Bi-columnar Plating For Supracondylar Fracture Extending Into Humeral Shaft : A Report Of Three Case And Literature Review

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1 Article ID: WMC Bi-columnar Plating For Supracondylar Fracture Extending Into Humeral Shaft : A Report Of Three Case And Literature Review Corresponding Author: Dr. Chander Bhushan, Postgraduate Trainee, Orthopaedics, PGIMER, Deptt.of Orthopaedics,PGIMER,Chandigarh, India Submitting Author: Dr. Vishal Kumar, Registrar, Orthopaedics, PGIMER, k-158,mdh,pgimer,chandigarh, India Article ID: WMC Article Type: Original Articles Submitted on:23-nov-2010, 05:03:10 PM GMT Article URL: Subject Categories:TRAUMA Keywords:Supra-condylar factures,extension,locking plates Published on: 24-Nov-2010, 04:39:13 PM GMT How to cite the article:kumar V, Bali K, Bhushan C, V.S S, H.S R, Rawall S, Aggarwal S. Bi-columnar Plating For Supracondylar Fracture Extending Into Humeral Shaft : A Report Of Three Case And Literature Review. WebmedCentral TRAUMA 2010;1(11):WMC Source(s) of Funding: No funding from any source was received for this study. Competing Interests: We had no competing interest/s. WebmedCentral > Original Articles Page 1 of 7

2 Bi-columnar Plating For Supracondylar Fracture Extending Into Humeral Shaft : A Report Of Three Case And Literature Review Author(s): Kumar V, Bali K, Bhushan C, V.S S, H.S R, Rawall S, Aggarwal S Abstract Supra-condylar humerus fractures with extension into shaft are difficult to treat and typically require open anatomical reduction and internal fixation. Here we describe our experience treating distal humerus fractures using a triceps splitting approach with bicolumnar locking plate fixation. Introduction Distal humerus fractures are rare and difficult injuries to manage due to the complex three-dimensional geometry of the distal humerus which poses a considerable challenge to reconstruction(1,2). Presence of comminution, significant soft tissue trauma and injury to neurovascular bundle further complicate the management.supracondylar fractures with fracture line extending into shaft are rare.surgical treatment is preferred in these cases. Internal fixation of these fractures with a single plate is technically difficult and fracture fixation is not stable. Here,we present three cases of supracondylar fracture with extension into shaft which was treated with bicolumnar plating(3,4). Methods All three cases reported to our emergency department sustaining road traffic accident with fall onto outstretched hand.amongst them,two were males and one female and mean age was 52.4.They complained of pain and swelling in distal part of the arm.clinical examination revealed two closed fractures and one open fracture with grade 1 injury(gustillo-anderson classification).on examination tenderness,abnormal mobility and crepitus was present in the distal humerus without neurovascular deficit. Three point congruency was maintained in all the three cases.. Antero-poaterior and lateral radiographs of elbow with humerus showed supracondylar fracture extending into humeral shaft. Initially in the emergency, the arm was temporarily immobilized in an above elbow plaster slab.open fracture was operated within six hours and other two were operated after five days once the swelling subsided. With patients placed supine, pneumatic tourniquet applied after general anaesthesia,the upper limb was placed in front of the chest, with the shoulder and elbow in flexion. A midline posterior triceps splitting approach was used in all the three cases. Intraoperatively,fracture reduction was relatively stable and no post-operative splintage was given.fracture pattern was non-comminuted and hence no bone grafting was required.gradual mobilisation at elbow and shoulder was started from forty-eight hours post surgery. Results Patients were reviewed at 3 weeks, 6weeks,3months and 6months. One of the patient who had developed radial nerve palsy in the form of neuropraxia,recovered during the course of follow up.at the end of follow up all patients have adequate clinical and radiological fracture union and functional range of motion at elbow and shoulder joint. Discussion The treatment of distal humeral fractures with extension into humeral shaft presents a challenge to the orthopaedic surgeon(6,7,8). Flattening of the humerus distally, the presence of the olecranon and coronoid fossae, the neurovascular structures in close proximity to the elbow and some physiological angulations that must be preserved make the surgical procedure difficult.with posterior approach,using single low contact dynamic compression plateleft limited number of holes for distal fragment fixation,which was not adequate hence we resorted to dual long locking plates(8,9).the optimal timing for initiating surgical distal humerus fractures remains controversial with some surgeons advocating emergency surgery within 24 hours of injury(8,9). In our experience, emergency surgery should be performed on patients with open fractures after WebmedCentral > Original Articles Page 2 of 7

3 thorough debridement. While in patients with closed fractures and severe initial local swelling, above elbow slab can be first applied and surgical fixation subsequently planned and performed once the swelling subsides. For patients with local blisters, blister extraction is necessary. Surgery should be performed once the swelling subsides and the blister scab(s) falls off. This improves surgical safety and facilitates early post-surgery functional range of motion exercises. Several commonly used approaches have been described for distal humerus fracture management (10,11).The posterior approach using triceps flap involves obliquely cutting the triceps muscle to produce a flap. Though this approach can result in significant bleeding, muscle fibre breakdown, swelling, and fibrosis, exposure is excellent. Many complications have been reported following surgical repair of distal humerus fractures(12,13).these include infection,nerve injury,joint stiffness, heterotopic ossification, and delayed union or non-union of the fracture.strict adherence to basic surgical principles,optimal exposure,adequate and stable fracture fixation followed by supervised post-operative physiotherapy led us to escape from all these tenacious complications and to achieve good radiological and functional outcome at the end. Conclusion(s) 5. Prokopis PM, Weiland AJ (2008) The triceps-preserving approach for semiconstrained total elbow arthroplasty. J Shoulder Elbow Surg 17: Hausman M, Panozzo A (2004) Treatment of distal humerus fractures in the elderly. Clin Orthop Relat Res 425:55 63 Bone Joint Surg Am 67(2): Ring D, Jupiter JB (2000) Fractures of the distal humerus. Orthop Clin North Am 31(1): Wong AS, Baratz ME (2009) Elbow fractures: distal humerus. J Hand Surg Am 34: Holdsworth BJ (2003) Distal humerus fractures. In: Ruedi TP, Murphy WM (eds) AO: principles of fracture management. Thieme Verlag, Stuttgart, pp Sanders RA, Sackett JR (1990) Open reduction and internal fixation of delayed union and nonunion of the distal humerus. J Orthop Trauma 4(3): Horne G (1980) Supracondylar fractures of the humerus in adults. J Trauma 20(1): Krotschek H, Jahna H, Wittich H (1973) Fractures on the distal end of the upper arm. Hefte Unfallheilkd 114: Holdsworth BJ, Mossad MM (1990) Fractures of the adult distal humerus. elbow function after internal fixation. J Bone Joint Surg Br 72(3): Supra-condylar fractures of humerus with extension into shaft pose difficulty in reduction-maintenance using single plate as it leaves less number of holes distal to fracture site for adequate absolute fixation.henceforth,we recommend two long locking plates on each column for fixation and rigorous physiotherapy protocol post-operatively to achieve good functional range of motion of neighbouring joints. Reference(s) 1. Kinzl L, Fleischmann W (1991) The treatment of distal upper arm fractures. Unfallchirurg 94(9): Pereles TR, Koval KJ, Gallagher M, Rosen H (1997) Open reduction and internal fixation of the distal humerus: functional outcome in the elderly. J Trauma 43(4): Waddell JP, Hatch J, Richards R (1988) Supracondylar fractures of the humerus: results of surgical treatment. J Trauma 28(12):161 4.McCarty LP, Ring D, Jupiter JB (2005) Management of distal humerus fractures. Am J Orthop 34: WebmedCentral > Original Articles Page 3 of 7

4 Illustrations Illustration 1 Pre-op radiograph showing supra-condylar fracture extending into humeral shaft WebmedCentral > Original Articles Page 4 of 7

5 Illustration 2 Lateral radiograph showing bicolumnar plate fixation WebmedCentral > Original Articles Page 5 of 7

6 Illustration 3 Antero-posterior radiograph showing bicolumnar plate fixation WebmedCentral > Original Articles Page 6 of 7

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