BRIEF RESUME OF INTENDED WORK

6.1. Need for study

Fractures of the distal humerus represent challenging problems to the modern
orthopaedic surgeon. Important factors to consider are the 3-dimensional geometry, limited peri-
articular bone stock for internal fixation, intra-articular comminution, and the need for early
mobilization. The increasing incidence of this fracture in the elderly patient in association with
poor bone quality and communition has introduced a significant challenge to the reconstructive
surgeon.
Historically, distal humeral fractures were treated non-operatively1 due to the poor results
of surgery. Surgery was complicated by high infection rates and poor fixation due rudimentary
implants. Although non-operative care may be appropriate in some situations, the modern
literature strongly supports open reduction and internal fixation of intra-articular distal humeral
fractures.2-9The surgical goals are to obtain anatomic restoration of the articular surface and
recreation of joint alignment with stable internal fixation, secure enough to allow early range of
motion.

6.2 Review of Literature.

Distal humeral fractures represent 2% of all fractures and approximately 30% of those involving
the humerus10. A single synovial joint encompasses 3 separate articulations ; ulno-humeral,
proximal radio-ulnar, and radiao-capitular. These articulations permit flexion, extension,
pronation, supination and a minimal extend of varus-valgus11. Anatomic restoration of these
multiple articulations ideally should allow loads of 0.3 – 0.5 times body weight12or substantially
more load as observed in a simple push up13.
Distal humeral can be thought of a 2 column fracture supporting the articular segment. Distal
portion of the lateral column (capitulum) protects anteriorly approximately 35-40 degrees. The
medial column terminates at the medial epicondyle and, in contrast, does not curve anterior. The
anatomy of the trochlea is analogous to that of a spool with distal articular segment oriented at
4-8degrees of valgus relative to the long axis of the humerus. Furthermore, the distal articular
segment is internally rotated 3-4degrees relative to the trans epicondylar axis14.
 Jupiter and Mehne classification of distal humerus fractures
based on intraoperative findings. A, High T. B, Low T. C, Y. D, H. E, Medial lambda. F, Lateral
lambda15
The selection of surgical approach for the management of distal humerus fractures is
dependent on several factors. These include – the surgeon’s experience and preferences, fracture
pattern, degree of articular involvement, associated soft tissue injury, rehabilitation protocols,
and whether intra-operative conversion to arthroplasty is contemplated. Ideal approach for each
individual fracture should provide adequate visualization to allow anatomic reduction and the
application of internal fixation to maintain elbow stability with minimization of soft tissue and
bone disruption to permit early motion. Approaches to the distal humerus can be categorized into
olecranon osteotomies, triceps splitting, triceps sparing(triceps on) and triceps reflecting (triceps
off)16.
OLECRANON OSTEOTOMY
With several modifications of MacAusland’s17original description, the olecranon osteotomy is
most the most commonly used approach for management of complex intra-articular distal
humeral fracture, as it offers the best visualization of the articular segment. The outcomes after
this approach, however can be complicated by malunion, non-union and hardware
concerns.Hewins et al18describe the steps required to minimize postoperative complications after
the creation of an olecranon osteotomy. These include precontouring and fixation of a 3.5 mm
reconstruction plate to the olecranon with screws directed ulnarly to avoid the proximal radio-
ulnar joint, identification of the bare spot through medial and minimal lateral dissection and
maintenance of subchondral bone before completion of osteotomy.18Triceps weakness after
olecranon osteotomy when compared with the contralateral limb has been shown,18however,
when compared with a triceps splitting approach, no discernible weakness was identified. Coles
et al19reported their 6 year follow-up results of patients undergoing an olecranon osteotomy. In
their retrospective review, 46 patients were surgically treated with intramedullary screw
supplemented with dorsal ulnar wiring and 24 patients with plate fixation. They reported no
nonunions, 1 delayed union, 2 hardware revisions, and 13 hardware removals. Most hardware
removals (11 patients) were associated with a secondary procedure (capsular release for
stiffness)19

6.3. OBJECTIVES OFSTUDY

1) Restoration of elbow joint congruity by anatomic reduction of articular fragments.
2) Allowing early joint movement with stable fixation of fragments.
3) Assessment of the elbow functions after transolecranon osteotomy approach.
MATERIALS AND METHODS
7.1.SOURCE OF DATA
The patients admitted to department of orthopaedics at Vijayanagar Institute of Medical
Sciences,Bellary with closedintraarticular distal humeral fractures in adultsduring the period
from DECEMBER 2011 to OCTOBER 2013 are selected.All patients who will operated during
this period are included in the study. Those patients who are above the age of 18 years of age and
managed surgically are included in the study.
7.2.a) METHOD OF COLLECTION OF DATA
( Including the sampling procedure if any )
The study will be conducted at the Department of Orthopaedics,VIMS,Bellaryduring the period
from DECEMBER 2011 to OCTOBER 2013. The complete data is collected from the patients in
specially designed Case Record Form (CRF) by taking history of illness and by doing detailed
clinical examination and relevant investigation.
Finally after the diagnosis the patients are selected for the study depending on
inclusion and exclusion criteria. Post operatively all the cases are followed for minimum period
of 6 months.

INCLUSION CRITERIA
a) Patients with both the sex are included in the study.
b) Patients with closed intraarticular distal humerus fracture.
c) Patients fit for surgery.
d) Patients with age more than 18 years and below 65years.

EXCLUSION CRITERA
a) Patients with distal neurovascular injury.
b) Patients with extraarticular distal humerus fracture.
c) Patients with compound intraarticular distal humerus fracture.

7.2 b)SAMPLE SIZE:

Patients admitted to department of orthopaedic, VIMS, BELLARY due to Closed Intraarticular
distal Humeral fractures during the period of DECEMBER 2011 to OCTOBER 2013.
7.3. DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
HUMANS OR ANIMALS?
Yes, In our study the following investigations are conducted are in each patients.All patients
included in study are investigated thoroughly with
 1) Routine blood investigation (Complete Blood Count, Random Blood Sugar, Blood
urea, Serum creatinine)
2) Urine Routine (Albumin, Sugar , Microscopy)
3) Radiological examination pre operatively done.
a. X ray of elbow joint
-AP view
-Lateral view
b. C.T. Scan of elbow joint if required.
Radiological examination will be repeated post-operatively and at the end of 6
weeks, 12 weeks and 6 months interval.
Patients will be followed up at 6 week, 12 week and at 6 month.
7.4 . HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
Yes. Ethical Clearance has been obtained from Institutional Ethical Committee (IEC)of
VIMS, Bellary.
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