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Anatomical plates; Distal humerus; Extra articular fracture; Mayo Elbow Performance score

Introduction

Because of the humerus's unique anatomy and limited surgical site, adult distal humerus fractures are difficult for orthopedic surgeons to treat.Because the distal portion of the humerus has a complex bone shape with irregular arrangements and irregularities, it is challenging to select the location of implants based on the type of fracture.The trochlea of the distal humerus and anatomical structures like the olecranon and coronoid fossa create a small opening for inserting the locking screw [1].A combination of plates might not be able to effectively fix proximal fragments because the screws are inserted in different directions.The restoration of the intricate geometry is the primary goal of treatment for these fractures in order to facilitate prompt mobilization.The annual incidence of adult distal humerus fractures is bimodal, ranging from 5.7 per 100,0001 to 5.7 per 100,0001.The first peak is mostly felt by men between the ages of 12 and 19, while the second peak is mostly felt by older women who have osteoporosis because of falls and lowenergy trauma.Distal humeral extraarticular fractures occur between the humeral shaft and the intercondylar region.These fractures have a more complicated pattern, a lot of compression, and the majority are displaced.The crack at the distal site may prevent it from achieving powerful strength and arrangement, even if utilitarian propping is the primary treatment.The delicate procedures of intramedullary nailing and locking are prevented by the short distal section.Some suggested plating techniques include dual plating, lambda plate fixation, and metaphyseal plate fixation, but the outcomes have not been satisfactory [2-5].

To accommodate this difficult fracture, the precise anatomical plates for the extraarticular distal humerus are introduced.These plates were used to create the difficult fractures.It is designed to be positioned distally at the parallel supracondylar edge and proximally along the focal humeral diaphysis.The system's high stability and rapid mobilization are also aided by the increased likelihood of inserting the locking screw into the distal fragment.For extra-articular distal humeral fractures, a para-tricepetal approach with a locking plate has recently demonstrated stable fixation, early mobilization, and minimal soft tissue loss.In light of this, the purpose of the current study was to investigate the radiological and practical effects of using a physical plate to reduce and concentrate more articular distal humerus cracks in adults (only A2 and A3) [6-8].

Patients and Methods

Study Design

Patients with a history of distal humerus trauma who presented to the OPD as well as casual patients of the Sushrut Hospital Research Centre and Post Graduate Institute of Orthopedics were included in this prospective observational study.The patients had an extra articular crack of the distal humerus that was exclusively of the kind A2 or A3 upon radiographic assessment.Between November 2016 and November 2018, the study was carried out.

Inclusion Criteria [9]

The study included patients over the age of 18 who were admitted to the hospital with close and open grade 1 fractures of the distal humerus.The study also included patients who had extra-articular distal humerus fractures (A2 and A3).

Exclusion Criteria

The study did not include any patients under the age of 18 or with poly-trauma, multiple fractures, open grade 2 and open grade 3 fractures, or repeat trauma to the same limb after the initial surgery. Preoperative Planning [10]

A brief history and clinical examination were carried out to evaluate the patient's stability.Plain radiographs of the distal humerus, including an anteroposterior and lateral view, were taken for the purpose of diagnosis and preoperative planning.The appendage was held in place with mortar support up to the bear joint above the elbow. Patients' informed consent was obtained prior to beginning surgery.

Surgical Technique

The patient was positioned lateral on the operating table, arm hanging over the side block underneath the brachial block.A pneumatic tourniquet was used in all cases.Material was used to cover the painted part.The triceps splitting posterior approach was utilized in all instances.A longitudinal incision was made in the middle of the posterior arm, 8 cm below the acromion, to get to the olecranon fossa. The triceps heads were then separated after the skin and subcutaneous tissue were dissected.The radial nerve was carefully isolated to prevent damage.To preserve blood supply to the area of injury, careful delicate tissue analysis was performed.As the fracture site approached, the anatomically aligned distal humerus plate was used to fix it.Two layers of sutures were present.

Post-Operative Protocol and Follow-Up

48 hours after the method, the patients got an intravenous implantation of anti-toxins.An elbow plaster splint held the arm in place.Routine analgesics were given as recommended.There was a radiographic examination.Ten to twelve days after surgery, the sutures were removed.At six weeks, a clinical pain assessment, an evaluation of the elbow's range of motion, and a radiological examination were performed.At 12 weeks, the radiological and clinical association were evaluated.The elbow's valuable limit and radiological and clinical affiliation were evaluated following 24 weeks.The Mayo Elbow Performance Score was used to determine the outcome.

In this prospective study, 22 patients (88 percent) sustained a close distal humerus fracture, while three patients (12%) sustained an open grade 1 fracture. Between the ages of 22 and 56, 48% and 44% of patients experienced trauma as a outcome of a road traffic accident or a fall.Most of patients (40%) in this study were between the ages of 31 and 40.72% of the individuals in our survey were male, as opposed to 28% of the female individuals.In 60% of patients, the right upper appendage was present.52% of patients had surgery in two hours, which took an average of 1.9 0.38 hours. In 72% of cases, the average time between injury and surgery was between two and four days. 52% of patients spent between 8 and 3 days in the hospital, with a range of 8 to 11 days. 72% of the patients in this study had no complications. A substantial embed was the most common difficulty, affecting 16% of patients.Sixty percent of the patients only experienced moderate pain, and none of them displayed any significant symptoms.56% of patients had an arc of motion ranging from 50 to 100 degrees, with a mean of 97.2 21.79 degrees .Union time lasted an average of 16.7 4.5 weeks in this study.Additionally, Type 13-A3 fractures required a longer union time than Type 13-A3 fractures (19.5 5.5 weeks versus 15.4 3.4 weeks).

96% of patients exhibited good stability, with only one patient being moderately unstable.The Mayo Elbow Performance Score was used to evaluate five functions at the final follow-up:21 patients (84 percent) who were able to comb their own hair;all 25 patients, or 10%, who could eat on their own;24 patients, or 96%, who were able to do their own daily hygiene;22 patients (88 percent) who were able to put on their own shirts;and 23 patients (92%) had score-based function outcomes that were excellent in five (twenty percent), good in seventeen (68 percent), fair in one (four percent), and poor in two patients.Our study's findings are presented in and include non-union, superficial infection, and exposed and palpable implants caused by severe compression (multifragmentary fracture) in three patients.The Mayo elbow performance score and the type of fracture did not have a statistically significant relationship (p=0.231). Of the 17 patients with A2 fractures, 16 (94 percent) received good or excellent grades, and only one (5.3 percent) received a poor grade.Similarly, pre- and postoperative radiographic evidence indicated that 75% of patients with A3 fractures had a good or excellent grade.

Discussion

The most complicated injuries, with significant morbidity and a negative impact on quality of life, are extra-articular distal humerus fractures.Due to the periarticular location, comminution with small distal fragments, and the absence of a clear consensus statement regarding the best implant for management, management is challenging and presents a significant challenge to surgeons.In order to allow early ROM to begin, the treatment aims to achieve a favorable arrangement with stable reproduction.As a outcome, surgery is preferable to conservative treatment.In the meantime, complications like non-union, radial nerve palsy, infections at the surgical site, and implant-related symptoms are linked to surgical intervention.

Standard plates cannot be effectively and stablely fixed because of the small distal fragment and the torsional forces at this junction. Numerous modifications to the plate designs have been suggested as a outcome of the numerous issues.Numerous alternative plates have also been suggested in light of the fracture's location.The horizontal tibial head brace locking plate was changed in a new report to prevent facture obsession from impinging on the olecranon fossa.According to the findings of the radiographs, the alignment as well as the callus bridging were both accomplished in 15 patients.Spitzer demonstrated in another report that a "hybrid" metaphyseal LCP can successfully fix proximal or distal metaphyseal humerus fractures. The implant has locking holes at one end that are 4.5 mm and 3.5 mm, respectively. Due to the use of small-caliber screws on smaller bone fragments, these arrangements have a high strength.According to the outcomes of 21 patients, there is no evidence of infection or implant failure during the healing process, which takes an average of 4.5 months.It was demonstrated in a previous study that distal humeral Lambda plates in the shape of a Y could be easily positioned in accordance with the type of fracture.However, in cases of compression and osteoporosis, there is a possibility of inadequate fixation due to the absence of locking holes on this compression plate.Although plate obliquity prevents compelling obsession, Moran asserts that positioning the conventional plate at an angle between 5° and 8° in the center from the long axis of the humerus improves distal fixation.Distal humerus fractures have also been treated with parallel and orthogonal dual plating. However, multiple complications, including soft tissue dissection, infection, and non-union, can outcome from dual plating.Scolaro found that the single pre-contoured posterolateral extra-articular LCP for distal humerus fracture fixations had significantly higher yield, bending, and torsional strengths than the conventional 3.5mm LCP in a saw bone model study.Due to the fact that the study was conducted on cadavers without taking into account the soft tissues that were present in the area, the authors also come to the consider that the replication of this method must be carried out with extreme caution.In routine clinical practice, it may stabilize or destabilize fracture fragments.

The posterior approach is the most typical method of mounting utilized for fracture repair.The triceps splitting posterior approach was used in all of our studies.The primary benefit of this method is that it makes it easier to visualize and gives you an extensor mechanism for early mobilization.The majority of injuries in this study are caused by high-energy roadside accidents, with type 13-A2 accounting for 68% of cases.The majority of injuries are brought on by road accidents and falls.The majority of patients were male, with a mean age of 38.9 9.6 years.weighed against Jain et al.Similar to our report, the study found that reunions took an average of 17.6 weeks, which is significantly longer than the average (12 weeks).16]These variations may be the outcome of the different study population's bone healing mechanism because these fractures outcome in direct bone healing with minimal callus bridging. In our study, the median time to fracture union was 16.7 4.5 weeks, with a range ofFracture union is difficult to observe in the first few days after surgery, and the analysis of reunion time may differ between observers.

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