PLATING” is a bonafide work done by me at Govt Mohan Kumaramangalam Medical College, Salem from November 2017 onwards under the guidance and supervision of Prof. C. KAMALANATHAN M.S.ORTHO, D.ORTHO, DNB., Professor and Head of the Department, Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College, Salem.

I have not submitted this dissertation to any other university for the award of any degree or diploma previously. This dissertation is submitted to the Tamilnadu Dr. M.G.R. Medical University, Chennai towards partial fulfilment of the rules and regulations for the award of M.S Degree in ORTHOPAEDIC SURGERY (BRANCH – II)

PLACE :

DATE : Dr. S ARAVINDAN

Reg.No : 221712352

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CERTIFICATE - II

This is to certify that this dissertation work titled

“COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL PLATING AND PARALLEL PLATING^” of the candidate S.ARAVINDAN with registration Number 221712352 for the award of M.S., DEGREE in the branch of ORTHOPAEDIC SURGERY BRANCH II. I personally verified the urkund.com website for the purpose of plagiarism Check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 13 percentage of plagiarism in the dissertation.

Guide & Supervisor sign with Seal.

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ACKNOWLEDGEMENT

I express my thanks and gratitude to our respected Dean Prof. Dr.K.THIRUMAL BABU, M.D D.M., Govt Mohan

Kumaramangalam Medical College, Salem for having given permission for conducting this study and utilize the clinical materials of this hospital.

I have great pleasure in thanking Prof T.M.MANOHAR, M.S.Ortho., Professor of Orthopaedics, Govt Mohan Kumaramangalam Medical College, Salem for this valuable advice throughout this study.

My sincere thanks to Prof C.KAMALANATHAN, M.S.Ortho., D.Ortho., DNB Ortho, Professor of Orthopaedics, Govt Mohan Kumaramangalam Medical College, Salem for this valuable advice throughout this study .

My sincere thanks and gratitude to Prof R.T.PARTHASARATHY, M.S.Ortho., Professor of Orthopaedics, Govt Mohan Kumaramangalam Medical College, Salem for his guidance and constant advice provided throughout this study.

My sincere thanks and gratitude to Prof A.D.SAMPATH KUMAR, M.S.Ortho., Professor of Orthopaedics, Govt Mohan Kumaramangalam Medical College, Salem, for his valuable advice and support.

My sincere thanks and gratitude to my co guide Dr. L.KUMAR, M.S.Ortho., for his constant advice and guidance provided throughout this study.

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My sincere thanks and gratitude to my co guide Dr. S.SELVAKUMAR, M.S.Ortho., for his constant advice and guidance

provided throughout this study.

My sincere thanks and gratitude to my co guide Dr. S.MOHANKUMAR, M.S.Ortho., and Dr. K.SATISHKUMAR D.Ortho, DNB Ortho for his constant advice and guidance provided throughout this study.

I sincerely thank Dr. S.KUMAR, M.S.Ortho, Dr. N.KARTHIKEYAN, M.S.Ortho, Dr. P.RADHAKRISHNAN,

M.S.Ortho, Dr. S.JAWAHAR, M.S.Ortho, Dr. P.ARUNANAND, M.S.Ortho, Dr.T.S.SENTHILKUMAR, D.Ortho, Dr. P.CHINNADURAI, D.Ortho, Dr. S.SYEDNASER, M.S.Ortho, Dr. SIVAKUMAR, M.S.Ortho, Dr. R.N.SURESHKUMAR, M.S.Ortho, Assistant Professors of this department for their valuable suggestions and help during this study.

I thank all anaesthesiologists and staff members of the theatre and wards for their endurance during this study.

I am grateful to all my post graduate colleagues for helping in this study.

My sincere thanks to all our patients, without whom this study would not have been possible.

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LIST OF TABLES

SL.

NO TABLES PAGE NO.

1 Sex Distribution 39

2 Side Distribution 40

3 Mode of injury 41

4 Types of fractures 42

5 Surgical approaches 43

6 Associated injuries 44

7 Grading of pain 45

8. Mayo elbow performance index 46

9. complications 47

10. Age vs Mayo elbow performance score 48

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ABSTRACT

AIM:

To evaluate and analyse the comparison of outcome of management of distal humerus fractures by orthogonal plating and parallel plating

MATERIALS & METHODS

A prospective study was done to evaluate the comparison of outcome of management of distal humeral fractures treated with plating applied orthogonally and parallelly in patients admitted in Government Mohan Kumaramangalam Medical College Hospital, Salem during the period from November 2017 to October 2019. Through posterior approach, the distal humerus fractures are fixed with anatomical locking plates by orthogonal and parallel plating technique.

DISCUSSION:

In our study, the mean age group of patients was 44 years with male preponderance. Road traffic accidents and accidental fall were the commonest mode of injury. The results were excellent for 10 elbows, good for 14, fair for 3, and poor for 3 patients using mayo elbow performance score.

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RESULTS:

Orthogonally applied locking compression plates provide no difference compared to the parallel plating. In conclusion, distal humerus fractures with intra articular extension treated with locking compression plates applied in a parallel configuration have no advantage over the orthogonal plating. However long terms follow up and a larger sample study is needed to further validate our findings.

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COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL PLATING AND

PARALLEL PLATING

AIM:

To evaluate and analyse the COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL PLATING AND PARALLEL PLATING in Government Mohan Kumaramangalam Medical College and Hospital, Salem.

INTRODUCTION:

Distal humerus compromise approximately 2% of all fractures. They have bimodal age distribution^1,2,3,4with peak incidence between 12 and 19 yrs in males and 80 years and older characteristically in females. The fractures are due to high energy injuries such as road traffic accidents in young adults and in elderly occur from low energy injuries such as trivial fall^2,3.

The most common mechanism of injury was a simple fall from standing height and the most common fracture was an extra articular fracture accounting for 40% of all fractures. Bicolumn or complete intrarticular fractures were the second most common accounting for 37%.The overall incidence of distal humerus fracture is increasing nowadays and difficult injuries to manage^5,6,7. In osteopenic bone it is often multifragmented and have limited options for fixation with complex anatomy. Elbow stiffness,

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pain and weakness are often associated with treatment outcomes. The mainstay of current fracture prevention is to screen for osteopenia and osteoporosis with bone mineral density measurements and then to treat with medication therapy⁵.A painless, stable and mobile elbow joint is necessary to perform daily activities. For making distal humerus fractures stable , mobile and pain free joint it requires a systematic approach like surgical approach, anatomic articular reduction and creating a rigid fixation construct to tolerate early range of movements.

In 1913, Albin Lambotte⁸ challenged conservative management for distal humerus and proposed open reduction and internal fixation by the principles of osteosynthesis and anatomic restoration with better return to function.

In 1937 Eastwood described the technique of closed reduction under general anaesthesia and immobilised in cuff and collar.

In 1953 Evans⁹coined bag of bones and made it appropriate for elderly patient and not for young patients.

Finally Arbeitsgemeinschaft fur osteosynthesefragen principles Association for study of internal fixation allow for healing and early postoperative motion 3,10,11,12,13,14,15.

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The guidelines for the fixation of distal humerus involves orthogonal /perpendicular plating (90⁰-90⁰) placing one plate over the medial column and another plate over posterolateral or dorsolateral colum and parallel plating (180⁰) placing the plate over the medial column and another plate over lateral column with screws in the distal fragment interdigiting each other maintaining the articular segments and function architecturally as a tie arch. The parallel plating technique causes extensive soft tissue damage and neurovascular compromise as complication.

REVIEW OF LITERATURE:

Schemitsch et al ¹⁶found that the parallel plating with medial 3.5 mm reconstrucation plate and lateral J plate had greatest construct rigidity when compared to orthogonal plating with 3.5 mm reconstruction plates.

Self et al ¹⁷found that parallel plating having greater stability and load to failure than orthogonal plating.

Arnander et al ¹⁸found two 3.5mm reconstruction plates applied in parallel fashion have increased stiffness and strength compared to two 3.5mm reconstruction plates applied orthogonally.

Stoffel et al ¹⁹reported higher stability in parallel plate system than orthogonal plate system.

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ANATOMY OF DISTAL HUMERUS AND ELBOW JOINT:

Elbow is a trocho-ginglymoid joint and it has trochoid motion through radiocapitellar and proximal radioulnar joints and ginglymoid motion through the ulnohumeral joint.

The distal humeral shaft is triangular in cross section and its apex directed anteriorly. It bifurcates into two divergent cortical columns named medial and lateral columns. The Medial column diverges 45 degrees from humeral shaft in coronal plane and named medial epicondyle. The lateral column in coronal plane diverges 20 degrees from shaft and distally it curves anteriorly projecting 35 to 40 ⁰.

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The trochlea is more distal than capitulum resulting in 4 to 8 degrees of valgus alignment. Thus elbow has a valgus angle named carrying angle in extension of 10 to 17 degrees. As the elbow flexes, distal humerus articular surface is internally rotated 3 to 8 degrees resulting in varus alignment.

The lateral column terminates anteriorly with the capitulum and the articular surface starts at the most distal aspect of lateral column and forms an arc of approximately 180 degrees in sagittal plane.

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The trochlea (pulley) is shaped like a spool and the intervening segment of bone between medial and lateral column terminal ends and it articulates with central ridge of greater sigmoid notch of ulna and covered by articular cartilage anteriorly, posteriorly and inferiorly making an arc of 270⁰_.

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The line of shaft forms 40 degree with the articular segment and functions at the point of maximum column divergence distally. The lateral epicondyle is projected slightly forward from the axis and the medial epicondyle is on the projected axis of the shaft.

LIGAMENTS OF ELBOW JOINT

The LCL complex consists of radial collateral, lateral ulnar collateral ligament and the annular ligament. The annular ligament attached to anterior and posterior margins of sigmoid notch and radial collateral ligament attaches to annular ligament. The lateral ulnar collateral ligament arises from lateral epicondyle and attaches to proximal ulna. The LCL complex functions as varus and posterolateral rotatory stability^20,21 to elbow .

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The MCL complex consists of anterior bundle, posterior bundle and transverse ligament. The anterior bundle originates from anteroinferior aspect of medial epicondyle elbow and inserts into sublime tubercle of coronoid and function as important restraint to valgus and posteromedial rotatory stability^22.23_.

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NERVES IN RELATION TO DISTAL HUMERUS

The ulnar nerve pierces the medial intermuscular septum and travel alongside of medial head of triceps in middle third of arm. The ulnar nerve travel behind the medial epicondyle to enter the cubital tunnel bordered by Osborne’s ligament medially, olecranon laterally and medial epicondyle superiorly and it exits the cubital tunnel between two heads of flexor carpi ulnaris.

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The radial nerve circles spiral groove around the posterior aspect of midhumeral shaft. The nerve enters spiral groove 20cm proximal to medial epicondyle and exists 14cm proximal to lateral epicondyle and gives branch to medial head of triceps and anconeus and lateral brachial cutaneous nerve approximately 10 cm proximal to lateral epicondyle before it pierces lateral intermuscular septum. The nerve lies between brachialis and brachioradialis and divides into posterior interosseous nerve and radial sensory nerve.

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The median nerve lies between biceps and brachialis and travels with brachial artery in anteromedial aspect of arm. The nerve passes between two heads of pronator teres.

VESSELS IN RELATION TO ELBOW JOINT

The blood supply to adult elbow by three vascular arcades:

1. medial, 2. lateral and 3. posterior.²⁴

The medial arcade formed by anterior and posterior ulnar recurrent arteries and superior and inferior ulnar collateral and supply medial epicondyle and trochlea. The lateral arcade formed by interosseous recurrent,radial collateral

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and radial recurrent and supplies radial head, trochlea,lateral epicondyle and capitulum. The posterior arcade formed by medial collateral artery and supplies supracondylar area and olecranon fossa.

BIOMECHANICS:

The ulnohumeral articulation is important in mobility and osseous stability in the flexion - extension plane especially coronoid process.

The coronoid process prevents posterior subluxation in extension beyond 30⁰ or greater. The medial facet of coronoid is important in varus

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stress stability. The coronoid or olecranon processes may ‘lock’ into their corresponding fossae at the extreme range of motion of ulno-humeral joint.

However, most activities in most patients depends on a combination of ligamentous and bony integrity of the articulation.

The medial side of the joint is secured by anterior band of MCL. The anterior surface of proximal ulna provides attachment to brachialis muscle.

The radial head adds elbow stability by widening the base of support of forearm acting as an anterior buttress and posterolateral ligament tensioned.

The elbow dislocation invoves fracture of the coronoid process, radial head, medial epicondyle, olecranon, making treatment more complex.

50% of varus stress in the extended position and 40% of the resistance to valgus stress are mainly by soft tissue structures.

The anterior bundle of the MCL depending on the amount of elbow flexion may provide one-third to onehalf of the elbow’s resistance to valgus stress.

Fracture of the coronoid process,medial epicondyle and rupture of the medial collateral ligament disrupt the medial structures.

The posterolateral rotatory instability is maintained by the lateral collateral ligament complex with annular ligament and its injury that may lead to recurrent dislocation if not properly protected during the rehabilitation.

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The muscles around the elbow like biceps / brachialis and triceps, stabilize the elbow as well. However, it is difficult to quantify the importance of the extensor muscles.

CLASSIFICATION SYSTEMS IN DISTAL HUMERUS FRACTURES:

ANATOMICAL CLASSIFICATION:

Supracondylar fractures, transcondylar fractures,

intercondylar fractures, fractures of the condyles (lateral and medial), fractures of articular surfaces (capitulum and trochlea) and fractures of epicondyles.

THE COMPREHENSIVE AO – OTA CLASSIFICATION:

Distal humeral fractures -13 A Extra Articular fracture

A1 : Apophyseal avulsion A2 : Metaphyseal simple

A3 : Metaphyseal Multifragmentary B Partial Articular fracture

B1 : Lateral sagittal B2 : Medial sagittal B3 : Frontal

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15 C Complete articular fracture

C1 : Articular simple , Metaphyseal simple

C2 : Articular simple , Metaphyseal multifragmentary C3 : Articular , Metaphyseal multifragmentary

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THE MEHNE AND MATTA CLASSIFICATION:

It is based on, jupiter’s model of distal humerus, which is composed of two divergent columns, that support an intercalary articular segment.

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17 Riseborough and Radin classification:

In 1969 classified intercondylar fractures on the Radiographic appearance. It provides some guidance to management and prognosis.

They are 4 types.

Type- I : Non-displaced fracture between the capitulum and trochlea.

Type- II : ‘T’ shaped fracture with separation of capitulum and trochlea without appreciable rotation of the fragments in frontal plane.

Type-III : ‘T’ shaped fracture with separation of fragments with rotational deformity

Type-IV : Severe comminuted articular surface with wide separation of humeral condyles.

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BIOMECHANICS OF FRACTURE FIXATION:

1. Humeral shaft along with attachement should be maintained with articular surfaces of distal humerus.

2. Reduction and fixation of the humeral shaft with lateral or medial condyle and then with articular surface followed by reduction and fixation of opposite condyle.

O DRISCOLL technical objectives for fixation of distal humeral fractures:

1. Every screw should pass through a plate.

2. Each screw should engage a fragment on the opposite side that is also fixed to a plate.

3. As many screws as possible should be placed in the distal fragments.

4. Each screw should be as long as possible.

5. Each screw should engage as many articular fragments as possible.

6. The screws should lock together by interdigitation within the distal fragment, thereby creating a fixed angle architecture that provides stability to the entire distal humerus.

7. Plates should be applied such that compression is achieved at the supracondylar level for both the columns.

8. Plates used must be strong and stiff enough to resist breaking or bending before union occurs at the supracondylar level.

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19 SURGICAL APPROACHES:

1. Posterior approach:

 Olecranon osteotomy^25,26,27

 Paratricipital (triceps on)^28,29

 Triceps off (triceps splitting, triceps reflecting and triceps tongue approaches).

2. Medial approach

 Kocher 3. Lateral approach

 koeber

 Jupiter

4. Anterior approach

 Henry

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20 POSTERIOR APPROACHES:

1. PARA TRICIPITAL APPROACH (ALONSO- LLAMES) ²⁸:

 Posterior skin incision and mobilisation of ulnar nerve

 Interval made between medial intermuscular septum and triceps muscle.

 From posterior aspect of distal humerus triceps muscle is elevated off.

 Two separate windows are created on either of the triceps muscle.

 This approach is indicated for AO/OTA types A2,A3,B1,B2 and possibly C1 and C2 fractures^29,30,31.

 Disadvantage is limited visualisation of articular surface of humerus and therefore inadequate for fixation of type C3 fractures.

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2. TRICEPS SPLITTING APPROACH (CAMPBELL³²):

 Triceps tendon is split in midline.

 Through subperiosteal dissection, the lateral and medial columns exposed.

 Extends proximally to expose radial nerve in spiral groove.

 Incision extended through triceps insertion to subcutaneous border of ulna and split made in triceps insertion on olecranon.

 Triceps tendon is repaired to olecranon with transosseous non absorbable braided sutures.

 This approach is indicated for total elbow arthroplasty for fractures invoving articular surface and column.

 Diadvantages is articular surface not accessible and triceps detachment may be at risk.

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3. TRAP APPROACH (O’DRISCOLL) ³³ :

 Involves completely detaching the triceps from proximal ulna with anconeus muscle.

 Kocher’s interval elevates the anconeus muscle.

 Lateral and medial portion of flap created.

 Anconeus flap reflected proximally to expose triceps insertion

 The entire triceps muscle released proximally and triceps anconeus flap developed.

 Approach provides good exposure to posterior elbow joint and protecting neurovascular supply to anconeus muscle.

 Disadvantages is risk of triceps muscle weakness and dehiscence.

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4. TRICEPS TONGUE APPROACH (van gorder ³⁴)

 At musculotendinous junction the triceps muscle is split.

 Transection of triceps done in the shape of ‘V’ for V-Y plasty

 This approach most commonly used for total elbow arthroplasty and rarely for distal humeral fractures.

 Disadvantages is triceps detachment and its access to articular surface.

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5. OLECRANON- OSTEOTOMY APPROACH (MACASULAND³⁵):

 Most commonly used for AO/OTA type C fractures.

 Good access to posterior articular surfaces for reconstruction.

 ‘V’ shaped chevron osteotomy provides rotation stability³⁶_.

 It has rotational stability and translational stability when compared to the transverse osteotomy²⁸.

 Disadvantages are non union and failure of fixation of osteotomy.

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25 MATERIALS AND METHODS STUDY DESIGN:

A comparative study done prospectively to evaluate the outcome of management of distal humeral fractures treated with plating applied orthogonally and parallelly and the results were analysed.

STUDY GROUP:

The study group consists of 30 Patients with distal humeral fractures based on randomised control study who underwent osteosynthesis with orthogonal and parallel plating technique between Nov 2017 and Oct 2019 in government mohan kumaramangalam medical college hospital, salem. The study was done after getting clearance from Hospital ethical committee.

Those who fulfilled the inclusion criteria given below were included in the study. Informed consent was obtained from all the patients willing to take part in the study.

Assessment done at 6 weeks, 3months, 6 months and 1year to assess the pain, stiffness, radiological union, clinical union and functional ability of elbow using mayo elbow performance score.

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26 GRADING OF RESULTS:

Mayo Elbow Performance Scoring System (MEPS)³⁷ Pain ( max.45 points)

None (45 points) Mild (30 points)

Moderate (15 points) Severe(0 points)

Range of motion( max 20 points) Arc > 100 degrees(20 points) Arc 50 to 100(15 points) Arc<50 degrees(5 points) Stability( max 10 points) Stable(10 points)

Moderately unstable( 5 points) Grossly unstable(0 points) Function (max 25 points)

Able to comb hair( 5 points) Able to feed oneself( 5 points)

Able to perform personal hygiene tasks( 5 points) Able to on shirt( 5 points)

Able to put on shoes( 5 points) Mean total (max 100 points)

Score greater than 90. excellent Score 75-89 .good

Score 60-74. Fair Score below 60. Poor

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MAYO ELBOW PERFORMANCE SCORE FUNCTION POINT Pain 45 Daily functional activities 25 Motion 20 Stability 20

A. INCLUSION CRITERIA:

 All patients with distal humerus fractures.

 Skeletally mature patients B. EXCLUSION CRITERIA:

 Open fractures(grade3)

 Skeletally immature patients.

 Patients medically unfit for surgery

On admission the history was elicited from all patients and attendants to find out the mechanism of injury and associated injuries. A detailed clinical examination and radiological assessment was done to assess the fracture pattern, deformity and neurovascular status. Then the injured limb was immobilized in an above elbow plaster slab until the day of surgery.

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28 PREOPERATIVE PLANNING:

The objectives are to obtain anatomic restoration of articular surface and recreation of joint alignment with rigid internal fixation, stable enough to allow early range of motion. Anteroposterior and lateral radiographs of elbow are sufficient to determine fracture pattern. A 3D CT scan is taken to demonstrate articular fractures and identify difficult fracture patterns such as coronal fractures of capitulum or trochlea, low fracture types and segmental articular farctures. It can also be manipulated to subtract the radius and ulna to allow unobstructed visualisation of articular communition. Patients are placed in well padded elbow splint and are encouraged to elevate the arm, ice the elbow and maintain hand and finger range of motion. On the day of surgery, the skin and soft tissues are re-examined and neurological status is redocumented. Patients generally given general anaesthesia with an upper extremity block for postoperative pain control and therapy. Preoperatively prophylactic antibiotics are administered intravenously.

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29 POSITIONING:

The patient, were given a general anesthesia or regional anesthesia and were positioned in the lateral position, with the involved limb supported over bolsters in OT table as depicted in the picture below.

An extensile posterior skin incision is used with elevation of full thickness medial and lateral fasciocutaneous flaps. The ulnar nerve is identified, dissected out and retracted gently with an umbilical cotton tape and tagged and prepared for anterior subcutaneous transposition which will be done at the completion of the procedure. Triceps muscle identified and released on either side from the intermuscular septum. In complex articular fractures Chevron V shaped olecranon osteotomy done incompletely with saw and completed with an osteotome to visualize the articular surface. In other types we utilized any of the described approaches like TRAP, Paratricipital or Triceps splitting approach. The olecranon osteotomy helps in wide exposure of intra articular fragments in type C fractures.

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The articular segment (AO/OTA type A fractures and type C fractures after articular fixation) requires rigid attachment to medial and lateral columns or distal humeral shaft .This can be accomplished by orthogonal ^38,39,40, parallel ^41,42 or triple plating ^43,44. No clinical superiorty of either method has been reported between orthogonal and parallel plating techniques. In our study we performed both orthogonal and parallel plating techniques. Thin and active patients have hardware irritation from a prominent lateral plate therefore posterolateral plate is preferred.

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31 ORTHOGONAL PLATING:

Orthogonal plating involves the placement of plates on both columns approximately 90-degree angles. Usually, the lateral plate is placed as distal as possible along the posterior aspect of the lateral column. The lateral plate should be contoured with bend that matches the posterior curvature of the lateral column. To achieve maximum distal fixation, the end of the plate lie just proximal to posterior articular surface of capitulum. Placement of plate further distal may lead to impingement of the radial head against the plate in extension resulting in pain and limited range of motion. Ideally the lateral plate should be a 3.5mm dynamic compression plate or equivalent. The medial plate is usually applied on the medial supracondylar ridge with contouring to curve around the medial epicondyle. The plate is typically a 3.5mm reconstruction plate to allow easier bending. A newer fracture specific precontoured plates may be preferred.

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TECHNIQUE OF ORTHOGONAL PLATING:

Step1: Reduce the fracture and fix temporarily using k wires.

Initially the articular fragments are aligned and fixed with k wires and temporarily fixing the distal fragment in both columns with k wires to ensure anatomy of distal humerus is restored

Step 2: Determine the type and length of plate

The plate lengths are selected that offer sufficient fixation proximal to the fracture lines. Medial and dorsolateral plates are placed of different lengths to prevent excessive diaphyseal stress.

For e.g: 5 holed medial plate is used with 8 holed dorsolateral plate.

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33 Step 3: Application of Dorsolateral plates

The dorsolateral plates are applied with locking 3.5mmcortical screw and fixed the bone with plate. The screws are all directed from posterior to anterior. Additional screws are inserted in lateral to medial direction for the condyles. During movement of the elbow to ensure screws are not in the joint confirm the screw placement and length with image intensifier.

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34 Step 4: Application of medial plate

Position the medial plate on medial supracondylar ridge and dorsal to intermuscular septum with distal tip of plate reaching down to insertion of medial collateral ligament . The longest possible screws are inserted in distal fragment.

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After fixing the fracture segments, osteotomized olecranon was fixed with tension band wiring either with two k wires or a 6.5mm Cancellous screw.

PARALLEL PLATING:

Parallel plating also uses two plates; however plates are placed relatively parallel to each other on their respective supracondylar ridges.

screws into the articular segment are preferentially placed through the plates to link the articular fragments to the humeral shaft. Ideally longest screws should be inserted through the plate to capture as many articular fragments as possible and to engage the fragments that are secured to the opposite Column^45,46,47. Longitudinal k wires are used to temporarily fix the reconstructed articular segment to the shaft to allow columnar plate application. Precontoured plates are then provisionally applied to the medial and lateral columns with k wires placed distally. As many screws as possible are inserted through the plates into articular segment. Ideally the screws should be as long as possible and engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa and it leads to impingement. The plates are then fixed to humeral shaft with first diaphyseal screws inserted in an eccentric fashion to provide supracondylar fracture compression. Plates should end in different levels to minimize the stress riser effect.

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TECHNIQUE OF PARALLEL PLATING:

Step 1: Articular reduction. Articular fragments were aligned and were fixed with K wires placed subchondrally not with interfering in plate placement.

Step 2: Plate placement and provisional fixation:

3.5mm plates were placed in medial and lateral ridges and both ends at different levels in the shaft region. A screw were placed in one of the proximal hole of each plate but not fully tightened for the plate to move proximally later during compression. K wires were used in distal fragments for provisionally fixation.

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37 Step 3: Articular fixation.

Long medial and lateral distal screws fixing maximum fragments were applied.

Step 4: Supra condylar compression

a. The screw proximal to fracture site on one side was loosened and a large bone clamp was applied distally on that side and proximally on the opposite cortex to eccentrically load the supracondylar region. A second screw was inserted through the plate in compression mode and then the loosened screw is retightened.

b. The same step repeated for opposite column also.

c. Diaphyseal screws was to be applied and achieve residual compression through precontoured plates.

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38 Step 5: Final fixation:

Provisional K wires in the distal fragment were removed and replaced with screws.

POST OP PROTOCOL:

Patients were placed in a well-padded plaster applied above elbow and the limb was elevated for first 3 days. Active finger movements and wrist mobilisation started on day 1. Intravenous antibiotics were given followed by oral antibiotics. Drain removal at 48 hours andsuture removal done on 12th day. Elbow range of motion was started between days 3 and 7 postoperatively, as tolerated by the patient. Generally, active range of motion and active-assissted were encouraged. Patients who underwent an approach involving extensor mechanism were given passive assisted extension exercises. Patients were allowed to their routine full activities at 6 months.

(53)

39 Table 1.comparison between gender

Comparison between Gender with Groups

Groups

Total 2 -

value P-value Orthogonal Parallel

Sex

Female Count 4 5 9

0.159 1.000 #

% 26.7% 33.3% 30.0%

Male Count 11 10 21

% 73.3% 66.7% 70.0%

Total Count 15 15 30

% 100.0% 100.0% 100.0%

# No Statistical Significance at P>0.05 level

0%

20%

40%

60%

80%

100%

Orthogonal Parallel

Percentage

Groups

Gender with Groups

Female Male

(54)

40 Table 2.comparison between sides

Comparison between Side with Groups

Groups

Total 2 - value

P- value Orthogonal Parallel

Side

Left Count 9 5 14

2.143 0.272

#

% 60.0% 33.3% 46.7%

Right Count 6 10 16

% 40.0% 66.7% 53.3%

% 100.0% 100.0% 100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

Side with Groups

Left Right

(55)

41

Table 3.comparison between mode of injuries:

Comparison between Mode of Injury with Groups

Groups

Total 2 - value

Mode of Injury

Assault Count 0 1 1

2.058 0.357

#

% 0.0% 6.7% 3.3%

Fall Count 2 4 6

% 13.3% 26.7% 20.0%

MVA Count 13 10 23

% 86.7% 66.7% 76.7%

% 100.0% 100.0% 100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

Mode of Injury with Groups

Assault Fall MVA

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42

Table 4.comparison between AO OTA types:

Comparison between AOType with Groups

Groups

Total 2 - value

AOType

13A2 Count 2 1 3

3.486 0.480

#

% 13.3% 6.7% 10.0%

13A3 Count 3 2 5

% 20.0% 13.3% 16.7%

13C1 Count 2 4 6

% 13.3% 26.7% 20.0%

13C2 Count 2 5 7

% 13.3% 33.3% 23.3%

13C3 Count 6 3 9

% 40.0% 20.0% 30.0%

% 100.0% 100.0% 100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

AOType with Groups

13A2 13A3 13C1 13C2 13C3

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43

Table 5.comparison between different approaches:

Comparison between Approach with Groups

Groups

Total 2 - value

P- value Ortho

gonal Parallel

Approach

Olecranon osteotomy

Count 7 9 16

1.393 0.707

#

% 46.7% 60.0% 53.3

% Paratricipital

Count 4 3 7

% 26.7% 20.0% 23.3

% Triceps

splitting

Count 3 3 6

% 20.0% 20.0% 20.0

% Triceps

tongue

Count 1 0 1

% 6.7% 0.0% 3.3%

Total

Count 15 15 30

% 100.0% 100.0% 100.0

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

Approach with Groups

Olecranon osteotomy Paratricipital Triceps splitting Triceps tongue

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44

Table 6.comparison between associated injuries:

Comparison between Associated Injuries with Groups

Groups

Total 2 -

Associated Injuries

No Count 13 13 26

0.000 1.000 #

% 86.7% 86.7% 86.7%

Yes Count 2 2 4

% 13.3% 13.3% 13.3%

Total

Count 15 15 30

% 100.0% 100.0% 100.0

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

Associated Injuries with Groups

No Yes

(59)

45 Table 7.comparison between grades of pain:

Comparison between Pain with Groups

Groups

Total 2 - value

Pain

Mild Count 3 2 5

0.600 0.741

#

% 20.0% 13.3% 16.7%

Moderate Count 3 2 5

% 20.0% 13.3% 16.7%

No Pain Count 9 11 20

% 60.0% 73.3% 66.7%

% 100.0% 100.0% 100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

Pain with Groups

mild moderate No Pain

(60)

46 Table 8.comparison between MEPI:

Comparison between MEPI with Groups

Groups

Total 2 - value

MEPI

Excellent Count 5 5 10

0.667 0.881

#

% 33.3% 33.3% 33.3%

Fair Count 1 2 3

% 6.7% 13.3% 10.0%

Good Count 7 7 14

% 46.7% 46.7% 46.7%

Poor Count 2 1 3

% 13.3% 6.7% 10.0%

% 100.0% 100.0% 100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

MEPI with Groups

Excellent Fair Good Poor

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47

Table 9.Comparison between complications in groups:

Comparison between Complications with Groups

Groups

Total 2 -

Complications

No Count 9 6 15

1.200 0.466 #

% 60.0% 40.0% 50.0%

Yes Count 6 9 15

% 40.0% 60.0% 50.0%

% 100.0% 100.0% 100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orthogonal Parallel

Percentage

Groups

Complications with Groups

Nil Yes

(62)

48

Table 10.comparison of age in groups and MEPS in groups:

Comparison of Age,MEPS by Unpaired T-Test

Groups N Mean S.D t-

value

P- value

Age Orthogonal 15 44 14

0.607 0.549

Parallel 15 41 14 #

MEPS Orthogonal 15 82.67 11.00 0.163 0.872 Parallel 15 83.33 11.44 #

0 5 10 15 20 25 30 35 40 45 50

Orthogonal Parallel

Mean

Groups

Age

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00

Orthogonal Parallel

Mean

Groups

MEPS

(63)

49 Observations and results:

1) The Mean age of the patients was 44 years ranging from 20 to 75 years in both groups. Nearly 30% patients belong to 3rd decade followed by 4th decade (25%). 71% of the patients belong to less than 50 years.

2) Males dominated our study group with a ratio of 2: 1 in both groups.

3) Right limb injuries were more common.

4) Motor vehicle accidents and accidental simple falls were the common mechanisms of injury.

5) Completely articular fractures constituted 75% while extraarticular transcondylar constituted only 25% of our cases in both groups.

6) Of the complete articular types, the order of most common types were C3(40%)>C2(13.3%)>C1(13.3%) in orthogonal plating groups whereas in parallel groups C2(33.3%)>C1(26.3%)>

C3(20%). One patient had associated skeletal injuries. Three patients had radial nerve injury in both groups.

7) Complications encountered in both groups were paraesthesia along ulnar nerve distribution, radial nerve neuropraxia, infection, stiffness, non-union at osteotomy site, decreased ROM due to heterotopic ossification and hardware prominence.

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50

8) Five patients had infection. Three patients was treated conservatively with antibiotics and SSG. Two other patients who had a wound gapping and implant failure and poor outcome.

9) One patient reported numbness and paraesthesia along ulnar border of little finger which was treated conservatively. One patient had radial nerve neuropraxia. Radial neuropraxia showed recovery after 1 year.

10) Stiffness was noted in 3 patients. Heterotopic ossification with reduced elbow ROM was observed in 1 patient.Three patients who developed hardware prominence.

11) One patient who had a nonunion at the osteotomy site was done a revision osteosynthesis with tension band wiring.

12) Thirty patients of distal humeral fractures were treated surgically with orthogonal and parallel plating and analyzed with average follow up of 12months (6 months – 2 years).

13) In our study, solid radiologic union was achieved primarily in all patients. The average time to union was about 10 weeks. Hardware failure developed in 2 patients in orthogonal groups.

14) The results were excellent for 10 elbows, good for 14, fair for 3, and poor for 3 patients.

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51

CASE ILLUSTRATIONS:

CASE 1

NAME : Nandakumar

IP NO : 41578

AGE : 22 yrs

OCCUPATION : sales representative.

DIAGNOSIS : Fracture of distal humerus left side

AO/ASIF : Type 13 C3

ASSOCIATED INJURIES : Nil

PROCEDURE DONE : Orthogonal plating via olecranon

osteotomy approach

COMPLICATIONS : Nil SECONDARY PROCEDURE : Nil

TIME OF UNION 10 weeks

ELBOW ARC OF MOTION 0⁰-135⁰

MAYO SCORE 95

FUNCTIONAL OUTCOME excellent

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52

PRE OP XRAY IMMEDIATE POST OP XRAY

6 WEEKS FOLLOW UP 3 MONTHS FOLLOW UP

1year postop follow up

Range of movements

(67)

53 CASE 2

NAME : Kandhasamy

IP NO : 9544

AGE : 64 yrs

OCCUPATION : Farmer

AO/ASIF : Type 13 A2

ASSOCIATED INJURIES : wrist drop

osteotomy approach

MAYO SCORE 95

FUNCTIONAL OUTCOME Excellent

(68)

54

Preop x-ray immediate post op x-ray

6 weeks postop follow up

3 months postop follow up

(69)

55

1 year postop follow up

Range of movements

(70)

56 CASE 3

NAME : Manikandan

IP NO : 9437

AGE : 30 yrs

OCCUPATION : driver.

osteotomy approach

MAYO SCORE 95

FUNCTIONAL OUTCOME excellent

(71)

57

Pre op x ray Immediate post op x ray

6 weeks post op follow up 3months post op follow up

1year post op follow up range of movements

(72)

58 CASE 4

NAME : Jayakandhan

IP NO : 17577

AGE : 52 yrs

OCCUPATION : businessman.

PROCEDURE DONE : Orthogonal plating via triceps on approach

COMPLICATIONS : wrist drop SECONDARY PROCEDURE : Nil

TIME OF UNION 10 weeks

MAYO SCORE 80

FUNCTIONAL OUTCOME good

(73)

59

Pre op x ray Immediate post op x ray

6 weeks post op follow up 3 months post op follow up

(74)

60

6 months post op follow up 1 ½ years post op follow up

Range of movements

(75)

61 CASE 5

NAME : Settu

IP NO : 9160

AGE : 34 yrs

OCCUPATION : Coolie

DIAGNOSIS : Fracture of distal humerus right side

PROCEDURE DONE : Orthogonal plating via triceps

reflecting approach

MAYO SCORE 85

FUNCTIONAL OUTCOME good

(76)

62

Preop x ray Immediate post op x ray

6 months follow up x ray Range of movements

(77)

63 CASE 6

NAME : Raniyammal

IP NO : 9760

AGE : 44 yrs

OCCUPATION : housewife

PROCEDURE DONE : Orthogonal plating via olecranon osteotomy

TIME OF UNION 10 WEEKS

ELBOW ARC OF MOTION 10-110

MAYO SCORE 80

FUNCTIONAL RESULT GOOD

(78)

64

6 weeks post op follow up x ray 6 months post op follow up

Range of movements

(79)

65 CASE 7

NAME : Sekar

IP NO : 74155

AGE : 40

OCCUPATION : Coolie

PROCEDURE DONE : Orthogonal plating via olecranon osteotomy

MAYO SCORE 80

FUNCTIONAL RESULT FAIR

(80)

66

1 year post op follow up

Range of movements

(81)

67 CASE 8

NAME : kamalakannan

IP NO : 8646

AGE : 32

OCCUPATION : Coolie

PROCEDURE DONE : Parallel plating via olecranon osteotomy

Elbow arc of motion 10-130

MAYO score 95

Functional result excellent

(82)

68

Preop x ray Immediate post op xray

6 month postop follow up

Range of movements

(83)

69 CASE 9

NAME : Saraswathi

IP NO : 9346

AGE : 64

OCCUPATION : housewife

PROCEDURE DONE : Parallel plating via olecranon osteotomy

MAYO SCORE 85

(84)

70

Preop x ray immediate post op x ray

8 months postop followup

Range of movements

(85)

71 CASE10

NAME : Harish

IP NO : 2234

AGE : 24

OCCUPATION : Student

PROCEDURE DONE : Parallel plating via paratricipital approach

MAYO SCORE 85

(86)

72 Preop x ray

Followup xray

Range of movements

(87)

73 DISCUSSION:

For a social and economic thriving, a good full-range elbow is necessary. Distal humerus fractures directly affect the functional movement of elbow. In comparing to study by Sanchez-Sotelo et al⁴⁸where majority of distal humerus from road traffic accidents and others fall from height. Since females travel less in our society high male:female ratio seen in our centre (2:1) as compared to 1:1 recorded by Sanchez-Sotelo et al ⁴⁸. Fracture patterns according to OTA also had a role in the outcome. AO OTA type A patients had a good outcome compared to AO OTA type C. This highlights the importance of the OTA classification. Study by Sanchez-Sotelo et al ⁴⁸ stated that the C and A types are far more common than type B as seen in our study also. Since the percentage of high velocity injuries is increasing day by day, type C is more common than type a fractures. Exposure, fixation and the post-operative rehabilitation are the main factors which play an important role in functional outcome of the elbow, with later two are of primary consideration. Individual fracture fragment fixation always depends upon a good exposure. Olecranon osteotomy provides the best visualisation of the intra-articular fragments. 16 cases in our study was operated by olecranon osteotomy. Eight of them were fixed with modified TBW with K wires and remaining 8 cases were fixed with cancellous screws with TBW. Trochlea, capitulum, olecranon and radial head was fully visualised using the olecranon approach.

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74

Medial and lateral supracondylar ridges were also accessible by this approach. Individual fragment specific fixation could be done by this approach. Only one case in our 16 osteotomized elbows showed a non-union which united with revision osteosynthesis with modified TBW. 15 cases in our study were performed surgery with parallel plating which provided a rigid stability for early rehabilitation. It is possible for lengthy screw placement while placement of the plate on the lateral column which is difficult in traditional orthogonal plating due to the presence of anterior capitular breach. Easy contour ability for both column fixations is possible because of 3.5mm reconstruction plates. To achieve a more fixed rigid construct for allowing early mobilization, instead of using the more pliable 1/3 tubular plate for the medial column which requires extra contouring, authors recommend at least a stronger 3.5mm plates or precontoured plates for both columns . No implant failures or non-union at the fracture site was observed in our study which is on par with the fact that parallel plating offers an inherently stable construct in a given clinical situation and in concurrence with studies done on parallel plating by Sanchez-Sotelo et al ⁴⁸ and Atalar et al ^49.

Bicolumnar locking compression plates used to fix distal humerus fractures applied orthogonally is studied in detail. The treatment modalities for articular fractures are numerous and are continuously refining over time.

Three dimensional geometry makes treatment very difficult. Complications

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75

like a rigid elbow, non-union and implant pullout has made these fractures very difficult to treat. Anatomical alignment, absolute stabilisation and early mobilisation were always followed by our patients in this study and their corresponding functional outcome. The mean age of patients in our study is 44 yrs which is comparable to the study conducted by Shin et al⁵⁰ whose average age is 44 yrs. The elderly group had a lower functional outcome than the younger age group (88%). This may be due to the presence of poor bone stock and poor adherence to the postoperative protocol leading to stiffness. 2 patients out of 15 patients in which anterior transposition of ulnar nerve was done. Ulnar neuropraxia was seen in 1 patient which recovered completely in 6 months which is comparable with the study conducted by Wang et al in 70 patients out of which only 2 patients developed ulnar nerve paraesthesia. Ring et al⁵¹ stated that, bursitis, implant prominence, displacement of k wire were the complications of olecranon osteotomy reported were. 2 cases of hardware prominence were seen in our study. In the study by Qi-X et al⁵², one case of myositis ossificans was present out of 21 cases of distal humerus fractures operated using paratricipital approach. One case developed stiffness due to heterotopic ossification out of 4 cases.

80 cases of intraarticular fracture underwent surgery through orthogonal plating in the study by Babhulkaret al⁵³, and had good functional outcome in 86 % of cases. Kaiser et al⁵⁴ study showed 22 patients treated with orthogonally applied LCP plates. The mean MEPS score was 84.7 .The

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76

complications reported were ulnar sensory neuropathy which recovered completely in 1 case. All patients had achieved stable reduction and union during follow up. In the study by Holub et al⁵⁵ the outcomes of conventional reconstruction plates and LCP were compared, excellent results were achieved with the use of locking compression plates particularly in intraarticular distal humerus fractures. The average operating time was 123 minutes using conventional plates. Our study had an average time of 100 minutes which may be attributed to the anatomically fit precontoured plates which does not need any contouring to fix with the bone. Lee et al⁵⁶ compared the outcomes of parallel and orthogonal plating technique using distal humerus LCP and no significant difference in outcomes of both techniques were noted. Stoffel et al⁵⁷ reported the same result in their study of parallel versus perpendicular locking plate systems in comminuted distal humerus fractures. No intergroup differences noted in terms of operating time, time to union and functional recovery were reported. Ian et al⁵⁸ too had reported no difference in MEPS score, flexion extension arc and operating time. Athwal et al⁵⁹ studied the outcomes of 37 patients treated by distal humerus LCP by parallel plate technique and 5 patients out of 24 had postoperative nerve injuries (16%) .In our study also postoperative nerve injuries were seen. This may be attributed to the safe and easier dissection required in orthogonal plating technique compared with parallel plating technique.

(91)

77 CONCLUSION:

Higher incidence of motor vehicle accidents is causing an increasing number of complex distal humerus fractures among younger. A better functional outcome is achieved by an early post operative rehabilitation which is achieved by an absolute stability system. In terms of arc of motion and stability a good to excellent functional outcome was achieved in >80%

of the study group. Locking compression plates provided a highly stable construct which explains the absence of implant failure and non-union. In cases of osteoporotic and communited bones, a rigid construct have to be achieved. Locking compression plates applied in orthogonal plating and parallel plating according to the AO principles is an excellent method for internal fixation of these complicated fractures. Orthogonally applied locking compression plates provide no difference compared to the parallel plating. In conclusion, distal humerus fractures with intraarticular extension treated with locking compression plates applied in a parallel configuration have no advantage over the orthogonal plating. However long terms follow up and a larger sample study is needed to further validate our findings.

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78

BIBILIOGRAPHY REFERENCES:

1. Palvanen M, Kannus P, Niemi S, et al. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J Epidemiol. 1998;14(2):159–164.

2. Palvanen M, Kannus P, Parkkari J, 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(10):822–831.

3. Robinson CM, Hill RM, Jacobs N, et al. Adult distal humeral0 metaphyseal fractures:epidemiology and results of treatment. J Orthop Trauma. 2003;17(1):38–47.

4. Robinson CM. Fractures of the distal humerus. In: Bucholz RW HJ, Court-Brown C,Tornetta P, Koval KJ, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:1051–1116.

5. Jarvinen TL, Sievanen H, Khan KM, et al. shifting the focus in fracture prevention from osteoporosis to falls. BMJ.

2008;336(7636):124–126.

“COMPARISON OF OUTCOME OF MANAGEMENT OF DISTAL HUMERUS FRACTURES BY ORTHOGONAL