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Large image of Figs. 1.

Figs. 1

Plain radiographs (Fig.1-A) revealed capitellar, trochlear, and lateral epicondylar fractures. A computed tomography scan (Fig. 1-B) showed a capitellar fracture with posterior wall comminution of the lateral condyle and trochlear fracture with lateral fragment separation. Anterior articular fragments were greatly displaced in the proximal direction. cap: capitellum, d tro: distal fragment of trochlea, l tro: lateral fragment of trochlea, epi: lateral epicondyle

Large image of Figs. 2.

Figs. 2

Distal part of the humerus (arrow) was osteotomized (Fig.2-A) and distal humeral fragment was turned in the clockwise direction to acquire an adequate visualization and stable fixation of articular fragments (Fig. 2-B).

Large image of Fig. 3.

Fig. 3

Plain radiographs taken twelve months after surgery showed union without arthritic changes or osteonecrosis in the capitellum and trochlea.

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ABSTRACT

A 60-year-old woman sustained a coronal shear fracture of the distal humerus. Open reduction and internal fixation were performed using distal humeral osteotomy combined with posterior olecranon osteotomy to obtain visualization of the anterior articular surfaces. Radiographs revealed union without osteonecrosis in the capitellum and trochlea at final visit. Distal humeral osteotomy combined with posterior olecranon osteotomy is recommended as a surgical option for coronal shear fractures of the distal humerus with posterior wall comminution when there is a need for two incisions, similar to the combined anterior and posterior approach.

The surgical approach for open reduction and internal fixation (ORIF) of coronal shear fractures of the distal humerus depends on multiple factors including fracture pattern, extent of articular involvement, rehabilitation protocols, associated soft tissue injury, and surgeon preference14x14Pollock, J.W., Athwal, G.S., and Steinmann, S.P. Surgical exposures for distal humerus fractures: a review. Clin Anat. 2008; 21: 757–768https://doi.org/10.1002/ca.20720

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. Common approaches include the extensile lateral approach,17x17Ruchelsman, D.E., Tejwani, N.C., Kwon, Y.W., and Egol, K.A. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am. 2008; 90: 1321–1329https://doi.org/10.2106/JBJS.G.00940

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anterolateral approach,5x5Imatani, J., Morito, Y., Hashizume, H., and Inoue, H. Internal fixation for coronal shear fracture of the distal end of the humerus by the anterolateral approach. J Shoulder Elbow Surg. 2001; 10: 554–556

Abstract | Full Text | Full Text PDF | PubMed | Scopus (41)
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and posterior olecranon osteotomy approach,2x2Coles, C.P., Barei, D.P., Nork, S.E., Taitsman, L.A., Hanel, D.P., and Bradford Henley, M. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006; 20: 164–171https://doi.org/10.1097/00005131-200603000-00002

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and several studies have recently reported a medial approach,19x19Yoshida, S., Sakai, K., Nakama, K., Matsuura, M., Okazaki, S., Jimbo, K. et al. Treatment of Capitellum and Trochlea Fractures Using Headless Compression Screws and a Combination of Dorsolateral Locking Plates. Cureus. 2021; 13: e13740https://doi.org/10.7759/cureus.13740

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| Google ScholarSee all References
lateral epicondyle osteotomy,10x10Li, J., Martin, V.T., Su, Z.W., Li, D.T., Zhai, Q.Y., and Yu, B. Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature. World J Clin Cases. 2021; 9: 4318–4326https://doi.org/10.12998/wjcc.v9.i17.4318

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and disruption of lateral collateral ligament complex (LCLC)1x1Chang, A.L., Dieterich, J.D., DiPrinzio, E.V., and Kim, J.M. Surgical Approach and Internal Fixation Techniques for Intra-Articular Distal Humerus Fracture With Coronal Shear Capitellar Fracture. Tech Hand Up Extrem Surg. 2020; 25: 25–29https://doi.org/10.1097/BTH.0000000000000301

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,16x16Ring, D. Open reduction and internal fixation of an apparent capitellar fracture using an extended lateral exposure. J Hand Surg Am. 2009; 34: 739–744https://doi.org/10.1016/j.jhsa.2009.01.026

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to treat complex coronal shear fractures of the distal humerus.

We introduce the posterior approach using double osteotomy (distal humerus and olecranon) for coronal shear fracture of the distal humerus with posterior wall comminution.

Case report

A 60-year-old woman presented to the emergency department after she accidentally fell from a ladder. Radiographs and a computed tomography scan revealed capitellar, trochlear, and lateral epicondylar fractures with posterior wall comminution of the lateral condyle, and anterior articular fragments were greatly displaced in the proximal direction (Fig.1-A, 1--B).

 Opens large image

Figs. 1

Plain radiographs (Fig.1-A) revealed capitellar, trochlear, and lateral epicondylar fractures. A computed tomography scan (Fig. 1-B) showed a capitellar fracture with posterior wall comminution of the lateral condyle and trochlear fracture with lateral fragment separation. Anterior articular fragments were greatly displaced in the proximal direction. cap: capitellum, d tro: distal fragment of trochlea, l tro: lateral fragment of trochlea, epi: lateral epicondyle

ORIF was performed 12 days following the initial injury. We opted to use the posterior olecranon osteotomy approach; thus, the patient was placed in the right lateral decubitus position under general anesthesia. After the posterior olecranon osteotomy, the olecranon and the triceps muscle were reflected proximally, and we attempted to reduce the anterior articular fragments of the capitellum and trochlea through the ulnohumeral joint. These fragments could not be observed directly due to the large displacement in the proximal direction. In order to visualize and reduce these fragments, a distal humeral osteotomy was performed (Fig. 2-A). The distal humeral osteotomy was performed 2 cm proximal to the olecranon fossa. The fragment of the lateral epicondyle was mobilized laterally, and the distal part of the humerus was turned in the clockwise direction while making the intact medial collateral ligament as a pivot point (Fig. 2-B). There were no periosteal attachments to the lateral and distal trochlea; therefore, these fragments were assembled on the back table with a headless compression screw. The reduced trochlea and capitellum were fixed from the anterior to posterior direction using other headless compression screws. All screw heads were buried beneath the articular surface. The osteotomy site of the distal humerus was reduced and stabilized provisionally with medial cerclage wires, followed by definitive medial plate fixation of the distal humerus. The fragment of the lateral epicondyle was reduced and fixed with a posterolateral plate of the distal humerus using its lateral support in addition to lateral cerclage wires. Finally, the osteotomized olecranon was fixed with tension band wire fixation using a cannulated screw. After immobilization in a splint for four weeks, the patient began active range of motion exercises. When clinical and radiographic evidence of fracture union was evident, strengthening exercises could be initiated. Twelve months after surgery, the patient had minimal elbow pain with an active range of motion from 30° to 130° flexion, 70° pronation, and 90° supination. Radiographs revealed a complete bony union without arthritic changes and osteonecrosis in the capitellum and trochlea (Fig. 3).

 Opens large image

Figs. 2

Distal part of the humerus (arrow) was osteotomized (Fig.2-A) and distal humeral fragment was turned in the clockwise direction to acquire an adequate visualization and stable fixation of articular fragments (Fig. 2-B).

 Opens large image

Fig. 3

Plain radiographs taken twelve months after surgery showed union without arthritic changes or osteonecrosis in the capitellum and trochlea.

DISCUSSION

There are many surgical options to treat coronal shear fracture of the distal humerus such as fragment excision,4x4Grantham, S.A., Norris, T.R., and Bush, D.C. Isolated fracture of the humeral capitellum. Clin Orthop Relat Res. 1981; 161: 262–269

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| Google ScholarSee all References
ORIF,11x11McKee, M.D., Jupiter, J.B., and Bamberger, H.B. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996; 78: 49–54

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| Google ScholarSee all References
arthroscopic reduction and fixation,8x8Kuriyama, K., Kawanishi, Y., and Yamamoto, K. Arthroscopic-assisted reduction and percutaneous fixation for coronal shear fractures of the distal humerus: report of two cases. J Hand Surg Am. 2010; 35: 1506–1509https://doi.org/10.1016/j.jhsa.2010.05.021

Abstract | Full Text | Full Text PDF | PubMed | Scopus (31)
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and total elbow arthroplasty6x6Kamineni, S. and Morrey, B.F. Distal humeral fractures treated with noncustom total elbow replacement. Surgical technique. J Bone Joint Surg Am. 2005; 87: 41–50https://doi.org/10.2106/JBJS.D.02871 (Pt 1)

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; however, ORIF is considered the gold standard for providing anatomical reduction with stable fixation and initiation in early range of motion exercises15x15Ring, D., Jupiter, J.B., and Gulotta, L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003; 85: 232–238https://doi.org/10.2106/00004623-200302000-00008

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. The limited surgical window makes it difficult to obtain stable internal fixation to allow early motion. To achieve good outcomes, it is essential to choose a suitable surgical approach that provides direct visualization of fracture fragments and facilitates anatomical reduction of the fracture fragments10x10Li, J., Martin, V.T., Su, Z.W., Li, D.T., Zhai, Q.Y., and Yu, B. Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature. World J Clin Cases. 2021; 9: 4318–4326https://doi.org/10.12998/wjcc.v9.i17.4318

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. Olecranon osteotomy provides the most visualization of the distal humerus articular surface, providing just over 50% exposure. Wu et al reported the anterior approach to the distal humerus provides access to 46% of the articular surface22x22WU, Z.Z., Wang, J.D., Ji, X.X., Ma, Z.J., Wu, J.H., and Wang, Q.G. Surgical exposure of the distal humeral fractures: An anatomical study of the anterior, posterior, medial and lateral approaches. Chin J Traumatol. 2018; 21: 356–359https://doi.org/10.1016/j.cjtee.2018.07.006

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.

The posterior olecranon osteotomy approach is used when there are capitellar and trochlear fractures with posterior wall comminution of the lateral or medial condyle3x3Dubberley, J.H., Faber, K.J., Macdermid, J.C., Patterson, S.D., and King, G.J. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am. 2006; 88: 46–54https://doi.org/10.2106/JBJS.D.02954

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. This approach can provide the widest exposure of the articular surfaces of the distal humerus; however, exposure of anterior articular surfaces is limited even if the elbow is passively flexed to the fullest extent possible. Thus, several supplementary procedures for obtaining an adequate visualization on this approach have been reported such as lateral epicondyle osteotomy10x10Li, J., Martin, V.T., Su, Z.W., Li, D.T., Zhai, Q.Y., and Yu, B. Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature. World J Clin Cases. 2021; 9: 4318–4326https://doi.org/10.12998/wjcc.v9.i17.4318

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and release of the LCLC1x1Chang, A.L., Dieterich, J.D., DiPrinzio, E.V., and Kim, J.M. Surgical Approach and Internal Fixation Techniques for Intra-Articular Distal Humerus Fracture With Coronal Shear Capitellar Fracture. Tech Hand Up Extrem Surg. 2020; 25: 25–29https://doi.org/10.1097/BTH.0000000000000301

Crossref | Scopus (1)
| Google ScholarSee all References
,16x16Ring, D. Open reduction and internal fixation of an apparent capitellar fracture using an extended lateral exposure. J Hand Surg Am. 2009; 34: 739–744https://doi.org/10.1016/j.jhsa.2009.01.026

Abstract | Full Text | Full Text PDF | PubMed | Scopus (21)
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. When the LCLC is released from the lateral condyle of the humerus, the decreased blood supply may potentially cause posterolateral rotatory instability (PLRI) with osteonecrosis in the capitellum12x12O’Driscoll SW. Acute, Recurrent, and Chronic Elbow Instabilities. In: Norris TR, editor. Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosement, IL: The American Academy of Orthopaedic Surgeons; 2002: pp 313-323.

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. Li et al proposed the lateral epicondyle osteotomy to prevent these disadvantages in ORIF for complex coronal shear fractures of the distal humerus10x10Li, J., Martin, V.T., Su, Z.W., Li, D.T., Zhai, Q.Y., and Yu, B. Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature. World J Clin Cases. 2021; 9: 4318–4326https://doi.org/10.12998/wjcc.v9.i17.4318

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. We also believe that osteosynthesis of the osteotomized site is more reliable than soft tissue repair such as reattachment of the LCLC. In this patient, a distal humeral osteotomy combined with the posterior olecranon osteotomy was performed to acquire an adequate visualization of anterior articular surfaces, because we determined that more soft tissue stripping was required to expose the greatly proximally displaced anterior articular fragments via the lateral epicondyle osteotomy approach alone.

An anterior approach in place of a distal humerus osteotomy may also be a viable option. The anterior approach combined with posterior olecranon osteotomy can potentially provide full exposure of the articular surfaces of the distal humerus by using two different windows. We believe that it is easier to reduce and fix fragments with one window of the distal humeral osteotomy combined with posterior olecranon osteotomy than two windows of the anterior approach combined with posterior olecranon osteotomy.

The distal humeral osteotomy poses a risk of nonunion of the osteotomy site of the distal humerus, because the metaphysis of the distal humerus 3 to 4 cm proximal to the olecranon, the so-called watershed area, is endured by a significantly lower density of arterial vessels per cancellous bone compared to the epicondylar regions7x7Kimball, J.P., Glowczewskie, F., and Wright, T.W. Intraosseous blood supply to the distal humerus. J Hand Surg Am. 2007 May-Jun; 32: 642–646https://doi.org/10.1016/j.jhsa.2007.02.019

Abstract | Full Text | Full Text PDF | PubMed | Scopus (47)
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,21x21Wegmann, K., Burkhart, K.J., Koslowsky, T.C., Koebke, J., Neiss, W.F., and Müller, L.P. Arterial supply of the distal humerus. Surg Radiol Anat. 2014 Sep; 36: 705–711https://doi.org/10.1007/s00276-013-1240-z

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. Minimal stripping of the periosteum and perforation of vessels should be carried out when performing the distal humeral osteotomy, and there is an option to make an oblique osteotomy for rigid fixation with a lag screw. If the patient is at risk of nonunion, such as the elderly or osteoporosis, there are options of low intensity pulsed ultrasound or the use of an anabolic agent such as parathyroid hormone or romosozumab.

“Good to excellent outcomes with ORIF are expected in the majority of patients with a distal humeral fracture9x9Lee, J.J. and Lawton, J.N. Coronal shear fractures of the distal humerus. J Hand Surg Am. 2012 Nov; 37: 2412–2417https://doi.org/10.1016/j.jhsa.2012.09.001

Abstract | Full Text | Full Text PDF | PubMed | Scopus (22)
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. The patient 60 years or older with a highly comminuted intra-articular fracture has a high risk for traumatic arthritis. Excision of the fragments could be employed with less risk, but it is fraught with complication and leads to instability, particularly when the trochlea is involved18x18Yari, S.S., Bowers, N.L., Craig, M.A., and Reichel, L.M. Management of distal humeral coronal shear fractures. World J Clin Cases. 2015 16; 3: 405–417https://doi.org/10.12998/wjcc.v3.i5.405

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. Although total elbow arthroplasty (TEA) is a good option in select elderly patients with a comminuted intra-articular distal humeral fracture deemed unrepairable, only short-term functional outcomes are available that deteriorate over time13x13Pogliacomi, F., Schiavi, P., Defilippo, M., Corradi, M., Vaienti, E., Ceccarelli, F. et al. Total elbow arthroplasty following complex fractures of the distal humerus: results in patients over 65 years of age. Acta Biomed. 2016; 13;87: 148–155 (No doi)

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. Moreover, long-term complications of the TEA such as loosening, peri-prosthetic fractures, and deep infections can be challenging to treat20x20Watson, J.J., Bellringer, S., and Phadnis, J. Coronal shear fractures of the distal humerus: Current concepts and surgical technique. Shoulder Elbow. 2020; 12: 124–135https://doi.org/10.1177/1758573219826529

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.”

To the best of our knowledge, there is no previous report using a distal humeral osteotomy. This is a novel approach to provide better visualization of anterior articular fragments of the trochlear and capitellum than the extended lateral approach combined with release of the LCLC; however, it may be necessary for the fracture to be accompanied by the lateral epicondyle of humerus fragment like this patient. We believe that a distal humeral osteotomy enables the conversion of a very difficult fracture pattern in the AO/OTA classification system, the type B fracture, into a less difficult C type fracture. Although this approach requires repairs to be performed with double-plate fixation, a posterolateral plate of the distal humerus can simultaneously fix the lateral epicondylar fracture and support the comminuted posterior aspect of the lateral condyle.

Conclusion

We reported the first documented case of a coronal shear fracture of the distal humerus treated via the distal humeral osteotomy combined with the posterior olecranon osteotomy approach. Based on our management experience, this approach is reliable and potentially useful for fractures of the distal humerus with posterior wall comminution of the lateral condyle. However, considering this report is limited to one case and a short follow-up period, additional high-quality clinical research may be required to verify the validity of this surgical intervention.

REFERENCES

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  18. 18Yari, S.S., Bowers, N.L., Craig, M.A., and Reichel, L.M. Management of distal humeral coronal shear fractures. World J Clin Cases. 2015 16; 3: 405–417https://doi.org/10.12998/wjcc.v3.i5.405
  19. 19Yoshida, S., Sakai, K., Nakama, K., Matsuura, M., Okazaki, S., Jimbo, K. et al. Treatment of Capitellum and Trochlea Fractures Using Headless Compression Screws and a Combination of Dorsolateral Locking Plates. Cureus. 2021; 13: e13740https://doi.org/10.7759/cureus.13740
  20. 20Watson, J.J., Bellringer, S., and Phadnis, J. Coronal shear fractures of the distal humerus: Current concepts and surgical technique. Shoulder Elbow. 2020; 12: 124–135https://doi.org/10.1177/1758573219826529
  21. 21Wegmann, K., Burkhart, K.J., Koslowsky, T.C., Koebke, J., Neiss, W.F., and Müller, L.P. Arterial supply of the distal humerus. Surg Radiol Anat. 2014 Sep; 36: 705–711https://doi.org/10.1007/s00276-013-1240-z
  22. 22WU, Z.Z., Wang, J.D., Ji, X.X., Ma, Z.J., Wu, J.H., and Wang, Q.G. Surgical exposure of the distal humeral fractures: An anatomical study of the anterior, posterior, medial and lateral approaches. Chin J Traumatol. 2018; 21: 356–359https://doi.org/10.1016/j.cjtee.2018.07.006

Disclaimers

Funding: No funding was disclosed by the authors.

Conflicts of Interest: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Patient Consent: Obtained

No institutional review board approval was required for this case report.

 

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