Abstract
Background: The short-term results of open reduction and internal
fixation of intra-articular distal humeral fractures are good to excellent in
approximately 75% of patients, but the long-term results have been less well
studied. This investigation addressed the long-term clinical and radiographic
results of surgical treatment of intra-articular distal humeral fractures (AO
Type C) as assessed with use of standardized outcome measures.
Methods: Thirty patients were evaluated at an average of nineteen
years (range, twelve to thirty years) after open reduction and internal
fixation of a fracture of the distal part of the humerus to assess the range
of elbow motion and the functional outcome. Twenty patients had an olecranon
osteotomy, and all had fixation with plates and/or screws and/or Kirschner
wires. No ulnar nerve was transposed.
Results: Excluding one elbow salvaged with an arthrodesis and
counted as a poor result, the average final flexion arc was 106° and the
average pronation-supination arc was 165°. The average American Shoulder
and Elbow Surgeons (ASES) score was 96 points, with an average satisfaction
score of 8.8 points on a 0 to 10-point visual analog scale. The average
Disabilities of the Arm, Shoulder and Hand (DASH) score was 7 points, and the
average Mayo Elbow Performance Index (MEPI) score was 91 points. Including the
patient with the arthrodesis, the final categorical ratings were nineteen
excellent results, seven good results, one fair result, and three poor
results. The presence of arthrosis did not appear to correlate with pain or
predict disability or function. Subsequent procedures were performed in twelve
patients (40%).
Conclusions: The long-term results of open reduction and internal
fixation of AO-Type-C fractures of the distal part of the humerus are similar
to those reported in the short term, suggesting that the results are durable.
Functional ratings and perceived disability were predicated more on pain than
on functional impairment and did not correlate with radiographic signs of
arthrosis.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
Open reduction and plate and screw fixation of AO-Type-C fractures of the
distal part of the humerus has been well
described1-4,
and the efficacy of this treatment has been supported by numerous short-term
retrospective case
series5-10.
However, the long-term function of these elbows has not, to our knowledge,
been studied. The purpose of this study was to evaluate the functional and
radiographic outcomes twelve years or more after open reduction and internal
fixation of AO-Type-C intra-articular fractures of the distal part of the
humerus and to identify predictors of diminished elbow function.
Inclusion and Exclusion Criteria
Between 1974 and 2002, all fractures at our institution were entered into a
database organized according to the Comprehensive Classification of
Fractures11. Using
this database, we identified seventy-seven consecutive adult patients who had
had operative treatment of a complete articular fracture of the distal part of
the humerus (Type C according to the Comprehensive Classification of Fractures
[AO
classification]11)
between 1974 and 1994. Patients were treated by an attending general
orthopaedic surgeon or a general trauma surgeon experienced in AO principles
and techniques of internal
fixation11.
Patients were invited to participate in a free research follow-up visit
under a protocol approved by our institutional review board. Twenty-six
patients had died. Seven patients declined to participate in the study,
thirteen patients had either emigrated or could not be located, and one
patient had had an amputation related to a brachial plexus injury and was
excluded from the study. The remaining thirty patients form the study
cohort.
These thirty patients were evaluated according to the Mayo Elbow
Performance Index
(MEPI)12, the
Broberg and Morrey Functional Rating Index (Broberg-Morrey
Index)13, and the
American Shoulder and Elbow Surgeons (ASES)
score14. They also
completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire,
which is an upper-extremity-specific outcome
questionnaire15.
Classification of Distal Humeral Fractures
Fractures were subclassified, on the basis of plain injury radiographs and
intraoperative findings, according to the Comprehensive Classification of
Fractures11. Eight
fractures were classified as AO Type C Group 1; eleven, as Group 2; and
eleven, as Group 3. Nine fractures were open injuries, but classification
according to the system of Gustilo and
Anderson16 was not
available for the majority of them.
Patient Characteristics
(Table I)
There were eighteen male and twelve female patients with an average age of
thirty-five years (range, thirteen to sixty-four years) at the time of
surgery. This represented a relatively young subgroup of the patients with a
Type-C distal humeral fracture in our trauma database. The average age of the
total group of seventy-seven patients with a Type-C distal humeral fracture in
our database was forty-two years (range, thirteen to eighty-six years) at the
time of surgery. Patients who had died prior to the time of the long-term
follow-up had had a significantly higher average age at the time of surgery
(sixty-three years; range, twenty-three to eighty-six years; p < 0.05).
At the final evaluation, at an average of nineteen years (range, twelve to
thirty years) after the injury, the average age of the study population was
fifty-five years (range, thirty-three to eighty-one years). At the time of
injury, seventeen patients were employed as laborers, eight were white-collar
workers, four were students, and one was a homemaker. The fractures occurred
in eighteen right elbows, fourteen of which were on the dominant side, and in
twelve left elbows, one of which was on the dominant side. Fourteen patients
were injured in a fall from a standing height, and one patient fell from 30 ft
(9 m). Six patients were involved in a motor-vehicle accident, three patients
were in a bicycle accident, and two were in an equestrian accident. Two
patients had a low-energy injury caused by a blunt projectile, one patient had
a crush injury, and one sustained a low-velocity gunshot wound.
Nine patients had multiple skeletal injuries. Three patients had an
associated closed head injury. Three patients had ipsilateral upper-extremity
skeletal injuries (one had a distal radial fracture, one had a distal radial
fracture with an associated olecranon fracture, and one had an olecranon
fracture). One patient, in addition to the excluded patient, had an
ipsilateral brachial plexus injury, which resolved.
Open reduction and internal fixation was performed at an average of one day
(range, zero to ten days) after the injury. Open fractures were first treated
with irrigation and débridement, and antibiotics were administered
prior to definitive surgical fixation.
Surgical Technique
Between 1974 and 1994, patients were treated according to the AO principles
of anatomic reduction and stable internal fixation with a goal of allowing
early
mobilization17.
Fracture fixation was performed with use of standard AO/ASIF technique through
a posterior
approach5. In
nineteen patients (including two with a coexisting olecranon fracture), the
distal part of the humerus was approached through an olecranon
osteotomy18. A
posterior triceps-splitting or triceps-sparing approach was used in the
remaining eleven patients.
The type of internal fixation varied according to the fracture
characteristics and surgeon preference. Generally 3.5-mm dynamic compression
plates, one-third tubular plates, or 3.5-mm pelvic reconstruction plates
(Synthes, Zeist, The Netherlands) were used. Plate fixation was unilateral in
nine patients and bilateral in nineteen; three plates were used to fix one
fracture. The plates were used with additional screws outside of the plates in
twelve patients and without such screws in seventeen. Stable fixation was
achieved with screws, Kirschner wires, and bone cement in one patient. The
ulnar nerve was not transposed as part of the procedure. The site of the
olecranon osteotomy (seventeen patients) or coexisting olecranon fracture (two
patients) was fixed with two longitudinal 2.0-mm Kirschner wires and a
figure-of-eight 18-gauge tension band wire in thirteen patients and with a
plate and/or screws in the remaining six. After the surgery, the patients
spent an average of 19.4 days (range, one to ninety-nine days) in the
hospital.
Evaluation
An author (P.J.v.D.) who was not involved in the original patient care
assessed the long-term functional outcome with use of the
MEPI12, the
Broberg-Morrey
Index13, and the
ASES score14.
Patients completed a validated Dutch-language translation of the DASH
questionnaire15,19.
To measure pain quantitatively, we used the pain subscales of the ASES score.
Patients rated their pain on five Likert scales, ranging from 0 (no pain) to
10 (the worst imaginable pain), for (1) pain when it is at its worst, (2) pain
at rest, (3) pain during lifting of a heavy object, (4) pain when performing a
task with repeated elbow movements, and (5) pain at night. We added the scores
derived with these five scales and subtracted the sum from 50. The resulting
value was divided by 2 to derive a summary pain score ranging from 0 to 25
points, with 25 points indicating no pain. Patients rated their satisfaction
with their elbow on a Likert scale of 1 to 10.
Radiographic evidence of arthrosis was rated by an independent observer,
according to the system of Broberg and
Morrey13, as Grade
0 (a normal joint), Grade 1 (slight joint-space narrowing with minimum
osteophyte formation), Grade 2 (moderate joint-space narrowing with moderate
osteophyte formation), or Grade 3 (severe degenerative change with gross
destruction of the joint).
Statistical Analysis
Continuous data are presented as the mean when they are normally
distributed; otherwise, the median and interquartile range are reported.
Histograms are used to show the distributions of ASES pain and DASH scores. We
examined the relationship between the score on each of the outcome instruments
and ten demographic and clinical variables: age, gender, injury to the
dominant side, AO classification of the fracture, open fracture, follow-up
time, total arc of flexion and extension, signs of ulnar neuropathy at the
time of final follow-up, arthrosis at the time of final follow-up, and pain.
Ordinary least-squares regression analysis was applied in order to
simultaneously test all ten clinical variables as well as pain as covariates
to determine their influence on each of the elbow evaluation scores. A
stepwise procedure using backward selection was utilized, and adjusted
R2 was used to
assess goodness-of-fit of the final
models20. A
multivariate model containing the significant independent predictors was
established for each elbow rating index (MEPI, Broberg-Morrey Index, ASES, and
DASH)21. The
Pearson product-moment correlation coefficient (r) was used to measure linear
association between ASES pain scores and elbow evaluation scores. Predicted
DASH scores were determined with use of ASES pain scores and age by regression
modeling employing the general form for a two-variable prediction equation: y
= ß0 + ß1x1 +
ß2x2, where x1 and x2 are
pain and age, respectively. DASH, MEPI, Broberg-Morrey, and ASES scores were
compared between patients with low and high flexion-extension arcs with use of
a cutoff value of 100° with the nonparametric Mann-Whitney U test, since
there were small numbers of patients in the two flexion-extension-arc
subgroups22.
Statistical analysis was performed with the SPSS software package (version
13.0; SPSS, Chicago, Illinois). Two-tailed p values of <0.05 were
considered significant for all tests.
Subsequent Procedures and Complications
Twelve patients (40%) had one or more subsequent surgical procedures. Seven
of them had removal of prominent hardware, which was combined with a release
of an elbow contracture in
two23. The index
surgery was complicated by wound infection in two patients (7%). One of them
underwent serial irrigation and débridement, implant removal, and
treatment with intravenous antibiotics but had an excellent result with no
pain eleven years after the last surgical procedure. The other patient was
treated with oral antibiotics alone.
One patient in whom a malunion of the distal part of the humerus developed
and one patient with hardware failure and substantial functional impairment
had revision of the osteosynthesis. Both of these patients had a third
operation: one had removal of implants, and the patient with the previous
hardware failure had a contracture release. A painful ulnar neuropathy
developed in one patient, who underwent anterior subcutaneous ulnar nerve
transposition. Another patient had a very stiff and painful arthritic elbow
after a Type-C1.2 open distal humeral fracture, and an elbow arthrodesis was
performed at one year after the injury. None of the thirty patients had a
total elbow arthroplasty.
Long-Term Functional Outcome
(Table II)
The final evaluation was performed at an average of nineteen years (range,
twelve to thirty years) after the injury.
Twenty-nine patients, excluding the patient with an arthrodesis, had an
average arc of elbow flexion and extension of 106° (range, 10° to
140°), with flexion averaging 129° (range, 95° to 145°) and an
average flexion contracture of 23° (range, 0° to 100°). The
average arc of forearm rotation was 165° (range, 125° to 180°),
with pronation averaging 77° (range, 40° to 90°) and supination
averaging 88° (range, 70° to 90°). All elbows were stable at the
time of final follow-up.
The average MEPI score for the twenty-nine patients who did not have an
arthrodesis was 91 points (range, 55 to 100 points), and the average Broberg
and Morrey score was 91 points (range, 68 to 100 points). Including the
patient treated with the arthrodesis (a poor result), there were nineteen
excellent results (63%), seven good results (23%), one fair result, and three
poor results according to the MEPI and twelve excellent, twelve good, four
fair, and two poor results according to the Broberg-Morrey Index. The average
ASES score of all thirty patients was 96 points (range, 69 to 100 points),
with an average patient satisfaction score of 8.8 points and an average ASES
pain score of 20 points (range, 5 to 25 points) out of 25 points. None of the
patients used pain medication.
The average DASH score for the patients, including the one with the elbow
arthrodesis (who had a score of 7 points), was 7 points (range, 0 to 66
points), which was identical to that recorded in the general population in the
United States15.
Seventeen patients still played sports and filled out the Sports Module on the
DASH questionnaire. Their score on that module averaged 3.7 of 100 points,
with a score of 0 points representing the ability to participate in sports as
usual and no impairment of upper-extremity function. Eleven of the seventeen
patients received a score of 0 points. Twenty-one of the thirty patients in
the series still played a musical instrument or created art, and their average
score on the section of the DASH dealing with those activities was 3
points.
Twenty-four (80%) of the thirty patients had arthrosis according to the
radiographic criteria of Broberg and
Morrey13. Eleven
patients (37%) had slight joint-space narrowing with minimum osteophyte
formation (Grade 1), eleven patients (37%) had moderate joint-space narrowing
(Grade 2), and two patients (7%) had severe arthrosis (Grade 3).
Statistical Analysis
Multivariate analysis showed pain (p < 0.0001), injury to the dominant
arm (p = 0.02), and the flexion-extension arc (p < 0.001) to be independent
predictors of MEPI scores, with the model with these three variables
accounting for 91% of the variability in the MEPI scores (R2 =
0.91). Multivariate analysis also showed pain (p < 0.001) and the
flexion-extension arc (p < 0.001) to be independent predictors of the
Broberg-Morrey Index, with the model with these two variables accounting for
87% of the variability in the Broberg-Morrey scores (R2 = 0.87),
and it identified pain (p < 0.001) and the flexion-extension arc (p <
0.001) as independent predictors of ASES scores, with the model accounting for
93% of the variability in the ASES scores (R2 = 0.93).
Multivariate analysis identified pain (p < 0.001) and age (p = 0.014) as
significant independent predictors of the DASH scores. The model with pain and
age accounted for 72% of the variability in the DASH scores (R2 =
0.72). Objective factors such as the ulnohumeral range of motion and arthrosis
were not found to be independent predictors of DASH scores.
The Pearson product-moment correlation coefficient (r) revealed a
significant linear association between the ASES pain score and the scores on
the DASH (r = —0.80) (Fig.
1), MEPI (r = 0.70), Broberg-Morrey Index (r = 0.62), and ASES (r
= 0.87) (all p < 0.0001) (Table
III). We derived the following equation to illustrate the
independent relationship of pain and age with the final DASH scores:
Y[DASH] = 41 — 2.2 × (ASES pain score) + 0.3 ×
(age) (Fig. 2).
Use of the nonparametric Mann-Whitney U test to compare DASH scores between
patients with a low flexion-extension arc (<100°) and patients with a
high arc (>100°) showed no significant difference (p = 0.72). There
was, however, a significant difference between these two groups with regard to
the scores on the physician based-evaluation instruments (p < 0.002 for the
ASES, p < 0.001 for the Broberg-Morrey Index, and p < 0.001 for the
MEPI).
This study must be interpreted in light of the fact that we evaluated
patients who were relatively young at the time of injury (since many patients
who were older at that time died before the time of the review). In addition,
as is typical of studies of trauma patients, particularly those with a very
long-term follow-up, a substantial percentage (39%) of the living patients
were not evaluated. In addition, information in the database and the medical
records was not precise with regard to the type of plates that had been used,
the handling of the ulnar nerve, and other details. Nonetheless, useful
information can be gleaned from this study.
The long-term outcome after open reduction and internal fixation of a
complex intra-articular fracture (AO Type C) was satisfactory in >80% of
our patients (Figs. 3-A,
3-B,
3-C, 3-D). This finding is
similar to those in shorter-term studies, which suggests that although these
fractures can be challenging to treat, the initial results are durable over
the long-term. Arthrosis was present in the vast majority (80%) of the
patients, but it was not an independent predictor of patient-rated disability
(DASH score) or surgeonrated elbow function. Consistent with the observations
in prior studies in other
settings21, pain
was an independent predictor of the scores derived with all of the
surgeon-based elbow-function rating systems (the MEPI, the Broberg-Morrey
Index, and the ASES) and with the patient-rated disability questionnaire (the
DASH), but pain did not correlate with arthrosis.
Pain, limb dominance, and the flexion arc predicted =87% of the
variation in the physician-based elbow rating scores. The ability of so few
factors to account for such a substantial percentage of the variability in
these scores is remarkable and quite distinct from the situation observed in
patients in the United States, where the best models were able to account for
only =79% of the variation in these scores.
It is remarkable that only one of our thirty patients had signs and
symptoms of ulnar nerve dysfunction at the time of long-term follow-up. We
know that none of the nerves were formally transposed, but we do not have
accurate information on intraoperative handling of the ulnar nerve. One can
assume that at least some amount of mobilization and protection of the nerve
was performed in some patients. We also do not know how many patients had
early postoperative nerve dysfunction. Nonetheless, the rarity of ulnar nerve
problems at the time of final follow-up certainly calls into question the need
for routine anterior subcutaneous transposition as recommended by some
authorities.
In conclusion, at an average of nineteen years after open reduction and
internal fixation of AO-Type-C intra-articular fractures of the distal part of
the humerus in relatively young adults, the average flexion arc was
>100°, the average DASH score was comparable with the average score in
the general United States population, and radiographic evidence of
arthrosis—although nearly inevitable—did not correlate with
impairment or disability and rarely required secondary surgery. When surgery
restores the native elbow—even when several operations are
needed—the elbow can be expected to function well in the long term. Open
reduction and internal fixation remains the treatment of choice for an
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