We included 60 patients with distal humeral fractures (AO type A 3) who underwent surgery at our hospital in this prospective cohort study conducted between 2015 and 2021.
Our inclusion criteria were as follows:
Our exclusion criteria were as follows:
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Vascular Injuries
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Pathological fractures
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Previous elbow skeletal injury
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Uncontrolled diabetes mellitus
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Non-united and mal-united fractures
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Rheumatoid patients
The 60 patients that were included in this study, 30 were assigned to group 1. Among these 30, there were 23 males and seven females with a mean age of 40 years and two months (40.20 ± 9.62, range: 23–48 years). Twenty-six (86.7%) of them were right-handed. The mean follow-up period was 62 months (range: 38–68 months). The patients in group 1 underwent ORIF with double anatomical LCP. There were 30 patients in group 2, 21 males and nine females with a mean age of 41 years and seven months (range: 24–52 years), with 20 (66%) of them being right-handed. The average follow-up period was 58 months (range: 38–68 months; Table 1). Fifteen of the patients in group 2 underwent ORIF with 3.5-mm nonlocked reconstruction plates. Written informed consent was obtained from all the patients, and the study was performed in accordance with the principles of the Declaration of Helsinki.
Co-morbidities such as HTN and smoking were present in five and six patients, respectively, in group 1 and in three and five patients, respectively, in group 2. The mechanism of injury was a road traffic accident in 16 patients, MBA (Motor bicycle accident) in 12 patients and falling on outstretched hands in 2 patients in group 1. In group 2, these were the mechanisms in 20 patients (53.3%), 7 patients, and 3 patients, respectively (Table 1).
The injured limbs were examined both generally and locally. Plain X-rays of the affected elbows and humeri were performed in both lateral and anteroposterior views. CT scans were done in five cases only, to confirm no intra-articular extension. All patients were immobilized in an above elbow slab. Antiedematous measures were taken as the patients were prepared for surgery. Randomization was performed by sequential selection.
Surgical technique
All patients in the study were put under general anesthesia and placed in the lateral decubitus and tourniquets were applied as high on the arm as possible. The posterior approach to the distal humerus was used in all patients. Triceps splitting and the para-tricepital approach were used in all cases [10, 11].
Group 1
All patients underwent ORIF with double anatomical columnar LCP plates. After reducing the fracture, the anatomical posterolateral plate was applied on the posterolateral aspect of the distal humerus with the lateral support extending over the most protruding tip of the lateral epicondyle, then a 2.7-mm locking screw was inserted into one of the threaded holes of the distal part of the plate. The medial plate was positioned on the medial ridge with its distal tip reaching down to the insertion of the medial collateral ligament.
Group 2
Fifteen patients underwent ORIF with nonlocked reconstruction plates. Both medial and lateral 3.5-mm reconstruction plates were slightly under-contoured to provide additional compression at the metaphyseal region when applied. The length of each plate was selected so that at least three screws could be placed at the proximal part of the humeral shaft, after which the medial plate was extended to the articular margin in cases of very distal or comminuted fractures. The lateral plate was applied in a posterior position that did not extend beyond the center of the capitellum distally to avoid injury to the LCL complex. Plates that ended at different levels proximally were always chosen to avoid the creation of stress-risers.
Postoperative management and follow-up
Surgery time, intraoperative blood loss, perioperative blood transfusion, and intraoperative complications were documented in the patients’ clinical records.
A complete follow-up was conducted for all patients by the main surgeons who performed postoperative clinical evaluations at the outpatient clinic. Immediate neurovascular status assessments were performed after the patient’s regained consciousness and immediate postoperative X-ray were performed at two weeks, with the concomitant removal of stitches. The patients were encouraged to use their hands and elbows at 6 weeks, 12 weeks, and 1 month till complete union. Radiological assessments were done by X-ray and functional assessments were done according to the MEPS.
Statistical analysis
The data were coded and entered into SPSS version 23, which was also used for statistical analysis. Continuous data were presented as mean values and standard deviations while categorical data were presented as frequencies and percentages. The comparison between two groups with quantitative data and parametric distribution was done by using Independent t-test while that for non-parametric data was done by using Mann-Whitney test. The quantitative variables were compared, and P-values of < 0.05 were considered statistically significant.