Distal humerus fracture constituteapproximately 2% of all fracture.1 Owing to intra-articularextension in majority of the cases, perfect anatomical reduction of thearticular fragments and rigid fixation enough for early mobilization, is utmostessential to achieve desirable functional results. However, it is verydifficult to realign the comminuted fragments because of complex anatomy of thedistal humerus, limited amount of subchondral bone and small fracture fragments.2Double plate osteosynthesis is accepted as the gold standard treatment ofdistal humerus fracture in the literature.3-5 Many configurations ofplate fixation have been advocated but the controversy still remains concerningplate configuration in order to achieve rigid stabilization enough for fractureunion.
6The commonly used plate configurationsare parallel, perpendicular and ‘Y’shaped, but the comparison between them inthe literature is not available enough to reach a definite conclusion. Most ofthem study are done in laboratory in term of biomechanical properties and itsvalidity in vivo is uncertain. There are very few studies available inthe literature comparing clinical and radiological outcome after parallelversus perpendicular plate configuration.2,6,7 Most of them are done in laboratory in termsof biomechanical properties and hence, its validity in vivo is uncertain.Present study aimed to compare the clinical and radiological outcome includingcomplication of parallel and perpendicular configuration of dual plating inintercondylar fracture of the distal humerus (AO type 13C). MATERIAL AND METHODS:We conducted a prospective randomizedstudy on the patients of distal humerus fracture treated in a tertiary referralinstitute between August 2012 to July 2015 and qualify the inclusion criteria.Patients included in this study were selected based on the following criteria:closed distal humerus fracture classified as type C according to theAssociation for Osteosynthesis/Association for the study of Internal Fixation (AO/ASIF)classification system, have follow-up of at least 24 months and willing toparticipate in the study. The patients with associated head injury, compoundfracture pathological fracture secondary due to primary or secondaryneoplasm and age of the patient <18 years were excluded from the study.
Patients who qualified the inclusion criteria wereallocated in two groups. The group allocation wasdone on the basis of computerized simple random sampling. All the patientsincluded in this study was treated by operative intervention.
The proceduredone was open reduction and fixation of the fracture by two 3.5 mm anatomicallocking plates. The construct of the plate was either parallel orperpendicular. Patients in Group A were treated by parallel plate construct andof Group B by perpendicular plate construct. The 3.5-mm pre-contouredanatomical plate made up of stainless steel was used in this study.
For allpatients, computed tomography (CT) with 3D reconstruction was donepreoperatively to identify comminution and to locate fracture fragmentsaccurately to be fixed. Preoperative conventional radiograph of elbow in twoorthogonal plain was also done.Surgical technique: All procedures were performed under general anaesthesia with brachialor axillary block for postoperative pain relief. After achieving adequateanaesthesia patient was positioned in lateral position with the index limbabove.
An olecranon post was applied at the elbow to flex the elbow to 90degrees. A straight posterior incision with slight radial curve over theolecranon was given; ulnar nerve was isolated and mobilized 6 cm proximal anddistal to the cubital tunnel. The nerve was secured and all efforts were madeto prevent damage of the nerve. Distal humerus was approached via a V-shapedolecranon osteotomy created approximately 2.5-cm distal to the olecranon tip.With the distal humerus articular fragments in view, the trochlea was reducedfirst.
Large fragments were held in place and fixed by 4-mm cannulatedcancellous screws. Small fragments were held temporarily in place by 1-mmK-wires. Definitive fixation of the articular fragments to the both columns wasbased in the use of strategically placed osteosynthesis, preserving as much asbone and soft tissues attached to it as possible. In group A, after reductionof the articular fragments, it was fixed to the both column in parallelfashion. One plate was applied on the lateral and one on the medial column. Wemodified the screws placement in distal fragment.
Instead of putting longerinterdigitated screws from either column, juxta-articular fragments were fixedby one or two 4-mm cancellous screws and smaller screws were used throughlocking holes of the plate Figure 1. In Group B, bone columns were reducedand stabilized with two plates one on the posterior aspect of lateral columnand another on the medial column Figure 2. After definitive fixation, allK-wires were removed and olecranon osteotomy was fixed using tension band wireor 6-mm cannulated cancellous screw. The anterior subcutaneous transposition ofulnar nerve was done as and if required. After fixation of the fracture,impingement of ulnar nerve onto the plate was checked on movement of elbow. Ifthere were impingement of the nerve, anterior transposition of the nerve wasconsidered.
Post-operative rehabilitation: The patients ineither groups were advised to follow similar postoperative physiotherapyregimen. Early controlled passive mobilization was initiated 48 hourspostoperatively. After removal of the negative pressure drain and long armPlaster of Paris slab was applied with the elbow in 70-80 degree of elbowflexion. 90 degrees elbow flexion was avoided to prevent wound dehiscence. Inorder to prevent heterotopic ossification Indomethacin 75-mg once a day for 4weeks was given in all patients. Active elbow physiotherapy was started soonafter removal of stitches (11 to 14 postoperative day). Passive mobilizationand massage was discouraged to prevent heterotopic ossification.
Clinical andradiological evaluations were performed regularly at 1 month, 3 months, 6months, 12 months and at 2 years. In follow-up standard anteroposterior andlateral radiograph of the elbow were obtained in order to assess union,fixation status and to determine the incidence of nonunion, metal failure andheterotopic ossification. The patient’s clinical evaluations consisted of pain,