Comparative Study of Results between Orthogonal and Parallel Plating in the Treatment of Distal Humerus Intra-Articular Fractures

Dr. Khaled Ibney Anwar, Dr. Avijit Chowdhury, Dr. Md Imrose Uddin, Dr. Md. Shaon Barua, Dr Swarupananda Chakraborty, Dr. Heba Hoque
Industry, Innovation, Medicine, Patient

19

Nov 24

ABSTRACT

Background:

This study was conducted to determine the outcome of the parallel plating and orthogonal plating in intra articular distal humerus fractures. These types of fractures remain one of the most difficult injuries to manage. In the treatment of distal humerus intra articular fractures double plate osteosynthesis is the standard treatment method. However, controversy still exists concerning the plate positions in terms of providing optimal stability of these kind of fractures.

Objectives: This study is aimed at finding any significant difference in outcome of these orthogonal and parallel plating methods of fracture fixation.

Methods: This quasi-experimental study was undertaken to compare the differences between these two dual plating methods. It was conducted in the department of Orthopedics and Traumatology of Chittagong medical college hospital, Chattogram, for a period of fifteen months. 36 patients were enrolled conveniently according to inclusion and exclusion criteria. Patients were followed up for 6 months and overall outcomes were measured by Mayo Elbow Performance Score (MEPS). Depending on the overall functional outcome, patients were grouped as having excellent to good outcome and fair to poor outcome.

Results: At 6th month follow up, mean MEPS in the parallel plating group was 87.89±6.50 (mean ± SD) and in the orthogonal group it was 83.72±7.45. There was no significant (p=0.785) difference between the two groups in functional outcome but in parallel plating group MEPS was better. The mean union time was 6.17±0.383 weeks in parallel plating group and 6.22±0.548 weeks in orthogonal plating group. P value was 0.549. Regarding complications, elbow stiffness developed in 3 (13.89%) cases in parallel and 4 (19.44%) cases in orthogonal group; superficial infection developed in one case in parallel and three cases in orthogonal group.

Conclusion: This study shows that, parallel plating group was superior to the orthogonal group in terms of better functional outcome, less union time, and less complications.

Key words: Parallel plating, Orthogonal plating, humerus fracture.

INTRODUCTION

Intra-articular distal humerus fractures remain one of the most difficult injuries to manage. These fractures comprise 2-6% of all fractures and have bimodal age distribution. The majority of these fractures occur either of two ways, low energy falls or high energy trauma. Most fractures in elderly patients are intra-articular with bi column involvement1. They are commonly multifragmental and occur in osteopenic bone. Straight forward fall in forward direction is the most common cause. Usually, 70% of patients that sustain an elbow fracture fall directly on to the elbow because they are unable to break their fall with an outstretched arm. High energy injuries like motor vehicle collisions, sports, and fall from height and industrial accidents are the causes of most intra-articular distal humerus fractures in young adults.1,2

According to the most widely used the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification, there are three major types of fracture: Extra articular (AO type A), Partial articular (AO type B), and Complete articular (AO type C). A TYPE fracture is non-articular, B TYPE fracture is partially articular where the fracture involves a part of the articular surface, but the rest of articulating segment remains in the continuity with the shaft. C TYPE fractures are complete articular and have no articular fragments remaining in the continuity with the shaft. C1:  T or Y fractures, C2:  articular fractures are simple, but the non-articular supracondylar area is segmental or comminuted. C3:  articular segment is segmental or comminuted.3,4

Fig-1: AO/OTA classification of all types of distal humeral fractures4

Earlier consensus favoured non operative management due to poor operative outcomes. Modern orthopaedic implants and surgical techniques overcame this problem by permitting rigid fixation and early motion that achieves painless functional range of motion at elbow. Any treatment that needs extended immobilization of elbow leads to a stiff joint. Closed methods like cast immobilization, traction, bag of bones technique is recommended for elderly patients and for those whose medical conditions don’t allow surgery.

The management of distal humeral fractures is a topic of controversy related to the correct surgical approach, fixation techniques, management of ulnar nerve, the role of total elbow arthroplasty depending upon the patient condition, etc.5,6  Restoration of diaphyseal metaphyseal contact and reconstruction of olecranon fossa is essential to provide more stability and allow best healing.7

Though relatively uncommon, intraarticular fractures of the distal humerus continue to provide operative challenges to the surgeons attempting to address this problem as it is complicated by the anatomy of the elbow, its small area for fixation and otherwise compounded by comminution and osteopenia of articulating surfaces.

The main principle of managing these fractures is reconstruction of the articular block and stable internal fixation of this reconstructed block with the shaft by plating on both pillars. Without this dual plate arrangement, the stability of fixation can be inadequate.

In complex fractures of the distal humerus, single column plating systems, which are proven to be less stable to loads compared to double column plating methods, is not recommended. Based on clinical and biomechanical studies, fixation with double plating is currently recommended.

However, controversy still exists concerning the plate positions in terms of providing optimal stability for these kinds of fractures. Among the placement, the main debate is between the perpendicular plating proposed by the AO/Association of the Study of Internal Fixation (AO/ASIF) group where plates are placed perpendicular to each other, one over the medial supracondylar ridge and the other one over the flat posterior surface of the lateral column also called orthogonal plating and, the principle stated by, O’Driscoll where two plates are placed parallel to each other, one over each supracondylar ridge, termed parallel plating. Various plate designs have been developed for the fixation of these fractures- the Y plates, reconstruction plates, pre contoured anatomical plates, and compression plates.3,5,7

Another study reported a retrospective study of 35 cases of distal humerus fractures which were treated using two different methods. Seventeen patients were treated with orthogonal plating (group I) and 18 patients with parallel plating (group II). The difference in the arc of flexion among the groups was not significant. The average Mayo Elbow Performance Score (MEPS) score for orthogonal plating showed good or excellent results in 14 patients (82%). In comparison, the score for the parallel plating group showed good or excellent results in 16 patients (89%). Regarding complications, there were 29% in group I and 38% in group II. They further concluded that while a higher number of patients in the orthogonal plating group achieved bony union, both plating techniques could provide anatomic restoration and adequate stability of the distal humerus.

Likewise, in a study of 25 patients with AO/OTA type C fractures of the distal humerus, 13 patients were treated using the orthogonal plate (group I) while 12 patients were treated with a Y plate (group II).8 These patients were followed up for 12 to 38 months. The average MEPS was 84% for Group I and 83% for Group II with good to excellent scores. As with these results, there was no significant difference in the clinical outcomes between the two plating techniques.

Recently, in a prospective randomized trial between orthogonal and parallel plating methods in 67 patients with AO type C1 to C3 with a minimum follow up of two years, noted no significant differences in terms of clinical outcomes and complication rates between the two techniques.9 Flexion arc, MEPS, and DASH scores were compared for both the orthogonal and the parallel plating groups. There were 3 and 2 cases of heterotopic ossification for orthogonal and parallel plating, respectively.

This quasi-experimental study was conducted to compare the clinical and radiological outcomes in terms of elbow function, bone union and complications following the management of intra-articular distal humeral fractures by parallel or orthogonal plating techniques.

Rationale of the study

Intra articular fractures of the distal humerus are not amenable to a single column plating system, which is proven to be less stable to loads compared to double column plating methods. Based on clinical and biomechanical studies, fixation with double plating is currently recommended. The optimal method for fixation is still debatable as both parallel and orthogonal plating treatment modalities have their advantages as well as disadvantages. Research done so far on this topic has failed to show any significant difference in the outcome of the two methods. This study was carried out to figure out if there was any significant difference in outcome between these two methods.

Objectives

General Objectives

  • To compare the functional, radiological, and clinical outcome of distal humeral intra-articular fracture fixation by parallel and orthogonal plating methods using Mayo Elbow Performance Score (MEPS), fracture union time, and postoperative complications.

Specific Objectives

  • To evaluate function of the elbow joint by MEPS.
  • To find out the time taken for union.
  • To get an idea about complications.

Fig 2(a-d) Distal humerus fracture classification.

Materials and methods

3.1 Type of Study                               :              Quasi experimental study

3.2 Place of Study                               :              Department of Orthopaedics and Traumatology,

                                                                            Chittagong Medical College Hospital  

3.3 Study Period                                :              15 months

3.4 Study Population                        :              All adult patients admitted and undergoing                                                                                                                       surgery with Intra articular fracture of the distal                                                                                                           part of the humerus as per inclusion criteria.

3.5 Sampling technique                    :              Consecutive sampling

3.6. Study Group                                :

                                     Group P          :               Patients treated by parallel plating method.

                                     Group O         :               Patients treated by orthogonal plating method.

3.7. Ethical issue                                 :              The protocol was approved by the Ethical Review Committee                                                                                  (ERC) of Chittagong Medical College Hospital, Chattogram,                                                                                   Bangladesh.

3.8. Selection criteria:

Inclusion criteria

  1. Age 18 years and above who have consented.
  2. Closed type B and C (according to AO/OTA classification).

Exclusion criteria

1. Age <18years.

2. AO/OTA type A fractures.

3. Pathological fractures.

4. Open fractures

5. Fractures with neurovascular complications.

RESULTS

This present quasi experimental study was conducted between the periods of September 2022 to November 2023 for a duration of fifteen months in the Department of Orthopaedics and Traumatology, Chittagong Medical College Hospital, Chattogram, Bangladesh. In this study, adult patients with intra-articular fracture of the distal humerus undergoing Parallel plating (Group P) or Orthogonal plating (Group O) were the study sample. A total of 36 samples were included in the study. In this study records from four follow ups were compiled at 4th week, 6th week, 3rd month and 6th month. The overall functional outcome was categorized according to MEPS and analyzed. The union time and complications were also compared.

Table I: Side of injury and mechanism of injury of the patients (n=36)

Injury detailsTypes of plating P value
POTotal
No% ageNo% ageNo% age
Side of injury     0.735ns
Right side738.89844.441541.67
Left side1161.111055.562158.33
Total181001810036100
Mechanism of injury         0.468ns
Road traffic accident527.78738.891233.33
Physical assault527.78633.331130.6
Fall from height316.6715.55411.11
Fall from standing height316.67422.22719.4
Sports injury211.1100.0025.56 
Total181001810036100
  • Statistical analysis was done by Chi square test.
  • P value > 0.05 indicates non-significant
  • ns= non-significant

MEPS: Function of elbow at 6 months

Figure 5: Function of elbow at 6th month (n= 36)

TABLE II: MEPS: RANGE OF MOVEMENT

ROMType of fixationTotalP value
PO
No%No%No%0.502ns  
>1009507391644
50-10095011612056
<5000.0000.0000.00
Total181001810036100 

Chi square= 0.450; df = 1; P value = 0.502

  • Statistical analysis was done by Chi square test
  • P value > 0.05 indicates non-significant
  • ns= non-significant

Table III: Various findings in follow up period

Categories in follow upParallelOrthogonalTotalP value
No% ageNo% ageNo% age
Time for union     0.377ns
6 weeks844.44633.331438.89
7 weeks633.331055.561644.44
8 weeks422.22211.11616.67 
Mean Union Time6.176.226.19 
Total181001810036100 
MEPS 
Excellent1055.56527.881541.67  0.156ns
Good738.89950.001644.44
Fair15.56422.22513.89
Poor00.0000.0000.00 
Mean87.8983.72     85.810.785 ns
Total181001810036100 
        
Complications       
Present738.891055.561747.22  0.317ns
           Absent1161.11844.441952.78
Total181001810036100
        
  • Statistical analysis was done by Chi square test
  • P value > 0.05 indicates non-significant
  • ns= non-significant

Discussion

Distal intra articular fractures of the humerus are difficult to treat and are frightening with complications and it is not uncommon for unpredictable results. This study was conducted among 36 adult patients.

According to side of injury, 58.33% patients had injuries on left side and 41.67% patients had injury on right side. Most of the patients had fractures on their left humerus, with the left to right ratio 21:15. Our study result was comparable toa study where the majority of the patients had fracture on their left humerus, with the left to right ratio being 26:12.10 According to mechanism of injury, maximum patients (33.33%) had history of road traffic accident. No significant statistical difference between parallel and orthogonal group according to side of injury (p=0.735ns) and mechanism of injury (p=0.468ns) was observed. Our study result was comparable to a study which showed that according to mechanism of injury, 66.67% had history of road traffic accident among parallel group and 53.33% in orthogonal group.11 Increasing number of motor vehicles and the lack of driving skill and with very few people following traffic rules, RTA was the major mode of injury sustained by our patients with respect to fall and assault.

Among 36 patients, according to AO/ OTA type of fracture- 38.89% patients had 13C2, 33.33% had 13C1, 22.22% had 13C3 and 5.56% had 13B3 type of fracture. No significant statistical difference between parallel and orthogonal group according to side of injury (p=0.853ns) was observed. This study result was comparable to singh et al., (2021), where, according to AO/OTA type of fracture, 43.33% patients had 13C2, 33.33% had 13C1, 20.00% had 13C3, and 3.33% had 13B1 type of fracture.

As per the MEPS, for the Parallel Plating group, the functional outcome was excellent in 10 cases, good in 7 cases, fair in 1 and poor in 0 cases. For the Orthogonal Plating group, the functional outcome was excellent in 5 cases, good in 9 cases, fair in 4 and poor in 0 cases. Mean MEPS in parallel group is 87.89 and in orthogonal group it was 83.72. With respect to P value (0.785), there was no significant difference found between the groups. This study result was comparable to studies that found the mean MEPS to be 85.6 points in parallel group, which corresponded to an excellent result in 5 elbows, a good result in 8, and a fair result in orthogonal group.12 The mean MEPS was 88.3 points group 2, which corresponded to an excellent result in 7 elbows, a good result in 6, and a fair result in 2. Mean MEPS in both groups were comparable to who found mean MEPS 85.6 in parallel group and 88.3 in the orthogonal group.13 According to P value (0.540) it was non-significant.

In the parallel plating group nine patients had flexion of more than 100°, nine had   50- 100° and none below 50°. The mean range of motion in parallel plating was 107°. In the orthogonal plating group seven patients had flexions of more than 100°, and eleven had 50-100° and none below 50°. The mean range of motion in orthogonal plating was 104°. This study result was comparable to who found it 121.66° in parallel group and 99.66° in orthogonal group.14 Out of 36 patients at 6 months follow up, 15(41.67%) in parallel group were able to comb by himself and 12(33.33%) in orthogonal group. No significant difference (P=0.248) was observed. 17 (47.2 %) patients were able to feed themselves in parallel group and 16 (44.44%) in the orthogonal group. The difference between these two groups was not significant (P=0.546). 17 (44.44%) in parallel group were able to maintain personal hygiene and 16 (44.44%) in orthogonal group. There was no significant (P=0.546) difference between these two groups. 16 (44.44%) patients in the parallel group were able to put on shirt and 15 (41.67%) in orthogonal group. The difference between these two groups was not significant (P=0.630). In both groups 15 (41.67%) patients (P=1.000) were able to put on shoes. The present study result was comparable to that who found that 13 (43.33%) in parallel group were able to comb by themselves and 11 (36.67%) in orthogonal group.15 15 (50%) patients were able to feed themselves in parallel group and 15 (50%) in the orthogonal group. 15 (50%) in parallel group were able to maintain personal hygiene and 15 (50%) in orthogonal group. 15 (50%) patients in the parallel group were able to put on shirt and 14 (46.67%) in orthogonal group.  In both groups 13 (43.33%) were able to put on shoes.

Among 36 patients, according to fracture, union was assessed radiologically. The mean union time for parallel group was 6.17 weeks and for orthogonal group it was 6.22 weeks. Most of the patients in parallel group united in 6 weeks (44.44%) and most of the orthogonal group united in 7 weeks (55.56%). No significant statistical difference between parallel and orthogonal group according to time of union (p=0.377ns). The present study was comparable to a study where the mean union time for Orthogonal plating was 9.53 weeks, which was higher than for that of the parallel plating (8.93 weeks).16

Over the last 1 year, after evaluation of 36 patients with intra-articular fracture of lower end of Humerus treated with parallel plating and orthogonal plating, the average MEPS for parallel plating group was 87.89 which was good and for orthogonal group was 83.72 which was also good. The difference in the mean MEPS of the two plating techniques was statistically non-significant in this study, (p=0.785).

In the present study, 48% of patients had complications. The complications were elbow stiffness, prominent hardware, superficial infection and transient ulnar nerve palsy. Post operatively, 7 patients developed elbow stiffness (p value=.480) who achieved improvement in functional range of motion with physiotherapy. 4 patients had prominent hardware (p value=1.000) which was removed after the bony union. 4 patients had superficial infection (p value=.289) which was treated with antibiotics and dressings and 2 patients had transient ulnar nerve neuropraxia (p value=1.000) which recovered spontaneously.  19 patients were free of complications. The results were comparable to a study where 44% patients had complications. The notable complications were painful hardware, superficial infection, and transient ulnar nerve palsy. Post-operatively, 8 patients had painful hardware which was removed after the bony union. 7 patients had superficial infection which got treated with antibiotics and dressings and 3 patients had transient ulnar nerve neuropraxia which recovered subsequently. 17 patients had no complications.17

Limitations

  • No randomization and blinding were done.
  • Small sample size.
  • Single centered study.
  • The sample was taken conveniently. So, there may be chance of bias which can influence the interpretation.

CONCLUSION:

Present study showed that, from a clinical perspective, a parallel plating method appears to provide better rigid fixation that is adequate for obtaining bone union. However, no statistically significant differences were observed between the orthogonal and parallel double plating methods in terms of clinical outcomes and complication rates. If appropriately applied with suitable plates, both parallel and orthogonal positioning can provide adequate stability and anatomic reconstruction of the distal humerus fractures. The goal is to get functional elbow which can be achieved by stable fixation and early mobilization and proper postoperative rehabilitation protocol.

Recommendations:

  • For more reliable results a multi-center study could be conducted.
  • Longer duration of prospective study and longer follow up of patients with respect to their functional status will be helpful.
  • Randomization and blinding are needed for reducing bias in future.
  • As the present study was done on a relatively small sample, a large scale study to be conducted to make the findings of the study generalized to reference population.

Acknowledgement

We are grateful to the Head of the Department Orthopaedics & Traumatology, CMCH and the Director of Chittagong Medical College Hospital.

Authors of this article

1. Dr. Khaled Ibney Anwar, MBBS, D-Ortho, Senior Consultant (Orthopaedics), Chittagong Medical College Hospital, Cell- 01819-377567, E-mail- shaon_khaled@yahoo.com

2. Dr. Avijit Chowdhury, MBBS, 3rd Part Resident (Orthopaedics), Chittagong Medical College

3. Dr. Md Imrose Uddin, MBBS, MS (Orthopaedics), Assistant Professor (Sports Medicine & Arthoscopy), Chittagong Medical College

4. Dr. Md. Shaon Barua, MBBS, MS(Ortho), Assistant Registrar Orthopaedics), Chittagong Medical College Hospital

5. Dr. Swarupananda Chakraborty, MBBS, MS (Orthopaedics), Junior Consultant CC, Upazilla Health Complex, Boalkhali, Chattogram

6. Dr. Heba Hoque, MBBS, MS, Consultant, EVERCARE Hospital Ltd, Chattogram

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