Unipolar Latissimus Dorsi Transfer for Restoration of Elbow Flexion in Residual Post-traumatic Brachial Plexus Palsy Associated with Distal Humeral Fractures

Introduction Elbow flexion is indispensable for both functioning and nonfunctioning hands. It is well perceived that restoration of elbow function is the first reconstructive priority in cases of brachial plexus injuries. The authors assessed the impact of associated distal humeral fractures on the functional outcome after unipolar latissimus dorsi transfer (ULDT) for restoration of elbow flexion in patients with residual brachial plexus palsy (BPP). Patients and Methods Twenty-three patients operated for restoring elbow flexion after residual post-traumatic BPP (with or without distal humeral fracture) by unipolar latissimus dorsi transfer (ULDT) were reviewed for a retrospective study. Patients were divided into two groups; associated distal humeral fracture group (HF-group; 10 patients) and non-associated distal humeral fracture group (NHF-group; 13 patients). Elbow flexion active range of motion (AROM), flexion deformity in addition to Mayo Elbow Performance Score (MEPS) were assessed. Results In both groups there were statistically better postoperative MEPS grading (p = 0.007, p = 0.001, respectively) and scoring with a mean of 81 ± 16.1 and 90 ± 4.6, respectively (p < 0.001). The mean postoperative elbow flexion AROM was statistically better in both groups. The mean supination AROM was better in NHF group (p = 0.057). Conclusion The use of ULDT in residual post-traumatic BPP is an efficient procedure in regaining functional flexion and supination. An associated distal humeral fracture does not significantly affect the final functional outcome. Level of Evidence Level IV.

The Relationship between Plate and Screw to Ulnar Nerve in Distal Humeral Fracture: A Cadaveric Study

Background: Plate and screw fixation during the treatment of distal humeral fracture in adults is considered to be a gold standard that makes anatomic and articular reduction. Injury of the ulnar nerve is a common condition that can be found in pre-operative, intraoperative, and postoperative. Intraoperative anterior subcutaneous transposition is still a controversial issue. Objective: To understand the variation of distance of the ulnar nerve during elbow motion with the anatomical landmark of distal humeral bone and plate position after fixation. Materials and Methods: The authors have studied ten fresh adult cadavers, who underwent autopsy at the Department of Forensic Medicine of Srinakharinwirot University. Results: The results showed that in zone 2, the Center of the medial condyle was the position of the distal humeral bone with the most variation in position changing during elbow flexion/extension. In the sagittal plane (+2.56 to –4.58 mm), the mean difference equaled to 7.14 mm, while in the coronal plane (+1.70 to –5.14 mm), the mean difference equaled to 6.84 mm, with the highest percentage of irritation up to 70%. Furthermore, 14 cases of ulnar nerve subluxation were found in 20 studies (70%). Conclusion: From the present study, the Medial condyle was the landmark with the most irritation and position changing of ulnar nerve during elbow flexion. The incidence of ulnar subluxation occurred after in situ release for plate fixation was also found higher than in previous studies. Keywords: Plate and screw fixation; Ulnar nerve injury; Distal humeral fracture; Anterior subcutaneous nerve transposition; Cadaveric study; Anatomical bony landmark of distal humeral bone; Ulnar nerve subluxation

Chronic type C3 distal humeral fracture associated with massive bone defects treated by open reduction and internal fixation with iliac crest autografts: a case report

Background Chronic intercondylar fractures of the distal humerus with massive bone defects and severe comminution in the metaphysis are rare and complex injuries that are challenging for surgeons to treat, as reconstructing the triangular structure of the distal humerus is difficult and may have a severe impact on functional outcomes, especially in young patients, for whom total elbow arthroplasty is usually not a suitable option due to significant impairment in upper limb strength. Here, we report a patient in such scenario who was young and active and was treated by structural iliac bone autografting and internal fixation. Case presentation A 26-year-old male patient experienced a major car accident and was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus with massive bone defects and severe intra-articular involvement, without neurovascular injuries or other associated injuries. Surgical debridement, negative pressure vacuum sealing drainage, and immobilization by braces were initially performed, and the wound was closed after 15 days. When the wound had finally healed and the soft tissue was in good condition without infection or effusion 45 days later, this young and active patient was diagnosed with a chronic type C3 distal humeral fracture associated with massive bone defects at the supracondylar level in both columns and severe comminution at the trochlear groove. We performed surgical debridement and arthrolysis around the fracture site, and then, we successfully reconstructed the triangular structure of the distal humerus using structural iliac crest autografts in both columns as well as in the defective trochlear groove. Finally, internal fixation via a parallel double-plate configuration was performed. Over a follow-up period of 3 years, the patient achieved almost full recovery of range of motion and an excellent functional score, without minor or major postoperative complications. Conclusion In this study, we proposed a surgical reconstruction strategy for complex chronic distal humeral fractures associated with massive bone defects and severe articular involvement in young and active patients using metaphyseal shortening and structural iliac crest bone autografting together with open reduction and internal fixation via a parallel configuration.

To determine frequency of union with orthogonal double locking plate in distal humeral fracture.

Objectives: To determine frequency of union with orthogonal double locking plate in distal humeral fracture. Study Design: Descriptive, case series. Setting: Orthopedic department Punjab Medical College. Period: From April 2, 2017 to October, 2017. Material & Methods: 75 consecutive patients with distal humeral fractures were managed by open reduction of internal fixation with double locking plates in orthogonal configuration. Radiographic evaluation was done to see the callus formation after 12 weeks of treatment. Results: There were 54 (72%) males and 21 (28%) female patients having the average age 43.5±15.9 years. Union was seen in 71 (94.7%) patients. In 4 (5.3%) patients there was non-union. Conclusion: Anatomically pre-contoured distal humeral locking plates are useful in providing stable internal fixation for complex distal articular fractures, and hence allowing early rehabilitation.