Injury, Int. J. Care Injured 33 (2002) 511–515

Intercondylar fractures of the distal humerus in adults:a critical analysis of 55 cases

Rakesh Gupta∗, Prakash KhanchandaniDepartment of Orthopaedics, Postgraduate Institute of Medical Sciences, 42/9 J Medical Enclave, Rohtak 124001, India

Accepted 20 September 2001

Abstract

Intercondylar fractures of the distal humerus in adults are difficult management problems on account of the complex anatomy of the elbow,small sized fracture fragments and the limited amount of sub-chondral bone, which is often osteopenic. The results of managing these frac-tures non-operatively are compromised by the failure to get anatomical reduction and early mobilization. This often results in a painful stiffelbow and/or pseudarthrosis, thereby making an operative approach for these fractures, desirable. Fifty-five such fractures, operated on by theauthor during the last 9 years, were reviewed. All the fractures were managed by open reduction and internal fixation followed by early mobi-lization. The outcome in 51 of these cases was graded as excellent or good using the evaluation criteria of Aitken and Rorabeck. Thirty-threeof these cases achieved a range of flexion of more than 130◦. There was minimal incidence of complications like ulnar nerve neuropraxia orheterotopic bone formation. Anterior transposition of the ulnar nerve was performed in only one of the patients. Dorsal application of boththe plates instead of the commonly advocated supracondylar crest placement resulted in a stable configuration requiring less extensive dis-section and retraction of the ulnar nerve and resulting in a low incidence of complications. © 2002 Elsevier Science Ltd. All rights reserved.

1. Introduction

Intercondylar fractures of the distal humerus in adults con-stitute a small percentage of fractures. These fractures areoften difficult to treat with an uncertain outcome. Recom-mended management in the literature varies considerably,ranging from plaster of Paris (POP) cast immobilization ortreatment as a bag of bones, to fully invasive open reductionand internal fixation[1–8]. Non-operative management ofthese fractures may lead to either a pseudarthrosis with grossinstability or a painful stiff elbow[7–9]. Moreover, accuratereconstruction of the articular surface is not always possibleby closed methods. As a result, many now favor open re-duction and internal fixation, although to obtain acceptableresults, it has to be followed by early mobilization of theelbow [1–3,5,6,9,10]. Authors recommending an operativeapproach differ widely in respect to the extent and type ofinternal fixation. In addition most of the authors advocatinginternal fixation propose placement of plates on the supra-condylar crest and have reported a significant incidence ofhetrotopic ossification and ulnar nerve involvement[10–12].

The present study analyses the long term results of theauthor’s experience of operative management of these frac-tures and attempts to address these problems.

∗ Corresponding author. Tel.:+91-1262-44799.E-mail address: gupta3@vsnl.com (R. Gupta).

2. Material and methods

Fifty-five patients with intercondylar fractures of the distalhumerus in adults operated on by the first author during1992–2000 and available for follow up, were reviewed. Theseries included long term follow up of 20 such cases reportedearlier by the author[13].

Fall on the point of the elbow was the most commonmode of trauma followed by road traffic crashes. Twelveof the patients had associated injuries elsewhere, includingadditional ipsilateral upper limb trauma (five patients). Therewere 37 males and 18 females and the average age of thepatients was 39 years (range 18–65 years). Six of the patientshad compound injuries of Gustilo type 1 (three patients) ortype 2 (three patients)[14].

As per Muller et al.[15] classification, 18 fractures wereof C1 type, 23 of C2 and the remaining 14 of C3 type. Twoof the patients had an additional dislocation of the medialcondyle from the olecranon notch of ulna. All but six ofthe patients were operated on within 7 days of injury. De-lay in surgery usually resulted from late presentation of thepatients though in some of the cases it was due to associ-ated injuries. One patient presented 8 months after injury,with pseudarthrosis and gross instability at the fracture site,demonstrating failed conservative treatment.

All the patients were operated on, in the lateral decubitusposition with the forearm hanging by the side over a sand

0020-1383/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved.PII: S0020-1383(02)00009-8

512 R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515

Fig. 1. Pre-operative radiograph.

bag, placed against the patient’s chest. A posterior midlineapproach to the elbow was used and the ulnar nerve wasexposed in all the cases. In 42 of the patients, an inverted“v” shaped triceps aponeurosis flap was reflected distally toexpose the fracture site. In the remaining 13, a transverse orchevron osteotomy of the olecranon was performed to reflecttriceps proximally. Holes were drilled in the ulna, prior tothe osteotomy, for subsequent tension band wiring.

A five hole 3.5 mm DCP/reconstruction plate was con-toured in both planes to fit the posterior flat surface of thedistal humerus and was used as a basic implant. It was usedto stabilize the larger of the articular fragments to the cor-responding pillar. The remaining articular fragments wereeither fixed to the other pillar or to the already reconstructedpillar or both, as determined by the assessment of stability.This was achieved by either an additional 3.5 mm plate (46cases) on the posterior flat surface of distal humerus orscrew fixation (8 cases). Fixation was supplemented with anadditional transcondylar screw to enhance stability, partic-ularly in the C3 type of fractures (Figs. 1 and 2). In one ofthe patients, the fracture was stabilized by multiple screwsonly. Special attention was paid to ensure proper reconstruc-tion of the trochlear component and the adequacy of the

Fig. 2. Final radiograph showing consolidation.

olecranon fossa. Stability of the reconstruction was con-firmed per-operatively by looking for any movement inbetween the fragments. The olecranon osteotomy was stabi-lized with a tension band wire supplemented with K-wires(seven cases) or a 6.5 mm cancellous lag screw (six cases).A suction drain and a POP back slab were used in all thepatients.

Active mobilization of the elbow was permitted from thefirst post-operative day, after breaking the POP slab at theelbow. The slab was discarded after 2–3 weeks dependingupon the fracture anatomy, the stability of fixation and theclinical progress of the patient. Subsequently, the patientswere subjected to extensive active physiotherapy of the el-bow. Patients were examined clinically and radiologicallywith regard to pain, activities of daily living, range of motionand fracture union. In addition, any deficit of ulnar nervefunction, whether early or late and evidence of secondaryosteoarthritis, were specifically looked into. Maximum fol-low up was 9 years with an average of 4 years.

3. Results

All the fractures including osteotomies of the olecranonhealed by 10–12 weeks. Full extension could be achievedin 15 of the patients, though loss of the last 5◦ of flexionwas observed in 20 other patients (Table 1). No limitationof supination or pronation of the forearm was observed inany patient. Regaining elbow function was observed to berelated to the stability of the fixation and to the extent ofphysiotherapy performed by the patients. The final outcomewas observed to be better in younger patients, although itwas probably more on account of their better physiotherapyrecord rather than their chronological age.

The results were evaluated using the criteria of Aitkenand Rorabeck[9] (Table 2). The final result was graded asexcellent in 41 patients with an arc of flexion >110◦ and nopain or disability. In 10 of the patients, it was graded as good.Four patients had an unacceptable (fair or poor) outcomewith an arc of flexion at elbow being<60◦ in two and >60◦in the other two. The range of motion of the elbow movementwas observed to improve up to 2 years following injury, butthe majority of this occurred in the first 12 months. Onepatient with significant heterotopic ossification was gradedas fair with a limited range of motion at the elbow (<75◦).

Table 1Range of motion at elbow

Range offlexion (◦)

Numberof cases

Extensionloss (◦)

Numberof cases

>130 33 Nil 15110–130 9 <5 2075–110 9 5–10 1560–75 2 10–15 2<60 2 >15 3

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Table 2Evaluation criteria (Aitken and Rorabeck[9])

Arc offlexion (◦)

Activity Pain

AcceptableExcellent 110 No limitation NoneGood 75 Activities of daily

livingMinimal

UnacceptableFair >60 Activities of daily

livingMild occasionalanalgesic

Poor <60 Arm used as a prop Constant

He was able to perform most of his activities of daily living.One of the two patients with poor grading had pre-operativepseudarthrosis while the other one had post-operative deepinfection, though both had no pain and some useful functioncould be performed by the limb.

The complications included ulnar nerve paraesthesias inthree patients, in the immediate post-operative period, whichdisappeared spontaneously by the third week. However, nolate ulnar nerve paraesthesias/deficit was observed in anyof the patients. None of the patients had any clinical or ra-diological evidence of secondary osteoarthritis in spite oflong term follow up of the majority of cases. Two patientshad early deep infection requiring the removal of implantsafter healing of the fracture. One of these had a grade 2compound fracture while the other one had associated frac-tures of the ipsilateral shaft of the humerus and ulna whichwere operated on simultaneously. Another patient had latelocal superficial infection due to scar breakdown at the siteof tension band wiring of olecranon, which healed after re-moval of the implants. Proximal migration of the K-wireswas seen in four of the patients and this necessitated theirremoval. Failure of fixation was not observed in any of thepatients, though one of the patients had late implant failurein the form of a broken one-third tubular plate which hadbeen used as a second plate in one of the cases instead ofthe usual 3.5 mm reconstruction plate. Three patients devel-oped heterotopic ossification around the elbow. In two ofthese patients, it was clinically not significant in view ofthe fact that it did not interfere markedly with the range ofmotion. The only patient with significant heterotopic ossi-fication was an elderly male with a severely comminutedfracture and significant soft tissue trauma. One patient had aclinically apparent cubitus varus deformity but without anyinterference in elbow function. No significant loss of powerin the triceps was observed in any of our patients.

4. Discussion

Intercondylar fractures of the distal humerus in adultsare difficult to treat because of the nature of injury. Thenon-operative approach to these fractures can neither ensure

good reconstruction of the articular surface nor permit earlymobilization of the elbow, key factors in achieving goodfunction. Operative management of these fractures has beencriticized in literature for additional surgical trauma and in-herent difficulty in securing stable fixation of small frag-ments. Consensus, though, is gradually building for surgicalstabilization of these fractures, largely as a consequence ofsignificant advances in surgical technique and implants dur-ing the last decade ensuring a stable osteosynthesis of smallintra-articular fragments.

Lateral position of the patient with his arm hanging by theside not only gives convenient patient access to the anaes-thetist but is also comfortable for the surgeon. Moreover,flexion of the elbow in this position was observed to give agood view of the articular surface of the distal humerus. Thisis confirmed by the fact that the intercondylar screws couldbe easily passed, in a number of patients in the present se-ries, without olecranon osteotomy. It may possibly also de-crease the need for an olecranon osteotomy for stabilizationof these fractures. An intact olecranon can act as a mouldover which reconstruction of distal humerus is easy withthe additional advantage of avoiding the creation of an ad-ditional intra-articular fracture. However, the authors are inagreement with Jupiter et al., that the trans-olecranon ap-proach offers excellent exposure for reconstruction of the ar-ticular surface especially in type C3 fractures[5]. Proximalmigration of K-wires was observed in four of the patients,where they were used for the stabilization of the osteotomy.The study reinforces the views expressed by Henley regard-ing the desirability of the use of 6.5 mm cancellous screwsinstead of K-wires for stabilization of the osteotomy, wher-ever it is performed[1].

Early active mobilization of the elbow has been univer-sally accepted as a ground rule to ensure an acceptable out-come[1–3,5,9]. It is reaffirmed by the present study, as anexcellent range of motion was achieved in all patients whereearly mobilization was possible due to stable internal fixa-tion. In fact, all patients with a lesser range of motion wereeither old patients or with a poor post-operative physiother-apy record, quite often on account of associated injuries.Some loss of extension at the elbow was observed in 40 ofour patients, which is similar to that reported by Sanderset al.[6]. The authors are of the opinion that an accurate re-construction with special emphasis on adequacy of the ole-cranon fossa is desirable to ensure minimal loss of extension.

A general perusal of literature regarding internal fixationof these fractures indicates a reasonably high incidence ofulnar nerve neuropraxia[10–12], so much so that Ring andJupiter[2] and Wang et al.[16] have advocated routine an-terior transposition of ulnar nerve in such cases. In addi-tion some of the authors have also indicated an incidenceof heterotopic ossification ranging from 4 to 49%, thoughmost of these reports have not commented upon the extentof heterotopic ossification encountered or its clinical signif-icance[1,3,10,17]. The majority of these authors have ad-vocated the posterior midline approach with supracondylar

514 R. Gupta, P. Khanchandani / Injury, Int. J. Care Injured 33 (2002) 511–515

Fig. 3. Illustration showing exposure and placement of plates on posteriorsurface of humerus.

crest placement of plates, ostensibly for more secure fixation[6,8,10,12,16,18]. However, it is apparent that the combina-tion of this approach and anatomical location of plates onsupracondylar crests, requires an extensive dissection andretraction of the triceps and brachialis muscles besides sig-nificant retraction of the ulnar nerve. The placement of bothplates on the posterior flat surface of the humerus, which isdirectly under vision by a posterior approach neither requiresextensive dissection nor significant retraction of the ulnarnerve (Fig. 3), thereby, decreasing the incidence of both ul-nar nerve neuropraxia or heterotopic ossification, as was ob-served in the present series. The only instance of significantheterotopic ossification observed in the present series wasmore on account of the severe nature of the pre-operativesoft tissue trauma rather than surgical dissection. We are ofthe opinion that the placement of both plates on the poste-rior flat surface of humerus after suitable contouring causesless irritation of the ulnar nerve, compared to the sharp edgeof the plate placed on the supracondylar crest. Moreover,zero incidence of fixation loss does indicate that posteriorplacement of both plates results in a equally stable fixation,which has been advocated as the main reason for the supra-condylar crest placement of the plates. Interposition of tri-ceps between the plate and the ulnar nerve takes care of anypossible late irritation of the nerve also. This is suggested bythe fact that no late ulnar nerve symptoms were observed inany of our patients in spite of long follow up. However, weare in complete agreement with Ring and Jupiter that wher-ever, per-operative assessment indicates a compromised ul-nar nerve, it should definitely be transposed anteriorly[2].

Our only experience of implant failure was with aone-third tubular plate and it corroborates the views ex-pressed by Henley[1] and Holdsworth and Mossad[18] thatthese plates are not strong enough and should be replacedwith 3.5 mm reconstruction/DC plate for stabilization ofthese fractures.

The rating system of Aitken and Rorabeck was used inthis study for the final outcome as it takes into considerationadditional features like pain and the activity level with therange of motion at the elbow[9]. Overall 93% of the pa-tients had acceptable results (41 excellent, 10 good) whichreinforces the desirability of an operative approach to thesefractures and compares favorably with the reports in theliterature [1,5,6]. A high percentage of acceptable resultscan probably be attributed to early open reduction, stableinternal fixation and early post-operative mobilization ofthe elbow. The age group in the present series was relativelyyounger, with a good bone stock and this may have been thereason for a lack of fixation failures and the higher percent-age of acceptable results. Kinik et al.[12] and Holdsworthand Mossad[18] have also indicated that old age is nocontraindication for surgical management of these fracturesand the final outcome is more dependent on the qualityof bone rather than the chronological age of the patient.The authors are in agreement with Sodegard et al.[11] andKuntz Jr. and Baratz[17] that the results are likely to beless gratifying if only elderly patients with poor bone stockare considered.

The present study therefore reaffirms that early openreduction and stable internal fixation followed by earlymobilization of elbow is the treatment of choice for thesecomplex fractures. Posterior placement of both the platesprovides an adequately stable fixation and requires less ex-tensive dissection or retraction of the ulnar nerve, thereby,decreasing the incidence of two of the most commonlyreported complication namely ulnar nerve neuropraxia andheterotopic ossification.

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