W. K. Roache1, A. Harris2 1Howard University College Of Medicine,Washington, DC, USA 2University Of Florida,Jacksonville,Gainesville, FL, USA
Introduction:
Distal humerus fractures in adults are rare (0.5-2% of all fractures) and are approximately 30% of all humeral fractures. Supracondylar/intercondylar fractures are even less common, having only a 0.31% incidence. These injuries often occur from high-energy trauma, particularly in the young adult, and often present as open fractures with complex fracture patterns. These fractures in adults can be debilitating and difficult injuries to treat and frequently require operative management to create a stable platform to allow for early range of motion (ROM).
Methods:
A retrospective analysis was completed on a consecutive series of skeletally mature adults treated at a Level I Trauma Center with a radiologically visible supracondylar/intercondylar humerus fracture during the period from Feb. 2006 to May 2013. Exclusion criteria were patients with still maturing epiphyseal plates, supracondylar humerus fractures that were not inter-articular, and patients treated non-operatively. Postoperative data such as date of union, status of infection, range of motion (ROM), further complications, subsequent surgeries, status of physical therapy or occupational therapy (PT/OT), and comorbidities was gathered from postoperative and clinic visit notes. Postoperative elbow ROM was measured by tracking the arc of the forearm from full extension to flexion.
Results:
High-energy mechanisms accounted for injuries in 81% of the cases treated. Using the AO/OTA classification, 42% had a C2 and 39% had a C3 fracture pattern, with 53% of the cases being open fractures and 50% of the cases being polytrauma. Operative management, however, is not without risks. Complications were seen in 57% of the cases, with the major issues being elbow stiffness (54% of all complications) and infection (17%), often related to a compromised soft tissue envelope. In cases of infection, all were associated with open fractures. In cases of post union stiff elbow, 54% were associated with an open fracture, while only 41% of functional elbow cases involved open fractures. However, all cases of frozen elbow involved open fractures. Mean time from injury to operative fixation was 28.8 hours sooner in cases resulting in functional elbows than stiff elbows. Of the patients who regained full ROM, 91% started aggressive PT/OT immediately after surgery.
Conclusion:
The combination of soft tissue damage and comminution may lead to arthrofibrosis and the formation of heterotopic bone. It appears clear however that the ability to regain functional range of motion or better is associated with early operative intervention and more importantly, immediate participation in therapy driven modalities. Aggressive physical/occupational therapy was extremely important in restoring ROM, while nearly all patients who achieved full ROM performed immediate therapy postoperatively. Secondary interventions (manipulation; HO excision) appear to prove beneficial in restoring functional motion if stiffness does occur.