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A Meta-Analysis of Outcomes of Surgically Repaired Distal Humerus Fractures: How Best to Manage the Ulnar Nerve
Jonathan Shearin, MD; Andrew Miller, MD; Asif Ilyas, MD
Rothman Institute at Thomas Jefferson University, Philadelphia, PA
Introduction: Multiple complications have been reported after open reduction and internal fixation of distal humerus fractures including ulnar neuropathy, with varied rates reported between 0-51%. Moreover, there is no consensus regarding the appropriate handling of the ulnar nerve during the surgical repair of these fractures. Intraoperative management includes in situ decompression versus transposition of the nerve. Given the paucity of data, the goal of this meta-analysis was to assess if a best method exists for handling the ulnar nerve, specifically whether in situ decompression versus ulnar nerve transposition results in a lower incidence of post-operative ulnar neuropathy.
Methods: We used electronic databases to identify retrospective studies involving complications of surgical fixation of distal humerus fractures, specifically those that commented on handling of the ulnar nerve. Forty-six studies were identified and 5 trials met our inclusion criteria, totaling 362 patients. Extracted data from the eligible studies included patient characteristics, sample size, fracture type, length of follow-up, surgical fixation, intra-operative management of the ulnar nerve, and outcomes related to ulnar nerve function. Incidence of ulnar neuropathy was calculated as a whole, and specifically as it related to in-situ decompression versus transposition. Weighted effect size was calculated (Cohen’s D) as it pertained to in situ decompression versus transposition as well as presence or absence of a medial plate.
Results: In total, 187 patients underwent in situ decompression while 179 underwent transposition. Overall incidence of ulnar neuropathy was 19.3%. Of those patients undergoing in situ release, the incidence was 15.3% of post-operative ulnar neuropathy. Of those that underwent a transposition, there was a 23.5% incidence of ulnar neuropathy. Furthermore, 28% of patients with a medial plate developed post-operative ulnar nerve dysfunction.
Conclusion: There is a substantial incidence of postoperative ulnar nerve dysfunction following open reduction and plate and screw fixation of the distal humerus, particularly in cases with application of a medial plate. Postoperative ulnar neuropathy was more prevalent in those patients who underwent a transposition as opposed to in situ decompression. We can draw the conclusion that transposition of the ulnar nerve during this procedure does not have a protective effect, and instead in situ release may be more advantageous. Moreover, the findings of this meta-analysis discourage the placement of a medial plate when mechanically allowed.
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