ORIGINAL ARTICLE. 15 Int J Res Med. 2013; 2(1);15-19 e ISSN: p ISSN: Treatment of intercondylar fractures of the humerus

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1 ORIGINAL ARTICLE TREATMENT OF INTERCONDYLAR FRACTURES OF THE HUMERUS - A PROSPECTIVE STUDY OF 30 CASES Shrivastava Rakesh 1*, Sagarsinh Parmar 2, Balaji Ghugare 3 1 Professor & Head, Orthopedic Department, GMERS Med College Gotri Vadodara Resident, Orthopedic Department, GMERS Med College, Gotri, Vadodara Assistant. Professor, Physiology Department, GMERS Med College, Gotri, Vadodara ABSTRACT BACKGROUND: Intercondylar fractures of the distal humerus in adults are difficult fractures to treat because of their rarity and associated significant comminution. Because of the anatomical difficulties due to congruence of articular surface which are increased by the comminution of the fragments, perfect reduction and immobilization cannot always be obtained. To study the outcome of management of thirty Intercondylar fracture Humerus bone. MATERIALS AND METHODS: It is a prospective study of 30 fractures of Intercondylar humerus. In Type- 1 fracture, plaster & early mobilization was done. Type 2 fractures, in the majority of the cases manipulation and immobilized in an above the elbow slab in the extension was done. In Few type 2 fracture and most cases of type 3 fractures, fragments were usually be brought into accurate alignment by means of open reduction and internal fixation by K-wire, plate & screw fixation to be considered. In Type 4 fracture (bag of bones) conservative followed by early mobilization. RESULTS: The overall results of conservative and operative were classified as excellent in seven (23.34%), good in eleven (36.66%), fair in ten (33.34%), and poor two (6.66%). CONCLUSION: The experience of managing 30 such fractures by operative as well as conservative methods with early mobilization showed that nineteen of these fractures attained acceptable results, 15 of which were graded as excellent in the final outcome. Keywords: Fractures of distal third of humerus, humeral fractures, Intercondylar fractures of humerus. INTRODUCTION The of Intercondylar fractures of the humerus in adults has been controversial since 1932 when Hitzrot 1 described twenty five patients treated with traction and on the basis of his results, condemned open reduction and advised early arthroplasty if a satisfactory reduction could not be obtained. 1 Management of Intercondylar fracture of humerus is a challenging task for orthopaedic surgeon because of its configuration and anatomical peculiarities around elbow joint. It is usually caused by fall on the point of the elbow or fall on the hand and force transmitted through the long axis of forearm, the olecranon being forced upwards as a wedge between the humerus condyles, prizing them apart from and displacing then upwards and backwards (Reich 1936Vryan& Bickel 1971&Shetty 1983). 2,3 *Corresponding Author Dr R. K. Shrivastava Dept of Orthopedics GMERS Med College Gotri Vadodara-Gujarat shrivastava_rkumar@yahoo.com Fracture usually occurs in adult or adolescent life and difficult fracture to treat and diversity of the views on the subject is an indication of the poor quality of result. It may be impossible to secure perfect replacement by manipulation and traction while operative reduction is very difficult. 4 It involves a free dissection of triceps and capsule of joint and there is usually no natural stability of fragment. (Evans, 1953) 5 The main cause of fracture is direct trauma to elbow which causes impact of ulna in the trochlear groove forcing the condyles of distal humerus apart. 1 The fracture is either T or Y shaped with or without comminution. 6 Clinically, the arm appears shortened due to proximal displacement of ulna and crepitus can be felt on compressing the condyles together. 7 Depending on the displacement and rotation of fragments various classifications are used to describe these fractures Based on the Risenborough & Radin classification. 6 The main aim of surgical is to re-establish articular congruity, optimal alignment and secure rigid fixation in order to allow early mobilization. Surgical approaches for open reduction and internal fixation (ORIF) of these fractures include those that divide triceps mechanism providing good exposure and those that save triceps mechanism but give 15 Int J Res Med. 2013; 2(1);15-19 e ISSN: p ISSN:

2 limited exposure. 2,9 Approaches that give good exposure are Campbell s V/Y tricepsplasty and transolecranonosteotomy. 8,10 With above background this prospective study was designed to evaluate and compare operative verses conservative approach depending upon type of fracture and early mobilization and functional rehabilitation and thereby to study the outcome of management of thirty Intercondylar fracture Humerus bone with an average follow up period of 2 years. MATERIALS AND METHODS This study was undertaken in the Department of Orthopedics, S.M.S. Medical College Hospital Jaipur. Study was approved by institutional ethics committee. A written informed consent was obtained from each patient and study was conducted according to World Medical association declaration of Helsinki. Present series consisted of 30 cases of fractures of Intercondylar humerus. This includes 14 fresh cases, 12 old treated cases, and 4 neglected cases. Fresh cases were interrogated particularly for the mechanism and duration of injury. Preliminary skiagram both in anteroposterior and lateral view were taken and studied for the type of displacement and of rotation of the condylar fragment both in horizontal and vertical axis extent of communition recorded and classified as described by Riseborough and Radin (1969) 7 Type -1: No displacement of fragments Type-2: Trochlear and Capitular fragments separated, but not appreciably rotated in the frontal plane. Type-3: Separation of fragments and significant rotatory deformity. Type-4: Sever communition of the articular surface and wide separation of the humeral condyles. In close fractures, conservative method by close reduction and manipulation under general anesthesia as favored by Watson Jones 7, Charnley 8 and Riseborough & Radin 6 was tried. Post reduction Result checked by X-RAY both in AP and lateral view. If fracture is inacceptable position, checked neurovascular status of the limb. Limb kept in triangular cuff and collar sling and active finger movement allowed for subsiding swelling. For two to three weeks limb kept in sponge traction by pulley and active movement of elbow started. Alternate method of includes passing a transolecronon pin through proximal ulna for traction on to the fracture and once fracture becomes sticky, a cast/functional cast/cast brace or hinged brace may be applied. Mobilization is begun as dictated and subsequently advanced as determined by patient comfort. Another method, used in case of comminuted fractures includes the placement of the arm in a collar and cuff with as much flexion as possible. The elbow is left hanging free, allowing gravity to exert a ligamentotaxic effect. Hand and finger motion and shoulder pendulum exercises are beginning after 10th day. Gradual elbow motion is started as guided by patient comfort. By 6 weeks, the collar and cuff are discontinued and more intensive exercises are begun. In type-4 fracture (bag of bones) Nonsurgical care of distal humerus fractures may be considered in those patients medically unfit for surgery, although no operative care may be recommended in certain special situation. Whenever closed reduction failed, planned open reduction and internally fixation with Kirschner wires, screws or plates having superior functional outcomes after operative. All open fractures will be treated by early debridement and cleaning of wound by copious amount of saline water, if there is no contamination of wound, then tried to fix the fragments by Kirschner Wire and wound will left open for drainage, lastly immobilize with forearm slab for two to three weeks then elbow movement started. Follow up was done monthly up to maximum recovery. Table 1 shows type of fixation device. Distal humerus fractures demand technically difficult operative, often with relatively high morbidity. 1 The preferred for displaced, intra-articular, Intercondylar fractures of the distal part of the humerus is open reduction and internal fixation. 2 Adequate exposure of the articular surface of the distal humerus and elbow joint is required for operative stabilization of bicolumnar distal humerus fractures. The transolecronon approach, which provides complete posterior visualization and access to the distal humerus, is the most commonly used surgical approach. 3 Depending upon the stability of the fixation, active assisted exercise was begun by the 4 th day. In cases where adequacy of fixation was in doubt, immobilization was delayed upto 4 weeks. POP back splint was applied after exercise regimen and at night. An alternative exposure is the extensor mechanism-sparing paratricipital posterior approach to the distal humerus through a midline posterior incision, as suggested by O' Driscoll et al. 5 This approach avoids an osteotomy and mobilizes the triceps and anconeus muscle off the posterior humerus and the intermuscular septae and provides adequate exposure for open reduction and internal fixation. Furthermore, this approach preserves neurovascular supply of anconeus, which is a dynamic stabilizer of the elbow. 5 Triceps-splitting or -peeling approaches have postulated a negative effect on muscle strength on the basis of the potential for weakened reattachment, direct muscle injury with resultant fibrosis and injury to intramuscular nerve branches. RESULTS The mean duration of follow-up was 18±4 months (range 12 to 36 months). 16 Int J Res Med. 2013; 2(1);15-19 e ISSN: p ISSN:

3 (According to Bickel and Perry, 1963) 3 The end results were categorized as excellent, good, fair and poor on the basis of somewhat arbitrary clinical and roentgenographic criteria. And excellent clinical result was one in which the elbow was stable, free of pain and deformity and possessed a normal and near normal range of motion. An excellent roentgenographic result required maintenance of joint line, good alignment of the distal and proximal segment.a good result was one in which elbow was stable and there was no deformity. There was at least 60% of flexion extension motion in the useful range, and supination and pronation were at least 50% of normal. Table no 2 shows fixed flexion deformity in conservative and surgical. Roentgenographically the joint line was maintained, alignment was good.a fair result was one in which mild pain with normal use, significant loss in range of motion or moderate deformity. Roentgenographic there was mild loss of joint line, fair alignment. Table 3 shows range of movements in surgical and conservative s. A poor result was one in which the elbow showed instability, pain, deformity or greatly restricted range of motion. Roentgenographic there was loss of joint line. The results of conservative and operative are comparable and depend upon types of fracture, of communition, status of contamination of wound, extend of soft tissue damage around the elbow, duration of injury. The overall results of conservative and operative were classified as excellent in seven (23.34%), good in eleven (36.66%), fair in ten (33.34%), and poor two (6.66%) as shown in table no 4. Our experience shows good results using this minimally invasive technique. The advantages of this technique are the immediate mobilization of the elbow joint and the rapid return to activities of daily living. Table1: Type of fixation device Type of Device No. of Patient % Only K-Wire A.O. Screw A.O. Screw with plate A.O. Screw & K-wire TOTAL Table 2: Fixed Flexion Deformity Fixed Flexion deformity in Less than 10 In between In between or more than 30 (%) Conservative (%) Surgical 13(59.09) 5 (62.50) 4(18.18) 3 (37.50) 5(22.72) TOTAL 22 (100) 8 (100) Table 3: Range of movements Range of Movement Flexion extension in Less than 40 (%) conservative (9.18) (36.33) 5 (62.5) Above (54.54) 3 (37.5) TOTAL 22 (100) 8 (100) No. of Cases (%) surgical Table 4: Overall results and its comparison with modality adopted. Results No. of Patients Conservative Excellent 7 (23.34) 6 1 Good 11 (36.66) 6 5 Fair 10 (33.34) 8 2 Sur. Treat. Poor 2 (6.66) 2 - TOTAL 30 (100) Int J Res Med. 2013; 2(1);15-19 e ISSN: p ISSN:

4 DISCUSSION The of Intercondylar fractures of the humerus in adults has been controversial since 1932 when Hitzrot 1 described twenty five patients treated with traction, and on the basis of his results, condemned open reduction and advised early arthroplasty if a satisfactory reduction could not be obtained Distal humerus fractures pose a challenge. The surgeon is faced with technical difficulties such as poor screw purchase in comminuted fracture fragments. Although some authors still advocate formal osteosynthesis with plates and report good to excellent results. 4,10 Nonoperative methods include traction with an olecranon pin until the fractures are sufficiently sticky and then conversion to a cast and/or functional cast, cast brace, or hinged brace, at which point controlled motion is encouraged. Another method of treating is the collar and cuff method, where the arm is suspended in a collar and cuff in as much flexion as possible, allowing gravity to perform the ligamentotaxis effect. The cuff is removed after six weeks and the elbow is then mobilized. Good results have been reported using this method in a bag of bones setting. 1 From our limited experience, we have come to the following conclusion: The best results are obtained if the Intercondylar and supracondylar fragment are reasonably aligned with minimum soft tissue damage. Open reduction and internal fixation requires wide exposure and therefore increase the trauma to the soft tissue. The three major variation of this fracture are associated with quite different therapeutic implications. Type 2 fractures, in the majority of the cases can be reduced by manipulation and immobilized in an above the elbow slab in the extension. Few type 2 cases and most type 3 fractures; it is evident that manipulation alone is not enough. But the fragments can usually be brought into accurate alignment by means of traction and manipulation.only if a reasonable reduction cannot be achieved by closed means should open reduction and internal fixation be considered. In type 4 fractures (bag of bone), result of conservative followed by early mobilization was better than operative. It would seem that an accurate reduction maintained by secure internal fixation of this severely comminuted fracture is extremely difficult. In addition, the soft tissue trauma consequent to surgical intervention only increases the scarring and soft tissue damage which further contributes to the unsatisfactory outcome. Since the only good results after the type 4 fractures in this series were obtained in patients treated by traction.we suggest that gentle manipulation in traction be used to restore alignment in preference to open reduction. The findings in this small series suggest that fractures with significant rotatory deformity but without gross comminution are more likely to have good results when skeletal traction is used rather than open reduction and internal fixation. Although the results of conservative in the series are no better than some surgeons have obtained by internal fixation, the smaller risk of producing a disastrously stiff and painful elbow and the several advantage of the method described make it attractive. Bradford Henley does not differentiate results according to A.O. Classifications. CONCLUSION Overall, the results of conservative and operative were classified as excellent in seven (23.34%), good in eleven (36.66%), fair in ten (33.34%), and poor two (6.66%) Union was defined as the presence of bridging callus or the disappearance of the managed by open reduction and stable internal fixation. However there could be circumstances where patient is not suitable to get operative. For example debilitated patients, patients with other ailments that make them a poor candidate for anesthesia, problem with local sites such as degloving injuries Such cases need to be treated conservatively. Our experience shows good results using this minimally invasive technique. The advantages of this technique are the immediate mobilization of the elbow joint and the rapid return to activities of daily living. To best of our knowledge, so far there is no published data about results of closed reduction and external fixation of distal humerus fractures. REFERENCES 1. Hitzrot J.R.-:Fractures at the lower end of the humerus in adults. Surg.Clin.North America.,1932:12(2): Reich R.S. Treatment of intercondylar fracture of elbow by means of traction.j.bone Joint Surg. 1936:18(6): Bickel WE, Perry RE. Comminution fracture of distal humerus. J.Am.Med. 1963:184(3): Shetty SL. Surgical of T and Y fracture of distal. Humerus.Injury.1983: 14(3): Evans EM. Supracondylar Y fractures of the humerus. J. Bone and joint surgery. 1953:35 (3): Riseborough EJ, Radin E.L. Intercondylar T.Fractures of humerus in adult.a comparision of operative and non operative in 29 cases. J.Bone and Joint Surg. 1969:57-A, Watson JR. fracture and joint injury. 4 th ed. vol bitt Williams co., Int J Res Med. 2013; 2(1);15-19 e ISSN: p ISSN:

5 8. Charnley J. closed of common fractures 3 rd ed, Baltimore; Williams &wilkins co.,70-71, Campbell WC. Incision for exposure of elbow joint. Am.J.Surg (1): Muller ME, Allgower M, Scheider R. Willenegger H. Manual of internal fixation technique recommended by AO group..2 nd ed, New York Springer Verlag, Int J Res Med. 2013; 2(1);15-19 e ISSN: p ISSN: