Hastomo Agung, Ismail Maryanto, Tito Sumarwoto

1. Hastomo Agung, Ismail Maryanto, Tito Sumarwoto CLinical evaluation OF the intercondylar distal humeral fractures treated by olecranon osteotomy (cassebaum) IN soeharso orThopaedic Hospital suraKarta Orthopaedic and Traumatology, Facultyof Medicine SebelasMaret University- Dr.Moewardi General Hospital- Prof.Dr.dr.R.SoeharsoOrthopaedic Hospital, Surakarta. 2013

2. Introduction • Distal humeral fractures remain some of the most challenging injuries to manage complex anatomy with limited options for internal fixation • Treatment outcomes are often associated with elbowstiffness, weakness and pain limit activity of daily living • Osteotomy of the olecranon provides the best visualization of the distal humerus articular surface Rockwood And Green's Fractures In Adults, 7th Edition,2010

3. Classification Riseborough and Radin AO/OTA Rockwood And Green's Fractures In Adults, 7th Edition,2010

4. Objective To review outcomes of olecranon osteotomy procedure (Cassebaum) in patients with intercondylar distal humeral fractures at Soeharso Orthopaedic Hospital

5. Materials and Methods • Retrospective review (January 2011-December 2012) • Patients ( ≥18 y.o) with intercondyler distal humeral fracture treated by Chevron osteotomy olecranon (Cassebaum) • Exclusion criteria : • Severe comminutive fracture (Riseborough & Radin 4, AO/OTA 13.C3) • Other fracture at the same side extremity • Neurovascular disturbance • Loss contact patients

6. Materials and Methods • Post operative rehabilitation : • Immediate – 1 week: gentle AROM to the entire extremity as soft tissue allow • 2 weeks : grips strengthening exercises • 4 – 6 weeks: active & active assistive ROM exercise • 8 – 12 weeks: resistive exercise, starting with 1-2 pounds • In cases with tenuous fixation,range of motion exercises can be delayed for 2 weeks

7. Materials and Methods • Clinical outcome has been evaluated by using Disability of Arm, Shoulder and Hand Score • The DASH score has been proposed by the AAOSas the standard tool for evaluation of hand and upper limb disability • The DASH is scored by the disability/symptom questions (30 items) American Academy of Orthopaedic Surgeons Outcomes Instruments, JBJS, 2002

8. DASH Score

9. DASH Score

10. RESULTS

11. Sex Distribution Age Distribution Female:Male= 3:2 Mean age: 39 y.o

12. Fracture Types Timing of Surgery

13. DASH Score Mean score: 12,85 (mild disability)

14. DASH Score Age Groups

15. DASH Score Fracture types

16. DASH Score Timing of Surgery

17. DASH Score Moderate disability: carry heavy object (>10 lbs), wash their back, move arm freely, pain during spesific activity, elbow stifness

18. Female, 29 y.o Riseborough & Radin 3 3 months post operative

20. 6 months follow up

21. Discussion

22. Discussion • Intraarticular distal humeral fractures have a bimodal age distribution (peak incidences 12 -19 yearsand > 80 y.o) • Ramawan & Yasin, reviewed 10 patients with intraarticular distal humeral fractures treated by Cassebaum approach in Soetomo General Hospital  mean DASH score was 10,083 (mild disability) • McKee et al, reviewed 26 patients who underwent osteotomy olecranon for open distal humerus fractures mean DASH score was 24 (mild disability) - Athwal GS. Distal humerus fractures. In: Rockwood and Green’s Fractures in Adults. 7th ed. 2010. Lippincott Williams & Wilkins.USA.p.961 - McKee MD, Kim J, Kebaish K, et al. Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. J Bone Joint Surg Br 2000;82(5):646-651 - Ramawan E, Yasin M. Post operative clinical evaluation on olecranon osteotomy approach (cassebaum) for intraarticular distal humeral fractures in Soetomo general hospital.2012.

23. Discussion • Yilmas & Bulut, reviewed 21 pts with distal humerus fractures AO/OTA type C treated by olecranon osteotomy found: • fair and poor functional results in > 50 y.o & timing of surgery > 11 days • Early surgery (within 48-72 hours) may lead to decreases complications such as heterotopic ossification and stiffness • Reported incidence of stiffness after surgical treatment of distal humerus fractures varies from 0% to 49% • Yilmaz E, Bulut M. Outcomes of the distal intraarticular humeral fractures treated by olecranon osteotomy. Orthop Clin North Am. Vol 36.p. 241-7 • Athwal GS. Distal humerus fractures. In: Rockwood and Green’s Fractures in Adults. 7th ed. 2010. Lippincott Williams & Wilkins.USA.p.961

24. Discussion • Coles and colleagues, reported on 70 distal humerus fractures exposed using a chevron-shaped olecranon osteotomy exposure, noted that all osteotomies united • Hewins and colleagues, similarly noted a 100% osteotomy union rate in 17 consecutive patients with distal humerus fracture treated with a chevron-shaped olecranon osteotomy • Jupiter et al, recommend chevron-shaped osteotomy because it can increased postfixation stability • Coles CP, Barei DP, Nork SE, et al: The olecranonosteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus.  J Orthop Trauma  2006; 20:164-171. • Hewins EA, Gofton WT, Dubberly J, et al: Plate fixation of olecranon osteotomies.  J Orthop Trauma  2007; 21:58-62. • Jupiter JB, Neff U, Holzach P, et al: Intercondylar fractures of the humerus: an operative approach.  J Bone Joint Surg Am  1985; 67:226-239

25. conclusion

26. Conclusions • Clinical outcome following olecranon osteotomy procedure (cassebaum) for intercondyler humeral fracture is affected by multifactors • According to DASH Score, in our study shows quite satisfactory results with DASh Score 12,85 (mild disability) • Patients with age < 50 y.o & timing of surgery within 72 hours, have better DASH Score results • Further investigation with more patients and analysis is needed to get better conclusion

27. Thank You