G Model
JINJ-5664; No. of Pages 5 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures Peng Yin a,b, Lihai Zhang a, Zhi Mao a, Yanpeng Zhao a, Qun Zhang a, Sheng Tao a, Xiangdang Liang a, Hao Zhang a, Houchen Lv a, Tongtong Li a,b, Peifu Tang a,* a b
Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China Medical College, Nankai University, No. 94 Weijin Road, Tianjin 300071, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 24 February 2014
Objective: The objective of this study was to compare treatment results and complication rates between lateral and posterior approaches in surgical treatment of extra-articular distal humeral shaft fractures. Material and methods: Between June 2008 and May 2012, a total of 68 patients with extra-articular distal humeral shaft fractures were treated by lateral and posterior approaches. Of the patients, 30 were operated by a lateral approach (group I) and 26 patients were operated by a posterior approach (group II). There was no statistical significance between the two groups in sex distribution, age, the mechanism of the injury, injured arms, AO/ASIF (Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Association for the Study of Internal Fixation) classification, and the time from injury to surgery (P > 0.05). Operation time, intraoperative bleeding volume, hospitalisation, clinical outcomes, and complications were compared between the two groups. The elbow functional results were evaluated by the Mayo Elbow Performance Score (MEPS). Results: All patients were followed up. The average of follow-up in group I was 15.53 2.636 months (range, 12–22 months), and was 16.12 2.889 months (range, 12–22 months) in group II. There was no significant difference in the operation time, intraoperative bleeding time, and hospitalisation between the two groups (P > 0.05). In group I, the mean time of bone union was 12.87 1.852 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 139.208 3.2748 (range, 134–1468), the mean degrees of elbow extension was 4.778 1.9068 (range, 0–88), and the mean points of MEPS was 87.00 7.724 (range, 70–100 points). In group II, the mean time of bone union was 12.96 2.218 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 137.858 4.0768 (range, 130–1458), the mean degrees of elbow extension was 5.158 2.3278 (range, 0–98), and the mean points of MEPS was 86.15 7.656 (range, 70–100 points). There was no significant difference in the bone union, range of elbow flexion, range of elbow extension and MEPS between the two groups (P > 0.05). The overall complication rate in group I was lower than that in group II (P = 0.041). Conclusions: Both lateral and posterior surgical approaches acquired satisfied treatment results in the management of extra-articular distal humeral shaft fractures, and there was a lower complication rate using the lateral approach. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Distal humeral shaft Fractures Lateral approach Posterior approach Complication
Introduction Fractures of the humeral shaft account for 1–3% of all fractures [1–3]. The incidence of humeral shaft fractures in North America is 20 per 100,000 inhabitants per year, and 20–30% are in the distal third [4].
* Corresponding author. Tel.: +86 1001066938101; fax: +86 1068161218. E-mail addresses: [email protected] (P. Yin), [email protected] (P. Tang).
Although conservative treatment has been used for the management of extra-articular distal humeral shaft fractures successfully [5,6], long term immobilisation in order to achieve bone union and inadequate fixation also cause various complications such as skin problems, mal-union and joint stiffness [6,7]. However, surgical treatment can provide potentially quicker recovery of function and a more predictable alignment [8–10]. Compared to any other surgical method, internal fixation with a plate and screws is more suitable for the management of distal humeral shaft fractures due to secure fixation of the distal fracture fragment [7].
http://dx.doi.org/10.1016/j.injury.2014.02.034 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
In order to expose the lateral supracondyle of the humerus and achieve sufficient fixation space using a plate and screws, we can choose either the lateral or posterior approach. These two surgical approaches have been applied successfully in the internal fixation of distal humeral shaft fractures [10–18]. Mills reported that the lateral approach allows extensile identification of the radial nerve and exposes the distal two-thirds of the humerus easily, and muscle splitting is not needed. But plate fixation may be affected by deltoid insertion [16]. Levy presented some advantages of the posterior approach [11]. He thought that a flat posterior surface of the distal humerus is suitable for plating, and the plate can be placed distally permitting more screw placement through direct visualisation, and far distal humeral shaft fractures are more suitable for the posterior approach. However, some authors recognised the exploration of the radial nerve in the posterior approach is difficult due to its anatomical course and because it limits mobility [7,19,20], which can increase the incidence of iatrogenic radial nerve injury during plate fixation. However, to our best knowledge, no comparative study about these two approaches in the management of extra-articular distal humeral shaft fractures has been reported. The purpose of the study is to compare treatment results and complication rates between lateral and posterior approaches in the management of extra-articular distal humeral shaft fractures. Material and methods Between June 2008 and May 2012, 68 patients with extraarticular distal humeral shaft fractures were operated by the lateral or posterior approach at our hospital. The inclusion criteria were: (1) patients of age of 18 years or more, (2) unilateral closed extra-articular distal humeral shaft fractures, and (3) the elbow and injured limbs were normal before injury. The exclusion criteria were: (1) old, open, or pathological fractures, (2) a history of elbow surgery, and (3) complicated by seriously nervous or vascular injury. According to the inclusion and exclusion criteria, 56 patients were included in our study. Appropriate clinical and radiological assessments were performed for all patients before a decision of surgical intervention. All fractures were classified according to the AO/ASIF (Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Association for the Study of Internal Fixation) classification. Thirty patients were operated by the lateral approach (group I). There were 16 males and 14 females, with an average of 37.73 years (range, 22–71 years). The mean time from injury to surgery was 38.77 h (range, 24–72 h). Twenty-six patients were operated by a posterior approach (group II). There were 14 males and 12 females, with an average of 38.08 years (range, 20–73 years). The mean time from injury to surgery was 40.08 h (range, 26–70 h). More demographic characteristics data of the two groups are listed in Table 1. There was no statistical significance between the two groups in sex distribution, age, the mechanism of the injury, injured arms, AO/ASIF classification, and the time from injury to surgery (P > 0.05, Table 1). Table 1 Demographic characteristics data of two groups. Characteristic
Group I
Group II
P-value
Sex distribution (male:female) Mean age (year) The mechanism of the injury (TA:F)a Injured arms (right arm:left arm) Classification of AO/ASIF (A:B:C) The mean time from injury to surgery (h)
16:14 37.73 10.395 22:8 16:14 5:16:9 38.77 9.884
14: 12 38.08 10.147 17:9 10:16 6:12:8 40.08 10.488
0.969 0.901 0.519 0.266 0.803 0.633
a
TA: traffic accident and F: fall.
Patients in group I underwent a lateral paratricipital approach using the tissue plane between the lateral head of the triceps and the lateral intermuscular septum, and patients in group II underwent a posterior approach by splitting the triceps belly along its fibres. All patients began to perform a full range of flexion–extension exercises at 2–3 days after the operation. The operation time, intraoperative bleeding volume, hospitalisation, bone union time, and complications were recorded. Clinical and radiological evolutions were performed regularly at 2 weeks, 1 month, 2 months, 3 months, 6 months, 9 months, 1 year, and then at 6-month intervals. At 1 year after the operation, the functional results of the elbow were evaluated by the Mayo Elbow Performance Score (MEPS) [21–23]. The data were analysed by SPSS 13.0 software with chi-square and Fisher’s exact test in nominal data and independent t-test in continuous data.
Results The mean operation time in group I was 129.40 11.337 min (range, 106–157 min), the mean intraoperative bleeding volume was 290.80 7.797 ml (range, 275–310 ml), and the mean hospitalisation was 7.23 0.898 days (range, 6–9 days). The mean operation time in group II was 132.15 11.845 min (range, 108–153 min), the mean intraoperative bleeding volume was 293.19 8.386 ml (range, 280– 310 ml), and the mean hospitalisation was 7.08 0.891 days (range, 5–9 days). There was no significant difference in the operation time, intraoperative bleeding time and hospitalisation between the two groups (P > 0.05, Table 2). All patients were followed up. The average follow-up in group I was 15.53 2.636 months (range, 12–22 months; Fig. 1), and 16.12 2.889 months in group II (range, 12–22 months; Fig. 2). Clinical outcomes were evaluated between the two groups. In group I, the mean time of bone union was 12.87 1.852 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 139.208 3.2748 (range, 134–1468), the mean degrees of elbow extension was 4.778 1.9068 (range, 0–88), and the mean points of MEPS was 87.00 7.724 (range, 70–100 points). According to MEPS, 18 patients had results rated as excellent, nine patients were rated as good, and three patients were rated as fair. In group II, the mean time of bone union was 12.96 2.218 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 137.858 4.0768 (range, 130–1458), the mean degrees of elbow extension was 5.158 2.3278 (range, 0–98; Fig. 3), and the mean points of MEPS was 86.15 7.656 (range, 70– 100 points). According to MEPS, 15 patients had results rated as excellent, eight patients were rated as good, and three patients were rated as fair. There was no significant difference in the bone union, range of elbow flexion, range of elbow extension and MEPS between the two groups (P > 0.05, Table 3). There was no failure of internal fixation in either group. One patient in group I had a postoperative superficial infection, which resolved with oral antibiotics. There were three patients who underwent iatrogenic radial palsy in group II, and all the patients were recovered completely within 3 months. Two patients in group II complained of pressure on the overlying skin and the implants were removed. After removal of the hardware, further rehabilitation was performed and the two patients showed good Table 2 Comparison of operation time, intraoperative bleeding volume, and hospitalisation between two groups. Indices
Group I
Group II
P-value
Operation time (min) Intraoperative bleeding volume (ml) Hospitalisation (days)
129.40 11.337 290.80 7.797
132.15 11.845 293.19 8.386
0.379 0.274
7.23 0.898
7.08 0.891
0.517
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
3
Fig. 1. X-ray films of a 28-year-old male with right extra-articular distal humeral shaft fracture caused by traffic accident (AO type B) in group I. (A) Before operation. (B) At immediate after operation. (C) At 12 months after operation.
Fig. 2. X-ray films of a 30-year-old female with left extra-articular distal humeral shaft fracture caused by traffic accident (AO type B) in group II. (A) Before operation. (B) At immediate after operation. (C) At 12 months after operation.
elbow functional outcomes. One patient sustained a triceps rupture, requiring repair. There was significant difference in the overall complication rate between the two groups (P = 0.041). Discussion This is a retrospective comparative study of lateral and posterior approach in the management of extra-articular distal humeral shaft fractures. The present study showed both approaches acquired satisfied outcomes. The excellent and good rate of elbow functional results was 90% (27/30) using the lateral approach and 88.46% (23/26) using the posterior approach. The overall complication rate was greater in the posterior approach compared to the lateral approach. In our study, the incidence of iatrogenic radial nerve palsies was 11.53% (3/26) using the posterior approach, which is higher than
the 5.3% reported by Yang et al. [10] and the 11.32% reported by Meloy et al. [24]. Although we paid more attention to protect the radial nerve, there were still three radial nerve palsies. However, in a lateral approach, there was no iatrogenic radial nerve palsy. Therefore, we considered that the reason was the limitation of the posterior approach. A lateral paratricipital approach is beneficial to improve mobilisation and for protection of the radial nerve from the level of the lateral intermuscular septum through the spiral groove (Fig. 4). But the exploration of the radial nerve in the posterior approach is difficult due to its anatomical course and because it limits mobility [7,19,20]. The rate of implant-related complications using the posterior approach has been reported to be 10.5–38.8% [10,24,25], and the 7.69% (2/26) rate in our study using the posterior approach was relatively lower. However, the rate was still higher than the patients who were operated by the lateral approach in our study. We thought that the different
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
4
Fig. 3. The patient in Fig. 2 showed an excellent functional range of movement at 1 year after operation. (A) Flexion. (B) Extension.
Table 3 Comparison of clinical outcomes between two groups. Indices
Group I
Group II
P-value
Bone union time (months) Range of elbow flexion (8) Range of elbow extension (8) MEPS (points)
12.87 1.852 139.20 3.274 4.77 1.906 87.00 7.724
12.96 2.218 137.85 4.076 5.15 2.327 86.15 7.656
0.862 0.174 0.497 0.683
positions of the plates might be the main reason causing the implant-related complications. The plates were placed in a nearer position to the elbow joint using the posterior approach compared to the lateral approach. In addition, one patient (3.85%) suffered a triceps rupture in our study using a posterior approach. The complication could be avoided by splitting the triceps belly meticulously. In our experience, the radial nerve is easily explored through the lateral approach, which protects the radial nerve and decreases the incidence of iatrogenic injury. The anterior and lateral surfaces of the humerus are accessible by the lateral approach, and this approach is extensile both proximally and distally, which contributes to fixing the plate through direct visualisation. However, in order to get better attachment, the plate is usually
Fig. 4. Lateral approach used in all cases of group I. Radial nerve was identified in the gap between brachialis and brachioradialis and was protected by a rubber band.
precontoured by the lateral approach due to the 20–308 intorsion in the junction between the middle and distal humeral shaft. Besides, the location of the plates is usually influenced by deltoid tuberosity using the lateral approach, and the exposure extent of distal humeral is relatively limited compared to the posterior approach. We think that the lateral approach is more suitable for high extra-articular distal humeral shaft fractures. The posterior approach causes more iatrogenic radial nerve palsy due to its anatomical course and it limits mobility, but the injured radial nerve usually recovers completely within 3 months, so the permanent radial nerve injury would not occur through the posterior approach as long as we pay more attention to protect the radial nerve. If the fracture extends to the middle humeral shaft, the lateral head of the triceps will be elevated laterally and then the radial nerve will be elevated in a superior direction in order to protect the radial nerve, as described by Gerwin [20]. We can make an adequate exposure for the distal humerus by the posterior approach, so more screws can be placed in a position nearer to the elbow joint to achieve rigid fixation, and we often need not precountour the plate due to the flat posterior surface of the distal humerus. We recognise that the approach is more suitable for low extra-articular distal humeral shaft fractures. Both lateral and posterior surgical approaches have respective advantages and disadvantages. Therefore, we should choose a surgical approach for extra-articular distal humeral shaft fractures based on specific conditions of the patient, such as fracture pattern, associated softtissue injury, fixation pattern and surgeon preference and experience, and we also should pay attention to make full preparations for the surgery. To the best of our knowledge, this is the first comparative study about lateral and posterior approaches in the management of extra-articular distal humeral shaft fractures. A number of data on the characteristics of patients, treatment results and complication rates were reported in our study. However, certain limitations need be addressed. Our study is retrospective in nature and the number of patients is relatively small. All operations were performed by three senior orthopaedic surgeons who perhaps have a preference in their surgical approach. Moreover, the pressure on the overlying skin was attributed to implant irritation in our study; however, the reason may be multifactorial. More prospective randomised controlled trials are needed to overcome the limitations of our study.
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
In conclusion, the present results showed that both lateral and posterior surgical approaches acquired satisfied treatment results in the management of extra-articular distal humeral shaft fractures, and there was a lower complication rate using the lateral approach.
[11] [12]
[13]
Conflict of interest Each author certifies that he/she has no commercial associations that might pose a conflict of interest with the submitted article. References
[14]
[15]
[16] [17]
[1] Ekholm R, Adami J, Tidermark J, Hansson K, Tornkvist H, Ponzer S. Fractures of the shaft of the humerus – an epidemiological study of 401 fractures. J Bone Joint Surg Br 2006;88B:1469–73. [2] Mahabier KC, Vogels LM, Punt BJ, Roukema GR, Patka P, Van Lieshout EM. Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients. Injury 2013;44:427–30. [3] Chen F, Wang Z, Bhattacharyya T. Outcomes of nails versus plates for humeral shaft fractures: a Medicare Cohort Study. J Orthop Trauma 2013;27:68–72. [4] Livani B, Belangero WD, Castro de Medeiros R. Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimallyinvasive percutaneous plate osteosynthesis. J Bone Joint Surg Br 2006;88:1625–8. [5] Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT. Functional bracing for comminuted extra-articular fractures of the distal third of the humerus. J Bone Joint Surg Br 1990;72:283–7. [6] Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular distal-third diaphyseal fractures of the humerus: a comparison of functional bracing and plate fixation. J Bone Joint Surg 2006;88:2343–7. [7] Lee TJ, Kwon DG, Na SI, Cha SD. Modified combined approach for distal humerus shaft fracture: anterolateral and lateral bimodal approach. Clin Orthop Surg 2013;5:209–15. [8] BR. Distal diaphyseal fracture of the humerus. Tech Orthop 2003;18:360–7. [9] Niall D, O’Mahony J, McElwain J. Plating of humeral shaft fractures—has the pendulum swung back? Injury 2004;35:580–6. [10] Yang Q, Wang F, Wang Q, Gao W, Huang J, Wu X, et al. Surgical treatment of adult extra-articular distal humeral diaphyseal fractures using an oblique
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
5
metaphyseal locking compression plate via a posterior approach. Med Prin Pract 2011;21:40–5. Levy JC, Kalandiak SP, Hutson JJ, Zych G. An alternative method of osteosynthesis for distal humeral shaft fractures. J Orthop Trauma 2005;19:43–7. Putti AB, Uppin RB, Putti BB. Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures. J Orthop Surg (Hong Kong) 2009;17:139–41. Zlotolow DA, Catalano III LW, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;14:754–65. Hannouche D, Ballis R, Raould A, Nizard R, Masquelet A. A lateral approach to the distal humerus following identification of the cutaneous branches of the radial nerve. J Bone Joint Surg Br 2009;91:552–6. O’Toole RV, Andersen RC, Vesnovsky O, Alexander M, Topoleski LD, Nascone JW, et al. Are locking screws advantageous with plate fixation of humeral shaft fractures? A biomechanical analysis of synthetic and cadaveric bone. J Orthop Trauma 2008;22:709–15. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma 1996;10:81–6. Singisetti K, Ambedkar M. Nailing versus plating in humerus shaft fractures: a prospective comparative study. Int Orthop 2010;34:571–6. Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. Int Orthop 2007;31:391–5. Dabezies E, Banta 2nd C, Murphy C, d’Ambrosia R. Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop Trauma 1992;6:10. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis. With reference to the radial nerve. J Bone Joint Surg 1996;78:1690–5. Lan X, Zhang LH, Tao S, Zhang Q, Liang XD, Yuan BT, et al. Comparative study of perpendicular versus parallel double plating methods for type C distal humeral fractures. Chin Med J 2013;126:2337–42. Clavert P, Ducrot G, Sirveaux F, Fabre T, Mansat P. Outcomes of distal humerus fractures in patients above 65 years of age treated by plate fixation. Orthop Traumatol Surg Res 2013. Gupta RK, Gupta V, Marak DR. Locking plates in distal humerus fractures: study of 43 patients. Chin J Traumatol Zhonghua chuang shang za zhi/Chin Med Assoc2013;16:207–11. Meloy GM, Mormino MA, Siska PA, Tarkin IS. A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: single-column plating. Injury 2013;44:1620–4. Celli A, Donini MT, Minervini C. The use of pre-contoured plates in the treatment of C2–C3 fractures of the distal humerus: clinical experience. La Chirurgia degli organi di movimento 2008;91:57–64.
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
JINJ-5664; No. of Pages 5 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures Peng Yin a,b, Lihai Zhang a, Zhi Mao a, Yanpeng Zhao a, Qun Zhang a, Sheng Tao a, Xiangdang Liang a, Hao Zhang a, Houchen Lv a, Tongtong Li a,b, Peifu Tang a,* a b
Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China Medical College, Nankai University, No. 94 Weijin Road, Tianjin 300071, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 24 February 2014
Objective: The objective of this study was to compare treatment results and complication rates between lateral and posterior approaches in surgical treatment of extra-articular distal humeral shaft fractures. Material and methods: Between June 2008 and May 2012, a total of 68 patients with extra-articular distal humeral shaft fractures were treated by lateral and posterior approaches. Of the patients, 30 were operated by a lateral approach (group I) and 26 patients were operated by a posterior approach (group II). There was no statistical significance between the two groups in sex distribution, age, the mechanism of the injury, injured arms, AO/ASIF (Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Association for the Study of Internal Fixation) classification, and the time from injury to surgery (P > 0.05). Operation time, intraoperative bleeding volume, hospitalisation, clinical outcomes, and complications were compared between the two groups. The elbow functional results were evaluated by the Mayo Elbow Performance Score (MEPS). Results: All patients were followed up. The average of follow-up in group I was 15.53 2.636 months (range, 12–22 months), and was 16.12 2.889 months (range, 12–22 months) in group II. There was no significant difference in the operation time, intraoperative bleeding time, and hospitalisation between the two groups (P > 0.05). In group I, the mean time of bone union was 12.87 1.852 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 139.208 3.2748 (range, 134–1468), the mean degrees of elbow extension was 4.778 1.9068 (range, 0–88), and the mean points of MEPS was 87.00 7.724 (range, 70–100 points). In group II, the mean time of bone union was 12.96 2.218 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 137.858 4.0768 (range, 130–1458), the mean degrees of elbow extension was 5.158 2.3278 (range, 0–98), and the mean points of MEPS was 86.15 7.656 (range, 70–100 points). There was no significant difference in the bone union, range of elbow flexion, range of elbow extension and MEPS between the two groups (P > 0.05). The overall complication rate in group I was lower than that in group II (P = 0.041). Conclusions: Both lateral and posterior surgical approaches acquired satisfied treatment results in the management of extra-articular distal humeral shaft fractures, and there was a lower complication rate using the lateral approach. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Distal humeral shaft Fractures Lateral approach Posterior approach Complication
Introduction Fractures of the humeral shaft account for 1–3% of all fractures [1–3]. The incidence of humeral shaft fractures in North America is 20 per 100,000 inhabitants per year, and 20–30% are in the distal third [4].
* Corresponding author. Tel.: +86 1001066938101; fax: +86 1068161218. E-mail addresses: [email protected] (P. Yin), [email protected] (P. Tang).
Although conservative treatment has been used for the management of extra-articular distal humeral shaft fractures successfully [5,6], long term immobilisation in order to achieve bone union and inadequate fixation also cause various complications such as skin problems, mal-union and joint stiffness [6,7]. However, surgical treatment can provide potentially quicker recovery of function and a more predictable alignment [8–10]. Compared to any other surgical method, internal fixation with a plate and screws is more suitable for the management of distal humeral shaft fractures due to secure fixation of the distal fracture fragment [7].
http://dx.doi.org/10.1016/j.injury.2014.02.034 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
In order to expose the lateral supracondyle of the humerus and achieve sufficient fixation space using a plate and screws, we can choose either the lateral or posterior approach. These two surgical approaches have been applied successfully in the internal fixation of distal humeral shaft fractures [10–18]. Mills reported that the lateral approach allows extensile identification of the radial nerve and exposes the distal two-thirds of the humerus easily, and muscle splitting is not needed. But plate fixation may be affected by deltoid insertion [16]. Levy presented some advantages of the posterior approach [11]. He thought that a flat posterior surface of the distal humerus is suitable for plating, and the plate can be placed distally permitting more screw placement through direct visualisation, and far distal humeral shaft fractures are more suitable for the posterior approach. However, some authors recognised the exploration of the radial nerve in the posterior approach is difficult due to its anatomical course and because it limits mobility [7,19,20], which can increase the incidence of iatrogenic radial nerve injury during plate fixation. However, to our best knowledge, no comparative study about these two approaches in the management of extra-articular distal humeral shaft fractures has been reported. The purpose of the study is to compare treatment results and complication rates between lateral and posterior approaches in the management of extra-articular distal humeral shaft fractures. Material and methods Between June 2008 and May 2012, 68 patients with extraarticular distal humeral shaft fractures were operated by the lateral or posterior approach at our hospital. The inclusion criteria were: (1) patients of age of 18 years or more, (2) unilateral closed extra-articular distal humeral shaft fractures, and (3) the elbow and injured limbs were normal before injury. The exclusion criteria were: (1) old, open, or pathological fractures, (2) a history of elbow surgery, and (3) complicated by seriously nervous or vascular injury. According to the inclusion and exclusion criteria, 56 patients were included in our study. Appropriate clinical and radiological assessments were performed for all patients before a decision of surgical intervention. All fractures were classified according to the AO/ASIF (Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Association for the Study of Internal Fixation) classification. Thirty patients were operated by the lateral approach (group I). There were 16 males and 14 females, with an average of 37.73 years (range, 22–71 years). The mean time from injury to surgery was 38.77 h (range, 24–72 h). Twenty-six patients were operated by a posterior approach (group II). There were 14 males and 12 females, with an average of 38.08 years (range, 20–73 years). The mean time from injury to surgery was 40.08 h (range, 26–70 h). More demographic characteristics data of the two groups are listed in Table 1. There was no statistical significance between the two groups in sex distribution, age, the mechanism of the injury, injured arms, AO/ASIF classification, and the time from injury to surgery (P > 0.05, Table 1). Table 1 Demographic characteristics data of two groups. Characteristic
Group I
Group II
P-value
Sex distribution (male:female) Mean age (year) The mechanism of the injury (TA:F)a Injured arms (right arm:left arm) Classification of AO/ASIF (A:B:C) The mean time from injury to surgery (h)
16:14 37.73 10.395 22:8 16:14 5:16:9 38.77 9.884
14: 12 38.08 10.147 17:9 10:16 6:12:8 40.08 10.488
0.969 0.901 0.519 0.266 0.803 0.633
a
TA: traffic accident and F: fall.
Patients in group I underwent a lateral paratricipital approach using the tissue plane between the lateral head of the triceps and the lateral intermuscular septum, and patients in group II underwent a posterior approach by splitting the triceps belly along its fibres. All patients began to perform a full range of flexion–extension exercises at 2–3 days after the operation. The operation time, intraoperative bleeding volume, hospitalisation, bone union time, and complications were recorded. Clinical and radiological evolutions were performed regularly at 2 weeks, 1 month, 2 months, 3 months, 6 months, 9 months, 1 year, and then at 6-month intervals. At 1 year after the operation, the functional results of the elbow were evaluated by the Mayo Elbow Performance Score (MEPS) [21–23]. The data were analysed by SPSS 13.0 software with chi-square and Fisher’s exact test in nominal data and independent t-test in continuous data.
Results The mean operation time in group I was 129.40 11.337 min (range, 106–157 min), the mean intraoperative bleeding volume was 290.80 7.797 ml (range, 275–310 ml), and the mean hospitalisation was 7.23 0.898 days (range, 6–9 days). The mean operation time in group II was 132.15 11.845 min (range, 108–153 min), the mean intraoperative bleeding volume was 293.19 8.386 ml (range, 280– 310 ml), and the mean hospitalisation was 7.08 0.891 days (range, 5–9 days). There was no significant difference in the operation time, intraoperative bleeding time and hospitalisation between the two groups (P > 0.05, Table 2). All patients were followed up. The average follow-up in group I was 15.53 2.636 months (range, 12–22 months; Fig. 1), and 16.12 2.889 months in group II (range, 12–22 months; Fig. 2). Clinical outcomes were evaluated between the two groups. In group I, the mean time of bone union was 12.87 1.852 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 139.208 3.2748 (range, 134–1468), the mean degrees of elbow extension was 4.778 1.9068 (range, 0–88), and the mean points of MEPS was 87.00 7.724 (range, 70–100 points). According to MEPS, 18 patients had results rated as excellent, nine patients were rated as good, and three patients were rated as fair. In group II, the mean time of bone union was 12.96 2.218 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 137.858 4.0768 (range, 130–1458), the mean degrees of elbow extension was 5.158 2.3278 (range, 0–98; Fig. 3), and the mean points of MEPS was 86.15 7.656 (range, 70– 100 points). According to MEPS, 15 patients had results rated as excellent, eight patients were rated as good, and three patients were rated as fair. There was no significant difference in the bone union, range of elbow flexion, range of elbow extension and MEPS between the two groups (P > 0.05, Table 3). There was no failure of internal fixation in either group. One patient in group I had a postoperative superficial infection, which resolved with oral antibiotics. There were three patients who underwent iatrogenic radial palsy in group II, and all the patients were recovered completely within 3 months. Two patients in group II complained of pressure on the overlying skin and the implants were removed. After removal of the hardware, further rehabilitation was performed and the two patients showed good Table 2 Comparison of operation time, intraoperative bleeding volume, and hospitalisation between two groups. Indices
Group I
Group II
P-value
Operation time (min) Intraoperative bleeding volume (ml) Hospitalisation (days)
129.40 11.337 290.80 7.797
132.15 11.845 293.19 8.386
0.379 0.274
7.23 0.898
7.08 0.891
0.517
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
3
Fig. 1. X-ray films of a 28-year-old male with right extra-articular distal humeral shaft fracture caused by traffic accident (AO type B) in group I. (A) Before operation. (B) At immediate after operation. (C) At 12 months after operation.
Fig. 2. X-ray films of a 30-year-old female with left extra-articular distal humeral shaft fracture caused by traffic accident (AO type B) in group II. (A) Before operation. (B) At immediate after operation. (C) At 12 months after operation.
elbow functional outcomes. One patient sustained a triceps rupture, requiring repair. There was significant difference in the overall complication rate between the two groups (P = 0.041). Discussion This is a retrospective comparative study of lateral and posterior approach in the management of extra-articular distal humeral shaft fractures. The present study showed both approaches acquired satisfied outcomes. The excellent and good rate of elbow functional results was 90% (27/30) using the lateral approach and 88.46% (23/26) using the posterior approach. The overall complication rate was greater in the posterior approach compared to the lateral approach. In our study, the incidence of iatrogenic radial nerve palsies was 11.53% (3/26) using the posterior approach, which is higher than
the 5.3% reported by Yang et al. [10] and the 11.32% reported by Meloy et al. [24]. Although we paid more attention to protect the radial nerve, there were still three radial nerve palsies. However, in a lateral approach, there was no iatrogenic radial nerve palsy. Therefore, we considered that the reason was the limitation of the posterior approach. A lateral paratricipital approach is beneficial to improve mobilisation and for protection of the radial nerve from the level of the lateral intermuscular septum through the spiral groove (Fig. 4). But the exploration of the radial nerve in the posterior approach is difficult due to its anatomical course and because it limits mobility [7,19,20]. The rate of implant-related complications using the posterior approach has been reported to be 10.5–38.8% [10,24,25], and the 7.69% (2/26) rate in our study using the posterior approach was relatively lower. However, the rate was still higher than the patients who were operated by the lateral approach in our study. We thought that the different
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
4
Fig. 3. The patient in Fig. 2 showed an excellent functional range of movement at 1 year after operation. (A) Flexion. (B) Extension.
Table 3 Comparison of clinical outcomes between two groups. Indices
Group I
Group II
P-value
Bone union time (months) Range of elbow flexion (8) Range of elbow extension (8) MEPS (points)
12.87 1.852 139.20 3.274 4.77 1.906 87.00 7.724
12.96 2.218 137.85 4.076 5.15 2.327 86.15 7.656
0.862 0.174 0.497 0.683
positions of the plates might be the main reason causing the implant-related complications. The plates were placed in a nearer position to the elbow joint using the posterior approach compared to the lateral approach. In addition, one patient (3.85%) suffered a triceps rupture in our study using a posterior approach. The complication could be avoided by splitting the triceps belly meticulously. In our experience, the radial nerve is easily explored through the lateral approach, which protects the radial nerve and decreases the incidence of iatrogenic injury. The anterior and lateral surfaces of the humerus are accessible by the lateral approach, and this approach is extensile both proximally and distally, which contributes to fixing the plate through direct visualisation. However, in order to get better attachment, the plate is usually
Fig. 4. Lateral approach used in all cases of group I. Radial nerve was identified in the gap between brachialis and brachioradialis and was protected by a rubber band.
precontoured by the lateral approach due to the 20–308 intorsion in the junction between the middle and distal humeral shaft. Besides, the location of the plates is usually influenced by deltoid tuberosity using the lateral approach, and the exposure extent of distal humeral is relatively limited compared to the posterior approach. We think that the lateral approach is more suitable for high extra-articular distal humeral shaft fractures. The posterior approach causes more iatrogenic radial nerve palsy due to its anatomical course and it limits mobility, but the injured radial nerve usually recovers completely within 3 months, so the permanent radial nerve injury would not occur through the posterior approach as long as we pay more attention to protect the radial nerve. If the fracture extends to the middle humeral shaft, the lateral head of the triceps will be elevated laterally and then the radial nerve will be elevated in a superior direction in order to protect the radial nerve, as described by Gerwin [20]. We can make an adequate exposure for the distal humerus by the posterior approach, so more screws can be placed in a position nearer to the elbow joint to achieve rigid fixation, and we often need not precountour the plate due to the flat posterior surface of the distal humerus. We recognise that the approach is more suitable for low extra-articular distal humeral shaft fractures. Both lateral and posterior surgical approaches have respective advantages and disadvantages. Therefore, we should choose a surgical approach for extra-articular distal humeral shaft fractures based on specific conditions of the patient, such as fracture pattern, associated softtissue injury, fixation pattern and surgeon preference and experience, and we also should pay attention to make full preparations for the surgery. To the best of our knowledge, this is the first comparative study about lateral and posterior approaches in the management of extra-articular distal humeral shaft fractures. A number of data on the characteristics of patients, treatment results and complication rates were reported in our study. However, certain limitations need be addressed. Our study is retrospective in nature and the number of patients is relatively small. All operations were performed by three senior orthopaedic surgeons who perhaps have a preference in their surgical approach. Moreover, the pressure on the overlying skin was attributed to implant irritation in our study; however, the reason may be multifactorial. More prospective randomised controlled trials are needed to overcome the limitations of our study.
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
G Model
JINJ-5664; No. of Pages 5 P. Yin et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
In conclusion, the present results showed that both lateral and posterior surgical approaches acquired satisfied treatment results in the management of extra-articular distal humeral shaft fractures, and there was a lower complication rate using the lateral approach.
[11] [12]
[13]
Conflict of interest Each author certifies that he/she has no commercial associations that might pose a conflict of interest with the submitted article. References
[14]
[15]
[16] [17]
[1] Ekholm R, Adami J, Tidermark J, Hansson K, Tornkvist H, Ponzer S. Fractures of the shaft of the humerus – an epidemiological study of 401 fractures. J Bone Joint Surg Br 2006;88B:1469–73. [2] Mahabier KC, Vogels LM, Punt BJ, Roukema GR, Patka P, Van Lieshout EM. Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients. Injury 2013;44:427–30. [3] Chen F, Wang Z, Bhattacharyya T. Outcomes of nails versus plates for humeral shaft fractures: a Medicare Cohort Study. J Orthop Trauma 2013;27:68–72. [4] Livani B, Belangero WD, Castro de Medeiros R. Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimallyinvasive percutaneous plate osteosynthesis. J Bone Joint Surg Br 2006;88:1625–8. [5] Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT. Functional bracing for comminuted extra-articular fractures of the distal third of the humerus. J Bone Joint Surg Br 1990;72:283–7. [6] Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular distal-third diaphyseal fractures of the humerus: a comparison of functional bracing and plate fixation. J Bone Joint Surg 2006;88:2343–7. [7] Lee TJ, Kwon DG, Na SI, Cha SD. Modified combined approach for distal humerus shaft fracture: anterolateral and lateral bimodal approach. Clin Orthop Surg 2013;5:209–15. [8] BR. Distal diaphyseal fracture of the humerus. Tech Orthop 2003;18:360–7. [9] Niall D, O’Mahony J, McElwain J. Plating of humeral shaft fractures—has the pendulum swung back? Injury 2004;35:580–6. [10] Yang Q, Wang F, Wang Q, Gao W, Huang J, Wu X, et al. Surgical treatment of adult extra-articular distal humeral diaphyseal fractures using an oblique
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
5
metaphyseal locking compression plate via a posterior approach. Med Prin Pract 2011;21:40–5. Levy JC, Kalandiak SP, Hutson JJ, Zych G. An alternative method of osteosynthesis for distal humeral shaft fractures. J Orthop Trauma 2005;19:43–7. Putti AB, Uppin RB, Putti BB. Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures. J Orthop Surg (Hong Kong) 2009;17:139–41. Zlotolow DA, Catalano III LW, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;14:754–65. Hannouche D, Ballis R, Raould A, Nizard R, Masquelet A. A lateral approach to the distal humerus following identification of the cutaneous branches of the radial nerve. J Bone Joint Surg Br 2009;91:552–6. O’Toole RV, Andersen RC, Vesnovsky O, Alexander M, Topoleski LD, Nascone JW, et al. Are locking screws advantageous with plate fixation of humeral shaft fractures? A biomechanical analysis of synthetic and cadaveric bone. J Orthop Trauma 2008;22:709–15. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma 1996;10:81–6. Singisetti K, Ambedkar M. Nailing versus plating in humerus shaft fractures: a prospective comparative study. Int Orthop 2010;34:571–6. Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. Int Orthop 2007;31:391–5. Dabezies E, Banta 2nd C, Murphy C, d’Ambrosia R. Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop Trauma 1992;6:10. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis. With reference to the radial nerve. J Bone Joint Surg 1996;78:1690–5. Lan X, Zhang LH, Tao S, Zhang Q, Liang XD, Yuan BT, et al. Comparative study of perpendicular versus parallel double plating methods for type C distal humeral fractures. Chin Med J 2013;126:2337–42. Clavert P, Ducrot G, Sirveaux F, Fabre T, Mansat P. Outcomes of distal humerus fractures in patients above 65 years of age treated by plate fixation. Orthop Traumatol Surg Res 2013. Gupta RK, Gupta V, Marak DR. Locking plates in distal humerus fractures: study of 43 patients. Chin J Traumatol Zhonghua chuang shang za zhi/Chin Med Assoc2013;16:207–11. Meloy GM, Mormino MA, Siska PA, Tarkin IS. A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: single-column plating. Injury 2013;44:1620–4. Celli A, Donini MT, Minervini C. The use of pre-contoured plates in the treatment of C2–C3 fractures of the distal humerus: clinical experience. La Chirurgia degli organi di movimento 2008;91:57–64.
Please cite this article in press as: Yin P, et al. Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.02.034
