Rev. bras. ortop. vol.50 número3

rev bras ortop.2015;50(3):352–355

w w w . r b o . o r g . b r

Case

Report

Bryan

and

Morrey

type

IV

intra-articular

fracture

of

the

distal

extremity

of

the

humerus

treated

surgically

with

anterior

access:

case

report

夽

Hugo

Bertani

Dressler

_,

_Ricardo

_Nunes

_Borges

_de

_Paula

SantaCasadeBeloHorizonte,BeloHorizonte,MG,Brazil

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t

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e

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o

Articlehistory:

Received23May2014 Accepted25June2014 Availableonline27April2015

Keywords:

Humeralfractures/surgery Elbow

Bonescrews Capitellum Trochlea

a

b

s

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c

t

Withinthecontextofelbow-leveltrauma,fractureswithacoronallineatthedistalextremity ofthehumerusarerareandresultfromindirectaxialtraumawiththearmextended.These aredifficult-to-treatintra-articularfractures,sincetheyrequirestableanatomicalreduction inordertomaintainjointcongruenceanddiminishcomplicationssuchasstiffness.This paperreportsacasethatoccurredinayoungmanwhosufferedafallfromaladderthat resultedinaBryanandMorreytypeIV_{intra-articularfractureofthehumerus.Theinjury} wastreatedsurgicallybymeansofananterioraccess,usingosteosynthesiswithtwoHerbert screwsthatwereinsertedfromanteriortoposterior.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Fratura

intra-articular

da

extremidade

distal

do

úmero

tipo

IV

_de

_Bryan

_e

Morrey

tratada

cirurgicamente

com

acesso

anterior:

relato

de

caso

Palavras-chave:

Fraturasdoúmero/cirurgia Cotovelo

Parafusosósseos Capitelo Tróclea

r

e

s

u

m

o

Nocontextodos traumatismos ao nível docotovelo,as fraturas comtrac¸o coronal da extremidadedistal do úmerosão rarase resultam de trauma axial indireto no mem-brosuperiorestendido.Sãofraturasintra-articularesdedifíciltratamentopordemandar reduc¸ãoanatômicaeestávelparaamanutenc¸ãodacongruênciaarticularereduc¸ãodas complicac¸õescomorigidez.Reporta-senesteartigoumcasoocorridoemumjovemdosexo masculino,vítimadequedadeescadaqueresultouemumafraturaintra-articulardoúmero distaltipoIV_{deBryaneMorreyequefoisubmetidoatratamentocirúrgicoporviadeacesso} anterioreosteossíntesecomdoisparafusosdeHerbertinseridosdeanteriorparaposterior. ©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽

WorkdevelopedattheOrthopedicsandTraumatologyServiceofSantaCasadeBeloHorizonte,BeloHorizonte,MG,Brazil.

∗ _{Correspondingauthor.}

E-mail:hugobertani@hotmail.com(H.B.Dressler). http://dx.doi.org/10.1016/j.rboe.2015.04.008

rev bras ortop.2015;50(3):352–355

353

Introduction

Fracturesofthecapitellumandtheirvariantsextendingtothe trochleaarerareandaccountforaround1%ofthefractures atelbowleveland6%ofthefracturesatthelevelofthedistal humerus.1,2_{Thisinjurypatternresultsfromashearingforce}

transmittedfromtheproximalextremityoftheforearmbones totheproximalextremityofthehumerusbymeansofaxial loading.Theseareintra-articularfracturesthatrequirecareful treatmentandanatomicalreductioninordertodiminishthe complications,suchasjointstiffness.3

Case

report

Thepatientwas a16-year-oldright-handedmale who suf-fered afall from a ladder in whichhis left hand took the force of the impact on the ground. This resulted in axial transmissionofenergythroughtheextendedleftarm.Inthe admissionexaminationattheemergencyservice,significant localpainwasnoted,withincreasedvolumeandlimitationof leftelbowmovement.Therewerenoskininjuries. Neurovas-cularexaminationoftheextremitydidnotdemonstrateany abnormalities. The initial radiographic evaluation revealed fracturingofthedistalextremityofthelefthumerus,without goodcharacterizationofthepattern(Figs.1and2).Inlateral view,the“doublearchsign”couldbeseen(Fig.2).4_Todefine

Fig.1–Anteroposteriorradiographicview,whichdoesnot

showthefracturepatternclearly.

Fig.2–Lateralradiographicviewshowingfracturewith

displacementanddouble-archsign.

thefracturepatternandenablebetterpreoperativeplanning, atomographicevaluationwasmade.Thisdefinedthecoronal outline,extendingfromthecapitellumtothetrochleaina sin-glefragment(Figs.3and4).Inthelightoftheimagingstudy, thefracturewasclassifiedastypeIVaccordingtothe classifi-cationofBryanandMorrey,1_{asmodifiedbyMcKeeetal.,}4_or

astype13B3.3accordingtotheAOclassification.5

Aftertheinitialevaluationhadbeenmade,fromwhich pro-visionalplaster-castimmobilizationwasperformedandother injuriesandcomorbiditieswereruledout,surgicaltreatment wasindicated.Thepatientwaskeptinhospitalforcare,and toawaitschedulingoftheoperationatthesamepublic ortho-pedicandtraumatologyservice.

After a hospitalstay of 14 days, the surgical treatment wasperformed. Itwasdecidedtouse ananterioraccessin the elbow, on a proximal internervous plane between the

Fig.3–Three-dimensionaltomographicreconstructionin

354

Fig.4–Three-dimensionaltomographicreconstructionin

medialviewshowingdisplacedbonefragment.

brachioradialismuscle(innervatedbytheradialnerve)and thebrachialismuscle(innervatedbythemusculocutaneous nerve),anddistallybetweenthebrachioradialisandthe prona-torteres muscle(innervated bythe mediannerve),6 _under

leftbrachial plexusblockinassociationwithsedation.The patientwaspositionedindorsaldecubituswiththeleftarm abductedandsupinatedonalateralsupporttable.After per-formingrigorousantisepsisandpreparationoftheskinusing achlorhexidinesolution,andplacementofsterilefields,the pneumatictourniquetwasinflated.Afterlayer-bylayer dis-section andidentification ofthe fracturefocus,anatomical reduction was performed, with fixation using two Herbert screwsthatwereinsertedfromanteriortoposterior.7

Discussion

Sincethiswasanintra-articularfracturepatternwith signif-icantdisplacement,asurgicalapproachbecamenecessaryin ordertoreestablishtheanatomyandjointcongruence.Inthis regard,openreductionwithstableinternalfixationbecause imperative.8_{Sincetheusualradiographicviewsdonotallow}

detailing of the fracture pattern, tomographic assessment plays an important role in understanding the injury and enablesbettersurgicalplanning.9

Inmostoftheseries,2–4,7_{thesurgicalapproachwaslateral,}

medialorposteriorandthesynthesismaterialwaspositioned fromposteriortoanterior.However,inthecasereportedhere, giventhatthetreatmentwasimplemented14daysafterthe fractureoccurred,thepossibilityofreductionbymeansofan anterioraccesswasconsideredtoallowforthepossibilityof osteoclasis(“calloclasis”),therebyexplainingthechoice.

Afteranatomicalreductionwith satisfactorypositioning of the bone fragment in its bed had been achieved, fix-ation was performed using two Herbert screws (Zimmer, Warsaw, Indiana) inserted from anterior to posterior. This

Fig.5–Anteroposteriorradiographicviewshowing

positioningofthesynthesismaterial.

couldbeobservedinthepostoperativeradiographic evalua-tion(Figs.5and6).

Althoughthesurgicalmethodusedinthis casewasnot the one chosenbythe majority ofthe surgeonswho treat this typeofinjury,thereisbackingforourapproachinthe

Fig.6–Lateralradiographicviewshowingpositioningof

thesynthesismaterialandanatomicalreductionofthe

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literature.1,3,4,6–8,10 _{Itsdisadvantageisitstechnicaldifficulty,}

giventheriskofneurovascularinjurytothestructuresofthe cubitalfossacubital.Ontheotherhand,itenablesextensive viewingofthefocusofthefracture,whichisespeciallyhelpful foranatomicalreduction,andthisisadecisivefactorforgood evolutionofthecase.10

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1. BryanRS,MorreyBF.Fracturesofthedistalhumerus.In: MorreyBF,editor.Theelbowanditsdisorders.Philadelphia: Saunders;1985.p.302–39.

2. DubberleyJH,FaberKJ,MacdermidJC,PattersonSD,KingGJ. Outcomeafteropenreductionandinternalfixationof capitellarandtrochlearfractures.JBoneJointSurgAm. 2006;88(1):46–54.

3.SenRK,TripahtySK,GoyalT,AggarwalS.Coronalshear fractureofthehumeraltrochlea.JOrthopSurg(HongKong). 2013;21(1):82–6.

4.McKeeMD,JupiterJB,BambergerHB.Coronalshearfractures ofthedistalendofthehumerus.JBoneJointSurgAm. 1996;78(1):49–54.

5.RüediTP,MurphyWM.PrincípiosAOdotratamentode fraturas.SãoPaulo:Artmed;2002.

6.PollockJW,AthwalGS,SteinmannSP.Surgicalexposuresfor distalhumerusfractures:areview.ClinAnat.

2008;21(8):757–68.

7.SinghAP,SinghAP,VaishyaR,JainA,GulatiD.Fracturesof capitellum:areviewof14casestreatedbyopenreduction andinternalfixationwithHerbertscrews.IntOrthop. 2010;34(6):897–901.

8.SimpsonLA,RichardsRR.Internalfixationofacapitellar fractureusingHerbertscrews.Acasereport.ClinOrthop RelatRes.1986;(209):166–8.

9.RingD,JupiterJB,GulottaL.Articularfracturesofthedistal partofthehumerus.JBoneJointSurgAm.2003;85(2): 232–8.