Diagnosing and Treating Intra-Articular Fractures.

Abstract

There are several characteristics of intra-articular fractures (defined here as fractures contained within the joint capsule) that make them challenging for orthopaedists to diagnose and treat. First, they’re quite rare and usually small. Second, because they are contained inside joints, other anatomical structures can “hide” them from routine radiographic views or from less-than-vigilant imaging analysis. When intra-articular fractures occur in the developing skeleton, as they did in 3 of the cases in this month’s “Case Connections,” diagnosis and treatment can become even trickier. Regardless of patient age, extra-careful analysis of imaging studies and creative, careful, and not-necessarily surgical approaches to treatment are keys to successful outcomes for patients with these fractures. In the February 10, 2016, edition of JBJS Case Connector, Elmaraghy et al. presented the case of a 20-year-old woman in whom an isolated intra-articular trochlear fracture went undetected for 12 weeks after a traumatic fall. After the fall, the patient sought medical attention from several specialists, all of whom interpreted the radiographs as being unremarkable. When she presented to the authors, her chief symptom was loss of elbow motion (5° to 85° flexion-extension arc), as opposed to pain or instability. A careful review of repeat radiographs indicated a displaced fracture of the medial part of the trochlea (Fig. 1). Computed tomography (CT) with 3D reconstruction showed a small fragment that was displaced 8 mm anteriorly at the articular surface, plus a fragment malunion at the anterior aspect of the distal medial humeral cortex. Fig. 1 Preoperative anteroposterior (A) and lateral (B) elbow radiographs. Arrows indicate unexpected double contours, suggestive of a trochlear fracture. Intraoperatively, surgeons observed the malunited trochlear segment and injury to the flexor pronator mass. After performing a capsulotomy and synovectomy to remove callus and debris, surgeons exposed the fragment, which was healed proximally but had a …