1 Introduction topenlarge
Trochlear fractures are difficult to see on radiographs. Computed tomography - with 3D reconstruction in particular - is especially useful for understanding the fracture anatomy.
There is often complex articular comminution.
Choice of approach
The best approach to the distal humerus depends on the main fracture morphology. In very complex fracture situations the posterior approach, using an osteotomy of the olecranon, provides an excellent access.
For less complex fractures, a lateral, anterior, or medial approach can be chosen to access the articular segment of the distal humerus.
The following describes the use of a posterior approach with an olecranon osteotomy.
2 Open reduction topenlarge
Clean the fracture site
Remove blood clots, small, unfixable loose pieces of bone, and any interposed tissue. Inspect the joint to ensure that no additional intraarticular fracture component is missed.
Disimpact fracture fragments
Many of the displaced fracture fragments are stable, which may suggest that they are appropriately aligned; however, these are often impacted into incorrect alignment. Using controlled force, these fragments must be disimpacted gently and brought into alignment with intact parts of the bone.
Reduce the fracture
Monitor fracture reduction by realigning the articular fracture lines.
Provisionally fix the fragments with small, smooth K-wires.
3 Internal fixation topenlarge
Headless screws, cannulated or non-cannulated, can be used to secure articular fragments that are large enough and have adequate bone quality.
Fixation of small fragments
Smaller articular fragments are secured with resorbable pins or headless compression screws.