Aim: To compare the functional outcome as well as elbow range of motion (ROM) after triceps splitting and triceps sparing approach for AO/OTA TYPE A distal humerus fractures. Materials and Methods: This is a prospective study done at our center between 2011 and 2014. A total of 50 patients presented with extra articular distal humerus fracture (AO/OTA 13 A2, 13A3). Exclusion criteria removed 16 patients from the study while 2 patients died due to medical comorbidities before the final follow up. Out of the remaining 32 patients, they were divided into two groups: triceps splitting (15 patients) and triceps sparing (17 patients). Elbow ROM, along with Disabilities of the Arm, Shoulder and Hand questionnaire scores, was compared between the two groups. Results: Triceps sparing group had greater elbow flexion (140.0 ± 4.0) compared to triceps splitting group (126.0 ± 10.0) with p < 0.001. Extension contracture was also significantly less in triceps sparing (5.0 ± 6.0) group as compared to triceps splitting group (24.0 ± 8.0) with p < 0.001. However, there was no statistically significant difference in terms of DASH scores between the two groups with DASH score being (24.28 ± 10.14) in the sparing group as compared to (30.41 ± 14.36) in the splitting group with p = 0.169. Conclusion: As compared to triceps splitting approach, triceps sparing approach results in better elbow ROM with less extension contracture, however both approaches result in similar functional outcome.
Extra articular distal humerus fractures can be tackled via both triceps splitting as well as triceps sparing approaches. Schildhauer et al. [
Remia et al. [
After obtaining clearance from ethical committee, patients presenting with extra articular distal humerus fractures (AO/OTA TYPE A) were included in the study. During 2011-2014, 50 patients presented with extra articular distal humerus fracture. 16 patients were excluded from the study. Exclusion criteria included patients presenting with pathologic fracture, periprosthetic fractures, isolated lateral or medial epicondyle fractures (AO/OTA 13A1), compound injuries as well as any other illness like mental illness, dementia, Parkinson disease that would affect the post operative rehabilitation protocol. Patients were divided into two groups depending upon the surgical approach chosen by the operating surgeon. The choice of surgical approach was based on discretion of treating surgeon.
The triceps sparing approach was performed as described by Schildhauer et al. [
After the exposure, the fracture site was identified and reduction was done either with or without lag screws depending upon the fracture morphology and an extra articular distal humerus plate was applied. The wound was washed thoroughly with saline and closure was done in layers over the negative suction drain.
The dressing was done on 3rd, 7th and 10th day with drain removal at first dressing and stich removal at 14 days. Elbow ROM was started as soon as the patients were comfortable. The patients were followed up there after every 2 months till the clinical and radiological union occurred.
Elbow ROM which included the degree of flexion occurring at elbow joint and the degree of extension contracture was measured after the radiological and clinical union occurred using a hand held goniometer and was recorded. Post-operative range of motion measures were done by an independent evaluator and not by the treating surgeon. DASH scores were recorded for assessment of functional outcome [
The DASH questionnaire is given below in
NO | MILD | MODERATE | SEVERE | UNABLE | ||
---|---|---|---|---|---|---|
DIFFICULTY | DIFFICULTY | DIFFICULTY | DIFFICULTY | |||
1. | Open a tight or new jar. | 1 | 2 | 3 | 4 | 5 |
2. | Write. | 1 | 2 | 3 | 4 | 5 |
3. | Turn a key. | 1 | 2 | 3 | 4 | 5 |
4. | Prepare a meal. | 1 | 2 | 3 | 4 | 5 |
5. | Push open a heavy door. | 1 | 2 | 3 | 4 | 5 |
6. | Place an object on a shelf above your head. | 1 | 2 | 3 | 4 | 5 |
7. | Do heavy household chores (e.g., wash walls, wash floors). | 1 | 2 | 3 | 4 | 5 |
8. | Garden or do yard work. | 1 | 2 | 3 | 4 | 5 |
9. | Make a bed. | 1 | 2 | 3 | 4 | 5 |
10. | Carry a shopping bag or briefcase. | 1 | 2 | 3 | 4 | 5 |
11. | Carry a heavy object (over 10 lbs). | 1 | 2 | 3 | 4 | 5 |
12. | Change a lightbulb overhead. | 1 | 2 | 3 | 4 | 5 |
13. | Wash or blow dry your hair. | 1 | 2 | 3 | 4 | 5 |
14. | Wash your back. | 1 | 2 | 3 | 4 | 5 |
15. | Put on a pullover sweater. | 1 | 2 | 3 | 4 | 5 |
16. | Use a knife to cut food. | 1 | 2 | 3 | 4 | 5 |
17. | Recreational activities which require little effort | |||||
(e.g., cardplaying, knitting, etc.). | 1 | 2 | 3 | 4 | 5 | |
18. | Recreational activities in which you take some force | |||||
or impact through your arm, shoulder or hand | ||||||
(e.g., golf, hammering, tennis, etc.). | 1 | 2 | 3 | 4 | 5 | |
19. | Recreational activities in which you move your | |||||
arm freely (e.g., playing frisbee, badminton, etc.). | 1 | 2 | 3 | 4 | 5 | |
20. | Manage transportation needs | |||||
(getting from one place to another). | 1 | 2 | 3 | 4 | 5 | |
21. | Sexual activities. | 1 | 2 | 3 | 4 | 5 |
NOT AT ALL | SLIGHTLY | MODERATELY | QUITE | EXTREMELY | ||
---|---|---|---|---|---|---|
A BIT | ||||||
22. | During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups? (circle number) | 1 | 2 | 3 | 4 | 5 |
NOT LIMITED | SLIGHTLY | MODERATELY | VERY | UNABLE | ||
AT ALL | LIMITED | LIMITED | LIMITED | |||
23. | During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? (circle number) | 1 | 2 | 3 | 4 | 5 |
Please rate the severity of the following symptoms in the last week. (circle number) | ||||||
NONE | MILD | MODERATE | SEVERE | EXTREME | ||
24. | Arm, shoulder or hand pain. | 1 | 2 | 3 | 4 | 5 |
25. | Arm, shoulder or hand pain when you performed any specific activity. | 1 | 2 | 3 | 4 | 5 |
26. | Tingling (pins and needles) in your arm, shoulder or hand. | 1 | 2 | 3 | 4 | 5 |
27. | Weakness in your arm, shoulder or hand. | 1 | 2 | 3 | 4 | 5 |
28. | Stiffness in your arm, shoulder or hand. | 1 | 2 | 3 | 4 | 5 |
NO DIFFICULTY | MILD DIFFICULTY | MODERATE DIFFICULTY | SEVERE DIFFICULTY | SO MUCH DIFFICULTY THAT I CAN’T SLEEP | ||
29. | During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number) | 1 | 2 | 3 | 4 | 5 |
STRONGLY DISAGREE | DISAGREE | NEITHER AGREE NOR DISAGREE | AGREE | STRONGLY AGREE | ||
30. | I feel less capable, less confident or less useful because of my arm, shoulder or hand problem. (circle number) | 1 | 2 | 3 | 4 | 5 |
DASH DISABILITY/SYMPTOM SCORE = ([(sum of n responses/n) − 1] × 25, where n is the number of completed responses). A DASH score may not be calculated if there are greater than 3 missing items.
The mean age of the patients in triceps sparing group was 38.0 ± 5.0 while the mean age of the patients in triceps splitting group was 36.0 ± 6.0 with p value = 0.311 which was found to be statistically non significant. Out of the 15 patients in triceps splitting group, 7 were males and 8 were females while in the triceps paring group, out of 17 patients , 10 were males and 7 were females as shown in
The fractures in both the groups united uneventfully with no post operative radial nerve palsies in either group as shown in
The mean time of union in triceps sparing group was 12.0 ± 3.6 months while the mean duration of union in triceps splitting group was 11.8 ± 2.8 with p value = 0.863, which was found to be statistically non significant.
SEX | TRICEPS SPARING | TRICEPS SPLITTING |
---|---|---|
MALES | 10 | 7 |
FEMALES | 7 | 8 |
TOTAL | 17 | 15 |
Radiological union was declared when three out of four cortices united on standard AP and lateral views and clinical union was confirmed when there was absence of pain or tenderness at fracture site.
Triceps sparing group had greater elbow flexion (140.0 ± 4.0) compared to triceps splitting group (126.0 ± 10.0) with p = 0.001. Extension contracture was also significantly less in triceps sparing (5.0 ± 6.0) group as compared to triceps splitting group (24.0 ± 8.0) with p < 0.001.
The patients in both the groups were given DASH questionnaires which was assessed at the final follow up. However, there was no statistically significant difference in terms of DASH scores between the two groups with DASH symptom score being (24.28 ± 10.14) in the sparing group as compared to (30.41 ± 14.36) in the splitting group with p = 0.169.
The aim of this study was to compare the clinical and functional outcome of extra-articular distal humerus fractures treated with triceps splitting and triceps sparing approaches. The true triceps sparing technique described by Schildhauer [
Various authors have compared the triceps splitting approach with olecranon osteotomy approach and have reported favorable results [
Remia et al. [
Emmanuel et al. [
The limitations of this study are that sample size is small and the choice of surgical approach was based on discretion of treating surgeon.
Both the triceps splitting as well as triceps sparing approach can be used to treat extra articular distal humerus fractures (AO/OTA TYPE A). Both the approaches result in similar functional outcome but triceps sparing approach results in better elbow ROM and less extension contracture in the final follow up. We therefore recommend triceps sparing approach for treating extra articular distal humerus fractures based on our study.
The patient has given his informed consent for the case report as well as for his photographs to be published.
Authors declare that they have no conflict of interest.
Singh, J., Kalia, A., Dahuja, A. and Bansal, K. (2018) Functional Outcomes after Triceps Splitting versus Triceps Sparing Approach for Extra-Articular Distal Humerus Fractures. Open Journal of Orthopedics, 8, 85-94. https://doi.org/10.4236/ojo.2018.83011