Ipsilateral simultaneous fracture of the trochlea involving the lateral end clavicle and distal end radius: a rare combination and a unique mechanism of injury

Isolated trochlea fracture in adults is a rare surgical entity as compared to its capitellar counterpart.It has been only mentioned sporadically in the literature as case reports.Fracture of the trochlea is accompanied by other elbow injuries like elbow dislocation,capitellum fracture,ulnar fracture and extraarticular condylar fracture.Here we report a unique case of isolated displaced trochlea fracture associated with fractures of the lateral end clavicle and the distal end radius.We propose a unique mechanism for this rare combination of injuries：typical triad of injury,i.e.fracture of the distal end radius with trochlea and fracture of the lateral end of the clavicle.Nonoperative treatment is recommended for undisplaced humeral trochlea fractures;but for displaced ones,anatomical reduction and internal fixation are essential to maintain the congruous trochleacoronoid articulation and hence to maintain the intrinsic stability of the elbow.     

Outcome of surgical treatment of type IV capitellum fractures in adults

Objective:Fractures of the capitellum and trochlea constitute less than 1％ of all elbow fractures and a shear fracture involving the capitellum and extending medially into most of the trochlea is rarel...     

Operative treatment of osteochondral nonunion of the distal humerus

Three patients with ununited osteochondral fracture fragments of the distal humerus (2 anterior capitellum and trochlea; 1 posterior trochlea) who had debridement and realignment of the nonunion, autogenous cancellous bone graft, and internal fixation an average of 6 (range, 5-8) months after injury were studied. The preoperative arc of elbow flexion was 80 degrees, 35 degrees, and 25 degrees. All 3 fractures healed without implant related complications or osteonecrosis. At 28, 27, and 46 months after the index procedure for nonunion, the patients had 95 degrees, 90 degrees, and 115 degrees arcs of elbow flexion. The scores on the Mayo Elbow Performance Index were 80, 80, and 95 (2 good, 1 excellent). Based on this limited experience, it seems that operative treatment of ununited osteochondral fracture fragments can achieve union without osteonecrosis. Attempts to improve the function of the native elbow rather than salvage the situation with interpositional or prosthetic arthroplasty are worthwhile.     

肘关节脱位与肱骨远端关节内骨折

Objective To describe dislocation of the elbow with articular fracture of the distal humerus,a type of elbow fracture-dislocation about which little has been written.Methods Four patients with a dislocation of the elbow and fracture of the distal humerus were identified.Three had dislocation and complex intraarticular fracture of the capitellum,trochlea,and lateral epicondyle.Results Two patients(one treated with a second operation to address avascular necrosis of the capitellum)achieved a functional arc of elbow motion and one patient was lost after removal of the implants 3 months after fracture with documented healing.The fourth patient had a complex open fracture dislocation involving the entire articular surface.An attempt to salvage the articular surface resulted in deep infection.Extensive heterotopic bone led to arthrodesis of the elbow.Conclusions Dislocations of the elbow with articular fracture of the humerus are uncommon.Most injuries involve the capitellum,lateral trochlea,and lateral epicondyle.Open reduction and internal fixation of the distal humerus fracture can restore stability without repairing the medial collateral ligament.     

Osteochondral flap fracture of the olecranon in a child

Osteochondral flap fracture in a child is rare. A 7 year-old boy with an osteochondral flap fracture is reported. Intraoperatively, the osteochondral fragment in the olecranon fossa was connected to a part of the medial collateral ligament. The authors suppose that this type of fracture occur not only as a result of a shearing force of the trochlea but also by a traction force through the medial collateral ligament when a complete tear of the medial collateral ligament was avoided for any reason. Furthermore, the immaturity of bone of the child may result in avulsion fracture, not in injury of the distal part of the ligament. Osteosynthesis with poly-L-lactic acid pins was useful to reacquire good elbow function.     

Anteromedial coronoid facet fractures

The anteromedial coronoid facet and the medial lip of trochlea represent one of the most important stabilizing columns of the elbow to prevent posterior dislocation of the elbow. But on average, 58 % of the anteromedial facet extends from the proximal ulnar without sufficient support by the proximal ulnar metaphysic. Some important soft tissue structures insert on the coronoid process. The fracture of anteromedial coronoid facet was recognized recently in clinic as a distinct type of the coronoid fracture. The special injury mechanism is varus posteromedial rotational injury force. This mechanism results in fracture of the anteromedial facet of the coronoid process most often associated with injury of the lateral collateral ligament (LCL) and either subluxation or complete dislocation of the elbow. But the anterior band of the medial collateral ligament is likely to be intact in the complex pattern injury. Standard radiographic evaluation of the fracture includes AP and lateral views of the elbow. Computed tomography, particularly 3D reconstruction, is particularly useful to diagnose the injury. But the LCL injury is easy to be missed, resulting in an earlier traumatic arthrosis. So, it is very important to increase recognition to the pattern injury. If the single distinct converse triangular fragment be found from the film, the surgeon should take care highly, and varus stress x-ray should be necessary to evaluate the LCL injury. Early experience suggests that the injuries should benefit from operative treatment. All injured structures should be repaired to restore the stability of the elbow. Intraoperative testing of the elbow stability is very important.     

Internal fixation for coronal shear fracture of the distal end of the humerus by the anterolateral approach

Six patients with a displaced coronal shear fracture of the distal end of the humerus were treated surgically with the anterolateral approach to the elbow, in which the capitulum and trochlea could be exposed widely. All underwent open reduction and internal fixation to reduce anatomically and mobilize the joint at an early stage. The mean duration of follow-up was 40 months (range, 24-54 months). All fractures healed with an acceptable functional result. In no case did we observe collapse of the capitulum or trochlea. We recommend open reduction by the anterolateral approach, which provides good exposure of the fracture sites and allows internal fixation to be accomplished with the use of Herbert screws, resulting in good fixation and compression of the bone fragments.     

Treatment of a coronal shear injury of the trochlea using a modified hedgehog-based technique through an anterior neurovascular interval approach: A case report

Introduction and importanceSurgical treatment for dislocated trochlear shear injuries is recommended due to its articular nature. However, the surgical exposure is often limited and large cartilaginous fragments with lack of subchondral bone stock makes a stable fixation technically challenging. Rapid swelling of the traumatized cartilage induces a size misfit between the cartilage of the fragment and the defect site. The use of a “modified hedgehog”-based technique might be a solution in these cases. However, this technique has only been described in chondral shear lesions of the knee.Case presentationA fifteen-year-old boy fell out of the still rings during gymnastics at school and suffered trauma to his elbow. A CT-scan of the right elbow showed a coronal shear injury of the trochlea with accompanied lateral condyle fracture of the humerus. The patient was treated throughout an anterior neurovascular approach with a modified hedgehog-based technique with triple fixation by creating an interlocking match of the cartilage, application of fibrin glue and additional screw fixation.Clinical discussionThe anterior neurovascular interval approach provides a clear exposure of the fracture site which is useful for anatomic reduction and triple fixation. The subsequent modified hedgehog-based technique has only been described once in children with shear-off chondral fragments of the knee, without additional screw fixation. Adding a screw fixation of the fragment creates some collateral damage to the cartilage and might not be necessary in future cases.ConclusionThe anterior neurovascular approach seems elegant and provides adequate exposure. Furthermore, a modified hedgehog-based technique delivers a stable triple fixation of the osteochondral fragment.     

Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament

PURPOSE: To determine the effectiveness of a protocol for the treatment of fracture-dislocations of the elbow based on the concept that, if dislocation of the elbow with associated fractures can be made to resemble a simple elbow dislocation by repairing or reconstructing the fractured structures, repair of the medial collateral ligament (MCL) will not be necessary. METHODS: Over a 5-year period, a single surgeon operated on 34 patients with a posterior dislocation of the elbow associated with one or more intra-articular fractures. The mean age of these 19 men and 15 women was 48 years. Associated fractures included the capitellum, trochlea, and lateral epicondyle in 3 patients; the olecranon in 1 patient; and the radial head in 30 patients (with concomitant fracture of the coronoid process-the so-called "terrible triad" of the elbow-in 22 patients, and concomitant fracture of the coronoid and olecranon in 1 patient). Operative treatment consisted of open reduction internal fixation (ORIF) or prosthetic replacement of all fractures and reattachment of the origin of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The MCL was not repaired. RESULTS: Two patients (1 with a terrible triad injury and 1 with fracture of the capitellum and trochlea) had postoperative instability related to noncompliance, had reconstructive procedures, and were considered failures. An average of 32 months after injury, the remaining 32 patients regained an average of 120 degrees ulnohumeral motion and 142 degrees forearm rotation. Twenty-five of 34 patients (74%) had good or excellent results according to the system of Broberg and Morrey. Patients with terrible triad injuries had an average of 117 degrees ulnohumeral motion and 137 degrees forearm rotation, and 17 of 22 patients (77%) had good or excellent results. CONCLUSIONS: MCL repair is unnecessary in the treatment of dislocation of the elbow with associated intra-articular fractures, provided that the articular fractures and the LCL are repaired or reconstructed.     

Osteochondral fracture of the trochlea associated with fracture-dislocation of the elbow

A case of osteochondral fracture of the trochlea occurring as part of a fracture-dislocation of the elbow is reported. The damage to the medial articular surfaces was not apparent until the joint was explored. The osteochondral fragment was replaced and fixed with Smillie's pins and the result of treatment was good.     

肘后路结合多种固定治疗肱骨远端冠状面骨折

目的探讨肘后路结合多种固定在肱骨远端冠状面骨折中的临床应用。 方法自2005年1月至2018年1月，本科共收治18例肱骨远端冠状面骨折患者，其中女15例、男3例，平均年龄50岁。摔倒10例，机动车交通事故4例，运动损伤1例，高处掉落3例。手术均顺利完成，采用肘后侧入路切开复位内固定，术中使用多种内固定方式固定骨折端。术后药物抗炎、止痛、预防固化性肌炎，携带肘关节支具保护6周，循序康复锻炼。 结果手术时间60~100 min，平均75 min。术后切口均I期愈合，均获骨性愈合，愈合平均时间6个月。本组患者上肢功能评分表（disability of arm shoulder and hand，DASH）评分20分。无骨不连和神经损伤病例，有2例创伤性关节炎（1例Broberg-Morrey1级，另1例Broberg-Morrey 2级，均行保守治疗），1例异位骨化（Brooker 1级，无症状）。 结论肘后路结合多种固定治疗肱骨远端冠状面骨折的方法，具有骨折显露充分、固定牢固、安全有效、易处理合并损伤等优点，临床疗效好。     

切开复位内固定治疗成人陈旧性肱骨小头-滑车冠状面骨折

目的 探讨切开复位内固定治疗成人陈旧性肱骨小头-滑车冠状面骨折的临床疗效.方法 回顾分析自2011-02-2018-12采用切开复位内固定治疗的9例成人陈旧性肱骨小头-滑车冠状面骨折,观察骨折愈合时间、术后并发症情况以及末次随访时肘关节屈伸活动度.结果 9例均顺利完成手术并获得随访,随访时间12～48个月,平均14.5...     

陈旧性肱骨远端冠状面骨折及其治疗

目的 探讨陈旧性肱骨远端冠状面骨折的诊断与治疗.方法 自2005年以来,对6例陈旧性肱骨远端骨折进行诊断与治疗.其中肱骨小头冠状面骨折4例,肱骨滑车冠状面骨折2例;受伤至就诊时间为8～16周,平均10.5周;肘关节平均活动度伸[(35±5)°,x/-±s,下同]、屈(50±10)°,前臂旋前(15±10)°、旋后(10±5)°.采用前外侧切口空心螺钉内固定,术后在带关节的外固定支架帮助下进行早期功能锻炼.结果 术后随访时间为4～18个月,平均11个月;骨折愈合时间为2～2.5个月,平均2.2个月.肘关节平均活动度为伸(15±9)°、屈(115±10)°,前臂旋前(65±5)°、旋后(70±5)°.1例并发尺神经麻痹症状者,经服用神经营养药物治疗,术后3个月恢复.按照Nayo肘关节评分标准评定:优3例,良2例,可1例;优良率为83.3%.结论 陈旧性肱骨小头与滑车的冠状面骨折易引起误诊,三维CT可明确诊断.术后在带关节的外固定支架帮助下进行早期功能锻炼,可获得较满意的关节功能.     

Elbow fracture-dislocation combined with Galeazzi fracture in adult: A case report and literature review

INTRODUCTIONGaleazzi fracture associated with ipsilateral posterior elbow dislocation and radial head fracture is a rare pattern of injury. Few reports exist that describes this injury pattern and its treatment. We describe a case report of simultaneous occurrence of Galeazzi fracture and ipsilateral dislocation of elbow.PRESENTATION OF CASEA 58 year-old female presented with Galeazzi fracture and posterior elbow dislocation associated with radial head fracture of left upper extremity. This was managed with closed reduction of the elbow, open reduction and internal fixation of the radial shaft fracture and K-wire stabilisation of the unstable distal radioulnar joint. Prophylactic fasciotomy was performed. At 10 months follow-up, the outcome was favourable with the American shoulder and elbow surgeon score of 92 and the disabilities of the arm, shoulder and hand score of 18.DISCUSSIONThe presumed mechanism of the injury was a forceful axial loading of a hyperpronated forearm and extended elbow. Our literature review shows that this pattern of injury occurs as a result of high energy trauma in young individuals, and successful outcome can be achieved by addressing each component of this complex injury individually.CONCLUSIONSimultaneous occurrence of elbow dislocation and Galeazzi fracture seems to be the result of extreme axial force and unique position of upper extremity at the time of impact. Individualised approach to each component of this injury can result in favourable outcome.     

Combined shear fractures of the trochlea and capitellum associated with anterior fracture-dislocation of the elbow.

This article presents two unusual cases of combined shear fractures of the trochlea and capitellum associated with anterior fracture-dislocation of the elbow. The mechanism of injury was thought to be a fall on the dorsum of a partially flexed forearm, in which the trochlea and capitellum are displaced by the fractured olecranon and the radial head.     

肱骨髁上骨折并发肘内翻畸形病理形态学分析

目的 :探讨肘内翻发生的病理形态学的改变特点。方法 :对 5 0例肘内翻进行X线片及术中所见病理形态学分析。结果 :大多数病例肱骨外髁膨大 ,内髁变小 ,滑车萎缩 ,尺骨鹰嘴窝变浅变形 ,肱骨远端尺偏、尺嵌及旋转 ,关节发育不均衡 ,尚有部分尺骨近端向肱骨尺神经沟方向滑脱。结论 :肘内翻是肱骨髁上骨折后由于肱骨远折端尺偏、尺嵌及内旋所引起 ,与骨骺损伤无关。内翻严重且日久者可造成肘关节的不稳定 ,关节面的不平衡从而出现肘外侧压痛等症状。宜早期发现 ,及早手术矫正。     

Outcome after open reduction and internal fixation of capitellar and trochlear fractures

BACKGROUND: Capitellar and trochlear fractures are uncommon fractures of the distal aspect of the humerus. There is limited information about the functional outcome of patients managed with open reduction and internal fixation. METHODS: The functional outcome of twenty-eight patients, with a mean age (and standard deviation) of 43 +/- 13 years, who were treated with open reduction and internal fixation for capitellar and trochlear fractures was evaluated at a mean duration of follow-up of 56 +/- 33 months. Patient outcomes were assessed with physical and radiographic examination, range-of-motion measurements, strength testing, and self-reported questionnaires (Short Form-36, Mayo Elbow Performance Index, American Shoulder and Elbow Surgeons Elbow Assessment Form, and Patient-Rated Elbow Evaluation scales). RESULTS: Eleven fractures involved the capitellum with or without fracture of the lateral ridge of the trochlea, four involved the capitellum and trochlea as one piece, and thirteen involved the capitellum and trochlea as separate fragments. These fractures were further characterized by the presence or absence of posterior comminution. Fourteen patients had isolated fractures, and fourteen had other elbow, forearm, or wrist injuries. Patients with more complex fractures required more extensive surgery, had more complications resulting in secondary procedures, and had poorer outcomes compared with those with simple fractures. The average score on the Mayo Elbow Performance Index (91 +/- 11), the average quality-of-life scores (46 on the physical component and 50 on the mental component of the Short Form-36), and the average range of motion (19 degrees to 138 degrees ) suggest favorable patient outcomes overall. Two comminuted fractures did not unite and required conversion to a total elbow arthroplasty. CONCLUSIONS: Patients with isolated noncomminuted capitellar and/or trochlear fractures have better results than those with more complex fractures. A classification system based on the radiographic patterns of these fractures is recommended.     

Chondral fracture of the lateral trochlea of the femur occurring in an adolescent: mechanism of injury

The trochlea of the femur is a very unusual site for chondral fracture. Little is known of the mechanism of injuries confined to the articular cartilage of the trochlea of the femur. A very unusual case of chondral fracture of the lateral trochlea of the femur occurring in an adolescent is reported here. The mechanism by which this injury occurred could be evaluated in this patient. The cartilage on the convex surface of the lateral trochlea was likely avulsed proximally by shear force of the patella during rapid extension of the weight-bearing knee from a flexed position. From a viewpoint of mechanism, this injury differs from the more usual osteochondral or chondral fractures of the weight bearing area of the femoral condyle, which are usually accompanied by twisting forces.     

Tricortical bone graft for primary reconstruction of comminuted distal humerus fractures

A tricortical bone graft harvested from the ilium was used to reconstruct a severely comminuted open intra-articular distal humerus fracture in an adult patient. The patient demonstrated a satisfactory functional and radiologic outcome despite loss of the lateral trochlear lip. When the lateral portion of the fractured trochlea cannot be repaired, excision of the fragments and insertion of an autogenous corticocancellous bone graft from the iliac crest can restore satisfactory function, even in the setting of an open fracture provided there is limited contamination and tissue devitalization. Radiocapitellar contact may be essential to good elbow function in this situation, because the corticocancellous bone graft does not restore the important lateral lip of the trochlea.     

Kaplan入路结合微型锁定钢板治疗肱骨远端冠状面骨折

目的探讨Kaplan入路结合微型锁定钢板治疗肱骨远端冠状面骨折的临床疗效。 方法对我科2012年3月至2016年12月收治的肱骨远端冠状面骨折患者进行回顾分析,共11例患者采用Kaplan入路,结合微型锁定钢板固定治疗方法。按Dubberley分型：IA型2例、IB型1例、ⅡA型3例、ⅡB型3例、ⅢA型1例、ⅢB型1例。术后复查肘关节摄片,了解关节面复位及内固定情况,门诊随访患者肘关节功能及骨折愈合情况。 结果所有11例患者均获得随访,无血管神经损伤,其中1例发生内侧异位骨化,经早期干预后未进展。 结论肱骨远端冠状面骨折采取外侧Kaplan入路,可充分显露关节面骨折块及骨折线,对于骨折复位及固定显露较好,可获得微型钢板稳定固定,术后患者可进行早期功能锻炼,肘关节功能恢复较好。