|Year : 2019 | Volume
| Issue : 1 | Page : 53-56
Management of supracondylar/intercondylar distal humerus fractures using triceps-reflecting anconeus pedicle approach
Rakesh Verma, Rahul Choudhari, Arvind Kumar Bohra, Shiv Bhagwan Sharma
Department of Orthopaedics, Jhalawar Medical College, Jhalawar, Rajasthan, India
|Date of Web Publication||19-Aug-2019|
Dr. Rahul Choudhari
Room No. 502, P.G. Boys Hostel, Jhalawar Medical College, Jhalawar, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: Chevron olecranon osteotomies are commonly used for intra-articular distal humerus fractures but are often associated with complications such as prominence of hardware, displacement, and nonunion of osteotomy. We studied the triceps-reflecting anconeus muscle pedicle approach (TRAP) with preservation of the extensor apparatus as a safe alternative, giving a sufficient exposure to the elbow joint. Materials and Methods: We reviewed the functional and radiological results of thirty consecutive patients with intercondylar fractures of the humerus treated by internal fixation through TRAP approach. The average age of the patients was 32 ± 4.5 years. Results: At a minimum follow-up of 12 months (average 18 ± 4 months), 27 (90%) patients had good triceps strength. The average range of motion was 118.4° ± 7° (range, 80°–130°). The average time to union was 3.2 ± 1.6 months. No patient had triceps rupture, implant failure, neurovascular deficit, or nonunion. One patient needed removal of the implant because of subcutaneous prominence. Conclusion: TRAP approach provides good visualization for fixation of intercondylar fractures of the humerus, without any noticeable untoward effect on triceps strength and postoperative rehabilitation; hence, one can avoid iatrogenic fracture of the olecranon and its associated complications.
Keywords: Humerus, intercondylar fracture, TRAP
|How to cite this article:|
Verma R, Choudhari R, Bohra AK, Sharma SB. Management of supracondylar/intercondylar distal humerus fractures using triceps-reflecting anconeus pedicle approach. J Orthop Traumatol Rehabil 2019;11:53-6
|How to cite this URL:|
Verma R, Choudhari R, Bohra AK, Sharma SB. Management of supracondylar/intercondylar distal humerus fractures using triceps-reflecting anconeus pedicle approach. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2019 Sep 20];11:53-6. Available from: http://www.jotr.in/text.asp?2019/11/1/53/264718
| Introduction|| |
Fractures of the distal humerus in adults represent approximately 2% of all fractures and a third of all humeral fractures. Most low-energy distal humeral fractures are resulted from simple falls in middle-aged and elderly females in which the elbow is either struck directly or axially loaded in a fall onto the outstretched hand. Road traffic accidents and sports are a more common cause of injury in younger males. The preferred treatment for displaced, intra-articular, intercondylar fractures of the distal part of the humerus is open reduction and internal fixation. Adequate exposure of the articular surface of the distal humerus and elbow joint is required for operative stabilization of bi-columnar distal humerus fractures. The transolecranon approach, which provides complete posterior visualization and access to the distal humerus, is the most commonly used surgical approach. An olecranon osteotomy and other extensor mechanism-disrupting approaches have risks and possible complications such as prominence/migration of hardware, displacement/nonunion of osteotomy, and triceps weakness.
Need for better surgical visualization of fracture geometry has produced numerous new approaches and their modification. Surgical approaches to the elbow joint that dissociate the triceps from the olecranon have distinct disadvantages of more extensive dissection, triceps weakness/failure, and delayed postoperative rehabilitation. Concerns regarding the potential complications of olecranon osteotomy have stimulated some authors to recommend triceps-splitting approach or triceps-reflecting approach.
For these fracture patterns, 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. 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 the neurovascular supply of anconeus, which is a dynamic stabilizer of the elbow. The purpose of this study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with the use of triceps-reflecting anconeus muscle pedicle approach.
| Materials and Methods|| |
Thirty patients with intercondylar fractures of the humerus were operated through triceps-reflecting anconeus pedicle (TRAP) approach. Patients with an ipsilateral or contralateral upper-extremity injury or a preexisting musculoskeletal condition were excluded from the study. Only patients who underwent plate fixation for both the medial and lateral columns through a posterior approach were included in the study. 30 patients with a minimum follow-up of 12 months are reported.
There were 21 males and 9 females. The average age of the patients was 32 years (range, 16–58 years). The right elbow was involved in 22 patients and the left elbow in 8 patients. The mechanism of injury was a fall in 15 patients, a motor vehicle accident in 12 patients, and direct trauma in 3 patients. Twenty-six patients presented to the casualty within 12 h and four patients reported 1 week after the injury. Three patients had ulnar deficit at presentation. Only patients with T-condylar or intercondylar fractures, AO type C (16 of C1, 10 of C2, and 4 of C3), were included in the study. Grade I open wound was seen in six patients with widely displaced fractures.
All operations were done under general anesthesia. The patients were placed in lateral position and sterile tourniquet was applied. We used the TRAP approach for exposure of the elbow as described by O'Driscoll. A straight posterior incision was made just lateral to the olecranon tip, approximately 10 cm proximal and 8 cm distal [Figure 1].
The medial and lateral skin flaps were raised to expose the supracondylar ridges on either side of the distal humerus. The ulnar nerve was first localized proximally where it emerged beneath the triceps tendon. The distal aspect of the intermuscular septum was released to increase the mobility of the ulnar nerve. The nerve was followed for at least 7 cm after the flexor pronator mass was entered. Its branches to the flexor carpi ulnaris were carefully preserved [Figure 2].
Laterally, the flap was elevated to expose the interval between the anconeus and the extensor carpi ulnaris.
The anconeus-triceps flap was detached from its distal attachment (5–7 cm from the tip of olecranon) and the lateral side of the elbow and proximal ulna was dissected off, preserving the integrity of the lateral collateral ligament complex, including the annular ligament.
This was accomplished easily by commencing the dissection distally and working proximally. The posterior capsule was incised, and the dissection was carried out proximally between the triceps and posterior humerus. The fibers of the deep head of the triceps were dissected off the posterior humerus by sharp and blunt dissection. The intra-articular component was reduced first, after which the reconstituted condylar block was reduced and fixed provisionally to the medial and lateral columns with 1.6- or 2.0-mm Kirschner wires. 3.5-mm reconstruction plates were contoured to fi t along the involved columns. Both columns were plated along the posterior surface [Figure 3]. The corticocancellous bone graft from the iliac crest was used to fill the bone gaps in ten patients.
Long screws aiming from the medial or lateral epicondyles through the medial and lateral columns provided additional fixation. Care was taken to ensure that the reconstructed humeral condyles did not narrow the trochlea, and an intact olecranon process helped in reconstructing the articular surface. The ulnar nerve was transposed anteriorly in patients with preoperative symptoms of nerve involvement or if the hardware protruded medially in the course of nerve.
After intraoperative radiographs were made to confirm the adequate placement of the hardware and reconstitution of the osseous anatomy, the elbow was moved through a range of motion to test the stability of the repair and also to guide the goals of postoperative rehabilitation. The triceps was reattached with interrupted number-2 braided polyester sutures, with the use of drill-holes through the bone in the region of the olecranon. A Hemovac drain was placed on the triceps fascia and the subcutaneous tissue and skin were closed in layers. An above-elbow POP slab was applied in 90° flexion for 2 weeks.
Gentle, active and active-assisted range-of-motion exercises were started under the supervision of a physical therapist after 2 weeks. Active extension was prohibited until 8 weeks postoperatively to avoid undue stress on the extensor mechanism repair.
Assessment included the recording of a history, physical examination, and evaluation of range of motion. Elbow-extension strength was measured at 45° and 90° flexion, with the forearm in neutral rotation. The unaffected arm was used as a control for each patient.
All patients were examined at monthly intervals for 3 months and then at 6 and 12 months after surgery. Each patient completed a comprehensive written questionnaire regarding functional capabilities, residual symptoms, and existing disabilities. The elbow range of motion and strength were noted. Triceps strength was graded according to the system given by Wolfe et al. [Table 1]. Radiographs were obtained in anteroposterior and lateral projections on each follow-up visit till bony union [Figure 4].
|Figure 4: Pre and post op xray; flexion and extension of elbow @ 4 weeks|
Click here to view
| Results|| |
The mean duration of follow-up was 18 ± 4 months (range, 12–36 months).
Twenty-seven patients (90%) had good triceps strength, two patients (6.67%) had fair strength, and one patient had an extension lag of 10°. No patient had a reoperation. No patient had triceps rupture at a minimum follow-up of 12 months.
Range of motion
The mean flexion contracture was 5.25° (range, 0°–20°). The mean arc of flexion-extension was 118.4° (range, 80°–130°). All patients had some loss of flexion and extension, and no patient had loss of forearm rotation. The range of motion improved in the first 6 months.
There was no evidence of anteroposterior elbow instability on manual testing. Manual stressing of the elbow in the varus-valgus plane, including provocative maneuvers for valgus and posterolateral instability, did not reveal any laxity in any patient.
Union was defined as the presence of bridging callus or the disappearance of the fracture line on three of four cortices seen on the anteroposterior and lateral radiographs. Intra-articular gap or step deformity was measured directly on radiographs. The average time of healing of the distal humerus fractures was 3.2 ± 1.6 months (range, 2–6 months). There was one malunion (varus angulation of 7°). No patient had nonunion. No fracture was fixed with >10° of angulation in flexion, extension, or rotation. No patient had a loss of reduction or fixation. Two patients needed removal of the implant in view of the subcutaneous prominence of the hardware.
There was one postoperative superficial infection, which resolved after treatment with oral antibiotics and dressing. There were no deep infections. Iatrogenic radial nerve palsy was observed in two patients, which resolved completely by 3 months. Preoperative ulnar nerve palsy resolved completely in 2 months in all the three patients.
| Discussion|| |
Triceps-splitting, triceps-reflecting, and olecranon osteotomy are the most common posterior surgical approaches to the adult elbow. Triceps-splitting or triceps-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. In the TRAP approach, the dissection is in the internervous planes and hence, muscle injury with resultant fibrosis and injury to intramuscular nerve branches are avoided with this approach.
It is generally thought that a posterior surgical approach provides optimal exposure of the intra-articular aspect of the distal part of the humerus, and the olecranon osteotomy is the gold standard against which other approaches are compared. However, its drawbacks (delayed union or nonunion, prominent hardware, and so on) have led to other avenues of dealing with the extensor mechanism.
Several authors have reported various complications associated with tension band wiring of olecranon.,,, Macko et al. reported elbow symptoms due to prominent K-wire in 15 cases (75%) out of their 20 cases and skin breakdown in four cases (20%).
In a study of 88 fractures of the olecranon, Horne et al. reported that 66 (75%) patients required removal of the wire within 1 year because of pain and 7% patients had nonunion. Ring et al. reported a nonunion rate of 30% of transverse olecranon osteotomy in surgical fixation of fractures of distal humerus. Gainor et al. observed that 27% of their patients necessitated removal of hardware because of symptoms related to wires and septic olecranon bursitis. Triceps-reflecting anconeus pedicle approach can avoid such problems altogether.
The median exposed articular surface for the triceps-splitting, triceps-reflecting, and olecranon osteotomy approaches was 35%, 46%, and 57%, respectively. Olecranon osteotomy exposed more articular surface than the triceps-splitting approach but was not significantly greater than the triceps-reflecting approach. Extreme flexion of the elbow allows visualization of most of the anterior articular surface of the humerus. We had no problem even in comminuted bicondylar fractures with triceps-reflecting anconeus pedicle approach.
In our study, 90% of the patients regained normal strength by 12 months, whereas Askew et al. in their study reported loss of strength of triceps in all patients with olecranon osteotomy or triceps-splitting approach. The TRAP approach allows extensive distal humerus exposure, including the supracondylar/intercondylar region. The TRAP approach is extensile enough in treating complex humeral fractures. Both articular reconstruction and fixation can be easily managed without creating an olecranon fracture. The repair is easy and strong enough to allow a rapid rehabilitation. No significant triceps weakness and dysfunction was observed after the TRAP approach in the treatment of intercondylar fractures of the humerus.
Our study has certain shortcomings. We measured muscle strength manually and that may insinuate the potential of subjective bias; objective testing of the muscle strength would have avoided this bias. The rate of posttraumatic degenerative changes in the elbow may increase with time, negatively affecting function and hence a longer follow-up is required.
| Conclusion|| |
The TRAP approach provides good visualization for fixation of intercondylar fractures of the humerus, without any noticeable untoward effect on triceps strength and postoperative rehabilitation; hence, one can avoid iatrogenic fracture of the olecranon and its associated complications.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]