JBJS | Functional Outcome Following Surgical Treatment of Intra-Articular Distal Humeral Fractures Through a Posterior Approach*

The Journal of Bone & Joint Surgery, Volume 82, Issue 12

Articles | December 01, 2000

Functional Outcome Following Surgical Treatment of Intra-Articular Distal Humeral Fractures Through a Posterior Approach*

Michael D. McKee, M.D., F.R.C.S.(C)†; Tracy L. Wilson, M.D., F.R.C.S.(C)†; Lucy Winston, B.Sc.(OT), C.H.T.†; Emil H. Schemitsch, M.D., F.R.C.S.(C)†; Robin R. Richards, M.D., F.R.C.S.(C)†

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Investigation performed at St. Michael's Hospital and the Toronto East General Hospital, University of Toronto, Toronto, Ontario, Canada
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Upper Extremity Reconstructive Service (M. D. McK., T. L. W., L. W., and R. R. R.) and Division of Orthopaedics (E. H. S.), St. Michael's Hospital and the University of Toronto, Suite 800, 55 Queen Street East, Toronto, Ontario M5C 1R6, Canada. E-mail address for M. D. McKee: mckee@the-wire.com.

The Journal of Bone & Joint Surgery. 2000; 82:1701-1701

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Abstract

Background: While surgical repair is considered the standard of care of displaced intra-articular distal humeral fractures, most investigators have assessed its results with use of surgeon-based and/or radiograph-based outcome measures. The purpose of our study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with use of a standardized evaluation methodology consisting of objective testing of muscle strength and use of patient-based questionnaires (both limb-specific and general health-status questionnaires).

Methods: We identified twenty-five patients (fourteen male and eleven female), with a mean age of forty-seven years, who had an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus repaired operatively through a posterior approach and fixed with plates on both the medial and the lateral column. All patients returned for follow-up that included recording of a complete history, physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing.

Results: The mean duration of follow-up was thirty-seven months (range, eighteen to seventy-five months). The mean flexion contracture was 25 degrees (range, 5 to 65 degrees), and the mean arc of flexion-extension was 108 degrees (range, 55 to 140 degrees). Significant decreases in mean muscle strength compared with that on the normal side were seen in both elbow flexion measured at 90 degrees (74 percent of normal, p = 0.01) and elbow extension measured at 45 degrees (76 percent of normal, p = 0.01), 90 degrees (74 percent of normal, p = 0.01), and 120 degrees (75 percent of normal, p = 0.01). The mean DASH score was 20 points, indicating mild residual impairment. The SF-36 scores revealed minor but significant decreases in the role-physical and physical function scores (p = 0.01 and 0.03, respectively) but no alteration of the mental component or mean scores. Six patients (24 percent) had a reoperation; three of them had removal of prominent hardware used to fix the site of an olecranon osteotomy.

Conclusions: The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Our study quantified a decrease in the range of motion and muscle strength of these patients, which may help to explain the mild residual physical impairment detected by the limb-specific outcome measures and physical function components of the general health-status measures.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The preferred treatment for displaced, intra-articular, intercondylar fractures of the distal part of the humerus is open reduction and internal fixation^{6-11,14,21,25,28} . Adequate exposure is critical for the visualization of the fracture fragments during reduction and fixation, and it is generally agreed that the best exposure of both columns of the distal part of the humerus and the articular surface is achieved through a posterior approach^7,8,10,16,20. This approach requires reflection of the extensor mechanism, typically through a triceps-splitting approach or an olecranon osteotomy.

Although there are numerous studies in the literature detailing the results of surgical fixation, most of them were performed with use of surgeon-based or radiographic outcome measures^9,11,28,30. There may be a great deal of variation among these scores. In addition, patients' evaluations of outcome more closely correlate with functional loss and are often different from the surgeons' assessments of outcome^13,27,29. Patient-based questionnaires have been developed as outcome instruments, and they have been shown to be reliable, valid, and responsive for assessing a variety of orthopaedic conditions^26,27,29.

Similarly, most previously reported measures of the outcome of fixation of intra-articular distal humeral fractures have used subjective measures of muscle strength such as resistance against the examiner's hand^23,27. The accuracy and reproducibility of such measures are questionable. Improved information regarding outcome following this severe injury would help surgeons to make prognoses, evaluate impairment, and compare treatment methods.

Using limb-specific and general health-status questionnaires and objective muscle-strength testing, in addition to standard evaluation, we sought to determine the functional outcome of surgical repair of displaced, intra-articular fractures of the distal part of the humerus.

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Table I: Patient Data

*Muscle strength on both the injured and the control side was measured at maximal extension (70, 55, and 55 degrees) for these three patients.

Case	Gender, Age (yrs.)	Involved Side	Approach	Arc of Motion (degrees)	Muscle Strength (percent of normal side)				DASH Score (points)	Duration of Follow-up (mos.)	Complications
Flexion Strength at 90 Degrees	Extension Strength at 45 Degrees	Extension Strength at 90 Degrees	Extension Strength at 120 Degrees
1	M, 36	Dom.	Triceps-split.	85	79	68	67	72	30	52	None
2	M, 55	Nondom.	Triceps-split.	130	95	100	93	89	0	18	None
3	M, 51	Dom.	Olec. osteot.	90	69	95	73	84	22	38	Ulnar nerve irritation
4	F, 49	Nondom.	Triceps-split.	120	75	95	78	72	18	51	None
5	F, 35	Dom.	Olec. osteot.	125	74	78	65	66	31	42	Wound infection
6	F, 70	Dom.	Triceps-split.	105	67	56	64	78	23	56	None
7	M, 48	Nondom.	Olec. osteot.	55*	18	25	26	29	52	41	None
8	F, 21	Dom.	Triceps-split.	125	75	66	67	80	10	18	Elbow stiffness (release)
9	M, 23	Nondom.	Olec. osteot.	105	94	82	88	78	29	23	None
10	M, 24	Nondom.	Olec. osteot.	95	54	48	66	68	31	25	25-degree varus malunion
11	F, 73	Dom.	Triceps-split.	125	81	81	85	87	9	18	None
12	M, 52	Dom.	Olec. osteot.	120	93	92	86	98	14	49	Tension-band removal
13	F, 37	Nondom.	Triceps-split.	110	94	72	76	80	10	25	None
14	M, 19	Dom.	Triceps-split.	130	93	92	85	69	8	34	None
15	F, 45	Nondom.	Triceps-split.	115	56	78	72	62	28	44	Temp. radial nerve palsy
16	M, 39	Nondom.	Triceps-split.	75*	45	66	65	67	41	34	Nonunion
17	F, 84	Dom.	Olec. osteot.	80*	35	87	84	54	25	51	None
18	M, 44	Nondom.	Olec. osteot.	100	91	83	82	71	15	32	Tension-band removal
19	F, 85	Dom.	Triceps-split.	115	87	84	86	95	21	33	None
20	M, 49	Nondom.	Olec. osteot.	140	72	92	81	89	7	40	Tension-band removal
21	M, 45	Dom.	Triceps-split.	115	92	83	86	93	5	75	None
22	F, 50	Nondom.	Olec. osteot.	95	75	63	69	66	22	24	Ulnar nerve irritation
23	M, 38	Nondom.	Triceps-split.	115	79	75	71	64	29	35	None
24	F, 63	Dom.	Triceps-split.	110	65	55	54	52	7	30	None
25	M, 45	Dom.	Olec. osteot.	125	93	88	77	106	3	34	Elbow stiffness (release)

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Table I: Patient Data

*Muscle strength on both the injured and the control side was measured at maximal extension (70, 55, and 55 degrees) for these three patients.

Case	Gender, Age (yrs.)	Involved Side	Approach	Arc of Motion (degrees)	Muscle Strength (percent of normal side)				DASH Score (points)	Duration of Follow-up (mos.)	Complications
Flexion Strength at 90 Degrees	Extension Strength at 45 Degrees	Extension Strength at 90 Degrees	Extension Strength at 120 Degrees
1	M, 36	Dom.	Triceps-split.	85	79	68	67	72	30	52	None
2	M, 55	Nondom.	Triceps-split.	130	95	100	93	89	0	18	None
3	M, 51	Dom.	Olec. osteot.	90	69	95	73	84	22	38	Ulnar nerve irritation
4	F, 49	Nondom.	Triceps-split.	120	75	95	78	72	18	51	None
5	F, 35	Dom.	Olec. osteot.	125	74	78	65	66	31	42	Wound infection
6	F, 70	Dom.	Triceps-split.	105	67	56	64	78	23	56	None
7	M, 48	Nondom.	Olec. osteot.	55*	18	25	26	29	52	41	None
8	F, 21	Dom.	Triceps-split.	125	75	66	67	80	10	18	Elbow stiffness (release)
9	M, 23	Nondom.	Olec. osteot.	105	94	82	88	78	29	23	None
10	M, 24	Nondom.	Olec. osteot.	95	54	48	66	68	31	25	25-degree varus malunion
11	F, 73	Dom.	Triceps-split.	125	81	81	85	87	9	18	None
12	M, 52	Dom.	Olec. osteot.	120	93	92	86	98	14	49	Tension-band removal
13	F, 37	Nondom.	Triceps-split.	110	94	72	76	80	10	25	None
14	M, 19	Dom.	Triceps-split.	130	93	92	85	69	8	34	None
15	F, 45	Nondom.	Triceps-split.	115	56	78	72	62	28	44	Temp. radial nerve palsy
16	M, 39	Nondom.	Triceps-split.	75*	45	66	65	67	41	34	Nonunion
17	F, 84	Dom.	Olec. osteot.	80*	35	87	84	54	25	51	None
18	M, 44	Nondom.	Olec. osteot.	100	91	83	82	71	15	32	Tension-band removal
19	F, 85	Dom.	Triceps-split.	115	87	84	86	95	21	33	None
20	M, 49	Nondom.	Olec. osteot.	140	72	92	81	89	7	40	Tension-band removal
21	M, 45	Dom.	Triceps-split.	115	92	83	86	93	5	75	None
22	F, 50	Nondom.	Olec. osteot.	95	75	63	69	66	22	24	Ulnar nerve irritation
23	M, 38	Nondom.	Triceps-split.	115	79	75	71	64	29	35	None
24	F, 63	Dom.	Triceps-split.	110	65	55	54	52	7	30	None
25	M, 45	Dom.	Olec. osteot.	125	93	88	77	106	3	34	Elbow stiffness (release)

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Table II: Mean SF-36 Values for the Study Patients Compared with Population Norms29

SF-36 Parameter	Study Mean (points)	Control Mean (points)	P Value
Physical function	74	84	0.03
Role-physical	62	81	0.01
Bodily pain	68	75	0.20
General health	71	72	0.82
Vitality	65	61	0.73
Social function	80	83	0.60
Role-emotional	74	81	0.21
Mental health	75	75	0.62

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Table II: Mean SF-36 Values for the Study Patients Compared with Population Norms29

SF-36 Parameter	Study Mean (points)	Control Mean (points)	P Value
Physical function	74	84	0.03
Role-physical	62	81	0.01
Bodily pain	68	75	0.20
General health	71	72	0.82
Vitality	65	61	0.73
Social function	80	83	0.60
Role-emotional	74	81	0.21
Mental health	75	75	0.62

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Inclusion and Exclusion Criteria

Patient charts encompassing the years 1990 to 1996 were retrospectively reviewed at St. Michael's Hospital and the Toronto East General Hospital (University of Toronto, Toronto, Ontario, Canada). All skeletally mature patients in whom an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus (AO type 13-C)²⁵ had been treated by operative repair were identified. Patients who were skeletally immature, who had fixation with Kirschner wires or only a single plate, or who had fixation through a medial and/or lateral approach were excluded. Patients with an ipsilateral or contralateral upper-extremity injury or a preexisting musculoskeletal condition were also excluded. Only patients who underwent plate fixation on both the medial and the lateral column through a posterior approach were included. The approach through the extensor mechanism was either an olecranon osteotomy or a triceps-splitting procedure, at the discretion of the surgeon. This decision was typically based on personal preference and not on fracture type or configuration.

Sixty-two patients were identified. Twenty-seven patients were excluded because they had an open fracture (eleven patients), an ipsilateral or contralateral injury or a preexisting condition (ten), fixation with one plate or Kirschner wires only (four), or a medial or lateral approach (two). Thirty-five patients met the inclusion criteria, but two had died and eight could not be located. The remaining twenty-five patients returned for a comprehensive assessment that included the recording of a history, standard physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing. The DASH is a thirty-item validated, responsive, patient-completed questionnaire for patients with upper-limb disorders^13,27. The SF-36 is a patient-oriented general health-status questionnaire that has been used extensively in the orthopaedic literature²⁹. For the radiographic analysis, union was defined as the presence of bridging callus or the disappearance of the fracture line on three of four cortices seen on the anteroposterior and lateral radiographs. Intra-articular gap or step deformity was measured directly on radiographs. Varus-valgus angulation was measured on the anteroposterior radiograph with the assumption of a normal 7-degree valgus angulation of the distal humeral joint surface. Anterior-posterior angulation was measured on the lateral radiograph with the assumption of a normal 30-degree anterior angulation of the condyles relative to the long axis of the humerus. For the assessment of posttraumatic arthritis, the scale of Knirk and Jupiter was used¹⁷. Grade 0 indicated no degenerative change; grade 1, slight narrowing of the joint space; grade 2, marked narrowing of the joint space with osteophytes; and grade 3, total loss of the joint space.

Surgical Technique

Fracture fixation was performed with use of standard AO/ASIF technique^15,25 through a posterior approach. In the eleven patients who underwent an olecranon osteotomy, a chevron osteotomy was performed approximately two centimeters from the tip of the olecranon with an oscillating saw, which is meant to exit in the "bare area" of the joint, the midportion of the trochlear fossa or notch where the olecranon is devoid of cartilage^20,25,28. At the conclusion of the procedure, the olecranon was reduced and then fixed with two longitudinal 2.0-millimeter Kirschner wires and an 18-gauge tension-band wire. In the fourteen patients treated with a triceps-splitting approach, a midline incision was made in the triceps aponeurosis from proximally to distally onto the shaft of the ulna. Equal portions of the triceps muscle were reflected medially and laterally, with use of sharp dissection to remove the triceps insertion from the olecranon¹⁶. At the conclusion of the procedure, the triceps insertion was reattached with interrupted, number-2 braided polyester sutures, with use of drill-holes through bone in the region of the olecranon.

The postoperative therapy regimen was similar for each group. Active flexion and passive gravity-assisted extension were initiated following splint removal at seven days, but active extension was prohibited until six weeks postoperatively to avoid undue stress on the extensor mechanism repair. Resisted extension was instituted at eight weeks.

Assessment

The authors (T. L. W. and L. W.) who were not involved in the clinical care of the patients performed a complete follow-up assessment, which included the recording of a history, physical examination, evaluation of range of motion, and stability testing. Anteroposterior and lateral radiographs were made. Patients also underwent isometric muscle-strength testing on the Baltimore Therapeutic Equipment (BTE) Work-Simulator (model WS-20; Hanover, Maryland)⁴. The unaffected arm was used as a control for each patient. Patients were seated in a chair, allowed to practice on the machine, and then allowed to rest before testing. Isometric elbow-extension strength was measured at 45, 90, and 120 degrees with the forearm in neutral rotation. Isometric elbow-flexion strength was measured in a similar fashion at 90 degrees. The mean of three trials with a coefficient of variation of less than 10 percent was determined for each patient^5,19. The same fourteen-inch (35.6-centimeter) lever-arm length was used for each patient. Values were expressed in inch-pounds and as a percentage of the value for the contralateral (normal) arm.

All patients completed both the DASH and the SF-36 in the office prior to examination and muscle-strength testing.

Statistical Analysis

Statistical analysis was performed with the SAS system software package (SAS Institute, Cary, North Carolina). A paired t test was used to determine differences in strength and motion parameters between sides, whereas a Student t test was used to evaluate differences between groups. Rates were compared between groups with use of a Fisher exact test (two-tailed test). A p value of 0.05 or less was considered significant. SF-36 data were compared with published normal control values²⁹. Correlations were investigated with use of Pearson product-moment correlation coefficients (r). Values of less than 0.25 indicate a trivial, or weak, correlation; values between 0.25 and 0.49, a mild correlation; values between 0.50 and 0.75, a moderate correlation; and values greater than 0.75, a good correlation²⁷.

Results

Introduction | Materials and Methods | Results | Discussion | References

The twenty-five patients were followed for a mean of thirty-seven months, with a range of eighteen to seventy-five months (Table I). The mean age was forty-seven years, with a range of nineteen to eighty-five years. There were fourteen men and eleven women. Thirteen patients had an injury of the dominant extremity, and twelve had an injury of the nondominant extremity. The mechanisms of injury included eleven motor-vehicle accidents, nine falls, two roller-blade accidents, two industrial accidents, and one sporting accident. Preoperatively, there were three associated ulnar nerve palsies. Twenty-two fractures were fixed within seventy-two hours after the injury, and the remaining three were fixed at five, seven, and ten days after the injury.

Range of Motion

The patients had a mean flexion contracture of 25 degrees, with a range of 5 to 65 degrees. The mean total arc of flexion-extension was 108 degrees, with a range of 55 to 140 degrees. This arc of motion was equivalent to 74 percent of that on the contralateral, normal side (145 degrees, p = 0.01). All patients had full forearm rotation except for two (both of whom had had an olecranon osteotomy) who had lost 25 and 30 degrees of rotation. There was no significant difference in the degree of flexion contracture (p = 0.83) or the total arc of flexion-extension (p = 0.78) between the patients who had been managed with a triceps-splitting approach and those who had been managed with an olecranon osteotomy.

Strength

The mean strength of elbow flexion on the injured side was 292 inch-pounds (33.0 newton-meters), or 74 percent of the strength on the contralateral side (394 inch-pounds [44.5 newton-meters], p = 0.01). The mean extension strength of the injured elbow was significantly decreased compared with that of the contralateral elbow at all three measurement angles. The extension strength on the injured side was 205 inch-pounds (23.2 newton-meters), or 76 percent of normal (269 inch-pounds [30.4 newton-meters], p = 0.01), at 45 degrees; 253 inch-pounds (28.6 newton-meters), or 74 percent of normal (342 inch-pounds [38.6 newton-meters], p = 0.01), at 90 degrees; and 228 inch-pounds (25.8 newton-meters), or 75 percent of normal (302 inch-pounds [34.1 newton-meters], p = 0.01), at 120 degrees.

There were no significant differences between the patients who had undergone a triceps-splitting approach and those who had been managed with an olecranon osteotomy with regard to any of the strength values (flexion, p = 0.74; 45 degrees of extension, p = 0.47; 90 degrees of extension, p = 0.75; and 120 degrees of extension, p = 0.70).

Stability

There was no evidence of anteroposterior elbow instability on manual testing. Manual stressing of the elbow in the varus-valgus plane, including provocative maneuvers for valgus and posterolateral instability, did not reveal any laxity in any patient²¹.

DASH Scores

A DASH score of 0 points indicates normal, pain-free function; a score of 100 points indicates complete impairment of the upper extremity¹³. The mean DASH score in our group was 20 points (range, 0 to 52 points), indicating mild residual impairment. The DASH scores showed a moderate inverse correlation with the total arc of flexion-extension (r = -0.73, p = 0.0001), with a greater arc of motion correlating with a lower, or better, DASH score. The DASH scores also showed a moderate inverse correlation with both elbow flexion strength at 90 degrees (r = -0.67, p = 0.0002) and extension strength at 90 degrees (r = -0.63, p = 0.0007), with greater strength correlating with lower, or better, DASH scores. There was no correlation between the DASH scores and the age of the patient (r = -0.13, p = 0.56) or the duration of follow-up (r = 0.16, p = 0.45).

SF-36 Scores

The SF-36 scores are shown in Table II. When compared with the scores in age-matched controls²⁹, the physical function (p = 0.03) and role-physical (p = 0.01) scores showed minor but significant decreases. There was a slight decrease in the pain score, but it was not significant; the mental component scores also were not significantly different from age-matched norms.

Radiographic Assessment

Radiographs revealed that no fracture was fixed with greater than a two-millimeter step or gap in the joint or greater than 10 degrees of varus or valgus angulation. Similarly, as seen in the lateral plane, no fracture was fixed with greater than 10 degrees of angulation in flexion, extension, or rotation. There was one malunion and one nonunion (see Complications). No other patient had a loss of reduction or fixation. At the final radiographic follow-up evaluation, fourteen elbows were grade 0, nine were grade 1, one was grade 2, and one was grade 3, according to the scale of Knirk and Jupiter for the assessment of posttraumatic arthritis¹⁷.

Complications

One patient required antibiotics for a superficial wound infection in the immediate postoperative period. There were no deep infections. Two patients (Cases 8 and 25) required an elbow release procedure because of an inability to regain a functional arc of motion^15,21. These two patients had a total arc of flexion-extension of 55 and 50 degrees following the initial treatment, and each patient obtained an arc of 125 degrees following a repeat posterior approach, hardware removal, elbow dè¡²idement, and capsulectomy. The values after the release were used for the analysis of our results. One patient required a second reoperation (which was successful) because of a nonunion with hardware failure at the metaphyseal-diaphyseal junction (the intra-articular portion of the fracture healed). One fracture healed in 25 degrees of varus malalignment at the metaphyseal-diaphyseal junction; the patient declined additional operative intervention. Three patients who had had an olecranon osteotomy required a reoperation, at a mean of fourteen months after the injury, for the removal of prominent hardware that had been used to fix the osteotomy site. Of the three patients who had ulnar nerve palsy preoperatively, two had mild, persistent ulnar nerve paresthesias; although they took medication for this problem, both declined operative treatment. Occasional pain and/or paresthesias were present in the ulnar nerve distribution postoperatively. However, these symptoms decreased with time, and, at the time of final follow-up, no patient required treatment for this problem. There was one iatrogenic nerve injury, a radial nerve palsy, in a patient who had undergone a triceps-splitting approach; the palsy resolved completely by three months. We postulate that this was a stretch injury caused by excessive retraction of the lateral triceps. The reoperation rate was six of twenty-five, or 24 percent, and three of the six reoperations were done for hardware removal.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Our range-of-motion results are consistent with those of other studies on the repair of intra-articular distal humeral fractures^{6-11,14,28,30}. There are few objective data in the medical literature regarding muscle strength following the operative repair of these fractures in adults¹⁶. In most studies, muscle strength has been measured against the examiner's manual resistance^11,23,27,30, which is a relatively insensitive technique. Previous studies with the BTE Work Simulator have shown that this device is more reliable than handheld devices and manual testing^2,4. Similarly, our method was designed to minimize variability and suboptimal effort^1,2,19. Although we performed only isometric testing, previous studies have shown that the results of such testing closely reflect those of isokinetic testing and that both flexion and extension strength values are maximal at 90 degrees of elbow flexion^1,2,19,24.

Despite a duration of follow-up that averaged more than three years, the patients in our study did not regain normal elbow strength^2,19,24. Isometric elbow extension strength was remarkably consistent at approximately 75 percent of that on the normal, contralateral side. Thus, patients who have this injury can be advised that they will lose approximately 25 percent of extension strength, regardless of the type of posterior approach (olecranon osteotomy or triceps-splitting) used for operative repair. Our patients received standard physiotherapy postoperatively, and they were generally discharged after range of motion and strength had "plateaued." The degree of weakness that we observed may not be functionally disabling for sedentary individuals, but it may explain the easy fatigability, the sense of weakness, and the loss of endurance that more active patients have when they attempt to return to rigorous tasks following this injury^15,21,28. It is uncertain whether additional physiotherapy would decrease the weakness that we observed.

Despite the fact that a posterior surgical approach was used in all patients, our patients lost approximately 25 percent of flexion strength as well. Since the elbow flexors were not involved in the surgical approach, it may be inferred that the equivalent loss of elbow flexion and extension strength seen in our study is intrinsic to the nature of the injury and its subsequent rehabilitation rather than to the type of surgical approach.

It is generally thought that a posterior surgical approach provides optimal exposure of the intra-articular aspect of the distal part of the humerus, and the olecranon osteotomy is the gold standard against which other approaches are compared^14,25,30. However, its drawbacks (delayed union or nonunion, prominent hardware, and so on) have led to other avenues of dealing with the extensor mechanism^3,7,18,22. Previous investigators of triceps-splitting or peeling approaches have postulated a negative effect on muscle strength on the basis of the potential for weakened reattachment, direct muscle injury with resultant fibrosis, and injury to intramuscular nerve branches^7,16. However, in our study, the restoration of elbow extensor strength was equivalent to that in the patients who had undergone an olecranon osteotomy.

DASH scores have been shown to correlate well with perceived functional loss in the upper extremity²⁷. The mean DASH score of 20 points in our study indicates a mild impairment and serves as a value against which other outcomes can be evaluated. At the present time, there are no control or normal values for the DASH scores. We previously showed that patient-oriented outcome measures can correlate with observer-based rating scales²⁶. The moderate correlation between DASH scores and strength and motion values in the current study lends additional support to their routine use in the evaluation of upper-extremity disorders. While most components of the SF-36, a general health-status measure, were within normal limits for our patients, the significant decreases in the role-physical and physical function categories show that, despite "successful" surgery, there was a significant residual impairment of the involved extremities^13,26,27,29.

Our retrospective study has several potential biases. A number of patients with worse outcomes may have been lost to follow-up. The recall of trauma patients is difficult even in prospective studies, and we believe that our data, based on more than 75 percent of the eligible patients, are valid. The mean duration of follow-up was three years. The low rate of posttraumatic degenerative change in the elbow could increase with time, negatively affecting function. The choice of surgical approach (olecranon osteotomy or triceps-splitting) was at the discretion of the surgeon. Patients were not randomized, and, although the two groups were similar in terms of patient and fracture characteristics, there may have been selection biases. We did not find any difference in the range of motion or strength between these two groups, but this finding must be interpreted cautiously because of the possibility of a beta error - that is, a true difference may have been missed because of small sample size. Finally, the data on two patients in whom severe contractures had developed following fracture were obtained after they had had a successful elbow release.

To the best of our knowledge, our study provides the first objective data quantifying elbow flexion and extension strength following the fixation of displaced intra-articular fractures of the distal part of the humerus in adults. Despite the accuracy of fracture fixation, significant deficits in strength and motion remained. This finding may help to explain the early fatigability and muscular pain that some patients who engage in strenuous physical labor or recreational activities feel following apparently successful repair of these injuries. The decrease in the range of motion and strength correlates with the mild residual physical impairment detected by limb-specific outcome measures and physical function components of general health-status measures.

References

Introduction | Materials and Methods | Results | Discussion | References

Amis, A. A.; Dowson, D.;; and Wright, V.: Elbow joint force predictions for some strenuous isometric actions. J. Biomech.,8: 765-775, 1980.8765 1980

Askew, L. J.; An, K. N.; Morrey, B. F.;; and Chao, E. Y.: Isometric elbow strength in normal individuals. Clin. Orthop.,222: 261-266, 1987.222261 1987 [PubMed]

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Topics

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Table I: Patient Data

*Muscle strength on both the injured and the control side was measured at maximal extension (70, 55, and 55 degrees) for these three patients.

Case	Gender, Age (yrs.)	Involved Side	Approach	Arc of Motion (degrees)	Muscle Strength (percent of normal side)				DASH Score (points)	Duration of Follow-up (mos.)	Complications
Flexion Strength at 90 Degrees	Extension Strength at 45 Degrees	Extension Strength at 90 Degrees	Extension Strength at 120 Degrees
1	M, 36	Dom.	Triceps-split.	85	79	68	67	72	30	52	None
2	M, 55	Nondom.	Triceps-split.	130	95	100	93	89	0	18	None
3	M, 51	Dom.	Olec. osteot.	90	69	95	73	84	22	38	Ulnar nerve irritation
4	F, 49	Nondom.	Triceps-split.	120	75	95	78	72	18	51	None
5	F, 35	Dom.	Olec. osteot.	125	74	78	65	66	31	42	Wound infection
6	F, 70	Dom.	Triceps-split.	105	67	56	64	78	23	56	None
7	M, 48	Nondom.	Olec. osteot.	55*	18	25	26	29	52	41	None
8	F, 21	Dom.	Triceps-split.	125	75	66	67	80	10	18	Elbow stiffness (release)
9	M, 23	Nondom.	Olec. osteot.	105	94	82	88	78	29	23	None
10	M, 24	Nondom.	Olec. osteot.	95	54	48	66	68	31	25	25-degree varus malunion
11	F, 73	Dom.	Triceps-split.	125	81	81	85	87	9	18	None
12	M, 52	Dom.	Olec. osteot.	120	93	92	86	98	14	49	Tension-band removal
13	F, 37	Nondom.	Triceps-split.	110	94	72	76	80	10	25	None
14	M, 19	Dom.	Triceps-split.	130	93	92	85	69	8	34	None
15	F, 45	Nondom.	Triceps-split.	115	56	78	72	62	28	44	Temp. radial nerve palsy
16	M, 39	Nondom.	Triceps-split.	75*	45	66	65	67	41	34	Nonunion
17	F, 84	Dom.	Olec. osteot.	80*	35	87	84	54	25	51	None
18	M, 44	Nondom.	Olec. osteot.	100	91	83	82	71	15	32	Tension-band removal
19	F, 85	Dom.	Triceps-split.	115	87	84	86	95	21	33	None
20	M, 49	Nondom.	Olec. osteot.	140	72	92	81	89	7	40	Tension-band removal
21	M, 45	Dom.	Triceps-split.	115	92	83	86	93	5	75	None
22	F, 50	Nondom.	Olec. osteot.	95	75	63	69	66	22	24	Ulnar nerve irritation
23	M, 38	Nondom.	Triceps-split.	115	79	75	71	64	29	35	None
24	F, 63	Dom.	Triceps-split.	110	65	55	54	52	7	30	None
25	M, 45	Dom.	Olec. osteot.	125	93	88	77	106	3	34	Elbow stiffness (release)

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Table I: Patient Data

*Muscle strength on both the injured and the control side was measured at maximal extension (70, 55, and 55 degrees) for these three patients.

Case	Gender, Age (yrs.)	Involved Side	Approach	Arc of Motion (degrees)	Muscle Strength (percent of normal side)				DASH Score (points)	Duration of Follow-up (mos.)	Complications
Flexion Strength at 90 Degrees	Extension Strength at 45 Degrees	Extension Strength at 90 Degrees	Extension Strength at 120 Degrees
1	M, 36	Dom.	Triceps-split.	85	79	68	67	72	30	52	None
2	M, 55	Nondom.	Triceps-split.	130	95	100	93	89	0	18	None
3	M, 51	Dom.	Olec. osteot.	90	69	95	73	84	22	38	Ulnar nerve irritation
4	F, 49	Nondom.	Triceps-split.	120	75	95	78	72	18	51	None
5	F, 35	Dom.	Olec. osteot.	125	74	78	65	66	31	42	Wound infection
6	F, 70	Dom.	Triceps-split.	105	67	56	64	78	23	56	None
7	M, 48	Nondom.	Olec. osteot.	55*	18	25	26	29	52	41	None
8	F, 21	Dom.	Triceps-split.	125	75	66	67	80	10	18	Elbow stiffness (release)
9	M, 23	Nondom.	Olec. osteot.	105	94	82	88	78	29	23	None
10	M, 24	Nondom.	Olec. osteot.	95	54	48	66	68	31	25	25-degree varus malunion
11	F, 73	Dom.	Triceps-split.	125	81	81	85	87	9	18	None
12	M, 52	Dom.	Olec. osteot.	120	93	92	86	98	14	49	Tension-band removal
13	F, 37	Nondom.	Triceps-split.	110	94	72	76	80	10	25	None
14	M, 19	Dom.	Triceps-split.	130	93	92	85	69	8	34	None
15	F, 45	Nondom.	Triceps-split.	115	56	78	72	62	28	44	Temp. radial nerve palsy
16	M, 39	Nondom.	Triceps-split.	75*	45	66	65	67	41	34	Nonunion
17	F, 84	Dom.	Olec. osteot.	80*	35	87	84	54	25	51	None
18	M, 44	Nondom.	Olec. osteot.	100	91	83	82	71	15	32	Tension-band removal
19	F, 85	Dom.	Triceps-split.	115	87	84	86	95	21	33	None
20	M, 49	Nondom.	Olec. osteot.	140	72	92	81	89	7	40	Tension-band removal
21	M, 45	Dom.	Triceps-split.	115	92	83	86	93	5	75	None
22	F, 50	Nondom.	Olec. osteot.	95	75	63	69	66	22	24	Ulnar nerve irritation
23	M, 38	Nondom.	Triceps-split.	115	79	75	71	64	29	35	None
24	F, 63	Dom.	Triceps-split.	110	65	55	54	52	7	30	None
25	M, 45	Dom.	Olec. osteot.	125	93	88	77	106	3	34	Elbow stiffness (release)

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Table II: Mean SF-36 Values for the Study Patients Compared with Population Norms29

SF-36 Parameter	Study Mean (points)	Control Mean (points)	P Value
Physical function	74	84	0.03
Role-physical	62	81	0.01
Bodily pain	68	75	0.20
General health	71	72	0.82
Vitality	65	61	0.73
Social function	80	83	0.60
Role-emotional	74	81	0.21
Mental health	75	75	0.62

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Table II: Mean SF-36 Values for the Study Patients Compared with Population Norms29

SF-36 Parameter	Study Mean (points)	Control Mean (points)	P Value
Physical function	74	84	0.03
Role-physical	62	81	0.01
Bodily pain	68	75	0.20
General health	71	72	0.82
Vitality	65	61	0.73
Social function	80	83	0.60
Role-emotional	74	81	0.21
Mental health	75	75	0.62