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Isolated fracture of the humeral trochlea: a case report and review of the literature
© Abbassi et al. 2015
Received: 30 August 2014
Accepted: 3 March 2015
Published: 28 May 2015
Isolated fracture of the trochlea is a rarely reported entity. To the best of our knowledge, only 15 cases have been published. We report the case of a patient with an isolated fracture of the trochlea and discuss through a literature review the underlying mechanisms and the clinical, radiological and therapeutic features of this lesion. This work will significantly advance our understanding of this particular fracture.
A 21-year-old Caucasian man received an elbow injury. An anteroposterior radiograph showed only an irregularity of the medial joint space, but a lateral radiograph showed an intra-articular half-moon-shaped fragment that had moved up and forward. A computed tomography scan confirmed an isolated fracture of his trochlea. Open reduction and internal fixation were performed with a good outcome.
An isolated fracture of the trochlea is rare. The mechanisms generating this fracture are complex. As with other front-line fractures of the distal end of the humerus, such as the capitulum, we recommend open reduction and internal fixation for displaced fractures, with excision of the small osteochondral fragments that do not permit any osteosynthetic repair.
The first description of an isolated fracture of the humeral trochlea was in 1853 by Laugier. Thus, the trochlea fracture is also sometimes known as Laugier’s fracture . Although this description is old, these fractures remain rare. Our review of the literature identified only eight reported cases [2-9] and two limited series relating respectively to two and five cases [10,11]. We report a case of an isolated fracture of the trochlea that was treated surgically. The purpose of this study is to discuss the mechanisms and the diagnostic and therapeutic issues relating to this entity.
Open reduction and internal fixation was planned for our patient. The joint was opened through a medial approach, passing between the triceps brachii in the back and brachialis in the front. His ulnar nerve was dissected and protected. Accessing the joint capsule required disinsertion of the humeral part of his pronator teres, without interrupting the medial collateral ligament, which was intact. His trochlea was fractured across the front line, with persistence of the posterior wall. The fragment had moved up and forward without any compaction or loss of cartilage substance.
In the reported cases, the cancellous screws were passed from the non-articular area. Their direction was oblique, from front to back and from medial to lateral, fixing the trochlea to the capitulum. Alternatively, Herbert screws were inserted into the articular surface buried beneath the cartilage; their direction was perpendicular to the fracture line, securing the fragment of the trochlea to the posterior wall with maximum compression. We opted for this type of osteosynthesis because it is more stable from a biomechanical point of view. Patients whose fractures were treated with screws were immobilized for one to two weeks. K-wires were used in only two cases, and the patients were immobilized for three weeks. Fracture healing was obtained in all cases within six weeks. All results were good, except for one patient whose fracture was treated by K-wire, who developed osteoarthritis after three years of follow-up .
Isolated fracture of the trochlea is rare. The mechanisms generating this fracture are complex. We recommend open reduction and internal fixation for displaced fractures, with excision of the small osteochondral fragments that do not permit any osteosynthetic repair.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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