Lateral Trochlear Ridge: A Non-Articulating Zone for Anterior-to-Posterior Screw Placement in Fractures Involving the Capitellum and Trochlea

J Bone Joint Surg Am. 2019 Aug 7;101(15):e75. doi: 10.2106/JBJS.18.01270.

Abstract

Background: Coronal shear fractures of the distal aspect of the humerus that involve the capitellum and the trochlea are rare; nevertheless, they are difficult to treat because of the complex fracture patterns and osteochondral nature of the fragments, limiting optimal screw placement. The use of anterior-to-posterior screw fixation by a lag technique (without countersinking) could potentially improve the strength of the construct. Our primary research question was to anatomically determine if there is a non-articulating zone for screw placement along the anterior aspect of the lateral trochlear ridge (aLTR) throughout normal elbow range of motion.

Methods: Eight fresh-frozen cadaveric elbows were used. The region of interest was defined with 3 polymeric pins inserted in the inferior, middle, and superior-most aspects of the aLTR of each elbow, with use of an extensor digitorum communis (EDC) split approach. The elbows were then mounted on a magnetic resonance imaging (MRI)-compatible compression frame and subjected to high-resolution 7-T MRI at 90°, 120°, and 145° of flexion (positions of potential impingement), and at neutral and maximal pronation and maximal supination for each position of flexion. Portions of the aLTR that had free adjacent space were identified using the sagittal and coronal scans. This non-articulating region was identified as the "non-articulating zone" (NAZ).

Results: The NAZ was found to encompass the proximal 38.2% (range, 30.2% to 48.9%) of the aLTR, measuring, on average, 5.2 mm in width. It was consistently located either directly adjacent to the apex of the ridge or just medial to it. The distal 61.8% of the aLTR articulated with either the ulna or the radial head in some of the elbows.

Conclusions: Our results suggest that there is a portion of the aLTR that, despite being covered with articular cartilage, is non-articulating throughout normal elbow range of motion.

Clinical relevance: In situations in which headless anterior-to-posterior and posterior-to-anterior screw insertion results in inadequate fixation of capitellar-trochlear fractures, anterior-to-posterior lag screw instrumentation along the non-articulating portion of the aLTR may provide a location for additional fixation in some patients. However, because of variation between patients, each case must be individualized.

MeSH terms

  • Biomechanical Phenomena
  • Bone Screws*
  • Cadaver
  • Elbow Joint / injuries
  • Elbow Joint / surgery*
  • Female
  • Fracture Fixation, Internal / instrumentation*
  • Fracture Fixation, Internal / methods
  • Humans
  • Humeral Fractures / surgery*
  • Intra-Articular Fractures / surgery
  • Male
  • Observer Variation
  • Pronation / physiology
  • Range of Motion, Articular / physiology
  • Sensitivity and Specificity
  • Supination / physiology