Clinical Details

Clinical and radiological findings:  This case is a 78-year-old male following a trip and fall onto the left forearm where he sustained a comminuted intra-articular fracture of the left distal humerus. Plain film and CT imaging demonstrated a sagittally split trochlea with an ulnar sided wedge/split component which had displaced ventrally and proximally. With it subluxation of the joint could be seen. More radially is a comminuted fracture of the remaining trochlea and capitellum. Not clearly appreciated in the imaging is an avulsion of the radial epicondyle. This was demonstrated intraoperatively to be a independent fragment. The operation was done prone with the arm positioned over a small side attachment allowing elbow flexion of over 90°. A simple dorsal approach with a radial curve around the olecranon was utilized. Given the size of the ulnar fragment I thought an olecranon osteotomy could be avoided in this case. After a neurolysis of the nerve we developed medial and lateral windows and then debrided the dorsal joint capsule. The ulnar fragment was able to be reduced anatomically with little difficulty. This allowed a solid basis for reconstruction of the residual joint surface from ulnar to radial. Due to poor bone stock of the comminuted radial fragments we opted for a fragment specific fixation using Arthrex 2.0 mm PLLA Trim It drill pins (re-absorbable K wires) along with 2 HBS midi PA screws to reconstruct the articular surface piece by piece. Following the reconstruction of the joint surface we placed dorsalradial and medioulnar distal humerus locking plates in 90° plating technique. The coronal screws from both plates in combination with the sub chondral transverse PLLA K wires produced a satisfyingly stable fixation of the articular components.