Comparison of the lateral elbow dislocation approach and nondislocation approach for the reduction and internal fixation of distal humeral coronal fractures

Comparison of the lateral elbow dislocation approach and nondislocation approach for the reduction and internal fixation of distal humeral coronal fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of the lateral elbow dislocation approach and nondislocation approach for the reduction and internal fixation of distal humeral coronal fractures Shangzhi Li, Jingzhi Yang, Jiaxia Liu, Shijie Kang, Tao Jiang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7480587/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To compare the efficacy of the lateral elbow dislocation approach with that of the nondislocation approach for open reduction and internal fixation of distal humeral coronal fractures. Methods A retrospective cohort study which included 20 males and 32 females, was performed to analyze the clinical data of 52 patients with distal humeral coronal fractures who were admitted to Qilu Hospital(Qingdao) from January 2018 to December 2023 . Classify the fractures according to the Dubberley classification. Overall, 23 patients underwent surgery via dislocation approach and 29 underwent surgery via nondislocation approach. The operation time, intraoperative bleeding volume, incision healing, 3D CT assessment of the reduction within one week after surgery, MEPS at 3 months after surgery, fracture healing and complications at the last follow-up were compared between the two groups. Results All patients were followed for at least one year. The operation time was 149.44±40.29（60~221） minutes in the dislocation approach and 130.38±44.11（67~213） minutes in nondislocation approach group（ P >0.05）. The intraoperative bleeding volume was 124.30±47.02（70~300） mL in dislocation approach and 117.59±43.40（50~200） mL in nondislocation approach group （ P >0.05）. All incisions healed uneventfully in stage I. All patients had good reduction in the dislocation group, whereas only 17 other patients had good reduction and the other 12 patients presented a separation or step>2 mm in the nondislocation group（ P <0.05）. At 3 months after surgery, the MEPS was 90.44±5.82（80~100） points in the dislocation approach group, with an excellent and good rating of 100%. In contrast, the MEPS was 79.83±10.13（60~100） points in the nondislocation approach group, with an excellent and good rating of 75.9%（ P <0.05）.All fractures had healed at the last follow-up. In the nondislocation approach group, osteoarthritis occurred in 11 patients, including 6 with screw protrusion, 3 with heterotopic ossification and 2 of advanced age with osteophyte formation around the joint. In the dislocation approach group, osteoarthritis occurred in only 2 patients of advanced age, with osteophyte formation around the elbow joint, and no screw cutting or heterotopic ossification. Conclusion Compared with the nondislocation approach, the lateral elbow dislocation approach is able to provide complete exposure of the articular surface, achieve anatomic reduction, restore elbow function and reduce complications in distal humeral coronal fractures. Level of evidence Level III; Retrospective Cohort Comparison; Treatment Study Humeral fractures Fracture fixation Surgical Technique Operative approach Prognosis Retrospective study Figures Figure 1 Figure 2 Figure 3 Introduction Coronal fractures of the distal humerus are clinically rare, accounting for approximately 6% of distal humeral fractures and 1% of elbow fractures [1], and are caused mostly by posterolateral subluxation or dislocation of the elbow joint, cutting the humeral cephalic head and trochlea through the radial head and coronal process. The sequential distribution of injuries from anterior inferior to posterior upward and from lateral to medial is commonly referred to as annular injury [2]. Many humeral cephalic fractures extend into the trochlear and are often accompanied by lateral epicondylar fractures, posterolateral humeral and trochlea compression, articular surface fragmentation, and even medial epicondylar involvement [3], which cannot be reduced without surgical treatment. Open reduction and internal fixation are considered the treatments of choice, but the complexity of these intra-articular fractures has led to controversy over the optimal approach for surgical exposure and fixation [4-14]. The lateral or anterolateral approach mainly reveals anterior fracture fragments, and the posterior approach mainly reveals posterior fracture fragments, and the olecranon envelope between the anterior and posterior parts of the ulna has never been reported in this context. Hoyt et al [15] reported that the lateral elbow approach dislocated 95.9% of the anterior surface and 100% of the small head, which was much greater than that of the olecranon osteotomy approach for the ulna. Hackl et al [9] reported that 53 patients with coronal fractures of the distal humerus were exposed and fixed through the fracture space approach, and achieved good functional outcomes. In clinical practice, the dislocation method was modified in combination with the lateral approach, which could completely expose the articular surface of the distal humerus, achieve anatomical reduction, and ensure precise internal fixation. There is no relevant literature report on this method. The authors used a retrospective cohort study to analyze the clinical data of 52 patients with distal coronal fracture of the distal humerus admitted to the Department of Trauma Orthopedics of Qilu Hospital (Qingdao) from January 2018 to December 2023, and compared the efficacy of lateral elbow dislocation and nondislocation reduction and internal fixation to provide a new surgical method for distal coronal fracture of the humerus. 1. Materials and methods 1.1 General Information The inclusion criteria were as follows: (1) the distal coronal fracture of the humerus was Dubberley classification [ 16 ] type 2 or 3;(2) the surgical approach involved a lateral incision; (3) the time from injury to surgery was 2 weeks (4) the postoperative follow-up time was ≥ 12 months; and (5) there was no obvious abnormality in the function of the elbow joint before surgery. The exclusion criteria were as follows: (1) pathological fractures (2) pain or dysfunction of the affected elbow before injury; (3) open fracture combined with vascular or nerve damage or multiple fractures of the affected limb. A total of 52 patients with distal coronal fractures of the humerus were included, including 20 males and 32 females ,age 48.39 ± 17.15 (ranged from 15 ~ 80) years. According to Dubberley classification, 20 cases were type 2A, 9 cases were type 2B, 11 cases were type 3A, and 12 cases were type 3B. The causes of injury were as follows: 35 cases of fall injury, 6 cases of traffic injury, 7 cases of sports injury, and 4 cases of fall from height injury. Twenty-three patients were treated via the lateral elbow approach for fracture reduction and internal fixation (dislocation group), and 29 patients were treated via the traditional exposure method involving the lateral elbow approach for fracture reduction and internal fixation (nondislocation group). There was no significant difference in the general data of the two groups ( P > 0.05), which were comparable (Table 1 ). All patients signed an informed consent form. This study was approved by the Medical Ethics Committee of Qilu Hospital (Qingdao) of Shandong University (No. KYLL-KS-2024248). The study was conducted in accordance with the principles outlined in the Declaration of Helsinki. 1.2 Treatment The patient abducts the affected limb in the supine position, brachial plexus block anesthesia or general anesthesia is used, and then a balloon tourniquet is used to stop bleeding. After anesthesia, the lateral elbow approach is performed, which descends from approximately 5 cm proximal to the lateral aspect of the humerus, crosses the brachioradial joint, and enters posteriorly through the elbow muscle (Kocher approach); If the posterior part does not require plate support, a shorter straight incision (Kaplan approach) may be used to cut part of the brachioradialis muscle and anterior joint capsule at the distal end of the humerus. Dislocation group: First, the lateral condylar fracture line was found, the lateral collateral ligament and extensor insertion point of the bone block were flipped to the distal end, the elbow joint was semi-flexed and inverted, and the medial side was similar to a hinge rotation axis. The tension-free lower humerus distal anterior-lateral flip dislocation was maintained so that the distal articular surface of the humerus was completely exposed. For better exposure, a K-wire can be placed at the metaphyseal end to facilitate the inversion of the distal humerus and the posterior fracture line can be exposed ( Figure.1A-C ). If the lateral condyle is intact, sharply peel from the high position of the lateral condyle ( Figure.1D ), clean up the coronal bone block under direct vision, dissect and reset all the bone blocks from the inside to the outside and from the back to the front, temporarily fix the K-wire needle, and select headless screws [Stryker GmbH] for internal fixation one by one. If the posterior condyle is compressed, and crushed, and the bone is defected, a semicortical bone block can be taken from the lateral epicondyle and implanted in the defect, fixed by a 1.0 ~ 1.2 mm K-wire through the subchondral parallel articular surface. Finally, the lateral condyle can be reduced, and the hollow nail or headless nail [Stryker GmbH] can be fixed. In the nondislocation group, the anterior articular surface was exposed, the periosteal dissection device was inserted into the medial epicondyle, a K-wire was inserted into the olecranon of the ulna and externally rotated, and the joint space was enlarged to expose the articular surface behind the coronal process ( Figure.1E ). The bone block was reduced from the inside to the outside, the posterior bone block was used as a template on the olecranon articular surface of the ulna, the K-wire needle was temporarily fixed, the fluoroscopy fracture was reduced satisfactorily, and the appropriate position was selected for headless nail fixation [Stryker GmbH]. For two groups of patients with posterior compression, crushing, or anterior bone fragments that are not strong enough to support early functional exercise, anatomical locking plates or hinged frames [Stryker GmbH] are placed posteriorly to assist in fixation. Fluoroscopy again revealed that the fracture was satisfactorily reduced, the fixation screw did not penetrate the articular surface, and the joints were matched. If lateral collateral ligament insertion is dissected, it is necessary to rotate the center of the bone or use anchors [DePuy Mitek] to reconstruct lateral stability and suture the extensor insertion and brachioradialis muscles. Finally, the incision was flushed, the tourniquet was loosened, the bleeding was completely stopped, one indwelling drainage tube was placed, and the incision was closed layer by layer. 1.3 Postoperative management Antibiotics are routinely given once postoperatively. The drain was removed 48 hours after surgery. On the 3rd day, axial flexion and extension active function exercise was started, auxiliary axial flexion and extension function exercise of the unaffected limb was started 2 weeks after the operation, and passive traction function exercise was carried out 6 weeks later (the fixed brace was removed 6 weeks after the operation). Strength training started at 3 months. 1.4 Observation indicators The operation time, intraoperative blood loss, incision healing, reduction of 3D CT assessment within 1 week after surgery (separation or step > 2 mm as poor), MEPS[ 17 ] at 3 months after surgery, fracture healing and complications at the last follow-up were compared between the two groups. 1.5 Statistical Analysis Statistical analysis was performed using R version 4.10. The Shapiro-Wilk test was used to assess the normality of the data, and Levene's test was applied for homogeneity of variances. Measurement data that followed a normal distribution are presented as x̄ ± s, and inter-group comparisons were conducted using the independent two-sample t-test. Count data are expressed as percentages, and inter-group comparisons were made using Fisher's exact test. All tests were two-tailed. P < 0.05 was considered statistically significant. 2. Results All patients were followed up for 20.35 ± 8.36 (ranging from 12 ~ 46) months. There was no significant difference in operation time or intraoperative blood loss between the two groups ( P > 0.05, Table 2 ). The postoperative incisions were all healed in stage I. The dislocation group exhibited good reduction, while 17 patients in the nondislocation group showed good reduction, and 12 patients had separation or steps > 2 mm posterior to the articular surface. Three months after the operation, the MEPS of the dislocation group was 90.44 ± 5.82(80 ~ 100) points, and the MEPS of the nondislocation group was 79.83 ± 10.13༈60 ~ 100༉ points( t =-4.74, P = 0.0000211). According to the MEPS, 15 cases were excellent and 8 cases were good in the dislocation group, with an excellent and good rate of 100%. There were 10 excellent cases, 12 good cases, 7 middle cases, and 0 poor case in the nondislocation group, with an excellent and good rate of 75.9%༈ P = 0.0135༉. The fractures had healed at the last follow-up. In the nondislocation group, there were 11 cases of joint degeneration, including 6 cases of screw cutting, 3 cases of ectopic ossification, and 2 cases of simple periarticular osteophyte formation in elderly patients. In the dislocation group, 2 elderly patients had joint degeneration and simple osteophyte formation, and no screw incisions or ectopic ossifications were found. Typical cases are shown in Figs. 2 and 3 . 3. Discussion In the past, for coronal fractures of the distal humerus, the anterior humerus head and trochlea were exposed through the lateral and anterolateral approaches for reduction and internal fixation. The lateral approach is suitable for fractures involving the humeral cephalic head and a small part of the trochlea, and has the advantages of good exposure and safety [ 18 ]. It has also been reported that the lateral approach can clearly expose fracture areas such as the metaphysis, humeral cephalic head, and trochlea, and if necessary, the lateral collateral ligament can be peeled from the lateral epicondyle to increase the extent of exposure and rebuild lateral stability postoperatively [ 19 ]. The anterolateral approach provides extensive exposure of the anterior humeral cephalic head and trochlea to facilitate reduction and fixation of intra-articular fragments [ 20 ]. Durakbasa et al [ 21 ] suggested that Dubberley fractures of types 1, 2, and 3A fractures can be treated with the lateral Kaplan approach and the posterior approach for type 3B fractures. A survey [ 22 ] of 114 orthopedic surgeons in Italy revealed that for type 3 fractures, particularly those involving medial extension with or without posterior comminuted fractures, an olecranon osteotomy approach was used to obtain a global visualization of the joint surface, exposing all intra-articular fragments for fixation. However, Chang et al [ 23 ] concluded that the distal humerus was intra-articular with coronal fractures, that the humeral microcephalic fragments were usually displaced anteriorly and proximally, and that conventional ulnar olecranon osteotomy had difficulty adequately visualizing and fixing the small head shear fragments because of intact soft tissue attachment. In addition to ulnar olecranon osteotomy, they exposed the anterior bone fragment by dissecting the lateral collateral ligament and pronation of the distal humerus. Johnson et al [ 24 ] suggested that if the margin of a humeral cephalic fracture is 83° or behind 83° (centered at the center point of rotation and 2:46 on the clock surface), it can be accessed vertically via the posterior approach, whereas a fracture located before this threshold may require a lateral approach for expose. For the coronal fractures of the distal humerus with an intact lateral epicondyle, Zhang et al [ 25 ] adopted the lateral combined approach, which achieved good reduction and fixation of the fracture and satisfactory function of the elbow joint. In practice, the author reported that the lateral or anterolateral approach can expose the lateral or anterior part of the joint, but there is a fracture in the olecranon enveloping part of the ulna, especially the posteromedial side, which is difficult to expose. Hoyt et al [ 15 ] performed an osteotomy on the cadaver specimen via the lateral condyle and dislocated the distal humerus, revealing 95.9% of the anterior surface of the distal humerus and 100% of the small head. The author modified the dislocation method in combination with the lateral approach and reported that when the lateral condylar fracture was combined, the lateral condylar fracture fragment with the lateral collateral ligament and extensor insertion point was flipped distally to the distal end during the operation, and the distal end of the humerus was turned forward and lateral to the dislocation through semiflexion and inversion of the elbow joint. The medial side was similar to a hinge rotation axis, which could completely expose the articular surface of the distal end of the fracture and could be accurately reduced and fixed under direct vision. The lateral stability of the elbow joint can be restored by lateral condylar bone reduction and internal fixation of hollow nails. When the lateral condyle is intact, an attempt is made to sharply dissect the lateral collateral ligament and extensor insertion from the high lateral condyle, and the articular surface can also be completely exposed; however, lateral elbow stability needs to be restored by anchors or bony reconstruction. 3.1 Open reduction and internal fixation of elbow joint dislocation via the lateral approach to the elbow The advantages and disadvantages of coronal fracture of the distal humerus: Its main advantages include the following: (1) All the articular surfaces of the distal humerus can be exposed, anatomical reduction and internal fixation can be performed under direct vision, and the postoperative follow-up function is well recovered. For articular surface fractures surrounding the olecranon of the ulna at the distal end of the humerus, such as Dubberley type 2A and 3A fractures, the fracture line extends to the posterior coronoid process and Dubberley type B fractures, the conventional lateral side is exposed, and the distal articular surface of the anterior and lateral parts can only be exposed without dislocation, and the medial and posterior articular surfaces of the distal humerus cannot be exposed, making it difficult to reduce. The elbow joint is semiflexed and varus, and a K-wire is placed at the metaphyseal end, which is reversed anteriorly and backward to expose the distal end of the humerus and the posterior articular surface. The bone fragment is reduced and fixed under direct vision to achieve anatomical reduction. Postoperative CT also confirmed anatomic reduction. The MEPS of the dislocation group at 3 months after surgery was 90.44 ± 5.82(80 ~ 100), of which 15 cases were excellent and 9 cases were good, with an excellent and good rate of 100%. In the nondislocation group, only the anterior articular surface and the distal articular surface of the lateral part were exposed, and the distal medial and posterior articular surfaces were blind areas. The reduction group lacked anatomical landmarks, and the bone fragment could only be pushed to the distal end during the operation, blocked by the olecranon of the ulna, and used as a template for distal or posterior bone fragment reduction; thus, postoperative CT revealed 12 cases of medial or posterior separation or step of the distal articular surface > 2 mm. The MEPS in the nondislocation group at 3 months after surgery was 79.83 ± 10.13༈60 ~ 100༉, of which 10 cases were excellent, 12 cases were good, 7 cases were fair, and 0 case was poor, with an excellent and good rate of 75.9%. Consistent with the findings of Vasudeva [ 26 ], anatomical reduction of intra-articular fractures is a key factor in determining the prognostic functional recovery of distal coronal fractures. (2) Cutting screws should be avoided, and the incidence of joint degeneration should be reduced. In this study, although the dislocation group had a complex exposure process, the intraoperative view was clear and convenient for internal fixation, and there was no significant difference in operation time or intraoperative blood loss between the dislocation group and the nondislocation group. The posterior articular surface could not be exposed during the operation in the dislocation group, and the anterior and posterior articular surfaces could not be exposed during the operation. The results of reduction and internal fixation could only be evaluated by fluoroscopy, and the effect under direct vision could not be achieved owing to the complexity of the elbow joint due to the interference of intraoperative fluoroscopy [ 27 ]; thus, 6 cases of screw incisions were found on postoperative CT. There were two cases of isolated osteophyte formation in each group, both of which were composed of elderly patients, which was considered to be related to age. The remaining 3 cases of joint degeneration in the nondislocation group were accompanied by ectopic ossification, which may be related to the ability of the violent operation to better reveal clarity during the operation. Although the lateral approach for elbow dislocation is clearly revealed, the stable structure of the elbow joint is destroyed to varying degrees during the operation, and the stability of the elbow joint needs to be restored at the end of the operation. Li Ying et al [ 28 ] reported that the lateral approach results in poor exposure to the medial trochlea, and better clinical results can be achieved by increasing the exposure range through elbow subluxation, and paying attention to protecting or repairing the starting point of the lateral collateral ligament. It has also been suggested that dissection of the lateral collateral ligament increases the disruption of the blood supply to the humeral cephalic head and affects fracture healing [ 29 ]. Therefore, it is necessary to perform fine intraoperative operations to reduce posterior soft tissue damage and rebuild lateral stability after surgery. 3.2 Indications for open reduction and internal fixation of the distal coronal fractures of the distal humerus by lateral elbow approach dislocation The lateral elbow approach dislocation method is mainly suitable for patients whose coronal fracture line of the distal humerus is surrounded by the olecranon of the ulna and cannot be exposed anteriorly or laterally. For patients with a fracture line in front of the coronal process or a simple fracture with a distal coronal fracture line in front of the coronal process or a simple fracture, the lateral incision can be solved by nondislocation exposure without the need to use the dislocation method, whereas for Dubberley type 2A and 3A fractures extending to the posterior coronoid process and Dubberley type B fracture, that is, the ulna olecranon wrapping part of the fracture, the nondislocation method can only reveal the anterior articular surface and lateral part of the distal articular surface, and only the dislocation method can observe the medial or posterior articular surface of the distal humerus, anatomical reduction and internal fixation under direct vision. 3.3 Precautions for the treatment of distal humeral coronal fractures by open reduction and internal fixation with lateral elbow dislocation (1) Ligament stripping method: The lateral epicondylar ligament must be dissected at a high level, mainly to leave sufficient length for the reconstruction of the ligament insertion, which can increase the contact area with the bone bed and enhance increase stability and the healing effect. (2) Hemorrhagic protection of the humerus cephalic head: Kimball et al [ 30 ] found that the lateral column of the distal humerus was supplied mainly by the posterior side connecting to the blood vessels and that the medial column was evenly vascular in the anterior and posterior columns, with the trochlea, olecranon fossa, and coronary fossa being the co-innervation areas. The lateral collateral ligament and extensor insertion point are peeled off, so that the posterior side does not exceed the lateral condylar ridge, the posterior side can be cleaved longitudinally with soft tissue if the posterior surface is insufficient, and the posterior attachment tissue is preserved as much as possible to protect blood circulation. In concomitant condylar fractures, the attached soft tissue should be protected when the lateral condyle is turned over to protect the blood vessels entering the bone fragment. (3) Dislocation exposure method: the elbow joint is semiflexed and varus, the medial side is similar to a hinge rotation axis, and the distal end of the humerus under tension is turned forward to the lateral side to turn and dislocate, otherwise there will be medial traction, which increases the degree of medial injury, especially ulnar nerve traction injury. (4) Reconstruction of elbow joint stability: elbow joint stability assessment was routinely performed during the operation, and there was no instability or dislocation from elbow flexion to extension of 30°to 45°, which was considered good [ 31 ]. If elbow joint stability is suspected, a cantilever test [ 32 ] should be used for further evaluation or with the addition of a hinged external frame. 3.4 Management of complications of open reduction and internal fixation of the distal humerus with open reduction and internal fixation for lateral elbow dislocation In this study, two elderly patients in the dislocation group had simple periarticular osteophyte formation, which was considered to be related to age and accelerated joint degeneration after trauma. However, because the lateral and posterior dissections of this approach are too large, there may be potential complications of elbow joint instability or humeral cephalic necrosis. During the operation, the posterior soft tissue should be dissected as little as possible, and if it is indeed difficult to expose, it can be revealed by longitudinal splitting to reduce the destruction of blood vessels. After the completion of internal fixation, lateral stability is routinely reconstructed, stability assessment is performed, and if necessary, hinged external fixing bracket assists fixation. If the humeral-ulnar joint is mismatched on the postoperative 3D CT scan, indicating elbow instability, a cast of the flexed elbow is maintained for 3 weeks. During long-term follow-up, if there is necrosis or nonunion of the humeral microcephalic fragments and if the clinical symptoms are obvious, humeral microcephalic replacement surgery should be considered. In summary, for coronal fractures of the distal humerus, the fracture line extends to the medial or posterior aspect of the distal articular surface of the humerus, and the lateral approach to the elbow joint dislocation method can completely expose the fracture fragments compared with the nondislocation method. It can not only achieve direct reduction and fixation, anatomical reduction and accurate internal fixation, but also recover the function of the elbow joint well with few complications. The number of patients in this study was small, and the follow-up time was short; thus, it was necessary to expand the sample size and increase the follow-up time to further verify the efficacy of the lateral elbow approach for dislocation reduction and internal fixation in the treatment of distal coronal fractures of the humerus. Declarations Ethics approval and consent to participate This study was approved by the Medical Ethics Committee of Qilu Hospital (Qingdao) of Shandong University (No. KYLL-KS-2024248). The study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Consent for publication Written consent for the publication of this paper was obtained from the legal guardians of the patients. Competing interests The authors declare that they have no competing interests. Funding This research was supported by Medical and Health Scientific Research Project of Shandong (No.202304070922), Medical and Health Scientific Research Project of Qingdao(No.2024-WJKY149),Shandong Provincial Natural Science Foundation(No.ZR2024QH583) and Qingdao Key Clinical Specialty of Orthopedics Center(QDZDZK-2022095). We thank Key Laboratory of Qingdao in Medicine and Engineering for consultation and instrument availability that supported this work. Author Contribution Li,Yang and Bao wrote the main manuscript text . All authors reviewed the manuscript Acknowledgements Not applicable. Availability of data and materials All the data in the study are available from the corresponding author on reasonable request. 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Tables Table 1 Comparison of Baseline Characteristics Between the Two Groups of Cases Group Case Gender Age (years, \(\:\stackrel{-}{x}\) ±s) Cause of Injury Dubberley Type Injury to Surgery Time(d, \(\:\stackrel{-}{x}\) ±s) Male Female Slip Traffic Fall Sports 2A 2B 3A 3B Dislocation approach 23 8 15 43.86 ± 17.45 17 1 3 2 3 6 5 9 4.52 ± 1.68 Nondislocation approach 29 12 17 54.09 ± 15.27 18 5 1 5 16 3 7 3 4.45 ± 1.50 t value — 4.522 ± 1.675 — — 0.868 P v alue 0.776 0.087 0.263 0.004 0.947 Note: “-” indicates Fisher's Exact Test. Table 2 Comparison of Operation Time and Intraoperative Bleeding Volume Between the Two Groups Group Case Operation Time Intraoperative Bleeding Volume Dislocation approach 23 149.44 ± 40.29 124.30 ± 47.02 Nondislocation approach 29 130.38 ± 44.11 117.59 ± 43.40 t value 0.114 0.595 P value 0.103 0.778 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7480587","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":521781131,"identity":"f4fcf2cb-ccf5-4928-baf6-c495797c5d56","order_by":0,"name":"Shangzhi Li","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Shangzhi","middleName":"","lastName":"Li","suffix":""},{"id":521781132,"identity":"4823b197-9c92-4896-a003-e0af9fcb8536","order_by":1,"name":"Jingzhi Yang","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Jingzhi","middleName":"","lastName":"Yang","suffix":""},{"id":521781133,"identity":"87c7be6e-75e2-4bd8-8a8c-5bc859ad52d7","order_by":2,"name":"Jiaxia Liu","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Jiaxia","middleName":"","lastName":"Liu","suffix":""},{"id":521781134,"identity":"1eb8de26-4d9d-4d2d-9a2d-4564456b0978","order_by":3,"name":"Shijie Kang","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Shijie","middleName":"","lastName":"Kang","suffix":""},{"id":521781135,"identity":"560a7263-bf47-4d83-95a7-51776ad47ab6","order_by":4,"name":"Tao Jiang","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Jiang","suffix":""},{"id":521781136,"identity":"01d53270-40e8-426c-bdaa-b1d78de84b6e","order_by":5,"name":"Dongsheng Huang","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Dongsheng","middleName":"","lastName":"Huang","suffix":""},{"id":521781137,"identity":"76718c81-f275-453b-ac31-229808dd1a20","order_by":6,"name":"Tao Liu","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Liu","suffix":""},{"id":521781138,"identity":"bebd1b71-84b2-4741-8d21-7d6a4fae140a","order_by":7,"name":"Fuxin Lv","email":"","orcid":"","institution":"Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong 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11:30:39","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":84885,"visible":true,"origin":"","legend":"","description":"","filename":"0555fbb8854844a18ac5cfc723c38d541structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7480587/v1/c4b4f68a6ef79e232c3a9a8a.xml"},{"id":92800025,"identity":"329d9c00-f5cd-4f8e-9e33-0536d35e408f","added_by":"auto","created_at":"2025-10-05 11:30:39","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92589,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7480587/v1/a55f5c8fdac5e06cf04c755d.html"},{"id":92801404,"identity":"fb3674ed-91c3-4abb-8eb4-dc2f1e089e27","added_by":"auto","created_at":"2025-10-05 11:38:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1015985,"visible":true,"origin":"","legend":"\u003cp\u003eA-D The lateral elbow dislocation approach A-C The lateral condylar fracture line was found, the lateral collateral ligament and extensor insertion point of the bone block were flipped to the distal end, the distal articular surface of the humerus was completely exposed. D The lateral condyle is intact, sharply peel from the high position of the lateral condyle, the distal articular surface of the humerus was completely exposed.\u003c/p\u003e\n\u003cp\u003eE The lateral elbow nondislocation approach: the anterior articular surface and part of the lateral distal articular surface were exposed\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7480587/v1/780159874139cf3bfd654f7e.png"},{"id":92800017,"identity":"ef33628e-03b7-459a-b698-55debdf3cb1a","added_by":"auto","created_at":"2025-10-05 11:30:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":467647,"visible":true,"origin":"","legend":"\u003cp\u003eA 58-year-old female was reduced and fixed via the lateral elbow nondislocation approach. A, C Preoperative X-rays and CT showed the trochlea, humerus cephalic head and lateral condyle, and the fracture line extended to the posterior coronoid process, without posterior partial compression (Dubberley classification type 3A). B X-rays showed that the fractures were reduced well, the length and position of the screws were appropriate. D CT showed steps on the medial articular surface, and the articular surface was cut by screws. E X-rays after 3 months showed the fractures healed well and articular surface steps. F After 15 months, the MEPS was good of 80 points.\u003c/p\u003e\n\u003cp\u003eNote: MEPS is the Mayo Elbow Performance Score\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7480587/v1/b354b4c0c71fc09f864ab833.png"},{"id":92801406,"identity":"d9b682e0-b106-46d3-86ae-e8d7a0effba9","added_by":"auto","created_at":"2025-10-05 11:38:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":455248,"visible":true,"origin":"","legend":"\u003cp\u003eA\u003cstrong\u003e \u003c/strong\u003e64-year-old female was reduced and fixed via the lateral elbow dislocation approach A, C Preoperative X-rays and CT showed the trochlea, humerus cephalic head and lateral condyle, and the fracture line extended to the posterior coronoid process，with posterior partial compression (Dubberley classification type 2B). B, D X-rays and CT showed that the fractures were reduced well, the humeral-ulnar joint was matched, the articular surface was flat, and the screws were not cut. E X-rays after 6 months, the fractures healed well and no humeral cephalic necrosis. F After 6 months, the MEPS was excellent of 100 points.\u003c/p\u003e\n\u003cp\u003eNote: MEPS is the Mayo Elbow Performance Score\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7480587/v1/f2b0ed9227027df8634e568c.png"},{"id":104779223,"identity":"2aa80bd1-ef1b-4205-893b-197656b07794","added_by":"auto","created_at":"2026-03-17 07:36:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3136030,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7480587/v1/b8b11834-a0a3-4d4c-bcb7-48eaeabae117.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the lateral elbow dislocation approach and nondislocation approach for the reduction and internal fixation of distal humeral coronal fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCoronal fractures of the distal humerus are clinically rare, accounting for approximately 6% of distal humeral fractures and 1% of elbow fractures [1], and are caused mostly by posterolateral subluxation or dislocation of the elbow joint, cutting the humeral cephalic head and trochlea through the radial head and coronal process. The sequential distribution of injuries from anterior inferior to posterior upward and from lateral to medial is commonly referred to as annular injury [2]. Many humeral cephalic fractures extend into the trochlear and are often accompanied by lateral epicondylar fractures, posterolateral humeral and trochlea compression, articular surface fragmentation, and even medial epicondylar involvement [3], which cannot be reduced without surgical treatment. Open reduction and internal fixation are considered the treatments of choice, but the complexity of these intra-articular fractures has led to controversy over the optimal approach for surgical exposure and fixation [4-14]. The lateral or anterolateral approach mainly reveals anterior fracture fragments, and the posterior approach mainly reveals posterior fracture fragments, and the olecranon envelope between the anterior and posterior parts of the ulna has never been reported in this context. Hoyt et al [15] reported that the lateral elbow approach dislocated 95.9% of the anterior surface and 100% of the small head, which was much greater than that of the olecranon osteotomy approach for the ulna. Hackl et al [9] reported that 53 patients with coronal fractures of the distal humerus were exposed and fixed through the fracture space approach, and achieved good functional outcomes. In clinical practice, the dislocation method was modified in combination with the lateral approach, which could completely expose the articular surface of the distal humerus, achieve anatomical reduction, and ensure precise internal fixation. There is no relevant literature report on this method. The authors used a retrospective cohort study to analyze the clinical data of 52 patients with distal coronal fracture of the distal humerus admitted to the Department of Trauma Orthopedics of Qilu Hospital (Qingdao) from January 2018 to December 2023, and compared the efficacy of lateral elbow dislocation and nondislocation reduction and internal fixation to provide a new surgical method for distal coronal fracture of the humerus.\u003c/p\u003e"},{"header":"1. Materials and methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 General Information\u003c/h2\u003e\u003cp\u003eThe inclusion criteria were as follows: (1) the distal coronal fracture of the humerus was Dubberley classification [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] type 2 or 3;(2) the surgical approach involved a lateral incision; (3) the time from injury to surgery was 2 weeks (4) the postoperative follow-up time was \u0026ge;\u0026thinsp;12 months; and (5) there was no obvious abnormality in the function of the elbow joint before surgery. The exclusion criteria were as follows: (1) pathological fractures (2) pain or dysfunction of the affected elbow before injury; (3) open fracture combined with vascular or nerve damage or multiple fractures of the affected limb.\u003c/p\u003e\u003cp\u003eA total of 52 patients with distal coronal fractures of the humerus were included, including 20 males and 32 females ,age 48.39\u0026thinsp;\u0026plusmn;\u0026thinsp;17.15 (ranged from 15\u0026thinsp;~\u0026thinsp;80) years. According to Dubberley classification, 20 cases were type 2A, 9 cases were type 2B, 11 cases were type 3A, and 12 cases were type 3B. The causes of injury were as follows: 35 cases of fall injury, 6 cases of traffic injury, 7 cases of sports injury, and 4 cases of fall from height injury. Twenty-three patients were treated via the lateral elbow approach for fracture reduction and internal fixation (dislocation group), and 29 patients were treated via the traditional exposure method involving the lateral elbow approach for fracture reduction and internal fixation (nondislocation group). There was no significant difference in the general data of the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), which were comparable (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All patients signed an informed consent form. This study was approved by the Medical Ethics Committee of Qilu Hospital (Qingdao) of Shandong University (No. KYLL-KS-2024248). The study was conducted in accordance with the principles outlined in the Declaration of Helsinki.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Treatment\u003c/h2\u003e\u003cp\u003eThe patient abducts the affected limb in the supine position, brachial plexus block anesthesia or general anesthesia is used, and then a balloon tourniquet is used to stop bleeding. After anesthesia, the lateral elbow approach is performed, which descends from approximately 5 cm proximal to the lateral aspect of the humerus, crosses the brachioradial joint, and enters posteriorly through the elbow muscle (Kocher approach); If the posterior part does not require plate support, a shorter straight incision (Kaplan approach) may be used to cut part of the brachioradialis muscle and anterior joint capsule at the distal end of the humerus.\u003c/p\u003e\u003cp\u003eDislocation group: First, the lateral condylar fracture line was found, the lateral collateral ligament and extensor insertion point of the bone block were flipped to the distal end, the elbow joint was semi-flexed and inverted, and the medial side was similar to a hinge rotation axis. The tension-free lower humerus distal anterior-lateral flip dislocation was maintained so that the distal articular surface of the humerus was completely exposed. For better exposure, a K-wire can be placed at the metaphyseal end to facilitate the inversion of the distal humerus and the posterior fracture line can be exposed (\u003cb\u003eFigure.1A-C\u003c/b\u003e). If the lateral condyle is intact, sharply peel from the high position of the lateral condyle (\u003cb\u003eFigure.1D\u003c/b\u003e), clean up the coronal bone block under direct vision, dissect and reset all the bone blocks from the inside to the outside and from the back to the front, temporarily fix the K-wire needle, and select headless screws [Stryker GmbH] for internal fixation one by one. If the posterior condyle is compressed, and crushed, and the bone is defected, a semicortical bone block can be taken from the lateral epicondyle and implanted in the defect, fixed by a 1.0\u0026thinsp;~\u0026thinsp;1.2 mm K-wire through the subchondral parallel articular surface. Finally, the lateral condyle can be reduced, and the hollow nail or headless nail [Stryker GmbH] can be fixed.\u003c/p\u003e\u003cp\u003eIn the nondislocation group, the anterior articular surface was exposed, the periosteal dissection device was inserted into the medial epicondyle, a K-wire was inserted into the olecranon of the ulna and externally rotated, and the joint space was enlarged to expose the articular surface behind the coronal process (\u003cb\u003eFigure.1E\u003c/b\u003e). The bone block was reduced from the inside to the outside, the posterior bone block was used as a template on the olecranon articular surface of the ulna, the K-wire needle was temporarily fixed, the fluoroscopy fracture was reduced satisfactorily, and the appropriate position was selected for headless nail fixation [Stryker GmbH].\u003c/p\u003e\u003cp\u003eFor two groups of patients with posterior compression, crushing, or anterior bone fragments that are not strong enough to support early functional exercise, anatomical locking plates or hinged frames [Stryker GmbH] are placed posteriorly to assist in fixation. Fluoroscopy again revealed that the fracture was satisfactorily reduced, the fixation screw did not penetrate the articular surface, and the joints were matched. If lateral collateral ligament insertion is dissected, it is necessary to rotate the center of the bone or use anchors [DePuy Mitek] to reconstruct lateral stability and suture the extensor insertion and brachioradialis muscles. Finally, the incision was flushed, the tourniquet was loosened, the bleeding was completely stopped, one indwelling drainage tube was placed, and the incision was closed layer by layer.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Postoperative management\u003c/h2\u003e\u003cp\u003eAntibiotics are routinely given once postoperatively. The drain was removed 48 hours after surgery. On the 3rd day, axial flexion and extension active function exercise was started, auxiliary axial flexion and extension function exercise of the unaffected limb was started 2 weeks after the operation, and passive traction function exercise was carried out 6 weeks later (the fixed brace was removed 6 weeks after the operation). Strength training started at 3 months.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e1.4 Observation indicators\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe operation time, intraoperative blood loss, incision healing, reduction of 3D CT assessment within 1 week after surgery (separation or step\u0026thinsp;\u0026gt;\u0026thinsp;2 mm as poor), MEPS[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] at 3 months after surgery, fracture healing and complications at the last follow-up were compared between the two groups.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e1.5 Statistical Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eStatistical analysis was performed using R version 4.10. The Shapiro-Wilk test was used to assess the normality of the data, and Levene's test was applied for homogeneity of variances. Measurement data that followed a normal distribution are presented as x̄ \u0026plusmn; s, and inter-group comparisons were conducted using the independent two-sample t-test. Count data are expressed as percentages, and inter-group comparisons were made using Fisher's exact test. All tests were two-tailed. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"2. Results","content":"\u003cp\u003eAll patients were followed up for 20.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.36 (ranging from 12\u0026thinsp;~\u0026thinsp;46) months. There was no significant difference in operation time or intraoperative blood loss between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The postoperative incisions were all healed in stage I.\u003c/p\u003e\u003cp\u003eThe dislocation group exhibited good reduction, while 17 patients in the nondislocation group showed good reduction, and 12 patients had separation or steps\u0026thinsp;\u0026gt;\u0026thinsp;2 mm posterior to the articular surface. Three months after the operation, the MEPS of the dislocation group was 90.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82(80\u0026thinsp;~\u0026thinsp;100) points, and the MEPS of the nondislocation group was 79.83\u0026thinsp;\u0026plusmn;\u0026thinsp;10.13༈60\u0026thinsp;~\u0026thinsp;100༉ points(\u003cem\u003et\u003c/em\u003e=-4.74,\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0000211). According to the MEPS, 15 cases were excellent and 8 cases were good in the dislocation group, with an excellent and good rate of 100%. There were 10 excellent cases, 12 good cases, 7 middle cases, and 0 poor case in the nondislocation group, with an excellent and good rate of 75.9%༈\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0135༉. The fractures had healed at the last follow-up.\u003c/p\u003e\u003cp\u003eIn the nondislocation group, there were 11 cases of joint degeneration, including 6 cases of screw cutting, 3 cases of ectopic ossification, and 2 cases of simple periarticular osteophyte formation in elderly patients. In the dislocation group, 2 elderly patients had joint degeneration and simple osteophyte formation, and no screw incisions or ectopic ossifications were found.\u003c/p\u003e\u003cp\u003eTypical cases are shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eIn the past, for coronal fractures of the distal humerus, the anterior humerus head and trochlea were exposed through the lateral and anterolateral approaches for reduction and internal fixation. The lateral approach is suitable for fractures involving the humeral cephalic head and a small part of the trochlea, and has the advantages of good exposure and safety [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. It has also been reported that the lateral approach can clearly expose fracture areas such as the metaphysis, humeral cephalic head, and trochlea, and if necessary, the lateral collateral ligament can be peeled from the lateral epicondyle to increase the extent of exposure and rebuild lateral stability postoperatively [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. The anterolateral approach provides extensive exposure of the anterior humeral cephalic head and trochlea to facilitate reduction and fixation of intra-articular fragments [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Durakbasa et al [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] suggested that Dubberley fractures of types 1, 2, and 3A fractures can be treated with the lateral Kaplan approach and the posterior approach for type 3B fractures. A survey [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] of 114 orthopedic surgeons in Italy revealed that for type 3 fractures, particularly those involving medial extension with or without posterior comminuted fractures, an olecranon osteotomy approach was used to obtain a global visualization of the joint surface, exposing all intra-articular fragments for fixation. However, Chang et al [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] concluded that the distal humerus was intra-articular with coronal fractures, that the humeral microcephalic fragments were usually displaced anteriorly and proximally, and that conventional ulnar olecranon osteotomy had difficulty adequately visualizing and fixing the small head shear fragments because of intact soft tissue attachment. In addition to ulnar olecranon osteotomy, they exposed the anterior bone fragment by dissecting the lateral collateral ligament and pronation of the distal humerus. Johnson et al [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] suggested that if the margin of a humeral cephalic fracture is 83\u0026deg; or behind 83\u0026deg; (centered at the center point of rotation and 2:46 on the clock surface), it can be accessed vertically via the posterior approach, whereas a fracture located before this threshold may require a lateral approach for expose. For the coronal fractures of the distal humerus with an intact lateral epicondyle, Zhang et al [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e] adopted the lateral combined approach, which achieved good reduction and fixation of the fracture and satisfactory function of the elbow joint. In practice, the author reported that the lateral or anterolateral approach can expose the lateral or anterior part of the joint, but there is a fracture in the olecranon enveloping part of the ulna, especially the posteromedial side, which is difficult to expose. Hoyt et al [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e] performed an osteotomy on the cadaver specimen via the lateral condyle and dislocated the distal humerus, revealing 95.9% of the anterior surface of the distal humerus and 100% of the small head. The author modified the dislocation method in combination with the lateral approach and reported that when the lateral condylar fracture was combined, the lateral condylar fracture fragment with the lateral collateral ligament and extensor insertion point was flipped distally to the distal end during the operation, and the distal end of the humerus was turned forward and lateral to the dislocation through semiflexion and inversion of the elbow joint. The medial side was similar to a hinge rotation axis, which could completely expose the articular surface of the distal end of the fracture and could be accurately reduced and fixed under direct vision. The lateral stability of the elbow joint can be restored by lateral condylar bone reduction and internal fixation of hollow nails. When the lateral condyle is intact, an attempt is made to sharply dissect the lateral collateral ligament and extensor insertion from the high lateral condyle, and the articular surface can also be completely exposed; however, lateral elbow stability needs to be restored by anchors or bony reconstruction.\u003c/p\u003e\n\u003cp\u003e3.1 Open reduction and internal fixation of elbow joint dislocation via the lateral approach to the elbow\u003c/p\u003e\n\u003cp\u003eThe advantages and disadvantages of coronal fracture of the distal humerus:\u003c/p\u003e\n\u003cp\u003eIts main advantages include the following: (1) All the articular surfaces of the distal humerus can be exposed, anatomical reduction and internal fixation can be performed under direct vision, and the postoperative follow-up function is well recovered. For articular surface fractures surrounding the olecranon of the ulna at the distal end of the humerus, such as Dubberley type 2A and 3A fractures, the fracture line extends to the posterior coronoid process and Dubberley type B fractures, the conventional lateral side is exposed, and the distal articular surface of the anterior and lateral parts can only be exposed without dislocation, and the medial and posterior articular surfaces of the distal humerus cannot be exposed, making it difficult to reduce. The elbow joint is semiflexed and varus, and a K-wire is placed at the metaphyseal end, which is reversed anteriorly and backward to expose the distal end of the humerus and the posterior articular surface. The bone fragment is reduced and fixed under direct vision to achieve anatomical reduction. Postoperative CT also confirmed anatomic reduction. The MEPS of the dislocation group at 3 months after surgery was 90.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82(80\u0026thinsp;~\u0026thinsp;100), of which 15 cases were excellent and 9 cases were good, with an excellent and good rate of 100%. In the nondislocation group, only the anterior articular surface and the distal articular surface of the lateral part were exposed, and the distal medial and posterior articular surfaces were blind areas. The reduction group lacked anatomical landmarks, and the bone fragment could only be pushed to the distal end during the operation, blocked by the olecranon of the ulna, and used as a template for distal or posterior bone fragment reduction; thus, postoperative CT revealed 12 cases of medial or posterior separation or step of the distal articular surface\u0026thinsp;\u0026gt;\u0026thinsp;2 mm. The MEPS in the nondislocation group at 3 months after surgery was 79.83\u0026thinsp;\u0026plusmn;\u0026thinsp;10.13༈60\u0026thinsp;~\u0026thinsp;100༉, of which 10 cases were excellent, 12 cases were good, 7 cases were fair, and 0 case was poor, with an excellent and good rate of 75.9%. Consistent with the findings of Vasudeva [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e], anatomical reduction of intra-articular fractures is a key factor in determining the prognostic functional recovery of distal coronal fractures.\u003c/p\u003e\n\u003cp\u003e(2) Cutting screws should be avoided, and the incidence of joint degeneration should be reduced. In this study, although the dislocation group had a complex exposure process, the intraoperative view was clear and convenient for internal fixation, and there was no significant difference in operation time or intraoperative blood loss between the dislocation group and the nondislocation group. The posterior articular surface could not be exposed during the operation in the dislocation group, and the anterior and posterior articular surfaces could not be exposed during the operation. The results of reduction and internal fixation could only be evaluated by fluoroscopy, and the effect under direct vision could not be achieved owing to the complexity of the elbow joint due to the interference of intraoperative fluoroscopy [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]; thus, 6 cases of screw incisions were found on postoperative CT. There were two cases of isolated osteophyte formation in each group, both of which were composed of elderly patients, which was considered to be related to age. The remaining 3 cases of joint degeneration in the nondislocation group were accompanied by ectopic ossification, which may be related to the ability of the violent operation to better reveal clarity during the operation. Although the lateral approach for elbow dislocation is clearly revealed, the stable structure of the elbow joint is destroyed to varying degrees during the operation, and the stability of the elbow joint needs to be restored at the end of the operation. Li Ying et al [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e] reported that the lateral approach results in poor exposure to the medial trochlea, and better clinical results can be achieved by increasing the exposure range through elbow subluxation, and paying attention to protecting or repairing the starting point of the lateral collateral ligament. It has also been suggested that dissection of the lateral collateral ligament increases the disruption of the blood supply to the humeral cephalic head and affects fracture healing [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, it is necessary to perform fine intraoperative operations to reduce posterior soft tissue damage and rebuild lateral stability after surgery.\u003c/p\u003e\n\u003cp\u003e3.2 Indications for open reduction and internal fixation of the distal coronal fractures of the distal humerus by lateral elbow approach dislocation\u003c/p\u003e\n\u003cp\u003eThe lateral elbow approach dislocation method is mainly suitable for patients whose coronal fracture line of the distal humerus is surrounded by the olecranon of the ulna and cannot be exposed anteriorly or laterally. For patients with a fracture line in front of the coronal process or a simple fracture with a distal coronal fracture line in front of the coronal process or a simple fracture, the lateral incision can be solved by nondislocation exposure without the need to use the dislocation method, whereas for Dubberley type 2A and 3A fractures extending to the posterior coronoid process and Dubberley type B fracture, that is, the ulna olecranon wrapping part of the fracture, the nondislocation method can only reveal the anterior articular surface and lateral part of the distal articular surface, and only the dislocation method can observe the medial or posterior articular surface of the distal humerus, anatomical reduction and internal fixation under direct vision.\u003c/p\u003e\n\u003cp\u003e3.3 Precautions for the treatment of distal humeral coronal fractures by open reduction and internal fixation with lateral elbow dislocation\u003c/p\u003e\n\u003cp\u003e(1) Ligament stripping method: The lateral epicondylar ligament must be dissected at a high level, mainly to leave sufficient length for the reconstruction of the ligament insertion, which can increase the contact area with the bone bed and enhance increase stability and the healing effect. (2) Hemorrhagic protection of the humerus cephalic head: Kimball et al [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] found that the lateral column of the distal humerus was supplied mainly by the posterior side connecting to the blood vessels and that the medial column was evenly vascular in the anterior and posterior columns, with the trochlea, olecranon fossa, and coronary fossa being the co-innervation areas. The lateral collateral ligament and extensor insertion point are peeled off, so that the posterior side does not exceed the lateral condylar ridge, the posterior side can be cleaved longitudinally with soft tissue if the posterior surface is insufficient, and the posterior attachment tissue is preserved as much as possible to protect blood circulation. In concomitant condylar fractures, the attached soft tissue should be protected when the lateral condyle is turned over to protect the blood vessels entering the bone fragment. (3) Dislocation exposure method: the elbow joint is semiflexed and varus, the medial side is similar to a hinge rotation axis, and the distal end of the humerus under tension is turned forward to the lateral side to turn and dislocate, otherwise there will be medial traction, which increases the degree of medial injury, especially ulnar nerve traction injury. (4) Reconstruction of elbow joint stability: elbow joint stability assessment was routinely performed during the operation, and there was no instability or dislocation from elbow flexion to extension of 30\u0026deg;to 45\u0026deg;, which was considered good [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. If elbow joint stability is suspected, a cantilever test [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] should be used for further evaluation or with the addition of a hinged external frame.\u003c/p\u003e\n\u003cp\u003e3.4 Management of complications of open reduction and internal fixation of the distal humerus with open reduction and internal fixation for lateral elbow dislocation\u003c/p\u003e\n\u003cp\u003eIn this study, two elderly patients in the dislocation group had simple periarticular osteophyte formation, which was considered to be related to age and accelerated joint degeneration after trauma. However, because the lateral and posterior dissections of this approach are too large, there may be potential complications of elbow joint instability or humeral cephalic necrosis. During the operation, the posterior soft tissue should be dissected as little as possible, and if it is indeed difficult to expose, it can be revealed by longitudinal splitting to reduce the destruction of blood vessels. After the completion of internal fixation, lateral stability is routinely reconstructed, stability assessment is performed, and if necessary, hinged external fixing bracket assists fixation. If the humeral-ulnar joint is mismatched on the postoperative 3D CT scan, indicating elbow instability, a cast of the flexed elbow is maintained for 3 weeks. During long-term follow-up, if there is necrosis or nonunion of the humeral microcephalic fragments and if the clinical symptoms are obvious, humeral microcephalic replacement surgery should be considered.\u003c/p\u003e\n\u003cp\u003eIn summary, for coronal fractures of the distal humerus, the fracture line extends to the medial or posterior aspect of the distal articular surface of the humerus, and the lateral approach to the elbow joint dislocation method can completely expose the fracture fragments compared with the nondislocation method. It can not only achieve direct reduction and fixation, anatomical reduction and accurate internal fixation, but also recover the function of the elbow joint well with few complications. The number of patients in this study was small, and the follow-up time was short; thus, it was necessary to expand the sample size and increase the follow-up time to further verify the efficacy of the lateral elbow approach for dislocation reduction and internal fixation in the treatment of distal coronal fractures of the humerus.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study was approved by the Medical Ethics Committee of Qilu Hospital (Qingdao) of Shandong University (No. KYLL-KS-2024248). The study was conducted in accordance with the principles outlined in the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eWritten consent for the publication of this paper was obtained from the legal guardians of the patients.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research was supported by Medical and Health Scientific Research Project of Shandong (No.202304070922), Medical and Health Scientific Research Project of Qingdao(No.2024-WJKY149),Shandong Provincial Natural Science Foundation(No.ZR2024QH583) and Qingdao Key Clinical Specialty of Orthopedics Center(QDZDZK-2022095). We thank Key Laboratory of Qingdao in Medicine and Engineering for consultation and instrument availability that supported this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLi,Yang and Bao wrote the main manuscript text . All authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eAll the data in the study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLamas C, Grau A, Almenara M et al(2020)Coronal shear fractures of the capitellum and trochlea: interobserver variability in classifying the fracture and the need for a computed tomography scan for the correct surgical planning. JSES Int. Dec 15;5:314-319. \u003c/li\u003e\n\u003cli\u003eTanwar YS, Kharbanda Y, Jaiswal A et al(2018)Retrospective analysis of open reduction and internal fixation of coronal plane fractures of the capitellum and trochlea using the anterolateral approach. SICOT J. 4:8. \u003c/li\u003e\n\u003cli\u003eCheung EV(2007)Fractures of the capitellum. Hand Clin. 23:481-6 vii. \u003c/li\u003e\n\u003cli\u003eSong Z, Wang Q, Ma T, et al(2020)Anti-sliding plate technique for coronal shear fractures of the distal humerus. J Orthop Surg Res. 15:18. \u003c/li\u003e\n\u003cli\u003eTeng L, Zhong G(2020)Surgical Treatment of Comminuted Coronal Shear Fracture of Distal Humerus. Orthop Surg. 12:1439-1447. \u003c/li\u003e\n\u003cli\u003eWatson JJ, Bellringer S, Phadnis J(2020)Coronal shear fractures of the distal humerus: Current concepts and surgical techniques. Shoulder Elbow. 12:124-135. \u003c/li\u003e\n\u003cli\u003eTarallo L, Novi M, Porcellini G et al(2021)Surgical tips and tricks for coronal shear fractures of the elbow. Arch Orthop Trauma Surg. 141:261-270. \u003c/li\u003e\n\u003cli\u003eVan Nguyen T, Kholinne E, AlSomali K et al(2021)Technique for Arthroscopic-Assisted Reduction and Cannulated Screw Fixation for Coronal Shear Fractures of the Distal Humerus. Arthrosc Tech. 10:e949-e955. \u003c/li\u003e\n\u003cli\u003eMichael Hackl,Fabian Lanzerath,Christian Ries et al(2023)Trans-fracture approach for ORIF of coronal shear fractures of the distal humerus. Arch Orthop Trauma Surg. 143:2519-2527.\u003c/li\u003e\n\u003cli\u003eBellato E, Giai Via R, Bachman D et al(2022)Coronal Shear Fractures of the Distal Humerus. J Funct Morphol Kinesiol. 7:7. \u003c/li\u003e\n\u003cli\u003eShergold S, Derias M, Moverley R et al(2022)Coronal shear fractures of the distal humerus managed according to the Modified Dubberley Classification System. J Shoulder Elbow Surg. 31:133-142. \u003c/li\u003e\n\u003cli\u003eShintaro Mukohara,Yutaka Mifune,Atsuyuki Inui et al(2021)Effects of trochlear fragmentation on functional outcome in coronal shear fractures: a retrospective comparative study. JSES Int. 5:571-577. \u003c/li\u003e\n\u003cli\u003eKalin J Fisher,Michael G Livesey,Oliver C Sax et al(2022)Are outcomes after fixation of distal humerus coronal shear fractures affected by surgical approach? A systematic review and meta-analysis. JSES Int. 6:1054-1061. \u003c/li\u003e\n\u003cli\u003eHasan SA, Fisher K, Henn RF et al(2023)Coronal Plane Articular Shear Fractures of the Distal Humerus. J Am Acad Orthop Surg. 31:e235-e245. \u003c/li\u003e\n\u003cli\u003eHoyt BW, Clark DM, Walsh SA(2021)Surgical Elbow Dislocation Approach to the Distal Humerus for Apparent Capitellar and Lateral Condyle Fractures in Adults. J Orthop Trauma. 35:e77-e81. \u003c/li\u003e\n\u003cli\u003eDubberley JH, Faber KJ, Macdermid JC(2006)Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am. 88:46-54. \u003c/li\u003e\n\u003cli\u003eBilsel K, Atalar AC, Erdil M et al(2013)Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation. Arch Orthop Trauma Surg. 133:797-804. \u003c/li\u003e\n\u003cli\u003eLee JJ, Lawton JN(2012)Coronal shear fractures of the distal humerus. J Hand Surg Am. 37:2412-2417. \u003c/li\u003e\n\u003cli\u003eMcKee MD, Jupiter JB, Bamberger HB et al(1996)Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 78:49-54. \u003c/li\u003e\n\u003cli\u003eYu T, Tao H, Xu F et al(2018)Management of isolated coronal shear fractures of the humeral capitellum with Herbert screw fixation through anterolateral approach. BMC Musculoskelet Disord. 19:108. \u003c/li\u003e\n\u003cli\u003eDurakbasa MO, Gumussuyu G, Gungor M et al(2013)Distal humeral coronal plane fractures: management, complications and outcome. J Shoulder Elbow Surg. 22:560-566. \u003c/li\u003e\n\u003cli\u003eVicenti G, Bizzoca D, Zaccari D, et al(2023)Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members. Injury. 54 Suppl 1:S78-S84. \u003c/li\u003e\n\u003cli\u003eChang AL, Dieterich JD, DiPrinzio EV et al(2020) Surgical Approach and Internal Fixation Techniques for Intra-Articular Distal Humerus Fracture With Coronal Shear Capitellar Fracture. Tech Hand Up Extrem Surg. 25:25-29. \u003c/li\u003e\n\u003cli\u003eJohnson CC, Roberts SM, Mintz D et al(2018) A matched quantitative computed tomography analysis of 3 surgical approaches for osteochondral reconstruction of the capitellum. J Shoulder Elbow Surg. 27:1762-1769. \u003c/li\u003e\n\u003cli\u003eZhang C, Chen FX, Ma K et al(2024) Surgical treatment of coronal shear fractures of the distal humerus with an intact lateral epicondyle by the lateral combined approach. Shoulder Elbow Surg. 33:1685-1693. \u003c/li\u003e\n\u003cli\u003eVasudeva Nagashree,Jayaramaraju Dheenadhayalan,Velmurugesan Purnaganapathi Sundaram et al(2024)Outcome determinants for coronal shear fractures of the distal humerus. Int Orthop. 48:1295-1302. \u003c/li\u003e\n\u003cli\u003eM\u0026uuml;ller SA, Adolfsson L, Baum C et al(2021) Fluoroscopy of the Elbow: A Cadaveric Study Defining New Standard Projections to Visualize Important Anatomical Landmarks. JBJS Open Access. 6:e20.00160. d\u003c/li\u003e\n\u003cli\u003eLi Y, Cha YJ, Li T et al(2016) Beijing Da Xue Xue Bao Yi Xue Ban. 48:1026-1031.\u003c/li\u003e\n\u003cli\u003eMighell M, Virani NA, Shannon R et al(2010) Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws. J Shoulder Elbow Surg. 19:38-45. \u003c/li\u003e\n\u003cli\u003eKimball JP, Glowczewskie F, Wright TW(2007) Intraosseous blood supply to the distal humerus. J Hand Surg Am. 32:642-646. \u003c/li\u003e\n\u003cli\u003eO\u0026apos;Driscoll SW, Jupiter JB, King GJ et al(2001)The unstable elbow. Instr Course Lect. 50:89-102.\u003c/li\u003e\n\u003cli\u003eGarrigues GE, Wray WH 3rd, Linden hovius AL et al(2011)Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 93:1873-1881. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of Baseline Characteristics Between the Two Groups of Cases\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eAge (years, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e\u0026plusmn;s)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eCause of Injury\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eDubberley Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eInjury to Surgery Time(d, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e\u0026plusmn;s)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSlip\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTraffic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSports\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2A\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2B\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e3A\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e3B\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDislocation approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.86\u0026thinsp;\u0026plusmn;\u0026thinsp;17.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNondislocation approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.09\u0026thinsp;\u0026plusmn;\u0026thinsp;15.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.522\u0026thinsp;\u0026plusmn;\u0026thinsp;1.675\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.868\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP v\u003c/em\u003ealue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.776\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.947\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"15\"\u003eNote: \u0026ldquo;-\u0026rdquo; indicates Fisher\u0026apos;s Exact Test.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of Operation Time and Intraoperative Bleeding Volume Between the Two Groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOperation Time\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntraoperative Bleeding Volume\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDislocation approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149.44\u0026thinsp;\u0026plusmn;\u0026thinsp;40.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124.30\u0026thinsp;\u0026plusmn;\u0026thinsp;47.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNondislocation approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e130.38\u0026thinsp;\u0026plusmn;\u0026thinsp;44.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117.59\u0026thinsp;\u0026plusmn;\u0026thinsp;43.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.778\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Humeral fractures, Fracture fixation, Surgical Technique, Operative approach, Prognosis, Retrospective study","lastPublishedDoi":"10.21203/rs.3.rs-7480587/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7480587/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo compare the efficacy of the lateral elbow dislocation approach with that of the nondislocation approach for open reduction and internal fixation of distal humeral coronal fractures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective cohort study which included 20 males and 32 females, was performed to analyze the clinical data of 52 patients with distal humeral coronal fractures who were admitted to Qilu Hospital(Qingdao) from January 2018 to \u003ca href=\"https://cn.bing.com/dict/search?q=November\u0026amp;FORM=BDVSP6\u0026amp;cc=cn\"\u003eDecember\u003c/a\u003e 2023 . Classify the fractures according to the Dubberley classification. Overall, 23 patients underwent surgery via dislocation approach and 29 underwent surgery via nondislocation approach. The operation time, intraoperative bleeding volume, incision healing, 3D CT assessment of the reduction within one week after surgery, MEPS at 3 months after surgery, fracture healing and complications at the last follow-up were compared between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were followed for at least one year. The operation time was 149.44±40.29（60~221） minutes in the dislocation approach and 130.38±44.11（67~213） minutes in nondislocation approach group（\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05）. The intraoperative bleeding volume was 124.30±47.02（70~300） mL in dislocation approach and 117.59±43.40（50~200） mL in nondislocation approach group （\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05）. All incisions healed uneventfully in stage I. All patients had good reduction in the dislocation group, whereas only 17 other patients had good reduction and the other 12 patients presented a separation or step\u0026gt;2 mm in the nondislocation group（\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05）. At 3 months after surgery, the MEPS was 90.44±5.82（80~100） points in the dislocation approach group, with an excellent and good rating of 100%. In contrast, the MEPS was 79.83±10.13（60~100） points in the nondislocation approach group, with an excellent and good rating of 75.9%（\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05）.All fractures had healed at the last follow-up. In the nondislocation approach group, osteoarthritis occurred in 11 patients, including 6 with screw protrusion, 3 with heterotopic ossification and 2 of advanced age with osteophyte formation around the joint. In the dislocation approach group, osteoarthritis occurred in only 2 patients of advanced age, with osteophyte formation around the elbow joint, and no screw cutting or heterotopic ossification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with the nondislocation approach, the lateral elbow dislocation approach is able to provide complete exposure of the articular surface, achieve anatomic reduction, restore elbow function and reduce complications in distal humeral coronal fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLevel III; Retrospective Cohort Comparison; Treatment Study\u003c/p\u003e","manuscriptTitle":"Comparison of the lateral elbow dislocation approach and nondislocation approach for the reduction and internal fixation of distal humeral coronal fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-05 11:30:34","doi":"10.21203/rs.3.rs-7480587/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93bc33ea-b849-4637-91be-e041efc8b18e","owner":[],"postedDate":"October 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-24T02:09:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-05 11:30:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7480587","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7480587","identity":"rs-7480587","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}