The elbow joint is a structure that has an important role in the fulfillment of daily life activities. If fractures involving the elbow joint are not treated appropriately, serious loss of function is observed in the upper extremity (1).
Humerus fractures show a bimodal distribution considering age and gender. According to the energy level, it can be divided into two groups as high-energy traumas and low-energy traumas. Especially in the young population, open fractures and other system injuries are more likely to occur because they occur as a result of high-energy traumas (4). In our study, in accordance with the literature, we mostly see it after high-energy traumas in young patients, and mostly after low-energy traumas such as simple falls in elderly patients.
Amis et al. (5) stated that the treatment of distal humerus fractures is difficult and the poor outcome cannot be less than 15%. However, as a result of our study, it was determined that there was no bad result according to the MAYO scoring, and one case (3.2%) had a bad result according to the Cassebaum score. We think that this expression used by Amis et al. is valid for fractures involving the joint and not for extra-articular fractures.
Treatment recommendations for 1/3 distal diaphysis and distal end extra-articular fractures of the humerus are largely based on studies evaluating non-surgical treatments such as functional braces (6, 7), and some surgeons advocate surgical treatment for these fractures. Advocates of conservative treatment state that surgery is unnecessary for these patients because of the risks of complications such as infection and neurovascular injury (7). These; While advocating good clinical results with functional braces published by Sarmiento et al. (6), those advocating surgical intervention; They argue that functional brace cannot provide proper alignment in these patients, especially in patients with polytrauma, that early movement with rigid fixation is better in terms of elbow functions (8), and that weight-bearing can be applied earlier in patients with polytrauma (9).
Sarmiento et al. (10) in their study; 69 extra-articular distal humeral fractures were treated with functional braces, and nonunion was reported in 3 patients. In addition, varus angulation was observed in 56 patients, angulation more than 10° in 28 patients, elbow flexion was decreased by 5–25° in 15 patients, and elbow extension was restricted by 5–25° in 14 patients.
Hanging-Arm-Cast, U-Splint and functional braces (Sarmiento) are mostly used in conservative treatment; However, patient compliance is very low due to disadvantages such as high risk of nonunion, not using the arm for weeks, bandage not fully relieving night pain, and partially preventing body care (11). When making a decision for conservative treatment, the patient should be well evaluated in terms of adherence to treatment.
For the upper extremity to be able to perform most daily activities, the elbow must have at least 100° of range of motion and a normal forearm rotation. They stated that achieving this goal after humeral distal end fractures is only possible with stable internal fixation and early rehabilitation provided by surgical treatment. (12, 13).
Conservative treatment may be preferred in non-displaced fractures. In addition, displaced fractures of elderly patients who cannot be surgically treated and patients with comorbid health problems can be treated conservatively after reduction, if the alignment is stable and can be achieved. While surgical treatment may be chosen for early mobilization in patients with polytrauma, conservative treatment will be more appropriate in elderly osteoporotic and health problems (14).
The main purpose of the surgical treatment of extra-articular distal humerus fractures; In order to achieve good functional results, it is to make stable fixation that allows early joint movements and to correct the alignment (15). Lin et al. (16) reported that the key to a successful surgical outcome is rigid fixation, which requires minimal soft tissue damage and minimal hardware. Good results after fixation can be obtained with patients who are compatible with physical therapy who want to perform active movements after surgery. Paiarinen et al. (17) stated that immobilization for more than 2–3 weeks negatively affects functional results. In distal humerus fractures, good and excellent results can be obtained with a good surgical technique and compatible patients with a rate of at least 80% (15, 18).
In general, triceps split is preferred for isolated distal fractures with posterior midline incision, and exposure from the lateral and medial triceps (modified posterior approach) is preferred to obtain a more comprehensive or closer view to segmental fractures (19).
According to O'Driscoll (20), the ideal approach is; It should provide sufficient view, it can be extended when necessary, it should be in the form of soft tissue dissection without osteotomy, dissection should be in the plane of the nerves and should not cross the nerves, all alternative surgical procedures can be applied with the same opening, allow early rehabilitation and possible revisions should be made with the same incision.
In our study, lateral incision was preferred more frequently. Compared with patients who had posterior and double incisions; It was observed that the Mayo score was better and the loss of extension was less in patients with lateral incisions. We believe that the single incision causes less loss of extension, faster rehabilitation of the patients and better elbow functions (Mayo Score) by causing less damage to the extensor mechanism, especially when compared to the double incision.
Although there is ample evidence that bicolumnar support is advantageous for intra-articular fractures, uncertainty remains as to whether double-plating is necessary for extra-articular supracondylar humeral fractures (21).
The disadvantages of using double plate fixation with a posterior exposure are the wide surgical exposure required to the posterior and medial aspects of the elbow. Ulnar nerve injury, postoperative wound problems, and elbow stiffness are frequently reported complications associated with double plate fixation (22, 23, 7).It is mentioned in the literature that a single plate was used as a reduction tool before (24). The lateral plate is not only a means of reduction, but also functions as a structural support. One of the methods used to reduce the surgical risk is the application of a single plate with only lateral exposure. Some authors; (7, 25) recommend fixation with a single posterolateral plate to avoid excessive stripping of large soft tissue and reduce surgical time. In some studies; (25, 26) showed that a single plate is sufficient for the fixation of extra-articular humeral distal fractures. Yet in another study; (21) found that posterolateral locking single plate and orthogonal anatomical double plate were biomechanically equivalent in distal humerus extraarticular supracondylar fractures. In addition, Lerman et al. (21) in his study; A posterolateral single locking plate designed for the distal humerus has been shown to be biomechanically equivalent to two preformed distal humeral plates placed perpendicular to each other.
On the other hand, in another study; (27) It was observed that the double plate was more resistant to anterior, posterior and lateral bending forces compared to the single plate, while there was no difference against axial and rotational forces. Aksu et al. (28) stated that a single plate placed only on the lateral column would not be able to prevent varus deformity without medial buttress and its resistance to varus pressures would be low, and stated that thicker and wider locking plate designs are needed to overcome this problem. Teiwani et al. (27) Schemitsch et al. (29) and O 'Driscoll (22) found that the durability of fixation with double locking anatomical plate against physiological anterior/posterior and lateral bending forces in fractures of this region was better than fixation with single plate. Some studies; They state that double plating is the best option in distal humerus fractures (30) and biomechanically demonstrated that it is better than others in diaphyseal fractures (29, 31). In some studies (22, 31, 32); 90º/90º orthogonal plating showed the highest resistance against bending and torsional forces. It has been reported that screwing over the posterolateral plate up to the most distal (for fractures in the coronal plane, such as the capitellum) is one of the anatomical advantages of orthogonal plating. In a study by Korner et al (31); The standard and locking plates were placed dorsally in pairs and orthogonally, and when compared, they stated that the orthogonal group was more resistant to sagittal bending and rotational forces. Taylo et al. (33) stated that parallel plating using locked distal humeral plates showed greater resistance against torsion and bending forces compared to the orthogonal method. Using a similar model, Arnander et al. (34); showed significantly higher endurance and stability in the parallel group than the orthogonal group against bending forces in the sagittal plane. On the other hand, in a biomechanical study of Schwartz et al. using epoxy composite humerus; (35) reported that there was no significant difference in hardness between the two configurations (orthogonal and parallel plating). In a biomechanical study on distal humeral locking plates and cadaver bones; (36) showed greater stability in the parallel plating group against compression and external rotation forces than in the orthogonal group. There is no consensus in the literature on which of the double plating techniques is superior.
In our study, no statistical significant difference was found between the two groups in terms of complication, union time and functional outcome in single plate or double plate fixation method. Since there is only one case in which the Y plate was made, it is not correct to comment on the Y plate in a statistical sense.
Normal range of motion of the elbow: 0°-150° flexion, 85° supination, 85° pronation (37) The most commonly used range of motion in daily life is 30°-130° flexion, 50° supination, 50° pronation (37) In our study, the mean range of motion was 118.8˚ and the mean extension loss was 7.14˚. When the patients are evaluated; We evaluated that the mean range of motion of the joint supports the recovery of elbow joint functions. While no significant difference was found between surgical techniques (Group I and Group II) in terms of ROM, when the patients who underwent surgery (Group I-Group II) were compared with the patients who were treated conservatively, the range of motion of the patients who were treated conservatively was significantly better.
In some studies; reported the most common complications as implant failure, followed by nerve damage and infection (34). Gofton et al (38); They published a complication rate of 48% (heterotopic ossification 17%, nonunion at the olecranon osteotomy line 9%, and infection 9%). Many studies (39) have published a complication rate between 11% and 29%.
Nonunion at the supracondylar level is the second most common complication. It may be due to insufficient internal fixation. It usually presents with pain and loss of movement. Incomplete union after 4 months after trauma/surgery; delayed-union, radiological absence of union and clinical pain persistence despite 6 months after trauma/surgery or no radiological change in callus formation at consecutive 3-month follow-up or implant failure that occurs at least 4 weeks after surgery is defined as non-union (40, 41). It is technically very difficult to achieve re-union in these cases. Changed anatomy, periarticular fibrosis, and decreased bone stock due to disuse osteoporosis are the main problems. Re-open reduction, internal fixation and autogenous grafting can be performed, as well as options such as external fixators or total elbow arthroplasty in appropriate cases.
In our study, we encountered 16% of complications. Of these, 13% were delayed union and 3% were nonunion. Our patients with non-union problem were re-operated, the implant used for fixation was changed (we revised the single plate with a double plate), and union was achieved by resuscitating the fracture line.
Ulnar neuropathy may occur during initial injury or iatrogenically during surgical fixation. While ulnar nerve lesion due to humeral distal end fractures or treatment is observed between 3–8%, the incidence of ulnar neuropathy during surgical fixation has been reported to be 0–12% (39, 12). The anterior transfer of the ulnar nerve is controversial. The ulnar nerve was not transposed anteriorly in the patients included in our study. No iatrogenic nerve damage was observed in our patients.
The incidence of post-surgical heterotopic ossification in distal humerus fractures has been reported to be between 0–49% (18). Heterotopic ossification may occur after head trauma and is particularly associated with delayed fixation or passive stretching of the elbow. In addition, in risky groups (central nervous system trauma, open fractures, etc.), pharmacological prophylaxis is recommended. Although there are not enough studies on which drug is more effective, indomethacin is generally used in the elbow. We also applied indomethacin prophylaxis in risky groups (those with head trauma, intubated followed, multi-trauma patients,etc.) and we did not see heterotopic ossification in any of our patients.
There are some limitations of our study. The low number of patient groups and the presence of many variable factors prevented us from obtaining statistical significant results. Prospective, randomized, multicenter studies with large numbers of patients are needed.