OTA 2004 Posters
Risk Factors for Stiffness following Operative Fixation of Supracondylar/Intercondylar Fractures of the Distal Humerus
Purpose: Open reduction internal fixation (ORIF) remains the standard of care for fractures of the distal humerus in active patients. Elbow stiffness, however, is not uncommon and frequently results in significant functional limitations. The purpose of this study was to identify risk factors associated with elbow stiffness after the ORIF of supracondylar/intercondylar fractures of the distal humerus.
Methods: We identified from a prospectively designed orthopaedic database 147 patients with fractures classified as AO/OTA type 13-C that were treated between 1998 and 2003. Exclusion criteria included skeletal immaturity, ballistic injuries, ipsilateral fractures involving the radial head or olecranon process or both, and non-salvageable upper-extremity injuries. Patients treated with arthroplasty were also excluded. Of the 105 patients who were operatively treated, 73 patients with 73 fractures had satisfactory follow-up. Patients' charts were reviewed to determine age, sex, smoking history, associated injuries, Injury Severity Score, and the most recent elbow flexion/extension arc. There were 46 men and 27 women with a mean age of 39.9 years (range, 14 to 75). The average length of follow-up was 12.8 months (range, 3 to 48). Forty fractures (54.8%) were open. The mean ISS was 11.2 (range, 4 to 43). Twelve patients were polytraumatized (ISS >18). Heterotopic ossification (HO) was evaluated on the most recent lateral radiograph and was considered to be either present or absent. Stiffness was defined as a flexion-extension arc of less than 100°. Statistical analysis was performed with use of a regression model.
Results: There were 11 C1 (15.1%), 26 C2 (35.6%), and 36 C3 (49.3%) fractures. An olecranon osteotomy was used to for 47 fractures (64.4%). Fifteen patients (20.5%) received postoperative indomethacin for HO prophylaxis. There were four distal humeral nonunions, all located at the distal metadiaphyseal region. There was no association between elbow stiffness and sex, age, hand dominance, smoking history, or open fractures. Similarly, the use of an olecranon osteotomy was not associated with stiffness, despite its use for more severe C3 injuries (P <0.05). Definitive ORIF delay of more than 48 hours was associated with stiffness in both the polytraumatized patients and those with an isolated injury (P <0.05). Eleven of the 12 polytraumatized patients (ISS >18) (91.7%) had stiffness (P <0.05). Even after accounting for delay of ORIF, multisystem trauma remained a significant independent risk factor (P <0.05). Fractures classified as AO/OTA type C3 were also significantly associated with stiffness (P <0.05), and this association was independent of ISS or delay to definitive surgical treatment. Not surprisingly, the presence of HO was associated with stiffness (P <0.05). Indomethacin use, despite a tendency for it to be used for patients with worse articular injuries, had a significant prophylactic effect against stiffness (P <0.05). Indomethacin, however, was strongly associated with the occurrence of nonunion (P <0.001).
Conclusion: Patients with multisystem trauma (ISS >18), articular comminution, and a delay of >48 hours to definitive surgical fixation had independent risk factors for the development of a restricted elbow flexion/extension arc after supracondylar/intercondylar fracture of the distal humerus. Open fractures were not associated with an increased risk of stiffness. Indomethacin helps minimize stiffness but appears to increase the risk of nonunion.