Institutional rev

005656).

*Reprint req

Surgery, Mayo C

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J Shoulder Elbow Surg (2014) 23, 573-578

1058-2746/$ - s

http://dx.doi.org

www.elsevier.com/locate/ymse

Low transcondylar fractures of the distal humerus:results of open reduction and internal fixation

Juan P. Simone, MD, Philipp N. Streubel, MD, Joaquin Sanchez-Sotelo, MD, PhD,Bernard F. Morrey, MD*

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA

Background: This study presents the outcomes of low transcondylar fractures of the distal humerus treatedby open reduction and internal fixation.Methods: Between 1996 and 2010, 263 distal humeral fractures were managed at our institution. Patientswith a true low transcondylar fracture treated by open reduction and internal fixation were included. Four-teen patients form the basis of this study. Fracture fixation was achieved through a triceps-sparingapproach, a triceps tongue, or an olecranon osteotomy. Internal fixation was performed with parallel plates,orthogonal plates, a single lateral plate, or a single medial plate. The clinical outcome was measured withpain levels, range of motion, and the Mayo Elbow Performance Score. Radiographs at latest follow-upwere assessed for union, delayed union, nonunion, and hardware failure.Results: At most recent follow-up, 11 patients had no pain, 2 had mild pain, and 1 had moderate pain. Themean Mayo Elbow Performance Score was 85. The mean arch of motion was 95�. Complications includednonunion, delayed union, wound complications, deep infection, and heterotopic ossification.Discussion: Stable internal fixation of low transcondylar fractures is perceived as difficult to achievebecause of the very small size of the distal fragment. However, the results of our study indicate that internalfixation of low transcondylar fractures of the distal humerus is associated with a high union rate and satis-factory clinical results. Elbow arthroplasty does not need to be considered for most patients with a lowtranscondylar distal humeral fracture.Level of evidence: Level IV, Case Series, Treatment Study.� 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Distal humeral fracture; low transcondylar fracture; open reduction and internal fixation

Distal humeral fractures have an incidence of 5.7 per100,000 persons in the population per year.21 So-called lowtranscondylar fractures represent about 9% of these and areconsidered a distinct pattern among the classical fractures ofthe distal humerus.17,21 These injuries are characterized by a

iew board approval was received for this study (No. 11-

uests: Bernard F. Morrey, MD, Department of Orthopedic

linic, 200 First Street SW, Rochester, MN 55905, USA.

ss: morrey.bernard@mayo.edu (B.F. Morrey).

ee front matter � 2014 Journal of Shoulder and Elbow Surgery

/10.1016/j.jse.2013.12.013

very consistent transverse extra-articular fracture line throughor below the lateral epicondyle and at the level of or justabove the medial epicondyle. Stable internal fixation may beextremely difficult to achieve because of the very small sizeof the distal fragment, especially in the presence of poor bonequality and comminution.8,14,17,21,24,28 For these reasons, totalelbow arthroplasty may be considered for selected lowtranscondylar fractures.2,10,18 However, the outcome of in-ternal fixation for this specific type of injury is difficult tounderstand because most reports on internal fixation of distalhumeral fractures group together multiple subtypes.8,17,20 The

Board of Trustees.

Table

IResults

Case

No.

Timeto

surgery

(d)

Age

(y)

Gender

Approach

Plate

position

UNT

Follow-up

(mo)

Rangeof

motion

(�)

Flexion

(�)

Extension

(�)

Pronation

(�)

Supination

(�)

MEPS

Pain

Complication

Further

surgery

11

57

Male

TSP

Yes

16

115

135

20

85

75

Excellent

None

Delayed

healing

No

23

84

Female

TOM

Yes

15

110

115

580

80

Excellent

None

Delayed

healing

No

37

59

Female

TOP

No

645

90

45

85

85

Poor

Moderate

Nonunion

Yes

42

64

Female

TSP

Yes

7140

140

085

85

Excellent

None

None

No

56

66

Female

TSP

No

695

110

15

85

85

Good

Mild

None

No

610

71

Male

TSP

No

795

120

25

85

85

Excellent

None

None

No

76

97

Female

TSP

Yes

12

100

120

20

85

85

Excellent

None

None

No

89

77

Female

TSP

Yes

14

90

100

10

85

85

Excellent

None

Nonunion

No

97

77

Female

IVT

OYes

11

120

130

10

80

50

Excellent

None

None

No

10

540

Male

TSL

No

16

75

125

50

80

65

Good

None

None

No

11

488

Female

IVT

PYes

13

110

140

30

60

60

Excellent

None

Skin

infection

anddehiscence

Yes

12

579

Male

IVT

PYes

11

100

130

28

80

70

Good

None

Deepinfection

Yes

13

673

Female

IVT

PYes

680

100

20

85

85

Excellent

None

None

No

14

664

Male

TSP

Yes

860

85

25

80

70

Fair

Mild

Heterotopic

ossification

Yes

IVT,

Inverted

Vtenotomy;

L,lateral;M,medial;O,orthogonal;P,parallel;TO,transolecranonosteotomy;

TS,tricepssparing;UNT,

ulnar

nerve

transposition.

574 J.P. Simone et al.

purpose of this study is to report on the outcome of a series ofpatients with a low transcondylar fracture of the distal hu-merus treated by open reduction and internal fixation.

Materials and methods

This is a retrospective case study of the outcome of a series ofpatients with low transcondylar fractures of the distal humerustreated by open reduction and internal fixation. Our trauma reg-istry was queried for adult distal humeral fractures that weretreated surgically between 1996 and 2010.

To be included in this study, the fracture had to be considered atrue low transcondylar fracture. We defined this fracture type as(1) an extra-articular fracture and (2) a fracture with a singletransverse fracture line that always exited at the level of or belowthe lateral epicondyle laterally and at the level of or just above themedial epicondyle. None of the fractures included in the studyextended proximal to the roof of the olecranon fossa affecting thecolumns. There were various amounts of comminution. Weexcluded patients with less than 6 months of follow-up.

We identified 263 consecutive distal humeral fractures throughour registry. Two individuals reviewed all radiographs to deter-mine how many fractures fulfilled the previously mentionedcriteria. A low transcondylar fracture treated with internal fixationwas found in 20 patients (7.6%). Of the 20 patients identified, 1patient died within a few days after surgery of causes unrelated tothe fracture. Five additional patients were lost to follow-up. Theremaining 14 patients form the basis of this study.

The mean age at the time of surgery was 71 years (range, 40-97 years). Three patients were aged between 40 and 60 years, 3patients were aged between 61 and 70 years, and 8 patients wereaged 71 years or older. Of the patients, 9 were women and 5 weremen. The left elbow was involved in 6 cases and the right elbow in8. The mechanism of injury involved a fall from a standing height(9 cases), a fall down the stairs (3 cases), a fall off a ladder (1 case),and a fall off of a stool (1 case). There were no open fractures.

Fracture fixation was achieved through a triceps-sparingapproach (8 elbows), a triceps tongue (4 elbows), or an olec-ranon osteotomy (2 elbows). The ulnar nerve was transposed in 10elbows. Internal fixation was performed with parallel plates (11elbows), orthogonal plates (1 elbow), a single lateral plate (1elbow), or a single medial plate (1 elbow). After closure, theelbow was placed in a bulky non-compressive dressing with ananterior plaster slab to maintain the elbow in extension, and theupper extremity was elevated. Active-assisted and passive motionwas encouraged 2 weeks after the surgical procedure. All patientswere permitted gentle daily activities and were instructed not tolift anything heavier than a glass of water for the first 6 weeks.

Clinical outcome was assessed based on pain level, range ofmotion, and the Mayo Elbow Performance Score (MEPS). Pain wasdescribed as none, mild, moderate, or severe. Range of motion wasmeasured in degrees for flexion, extension, pronation, and supina-tion. Radiographs obtained at latest follow-up visit were assessedfor union, delayed union, nonunion, and hardware failure.

Results

Mean follow-up time was 11 months (range, 6-16 months).Mean time between the injury and surgery was 6 days

Figure 1 (A) Computed tomography scans with 3-dimensional reconstruction of a left comminuted low transcondylar fracture in a 59-year-old woman. (B) Immediate postoperative radiographs showed a lateral metaphyseal defect. (C) At 6 months postoperatively, radio-graphs showed an established nonunion, fracture collapse, and hardware loosening.

Transcondylar fractures of the distal humerus 575

(range, 1-10 days). At most recent follow-up, 11 patientshad no pain, 2 had mild pain, and 1 had moderate pain.Mean arch of motion was 95� (range, 45�-140�). Meanflexion was 117� (range, 85�-140�); extension, 22� (range,0�-50�); pronation, 81� (range, 60�-81�); and supination,76� (range, 50�-85�). Mean MEPS was 85 points (range,35-100 points). On the basis of the MEPS, 9 patients hadan excellent score; 3, good; 1, fair; and 1, poor. The 2patients with a fair or poor result underwent revision to atotal elbow arthroplasty because of nonunion and severeheterotopic ossification with post-traumatic arthritis.

When assessed per age group, that is, 40 to 60 years, 61to 70 years, and 71 years or older, the mean range of motionwas 78�, 98�, and 101�, respectively, and the mean MEPSwas 70 points, 80 points, and 95 points, respectively.

Of the 14 fractures included in the study, 2 (14%)evolved into a nonunion. One of the patients with anonunion underwent revision to a total elbow arthroplasty,whereas the second patient with a nonunion declinedadditional surgical treatment. The remaining 12 fractureshealed. In 2 instances, screw migration was appreciatedduring the early months after fixation, but the fractureseventually healed without additional surgery. These 2 el-bows were considered to have a delayed union.

There were a total of 7 complications (50%): nonunion(2 elbows), delayed union (2 elbows), wound complications(1 elbow), deep infection (1 elbow), and heterotopic ossi-fication limiting motion (1 elbow). In 4 elbows (29%),additional surgery was required: 1 nonunion was convertedto a total elbow arthroplasty (case 3); 1 deep infection

underwent irrigation, debridement, and a 6-week period ofintravenous antibiotic administration (case 12); 1 case ofwound dehiscence required a flexor carpi ulnaris muscleflap (case 11); and 1 case underwent removal of heterotopicossification (case 14) (Table I).

Discussion

The results of our study show a rate of delayed union andnonunion of 29% for this fracture pattern. Stable internalfixation of low transcondylar fractures is perceived as difficultto achieve because of the very small size and fragility of thedistal fragment. Some fixation methods allow the placementof more distal screws than other fixation methods. Imataniet al8 developed a custom AO small T plate for transcondylarfractures. They reported 17 cases (12 of which were AO/ASIFclass A2) with complete union and no perioperative compli-cations. Range of motion averaged 20� to 126� at a meanfollow-up of 20 months. The same study group latercompared 4 fixation techniques in cadavers and tested themfor fixation rigidity after creating and fixing low transcondylarfractures.24 The comparison groups were as follows: (1) acustom plate in the lateral column and a medial 4.5-mmcancellous cannulated screw, (2) 2 conventional low contourplate (LCP) reconstruction 3.5-mm plates, (3) 1 lateral LCPplate combined with a cancellous cannulated 4.5-mm screw,and (4) 2 cancellous 4.5-mm screws placed in a crisscrossorientation. Groups 3 and 4 failed at a statistically signifi-cantly lower axial load than groups 1 and 2. Group 4 alsofailed at a statistically significantly lower extension load than

Figure 2 (A) Radiographs of the right elbow of a 77-year-oldwoman with a displaced low transcondylar fracture. (B) Imme-diate postoperative radiographs showed a stable construct. (C)Nonunion was noted at 1 year of follow-up.

576 J.P. Simone et al.

groups 1, 2, and 3. To our knowledge, our study is the onlybiomechanical study analyzing this specific injury pattern.

Most of the surgical approaches were performed througha triceps-sparing approach because the fracture is an extra-articular fracture. Whether to use a transolecranon osteot-omy or inverted V tenotomy depended on the surgeon’schoice to achieve a better view and fixation. Ljungquistet al,13 in a systematic review, found insufficient data toconclude that one approach is superior to another for fix-ation of distal humeral fractures. Function will most likely

depend on fracture complexity, quality of reduction,implant choice, and early motion.

The first 2 cases in our study group underwent surgerybefore 2003. The first case was fixed with a lateral 7-holeDupont J plate (Stryker, Kalamazoo, MI) and a medial 7-hole 3.5-mm pelvic reconstruction plate. The second casewas fixed with a medial Zimmer precontoured supra-condylar humerus plate system (Zimmer, Warsaw, ID) and2 lateral 3.5-mm partially threaded cancellous screws. Adelayed union and screw migration developed in bothcases. From 2003 onward, new plate designs includinglocking anatomic plates were available. Over the pastdecade, we have preferred to stabilize distal humeral frac-tures on the basis of 2 parallel plates fixed to the shaftproximally and locked together distally with as manyinterdigitating screws as necessary to stabilize the fracture.The rigidity of this construct seems to allow an earlyrehabilitation program immediately after surgery.16,22,23,26

It has become our preference for distal fractures in whichbone quality and quantity are scarce. One of the nonunionsin our series was the case of a 59-year-old woman with acomminuted lateral epicondyle. After reduction and platefixation, a large metaphyseal defect was noted. Deminer-alized bone was used to graft this defect. Ten months aftersurgery, with persistent pain and lack of motion, the patientunderwent revision to a total elbow arthroplasty (Fig. 1).

Still, healing rates may not only be affected by theinstability of the fracture pattern but also by biologicalfactors in an elderly patient population. Our secondnonunion case had a stable fixation construct. The constructmight have failed to heal because of either lack of bonequality or a biological response to healing (Fig. 2). Avascular watershed area has been described for the distalsegment of the humerus involving the olecranon, coronoid,and radial head fossa during investigations of the intra-osseous blood supply to the distal humerus.12,29

Robinson et al21 reported a greater risk of union com-plications in low configurations of distal humeral fractures(odds ratio, 7.5; 95% confidence interval, 2.3-24.7) ascompared with higher fractures. In their series, 37.5% offractures with a ‘‘low’’ configuration subsequently had adelayed union or nonunion.

Distal humeral fractures have a bimodal distribution interms of age and gender, affecting more male patients in ayounger population and more female patients in an elderlypopulation.21 Our study group was inclined more toward thelatter, as was the case in the 2 previously published articleson this fracture pattern.8,17 As life expectancy and surgicaloutcome expectations increase, different treatment modal-ities are expanding. Fifty-seven percent of the patients in ourseries were aged older than 70 years. Despite this fact, theyhad overall better range of motion and a higher MEPS thanpatients aged 70 years or younger. This finding may bebiased because in the group aged 70 years or younger, 1patient had a symptomatic nonunion and another case had afair MEPS with symptomatic heterotopic ossification. With a

Figure 3 (A) Anteroposterior and lateral radiographic views of the right elbow of a 64-year-old man with a low transcondylar fracture.(B) Radiographs obtained 3 months later showed severe heterotopic ossification limiting function.

Transcondylar fractures of the distal humerus 577

larger series of cases, stronger conclusions may be drawn asto whether age influences outcomes for this specific fracturepattern. Recent publications report good to excellent resultsin elderly patients with fractures treated with elbow arthro-plasty.1,6,10,11 In 2009, McKee et al14 reported better out-comes after total elbow arthroplasty compared with internalfixation in elderly patients with class 13C (OTA/AO) frac-tures in a randomized prospective trial. Although the resultsseem to be promising, total elbow arthroplasty yields a fairamount of complications. A recent systematic review hasshown that primary total elbow arthroplasty for acute traumahas an associated complication rate of 21.5% � 9.2%.27 Thisincludes loosening, instability, deep infection, and ulnarnerve complications among others. Although our series ofpatients showed a complication rate of 50% (reoperation rateof 29%), these included 4 excellent results, 1 good result, 1fair result, and 1 poor result. Prasad and Dent19 comparedprimary total elbow replacement for distal humeral fracturesin the elderly with delayed total elbow replacement andfound no statistically significant difference in the functionaloutcome or complication rates. If primary fixation fails, anelbow replacement is a good option.

Patient selection is crucial to predict better outcomeswith a primary elbow arthroplasty rather than open reduc-tion and internal fixation for distal humeral fractures. Anelbow arthroplasty should be considered in a physiologi-cally elderly patient with low demands, severe osteopeniaor a comminuted fracture that will provide unreliable fix-ation, and previously symptomatic or end-stage arthritis.

An infection occurred in 2 patients in our series (14%).One was a deep infection, and the other was a skin infectioninvolving a wound complication. Our infection rate ismarkedly higher than the infection rates reported for openreduction and internal fixation of the distal humerus in severalother series with different fracture patterns (0%-6.7%).7-9,18,21,22,25,26 This may be because of under-reported super-ficial skin infections because deep infections are substantiallymore serious. The likely causes of increased infection ratesare an older population, soft tissue damage with the originalinjury, and a superficial joint prone to this complication.

In 1 patient (7%), an additional surgery was performed forheterotopic ossification and loss of motion (Fig. 3). This isnot uncommon after elbow injuries, and our result is within

the range of incidences reported for distal humeral fracturestreated with internal fixation (0%-16%).4,7,18,23,25,26 How topredict the likelihood of heterotopic bone formation is stillundetermined, but there has been a reported association withdelayed treatment and a prolonged immobilization period.3,5

Our results showed a mean range of motion of 22� ofextension to 117� of flexion. Despite the extra-articularfracture pattern of these fractures, they are low enough tobreak through the capsule and act as intra-articular lesionsin nature. That is probably why range of motion is not anybetter than that reported for complex intra-articular frac-tures.18,23,25,26 When one is analyzing extra-articular frac-tures of the distal humerus, it is important to distinguishwhether they are high (extracapsular) or low (intracapsular)because the results will vary.15,21

The weaknesses of our study are the low number ofcases and our retrospective analysis of the data. The overallfollow-up time may be considered short-term, but 6 monthsis a clear cutoff point at which to determine whether afracture has healed. For the specific treatment and fracturepattern studied, it is rather unlikely that a surgicalcomplication would arise or outcomes would significantlychange after a 6-month period. It seems that parallel platefixation with locking distal screws and a stable constructwith early motion yields better outcomes. However,because this specific fracture pattern is uncommon, the lownumber of cases in our study does not allow us to provestatistically that the patient’s age, dominant arm, gender,surgical exposures, and type of internal fixation will guar-antee better results because we had mixed results.

Our main strength was the ability to exclude any otherfracture pattern and include only a true low transcondylarfracture pattern as previously defined.

Conclusion

Low transcondylar fractures of the distal humerusare distinct lesions that involve an older populationwith rather low-energy trauma. Several important ob-servations may be made: (1) Although open reduc-tion–internal fixation is challenging, our results show that86% of fractures heal with good to excellent outcome

578 J.P. Simone et al.

scores and no pain. (2) Despite the good overall outcome,the complication rate is surprisingly high, with 29% ofpatients requiring additional surgery. (3) A stable rigidfixation construct should be achieved to improve healingexpectations, although biological factors might play asignificant role as well. (4) The alternative treatment ofelbow arthroplasty should be considered in a primarysetting for cases of marked osteopenia or a severelycomminuted fracture in which stable fixation would notseem able to be achieved in a low-demand elderly patientor in a patient with previous elbow arthritis.

Disclaimer

The authors, their immediate families, and any researchfoundations with which they are affiliated have notreceived any financial payments or other benefits fromany commercial entity related to the subject of this article.

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