Outcomes of Intra-articular Distal Humerus Open Reduction and Internal Fixation Based on Severity of Articular Comminution.
Academic Article
Overview
abstract
BACKGROUND: The advent of modern, precontoured locking plates has improved treatment of distal humerus fractures (DHFs) by providing an anatomic fit and a reliable locking mechanism with interdigitating screws. However, severe articular comminution may predispose surgical failure despite anatomic reduction and a biomechanically strong construct. METHODS: A retrospective review was performed to identify patients who underwent distal humerus open reduction internal fixation (ORIF) between 2015 and 2020. Fractures were classified using the AO/OTA classification and further categorized by anatomic location and number of fragments on preoperative imaging. Articular comminution was defined as the number of articular fracture fragments ≥1.5cm and stratified as high (>= 5 fragments) and low (<5 fragments) comminution. Outcomes included elbow range of motion, quick Disabilities of the Arm, Shoulder, and Hand (qDASH), and Mayo Elbow Performance Score (MEPS). Complications were classified as major or minor based on the need for reconstructive reoperation. Outcomes and complications between high and low comminution DHFs were compared using Student's t-test and Fisher's exact test. RESULTS: The study cohort consisted of 51 patients, 38 female (75%) and 13 male (25%), with an average age of 63.3 years. Fracture types included 9 AO/OTA type A, 7 type B, and 35 type C. At a mean follow-up of 47 months, the mean arc of motion in the high comminution group was 104° versus 109° in the low comminution group (p=0.595). The mean MEPS was 79 versus 88 (p=0.376) and mean qDASH score was 29 versus 19 (p=0.219) in the high comminution and low comminution groups respectively. Among the intra-articular fractures, patients with high comminution fractures experienced significantly more major complications (87.5% vs. 16.3%, p<0.001) and overall complications (87.5% versus 30.2%, p=0.001) compared with those in the low comminution group. Major complications in the high comminution group included bone resorption with conversion to arthroplasty and radical contracture releases with heterotopic ossification excision. Major complications in the low comminution group included nonunion, elbow contractures, deep infection, and bone resorption with implant failure. All highly comminuted fractures achieved satisfactory reduction with parallel plate fixation. Final qDASH and MEPS scores were not affected by comminution severity, although a significantly higher proportion of patients required revision surgery in the high comminution group. CONCLUSION: Precontoured locking plates provide reliable fixation for intra-articular DHFs. However, severe articular comminution is associated with complications resulting in major reconstructive reoperations, even with satisfactory fixation. Despite this, conversion to total elbow arthroplasty remains low.
