Treatment results for open comminuted distal humerus intra-articuler fractures with Ilizarov circular external fixator

Military Medicine, Sep 2003 by Komurcu, Mahmut, Yanmis, Ibrahim, Atesalp, A Sabri, Gur, Ethem

In open, intra-articular distal humerus fracture caused by gunshot injury, full functional recovery is difficult to obtain. Three basic treatment methods are available: minimal internal fixation, open reduction-internal fixation, and external fixation. In Gulhane Military Medical Academy Department of Orthopedics and Traumatology, 19 of 20 cases of gunshot injuries were treated with circular external fixator between the January 1995 and December 2000. Nine (45%) cases were type III-A, eight (40%) were type III-B, and three (15%) were type III-C. Eight (40%) cases were brought to the hospital 6 to 8 hours after the injury and 12 (60%) were in late stage. An amputation was done in one case. Mean follow-up period was 34.3 (14-55) months. Union was achieved in all 19 of the cases, and circular external fixator was taken out in a mean period of 4.6 (3-7) months. In the early treatment group, three (42.9%) were good, three (42.9%) were moderate, and one (14.2%) was unsatisfactory. In the late treatment group, five (41.7%) were good, four (33.3) were moderate, and three (25%) were unsatisfactory. Circular external fixator can be preferred as a treatment alternative in selected cases of distal humerus intra-articular open communited fractures because it protects the soft tissue connections and blood circulation of bone fractured, permits early elbow movements, and allows the patient to return to daily life very early.

Introduction

Open fractures are fractures in which the wounds attributable to trauma of the skin and the subcutaneous tissue are in direct contact with the fracture and the hematoma. Fractures due to high-energy gunshot injuries (GSI) are considered as type III according to Gustillo-Andersen.1,2 Distal humerus open, intra-articular fractures are difficult to treat, have unsatisfactory outcomes clinically, and they bring forth economical, psychological, and social problems to the patient; there are also difficulties for the orthopedists. The kinetic energy and ballistic effect of the shooting make the fractures even more difficult in this region. There are various alternatives in the treatment of the distal open and communited fractures such as minimal internal fixation, open reduction and internal fixation (ORIF), and external fixation.3-7

In this study, we discussed our treatment results with circular external fixator (CEF) in open communited intra-articular distal humerus fractures in GSI along with the literature review.

Materials and Methods

Nineteen of 20 cases with communited open, distal humerus intra-articular fractures caused by GSI were treated in the Gulhane Military Medical Academy Department of Orthopedics and Traumatology between January 1995 and December 2000 with CEF. All of the cases were males. The mean age was 22 (range, 19-36) years. Nine (45%) were type III-A, eight (40%) were type III-B, and three (15%) were type III-C according to the classification of Gustillo-Andersen (Table I).

Eight (40%) of 20 cases were brought to the hospital within 6 to 8 hours after the injury, and 12 (60%) of them were brought in the late period. In all of the eight cases that were brought in the early period, vascular structures were assessed with angiography. Parenteral antibiotic therapy was started in all of the cases with first generation cephalosporin (2x 1 g) and it was continued for 5 days. This group was assessed according to Mangled Extremity Severity Score (MESS).1,3 Extremity-protective surgical treatments were planned for the cases in which the score was 6 and lower.3,5 We performed emergent wound washing, excision of the dead soft tissue, debridement, removal of the small nonviable bone fragments, and soft tissue repair under general anesthesia to the patients. Primary repair was performed in all cases, whereas local flaps were used in one case and skin grafts in two cases for the wounds. CEF was applied to all of the cases in the same operation. In two cases, the tissues with doubtful liveliness were preserved, and debridement was repeated after 24 hours. There was ulnar nerve injury in one case, and it was repaired with primary epineural. Brachial artery and vein repair was performed in two cases with vascular injury. Amputation had to be performed in one case with vascular injury and wide tissue defect, and the MESS score was 8. Twelve (60%) cases were brought in the late period between 20 hours and 12 days, as indicated in Table I. We performed wound washing, excision of the dead soft tissue, and removal of the small nonviable bone fragments. Minimal internal fixation implants were removed in seven cases in which they were operated on before at another medical center. There was radial nerve injury in two cases and ulnar nerve injury in one case. Delayed primary repair was applied to those nerves.

CEF frames with three levels were applied to the patients. Frames were constructed with 5/8 rings on the one-third distal of the humerus (fracture side), one ring on the one-third middle of humerus, and one ring proximal of humerus. Two 1.2-mm K-wires with olive passed with positions medially and laterally oblique with respect to each other in the condylar region. Large fragments in the supracondylar region were reduced with two K-wires with olive. This wire was connected to the % ring with the help of straight plates. Two 1.5-mm K-wires were passed through the middle ring in the medial and lateral oblique positions. Another two 1.5-mm K-wires were passed through the proximal ring in the medial and lateral oblique positions. Sometimes one 4-mm threaded Steinmann pin in the distal and one in proximal of the proximal ring were placed in oblique positions and were fixed to the ring with single-threaded Steinmann pin holders.