Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature

Abstract

BACKGROUND
Coronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage. Open reduction and internal fixation (ORIF) has become the preferred treatment because it provides anatomical reduction, stable internal fixation, and early motion, but the optimal surgical approach remains controversial.

CASE SUMMARY
We report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach, in which lateral epicondyle osteotomy was performed based on the extended lateral approach. We named the novel surgical approach the lateral epicondyle osteotomy approach. All patients underwent surgical treatment and were discharged successfully. All patients had excellent functional results according to the Mayo elbow performance score. The average range of motion was 118° in flexion/extension and 172° in pronation/ supination. Only case 2 had a complication, which was implant prolapse.

CONCLUSION
We demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.

Keywords: Distal humerus fracture, Coronal shear fracture, Lateral epicondyle, Surgical approach, Osteotomy, Case report.

Full text

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EDITORIAL
Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?
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Wang ZR, Ni GX
MINIREVIEWS
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Why MUC16 mutations lead to a better prognosis: A study based on The Cancer Genome Atlas gastric
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Huang YJ, Cao ZF, Wang J, Yang J, Wei YJ, Tang YC, Cheng YX, Zhou J, Zhang ZX
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Self-perceived burden and influencing factors in patients with cervical cancer administered with
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META-ANALYSIS
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Diagnosis and treatment of pediatric anaplastic lymphoma kinase-positive large B-cell lymphoma: A case
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Acute liver failure with thrombotic microangiopathy due to sodium valproate toxicity: A case report
4310
Mei X, Wu HC, Ruan M, Cai LR
Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three
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4318
Li J, Martin VT, Su ZW, Li DT, Zhai QY, Yu B
Pancreatic neuroendocrine carcinoma in a pregnant woman: A case report and review of the literature
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Minimally invasive surgery for glycogen storage disease combined with inflammatory bowel disease: A
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Efficacy of artificial liver support system in severe immune-associated hepatitis caused by camrelizumab:
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DOI: 10.12998/wjcc.v9.i17.4318 ISSN 2307-8960 (online)
CASE REPORT
Lateral epicondyle osteotomy approach for coronal shear fractures
of the distal humerus: Report of three cases and review of the
literature
Jie Li, Vidmi Taolam Martin, Zhi-Wen Su, Dong-Tai Li, Qi-Yi Zhai, Bo Yu
ORCID number: Jie Li 0000-0001-
6545-1070; Vidmi Taolam Martin
0000-0003-0179-3906; Zhi-Wen Su
0000-0002-9822-9326; Dong-Tai Li
0000-0002-6947-324X; Qi-Yi Zhai
0000-0002-5899-8403; Bo Yu 0000-
0001-9765-1341.
Author contributions: Yu B was
responsible for the patients’
surgical treatment; Martin VT, Su
ZW, Li DT, and Zhai QY were part
of the surgical team; Li J drafted
the manuscript; all authors read
and approved the final manuscript;
all authors helped collect the data
and write and revise the
manuscript.
Informed consent statement: All
patients gave their informed
consent.
Conflict-of-interest statement: All
authors declare that they have no
conflicts of interest to disclose.
CARE Checklist (2016) statement:
The authors have read the CARE
Checklist (2016), and the
manuscript was prepared and
revised according to the
CAREChecklist-2016.
Open-Access: This article is an
open-access article that was
selected by an in-house editor and
fully peer-reviewed by external
Jie Li, Vidmi Taolam Martin, Zhi-Wen Su, Dong-Tai Li, Qi-Yi Zhai, Bo Yu, Department of
Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282,
Guangdong Province, China
Corresponding author: Bo Yu, MD, PhD, Assistant Professor, Department of Orthopedics,
Zhujiang Hospital of Southern Medical University, No. 253 Industrial Avenue Middle Street,
Haizhu District, Guangzhou 510282, Guangdong Province, China. gzyubo@163.com
Abstract
BACKGROUND
Coronal shear fractures of the distal humerus are rare injuries and are technically
challenging to manage. Open reduction and internal fixation (ORIF) has become
the preferred treatment because it provides anatomical reduction, stable internal
fixation, and early motion, but the optimal surgical approach remains contro-
versial.
CASE SUMMARY
We report three cases of coronal shear fractures of the distal humerus treated
successfully by ORIF via a novel surgical approach, in which lateral epicondyle
osteotomy was performed based on the extended lateral approach. We named the
novel surgical approach the lateral epicondyle osteotomy approach. All patients
underwent surgical treatment and were discharged successfully. All patients had
excellent functional results according to the Mayo elbow performance score. The
average range of motion was 118° in flexion/extension and 172° in pronation/
supination. Only case 2 had a complication, which was implant prolapse.
CONCLUSION
We demonstrated that the lateral epicondyle osteotomy approach in ORIF is
effective and safe for coronal shear fractures of the distal humerus.
Key Words: Distal humerus fracture; Coronal shear fracture; Lateral epicondyle; Surgical
approach; Osteotomy; Case report
©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.

Li J et al. Coronal shear fracture of distal humerus
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P-Editor: Wang LL
Core Tip: Coronal shear fractures of the distal humerus are rare and technically
challenging to manage. Open reduction and internal fixation (ORIF) has become the
preferred treatment, but the optimal surgical approach remains controversial. We report
three cases of coronal shear fractures of the distal humerus treated successfully by
ORIF via the lateral epicondyle osteotomy approach, in which lateral epicondyle
osteotomy was performed based on the extended lateral approach. Our management
experience in the three cases demonstrated the effectiveness and safety of this novel
approach.
Citation: Li J, Martin VT, Su ZW, Li DT, Zhai QY, Yu B. Lateral epicondyle osteotomy
approach for coronal shear fractures of the distal humerus: Report of three cases and review of
the literature. World J Clin Cases 2021; 9(17): 4318-4326
URL: https://www.wjgnet.com/2307-8960/full/v9/i17/4318.htm
DOI: https://dx.doi.org/10.12998/wjcc.v9.i17.4318
INTRODUCTION
Coronal shear fractures of the distal humerus are rare, accounting for 6% of distal
humerus fractures and 1% of elbow fractures[1]. These fractures are technically
challenging to manage due to their small size, associated osteochondral fragments,
and propensity to displace, and they lead to limited elbow motion. Open reduction
and internal fixation (ORIF)[2-10] has become the preferred treatment because it
provides anatomical reduction, stable internal fixation, and early motion, but the
optimal surgical approach remains controversial. Currently, the common surgical
approaches include the anterolateral approach[2,3], posterior olecranon osteotomy
approach[4-7], and extended lateral approach[7-10].
We report three cases of coronal shear fractures of the distal humerus treated
successfully by ORIF via a novel surgical approach, in which lateral epicondyle
osteotomy was performed based on the extended lateral approach. We named the
novel surgical approach the lateral epicondyle osteotomy approach. We discuss the
advantages and disadvantages of various surgical approaches with regard to our
management experience.
CASE PRESENTATION
Chief complaints
Case 1: Right elbow and right upper arm pain accompanied by limited range of
motion (ROM).
Case 2: Left elbow pain accompanied by limited ROM.
Case 3: Right elbow pain accompanied by limited ROM.
History of present illness
Case 1: A 57-year-old man was admitted to our hospital with right elbow and right
upper arm pain accompanied by limited ROM for 12 d after he accidentally fell from a
ladder and landed on his right hand.
Case 2: A 64-year-old man was admitted to our hospital with left elbow pain
accompanied by limited ROM for 7 d after he accidentally fell onto his outstretched
left hand when walking down stairs.
Case 3: A 31-year-old man was admitted to our hospital with right elbow pain
accompanied by limited ROM for 3 d after he fell accidentally and landed on his right
elbow.
History of past illness
Case 1 underwent ORIF of the left calcaneus fracture 4 years earlier. Cases 2 and 3 had
no history of other diseases.

Li J et al. Coronal shear fracture of distal humerus
WJCC https://www.wjgnet.com 4320 June 16, 2021 Volume 9 Issue 17
Personal and family history
No family history to note.
Physical examination
Case 1: The physical examination revealed pain in the right elbow and right upper arm
accompanied by limited ROM but no open wounds.
Case 2: The physical examination revealed pain in the left elbow accompanied by
limited ROM but no open wounds.
Case 3: The physical examination revealed swelling and pain in the right elbow
accompanied by limited ROM but no open wounds.
Laboratory examinations
No obvious abnormalities were observed in the preoperative examinations.
Imaging examinations
Case 1: Radiographs revealed a right humerus shaft fracture and right capitellar
fracture (Figure 1A and B). A computed tomography scan revealed a right humerus
shaft fracture and right capitellar and trochlea fractures (Figure 1C and D).
Case 2: Radiographs revealed left capitellar and trochlea fractures (Figure 2A and B).
A computed tomography scan revealed left capitellar and trochlea fractures
accompanied by a left olecranon avulsion fracture (Figure 2C and D).
Case 3: Both radiographs and a computed tomography scan revealed right distal
humerus fractures, including lateral epicondyle, capitellum, and trochlea fractures
(Figure 3A-D).
FINAL DIAGNOSIS
Case 1
The final diagnosis was coronal shear fractures of the right distal humerus (type 3A
according to Dubberley et al[7]) and a right humerus shaft fracture.
Case 2
The final diagnosis was coronal shear fractures of the left distal humerus (type 3B
according to Dubberley et al[7]) accompanied by a left olecranon avulsion fracture.
Case 3
The final diagnosis was coronal shear fractures of the right distal humerus (type 2B
according to Dubberley et al[7]) accompanied by a lateral epicondyle fracture.
TREATMENT
Case 1
The examination performed after anesthesia showed that the affected elbow joint was
not unstable in varus or valgus. The extended lateral approach was used in ORIF, and
then, lateral epicondyle osteotomy was performed. The lateral epicondyle was
mobilized distally along with the origins of the common wrist and digit extensor
muscles and the lateral collateral ligament to provide ideal visualization of the distal
humerus articular surface, thereby allowing the fracture fragments to be anatomically
reduced under direct vision and the screws to be placed in the anterior-posterior
direction. During surgery, fragmentation of the articular surface was noted, and both
the capitellum and lateral trochlea were involved as separate fracture fragments. The
fracture fragments were reduced and temporarily fixed with K-wires. First, six screws
were placed as follows with countersinking: Five screws were placed in the anterior-
posterior direction, and the remaining screw was placed in the distal-proximal
direction. Then, a K-wire was inserted for bone stabilization. Finally, two lag screws
were used to stabilize the osteotomy region. The right humerus shaft fracture was also
treated by ORIF. Passive activities were encouraged starting on the second day after
surgery.

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Figure 1 Imaging examinations performed before and 12 mo after surgery. A-D: Preoperative radiographs and computed tomography scan showed a
type Dubberley 3A fracture and a right humerus shaft fracture; E and F: Radiographs taken 12 mo after surgery showed union without osteonecrosis.
Case 2
The examination after anesthesia showed that the elbow joint was not unstable in
varus or valgus. As in the first case, the extended lateral approach was used in ORIF,
and then, lateral epicondyle osteotomy was performed. During surgery, we noted that
the fracture involved the capitellum, medial trochlea, and posterior aspect of the
lateral condyle. The fracture fragments of the capitellum and trochlea were sequen-
tially reduced and temporarily fixed with K-wires; then, final fixation was performed
by placing screws in the anterior–posterior direction and in the distal–proximal
direction. All screws were inserted with the screw head buried beneath the articular
surface. Three K-wires were retained. Finally, the posterolateral plate of the distal
humerus was used to fix the osteotomy region and the fracture of posterior aspect of
the lateral condyle at the same time. Regarding the olecranon avulsion fracture, after
elevating the lateral aspect of the triceps from the distal humerus and the proximal
olecranon, we removed the free fracture fragments and repaired the triceps tendon
with two absorbable rivets. Passive activities were encouraged starting on the second
day after surgery.
Case 3
The examination after anesthesia showed that the elbow joint was unstable in varus
but not unstable in valgus. The extended lateral approach was used in ORIF, and a
lateral epicondyle fracture was noted. The origins of the lateral collateral ligament and
the common extensor muscles were attached to the fracture piece, as in the lateral
epicondyle osteotomies performed in the two cases above. During surgery, a large
fracture fragment consisting of the capitellum and the medial trochlea was seen, and it
was reduced and temporarily fixed with K-wires. Then, screws were placed in the
anterior–posterior direction and in the lateral–medial direction for fixation. Finally, the
fracture piece of the lateral epicondyle was reduced and fixed with a posterolateral
plate of the distal humerus. Passive activities were encouraged starting on the second
day after surgery.

Li J et al. Coronal shear fracture of distal humerus
WJCC https://www.wjgnet.com 4322 June 16, 2021 Volume 9 Issue 17
Figure 2 Imaging examinations performed before and 5.5 mo after surgery. A-D: Preoperative radiographs and computed tomography scan showed a
type Dubberley 3B fracture accompanied by a left olecranon avulsion fracture; E and F: Radiographs taken 5.5 mo after surgery showed union without osteonecrosis.
OUTCOME AND FOLLOW-UP
Case 1
At 12 mo after surgery, radiographs showed union without osteonecrosis (Figure 1E
and F). At the 33-mo follow-up, the postoperative elbow ROM values were as follows,
without pain or instability: Extension 33°, flexion 147°, pronation 86°, and supination
90°. The Mayo elbow performance score (MEPS) was 95 points (excellent), and the
disability of the arm, shoulder, and hand (DASH) score was 10 points.
Case 2
At 5.5 mo after surgery, radiographs showed union without osteonecrosis (Figure 2E
and F). At 6 mo after surgery, the patient underwent hardware removal because of
prominent implants, and during the second surgery, two K-wires and one loose screw
were removed. At the 12.5-mo follow-up, the postoperative elbow ROM values were
as follows, without pain or instability: Extension 21°, flexion 133°, pronation 78°, and
supination 90°. The MEPS was 100 points (excellent), and the DASH score was 1.7
points.
Case 3
At 16 mo after surgery, radiographs showed union without osteonecrosis (Figure 3E
and F). At the 20-mo final follow-up, the postoperative elbow ROM values were as
follows, without pain or instability: Extension 0°, flexion 128°, pronation 82°, and
supination 90° (Figure 4). The MEPS was 100 points (excellent), and the DASH score
was 0 points.
DISCUSSION
Coronal shear fractures of the distal humerus are rare injuries, accounting for 6% of
distal humeral fractures and 1% of elbow fractures[1]. With the development of digital
imaging and computed tomographic scans, the complex nature of these fractures is
now better understood[4,8]. These fractures are technically challenging to manage due
to their small size, associated osteochondral fragments, and propensity to displace,
and they can result in limited elbow motion. Compared to surgical treatments,

Li J et al. Coronal shear fracture of distal humerus
WJCC https://www.wjgnet.com 4323 June 16, 2021 Volume 9 Issue 17
Figure 3 Imaging examinations performed before and 16 mo after surgery. A-D: Preoperative radiographs and computed tomography scan showed a
type Dubberley 2B fracture accompanied by a lateral epicondyle fracture; E and F: Radiographs taken 16 mo after surgery showed union without osteonecrosis.
Figure 4 Elbow range of motion 20 mo after surgery.
nonsurgical treatments are often associated with worse results and more complic-
ations, such as elbow stiffness, traumatic arthritis, chronic pain, and joint
instability[11-13]. The surgical treatments available include ORIF[2-10], arthroscopic
surgery[14,15], fragment resection[16,17], and elbow joint replacement[18,19].
Currently, ORIF has become the preferred treatment because it provides anatomical

Li J et al. Coronal shear fracture of distal humerus
WJCC https://www.wjgnet.com 4324 June 16, 2021 Volume 9 Issue 17
reduction, stable internal fixation, and early motion. However, the limited surgical
window and associated osteochondral fragments make it difficult to obtain stable
internal fixation to allow early motion. Therefore, it is essential to choose a suitable
surgical approach that provides direct visualization of fracture fragments and
facilitates anatomical reduction of the fracture fragments to achieve good outcomes.
The common surgical approaches include the anterolateral approach, posterior
olecranon osteotomy approach, and extended lateral approach. Some surgeons choose
the anterolateral approach[2,3], which starts from the space between the biceps brachii
and brachioradialis. The anterolateral approach provides access to trochlear fragments
and facilitates anatomical reduction in the fragment without the need for lateral
collateral ligament complex (LCLC) release or olecranon osteotomy, but it is difficult
to stabilize the fractures with posterior comminution via this approach alone.
Therefore, ORIF through the anterolateral approach is suitable for Dubberley type A
fractures. However, the surgical dissection of this approach is relatively cumbersome,
given the risk of neurovascular injury to the structures of the fossa cubitalis.
The posterior olecranon osteotomy approach[4-7] has been used frequently in ORIF
for coronal shear fractures of the distal humerus, because it can provide the widest
exposure of the articular surfaces of the distal humerus[20,21]. This approach is
especially suitable for capitellar and trochlea fractures combined with posterior
comminution of the lateral or medial condyle. The disadvantages of the posterior
olecranon osteotomy approach include the need for additional internal fixation of the
osteotomy and the risk of complications related to osteotomy, such as olecranon pain,
nonunion, delayed healing, malunion, and implant prolapse[7,22,23].
We prefer the extended lateral approach[7-10]. A skin incision that is centered on
the lateral epicondyle and extended from the lateral column of the distal humerus to
approximately 2 cm distal to the radial head is made. The common origin of the wrist
and digit extensor muscles along with the anterior capsule is elevated anteriorly as a
full-thickness sleeve. A continuous full-thickness anterior soft-tissue flap is created by
connecting the distal Kocher space to the proximal exposed region. However, due to
obstruction from the LCLC, this approach does not provide adequate visualization of
the trochlear fragments or facilitate anatomical reduction of the fragments. In cases in
which the fracture involves the trochlea, the LCLC may need to be released to provide
adequate visualization of the trochlear fragments[7,10,24]. However, this additional
procedure increases the risk of posterolateral rotatory instability due to laxity of the
lateral collateral ligament[25]. Mighell et al[26] thought that release of LCLC would
affect the blood supply of the capitellum, thus affecting fracture healing. Therefore, we
performed lateral epicondyle osteotomy based on the extended lateral approach to
provide ideal visualization of the medial trochlea fragments and permit direct
reduction and screw placement in the anterior–posterior direction. Concerning screw
fixation, the ideal direction of implantation is still controversial. Sano et al[6] showed
that screws placed in the posterior–anterior direction fail to fix thin fragments because
the threads do not completely pass through them. Additionally, given the cancellous
screw’s solid core and higher ratio of the outer-to-inner diameter, anterior-to-posterior
screw insertion without countersinking may be more biomechanically robust than
headless screws as well as countersunk anterior-to-posterior screws and posterior-to-
anterior screws, although no direct comparisons have been made[27,28]. Matache
et al[29] conducted an anatomical study and indicated that there is a nonarticulating
zone for screw placement along the anterior aspect of the lateral trochlear ridge
throughout the normal elbow ROM. The use of a partially threaded cancellous screw
inserted anterior-to-posterior into this region without countersinking could theoret-
ically improve the stability of some fractures that extend into the anterolateral aspect
of the trochlea. Therefore, the lateral epicondyle osteotomy approach may be superior
to the olecranon osteotomy approach regarding the direction of screw implantation.
In lateral epicondyle osteotomy, two hollow lag screws or the posterolateral plate of
the distal humerus can be used for fixation. Regarding Dubberley type B fractures, the
posterolateral plate of the distal humerus can simultaneously fix the osteotomy region
and the fractured posterior aspect of the lateral condyle. The plate ensures firm
internal fixation for early postoperative functional exercises and maximizes the motion
of elbow joint function[8,30-32].
In conclusion, we report three cases of coronal shear fractures of the distal humerus
treated by ORIF via the lateral epicondyle osteotomy approach and discuss the
advantages and disadvantages of various surgical approaches. According to our
management experience, the lateral epicondyle osteotomy approach is reliable and
potentially useful for coronal shear fractures of the distal humerus. However, due to
the limited number of cases and the short follow-up time in this study, additional
high-quality clinical research needs to be conducted to verify the practicality of this

Li J et al. Coronal shear fracture of distal humerus
WJCC https://www.wjgnet.com 4325 June 16, 2021 Volume 9 Issue 17
surgical approach.
CONCLUSION
The three patients had excellent functional results according to the MEPS. The average
ROM was 118° in flexion/extension and 172° in pronation/supination. Only case 2
had one complication, which was implant prolapse. Our experience regarding the
management of these three cases initially proved the effectiveness and safety of the
lateral epicondyle osteotomy approach.
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