Treatment of Fractures of the Humeral Capitellum Using Herbert Screws

Outcome determinants for coronal shear fractures of the distal humerus

PURPOSE

Coronal shear fractures of the distal humerus involving the capitellum and trochlea are rare injuries. Internal fixation with headless compression screws provides a stable construct facilitating early mobilisation. Our study aimed to identify the key determinants of both radiological and functional outcomes of patients with distal humerus coronal shear fractures treated with internal fixation.

METHODS

A retrospective analysis of 61 patients with distal humerus coronal shear fractures who were treated surgically was done. Demographics, fracture morphology, time to surgery, operative details such as surgical approach and implant used, quality of reduction, time to union, and associated complications from hospital records. Radiological outcomes were assessed using plain radiographs, and the functional outcomes were by Oxford Elbow Score (OES) and Mayo Elbow Performance Index (MEPI).

RESULTS

Patients with anatomical reduction of the fracture had better functional outcomes and range of motion. The presence of posterior comminution of capitellum resulted in poorer outcomes (p = 0.03). Delayed presentation did not alter the outcome when the anatomical reduction was achieved. Myositis ossificans was noted in nine patients and non-union in five patients. Two patients developed avascular necrosis of the capitellum and arthritis of the elbow joint.

CONCLUSION

Anatomical reduction and posterior comminution are the two key determinants of the functional outcome in these coronal shear fractures of the distal humerus. Early mobilisation following a stable fixation is crucial in achieving a good outcome.

The Operative Management of Capitellum Fractures

Capitellum fractures represent fewer than 1% of elbow fractures. Most commonly, these fractures occur secondary to either axial loading with the elbow fully extended or direct impact to the lateral aspect of the elbow. Numerous classification systems exist, with many types and subtypes. Since capitellum fractures are uncommon and fracture type varies widely, there is a lack of consensus with regard to treatment recommendations. We present a case series of seven patients with capitellum fractures, who presented between January 2016 and August 2020 to Addenbrooke's Hospital (Cambridge, the United Kingdom). All patients were female, with an average age of 33 years. In each case, the affected elbow joint was immobilised using a backslab before open reduction and internal fixation (ORIF) was performed. Joint mobility was recorded both on the day of the injury and at clinic review postoperatively (first at two weeks and then at between four and eight weeks). The Oxford Elbow Score (OES) was measured retrospectively, relating to (1) before the injury and (2) six months after fracture reduction. ORIF was associated with a near-full return of pronation and supination by eight weeks, with flexion-extension also improving significantly. The Oxford Elbow Score at six months reached 82.0% of pre-injury scores. Overall, our results suggest that ORIF is a well-tolerated and effective treatment strategy for capitellum fractures. Future studies with a greater sample size are required to assess the outcomes across a longer period, to determine whether outcomes are maintained and continue to improve.

Surgical treatment of Hahn-Steinthal fracture using Herbert screws

Hahn-Steinthal fractures are rare and often neglected. Their initial management should be early, given the relatively high complication rate. We report eight cases of type I capitellum fractures treated by Herbert screw fixation. Between 2019 and 2022, we selected eight patients (six men and two women) with a mean age of 25 years (18-40 years). The mean follow-up was 2 years (1-3 years). Clinical results were assessed using the Mayo Clinic Elbow Performance Score (MEPS). The mean arc of mobilitý was 135° (105°-150°) for flexion/extension and 161° (150°-175°) for pronosupination. The mean MEPS was 90.6 points, with seven excellent results and one good result. The aim of this study was to highlight the good results of Herbert screw fixation technique in the management of Hahn-Steinthal fractures.

Rate of Complications After Capitellum Fracture Fixation: A Systematic Review and Meta-Analysis

PURPOSE

This systematic review aimed to determine the incidence of complications following surgical fixation of an acute capitellum fracture. We secondarily aimed to compare the complication rate between anterior-to-posterior (A-P) versus posterior-to-anterior (P-A) screw insertion.

METHODS

PubMed, EMBASE, and Scopus were searched to identify studies on surgical fixation of capitellum fractures in skeletally mature patients. The main outcome was the rate of complication after fracture fixation. Subgroup analysis was performed to assess the impact of the fixation technique on the outcomes after surgery. An inverse variance method using random or fixed effects models was used to perform a meta-analysis based on the degree of heterogeneity between studies. Study heterogeneity was evaluated using Q statistics to calculate the I2 index.

RESULTS

We included 42 studies in the final analysis. The most reported complications after surgical fixation of capitellum fractures included elbow pain (21%), radiocapitellar arthritis (19%), hardware removal (17%), and heterotopic ossification (13%). When groups were stratified based on the direction of screw insertion, the mean rate of avascular necrosis was higher in the P-A direction (29% vs 11%). In comparison, the rate of revision fixation (2.9% vs 6.7%) and heterotopic ossification (7.3% vs 22%) were higher in the A-P direction. Transient posterior interosseous nerve palsy was reported in four patients in four studies, of whom three patients had A-P screw fixation.

CONCLUSION

Fixation of a displaced capitellum fracture is recommended when possible. However, patients should be counseled about the potential risk of complications and chances of undergoing an unplanned surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treating AO Type C2-3 Distal Humerus Fractures With the Anconeus Flap Transolecranon Approach

We evaluated the outcomes of precontoured locking plate fixation with the anconeus flap transolecranon (AFT) approach to treating AO type C2-3 comminuted intra-articular distal humerus (IDH) fractures among active patients. Thirty-six patients (age <65 years) with IDH fractures treated with precontoured distal humerus locking plate fixation were divided into 2 groups: group 1 (n=18; transolecranon [TO] approach) and group 2 (n=18; AFT approach). The radiographic examination included assessments of implant failure, fracture site union, and olecranon osteotomy site union. Clinical examination included assessments of operating time, range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disability of the Arm, Shoulder and Hand (DASH) score, and complications. The mean follow-up time was 25.2 months (range, 18-79 months). The mean operating time was 134.3 minutes and was significantly longer for group 2 (AFT; 141.2 minutes) than for group 1 (TO; 124.2 minutes). The mean olecranon osteotomy site union time was significantly longer in group 2 (7.4 weeks) than in group 2 (4.0 weeks). Olecranon osteotomy site resorption occurred among 6 of 18 patients only in group 2. No significant difference in ROM (flexion, 130°; extension, -0.7°), MEPS (85.7 points), DASH score (20.0 points), or frequency of major complications (TO, 5; AFT, 6) was observed between the groups. Our results showed no advantage of the AFT approach over the TO approach, despite preserving the anconeus. Prospective randomized trials will be necessary to compare the AFT and TO approaches for treating comminuted IDH fractures. [Orthopedics. 2022;45(6):e326-e334.].

Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members

INTRODUCTION

Coronal shear fractures of the distal humerus are uncommon injuries representing 6% of distal humeral fractures. There is no univocal consensus about the correct management of this type of fracture. A national survey was conducted to gain more insight into the current classification, diagnosis and treatment of coronal shear fractures in Italy.

MATERIALS AND METHODS

A postal survey was sent to all AO Italian members including residency orthopaedic surgeons. The survey consisted of general questions about personal experience in the management of these fractures: types of classification systems used, surgical approaches, treatment options and rehabilitation programs.

RESULTS

114 orthopaedic surgeons answered a 13-items questionnaire. The most used classification system was AO/OTA (72,8%). Independent screws and if necessary plates were the most answered regarding surgical treatment (81,6%). The most encountered post-surgical complication was stiffening of the elbow (81,6%).

CONCLUSION

An algorithm of treatment has been proposed. To better classify coronal shear fractures, the authors recommended the integration of two classification systems: AO and Dubberley classifications. In the case of posterior wall comminution, a Kocher extensile approach is recommended, otherwise, if a posterior wall is intact, Kocher or Kaplan approach can be used. The posterior transolecranic approach can be reserved to Dubberley type III or AO 13B3.3. The best treatment choice is represented by independent screws and plates placed according to fracture patterns while arthroplasty is indicated when a stable ORIF is not possible. Mobilization is postponed for about 2 weeks.

Humeral Capitellum Fractures in Adolescents: A Study of 6 Cases Treated by Open Reduction and Internal Fixation with Bioabsorbable Nails

Purpose

The purpose of our study was to evaluate the clinical outcome following open reduction and internal fixation of humeral capitellum fractures in adolescents and to assess the usefulness of bioresorbable implants in that procedure. Due to the rarity of these fractures, there are not many studies dealing with the problem in the literature.

Methods

We retrospectively evaluated a group of 6 skeletally immature patients aged 10.6–15.3 treated at our department from January 2015 to December 2021. Four type I and two type IV were diagnosed based on the Bryan and Morrey classification. Our patients underwent an open reduction and internal fixation of coronal shear fractures with the use of SmartNail®.

Results

All patients were satisfied with the treatment outcome and had full pronation and flexion after surgery. Two patients presented minor deficits of extension and supination compared with the contralateral elbow. At the one-year follow-up, all patients scored 100 on the Mayo Elbow Performance Score.

Conclusions

Correct diagnosis and early surgical intervention in humeral capitellum fractures are crucial. That fractures should be anatomically reduced with no articular cartilage damage in order to prevent osteoarthritis. Based on our experience, SmartNail® implant is accurate for the osteochondral fragment fixation.

Coronal Shear Fractures of the Distal Humerus

Coronal shear fractures of the distal humerus are rare, frequently comminuted, and are without consensus for treatment. The aim of this paper is to review the current concepts on the diagnosis, classification, treatment options, surgical approaches, and complications of capitellar and trochlear fractures. Computed Tomography (CT) scans, along with the Dubberley classification, are extremely helpful in the decision-making process. Most of the fractures necessitate open reduction and internal fixation, although elbow arthroplasty is an option for comminuted fractures in the elderly low-demand patient. Stiffness is the most common complication after fixation, although reoperation is infrequent.

ISOLATED CAPITELLAR FRACTURE FIXATION WITH HEADLESS SCREWS IN DIFFERENT CONFIGURATIONS

Introduction

We evaluated the clinical and radiological outcomes of capitellar fractures treated with modified screw insertion (inserting the first fixation screw anteroposteriorly and the second screw posteroanteriorly), a technique that can be applied with a minimally invasive lateral elbow approach.

Materials and Methods

Twenty-one isolated capitellum fractures that were surgically treated were included in the study. Fixation was achieved with two headless cannulated compression screws placed in anteroposterior and posteroanterior order using the modified lateral elbow approach. The Broberg-Morrey rating system was used to assess the post-operative functional status of the patients.

Results

According to the Broberg-Morrey criteria, the mean score was 92.7 (77-100) and 13 cases had excellent, 7 had good, and 1 had fair results. None of the patients developed avascular necrosis or heterotopic ossification. According to the Broberg-Morrey arthrosis score, two cases had Grade 1 and one had Grade 2 arthrosis. One patient had a superficial wound site infection that was treated with antibiotics, and in one case a 60° extension loss was observed in the elbow.

Conclusion

Treatment of isolated capitellar fractures with 2 headless screws placed anteroposteriorly and posteroanteriorly can provide stable fixation and is less traumatic for the elbow joint. Level of Evidence IV; Therapeutic Studies - Investigating the results of treatment.

Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes

Fractures of the capitellum and trochlea are uncommon fractures of the elbow and can be challenging to treat due to their size, location, and articular nature. Because of their intra-articular nature and predilection toward displacement, these fractures are typically treated operatively. Furthermore, capitellum fractures have high rates of associated injuries, including radial head fractures or lateral collateral ligament injury in ~30% to 60% of patients. In addition to open reduction internal fixation, operative options include fragment excision, arthroscopic assisted reduction and fixation, and elbow arthroplasty. In this article, we undertake a comprehensive literature review of capitellum fractures of the distal humerus, in an attempt to summarize the existing body of evidence and propose areas of future study.

Effects of trochlear fragmentation on functional outcome in coronal shear fractures: a retrospective comparative study

Background

Coronal shear fractures of the distal humerus are rare injuries, and fragmentation of the capitellum and trochlea with posterior comminution is challenging for surgeons. We retrospectively evaluated the functional outcomes of patients with coronal shear fractures managed with open reduction and internal fixation, focusing on the number of trochlea fragments in Dubberley type 3B fractures.

Materials and methods

The functional outcomes of 25 patients, including 8 patients with type 3B fractures, with a mean age (and standard deviation) of 57 ± 20 years, were evaluated at a mean follow-up duration of 15 ± 9 months. Type 3B fractures were classified into two groups: those with two trochlea fragments or less group (group A) and those with three or more fragments (group B). Patient outcomes were assessed with clinical and radiographic examination, range of motion, and the Mayo Elbow Performance scale (MEPS).

Results

Two patients with type 3B in group B experienced nonunion, and two patients with type 3B in group A and 1 patient with type 1B demonstrated avascular necrosis on radiographs. The average MEPS score was 96.3 points (range, 70-100), with 18 excellent, 5 good, and 1 fair results. The average range of motion was 10 ± 8 to 130 ± 12. The MEPS score worsened as Dubberley classification progressed from type 1 to type 3 (98.3 vs. 96.7 vs. 88, P = .014, respectively) and subtypes A to B (97.9 vs. 90, P = .014, respectively). In comparing groups A and B, the MEPS score was significantly worse in group B (93.8 vs. 76.3, P = .006).

Conclusion

Our open reduction and internal fixation results were largely good, although functional outcomes were diminished as Dubberley classification progressed from type 1 to type 3 and subtype A to B. Type 3B fractures with three trochlea fragments or more in the elderly were the most difficult to treat with open reduction and internal fixation and possibly 1-term total elbow arthroplasty.

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

Background

To determine interobserver agreement in the classification by X-rays and by computed tomography (CT) scan of the coronal shear fractures of the capitellum and trochlea as well as the agreement between these two tests.

Methods

Patients with coronal shear fractures of the capitellum who were managed at our center between January 2008 and December 2017 were included. This retrospective cohort study was carried out with the approval of the ethics committee of our institution (Nº: IIBSP-Cod-2019-02, Ref. 19/070). Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated. Three observers analyzed the preoperative X-rays from all the cases. Each one of them independently classified the fractures according to the Bryan and Morrey classification (with the modification of McKee et al). The interobserver agreement was calculated by Cohen kappa coefficient. The same methodology was used to analyze the CT scan. Thereafter, one single value was determined for each X-ray and CT scan, from the good interobserver agreements. Finally, the agreement between the global X-ray classification and the global CT scan classification was calculated using the agreement percentage and the Cohen kappa coefficient.

Results

There were 3 males and 6 females, with a mean age of 47 years (range, 18-83). The mean follow-up period was 18 months (12-40). The average Mayo Elbow Performance Index score was 85 (range, 65-100) points. The complications were nonunion in one patient (11 %), degenerative arthritis in 7 (78 %), joint step-off in 5 (55%), and heterotopic ossification in 7 (78%). The agreement analysis between the global X-ray classification and the global CT scan classification showed a 57.1% agreement, with a kappa coefficient of −0.167. These values imply the absence of agreement.

Conclusion

Our results demostrated that simple X-rays do not allow for the adequate interpretation of distal humeral coronal plane fractures. Although an acceptable interobserver agreement was found, there is no agreement when the same fractures were analyzed by CT scan. The authors routinely recommend CT scan to assess the extent of the fracture and perform surgical planning.

Functional Outcomes of Capitellum Fractures Treated by Open Reduction and Internal Fixation with Herbert Screw: A Descriptive Cross-sectional Study

Introduction:

Based on the complex intra-articular nature of capitellum fractures, it has been sometimes difficult to formulate a universally accepted method of surgical treatment. The purpose of this study is to present the functional outcomes of capitellum fractures after fixation with Herbert screw including the safety and tips of the surgical approach.

Methods:

This descriptive cross-sectional study was done from December 2014 to November 2019. Ethical approval was taken. The study included 22 capitellum fractures treated by open reduction and internal fixation with Herbert screws either lateral or anterolateral approach. Functional outcomes were assessed with Mayo elbow performance index scores at the latest follow-up visit. Convenient sampling was done. Data entry was done using the Statistical Package for the Social Sciences (version16.0).

Results:

Out of 22 surgeries, the average time to unite the fracture was 11.13±1.20 weeks (range 9 to 15). The mean range of movement for flexion and extension was 138.41±8.22 degree while the mean supination and pronation range was 161.59±6.79 degree. The average time of follow-up in this series was 37.45±9.43 weeks (range 22 to 58 weeks). Similarly, the mean Mayo elbow performance index score at the latest follow-up was 90.22±8.65 (range 70 to 100).

Conclusions:

Careful assessment and radiological evaluation, anatomical reduction, and stable fixation with Herbert screws maintaining the minimal damage to the articular cartilage can maximize the functional outcomes and minimize the incidence of complications.

Surgical Treatment of Comminuted Coronal Shear Fracture of Distal Humerus

Objective

To investigate the surgical approach, fixation, and clinical effect of comminuted coronal shear fracture of distal humerus.

Methods

From March 2017 to February 2019, we had used open reduction and internal fixation to treat 19 cases of comminuted distal humeral coronal shear fracture. There were 8 males and 11 females, with an average age of 44.6 years (19–72 years). There were 10 cases on left side and 9 cases on right side. All cases were closed fractures. According to Dubberley's classification, there were six cases of type 1, six cases of type 2, and seven cases of type 3. The lateral Kocher approach, extended Kocher approach, extended Kocher approach combined with a medial incision and the olecranon osteotomy approach were used for exposure. Headless screw, Kirschner wire, and suture were used to fix the fractures. Two cases were fixed with hinged elbow fixators additionally. The follow‐up was evaluated by Mayo Elbow Performance Score (MEPS).

Results

All patients were followed up for an average of 17.1 months (range, 12 to 30 months). The average time of fracture union was 8.8 ± 1.9 weeks. There were three cases of degenerative osteoarthritis of elbow and one case of heterotopic ossification after operation. A total of 10 patients underwent removal of implants. At the last follow‐up, the elbow flexion‐extension arc was 130.5° ± 10.5°. The forearm rotation arc was 167.4° ± 6.1°. The MEPS was 85.8 ± 8.5, the results were classified as excellent in nine cases, good in eight, and fair in two. The excellent and good rate was 89.5%. The time of fracture union of type 1 was shorter than type 3 (P = 0.024), the elbow flexion‐ extension arc of type 1 fracture was better than type 2 (P = 0.043) and type 3 (P = 0.012), the forearm rotation arc of type 1 fracture was better than type 3 (P = 0.006), the MEPS of type 1 fracture was better than type 2 (P = 0.009) and type 3 (P = 0.002).

Conclusion

Open reduction and internal fixation with headless screw, Kirschner wire, and suture can be used for the treatment of comminuted distal humeral coronal shear fractures. The elbow joint function can be restored satisfactorily.

Capitellum fractures: Treatment with headless screws and outcomes

Objectives

This study aims to present the results of 21 patients with capitellum fractures treated with open reduction and headless screws by a single experienced surgeon.

Patients and methods

Twenty-one patients (13 males, 8 females; mean age 39 years; range, 18 to 63 years) who were admitted to our clinic between June 2011 and January 2018 with the diagnosis of capitellum fracture and followed-up for a mean period of 45 months (range, 12 to 90 months) were included in this retrospective study. The fractures were fixed with headless cannulated screws by a single surgeon.

Results

The mean range of motion was 102° (range, 65° to 140°) during flexion-extension and 165° (range, 130° to 180°) during supination-pronation. The mean preoperative visual analog scale (VAS) score was 8.5 (range, 6 to 10), whereas the mean postoperative VAS score was 2.2 (range, 0 to 6). According to the Mayo Elbow Performance score, nine patients were evaluated as excellent, six patients as good, four patients as fair, and two as poor. The mean Quick-Disabilities of the Arm, Shoulder and Hand score was 25.1 (range, 4 to 57). Avascular necrosis developed in three patients (14%) and heterotopic ossification was detected in one patient (4%).

Conclusion

Capitellum fractures are difficult to diagnose and treat, and good results can only be achieved by an accurate diagnosis, careful surgical technique, and stable fixation. Larger and more comprehensive studies are required to establish a generalization and more accurate inferences on this limitedly studied subject.

Coronal shear fractures of the distal humerus: Current concepts and surgical techniques

Coronal shear fractures of the distal humerus are a unique subset of distal humeral fractures which entail partial or complete articular fractures of the distal humerus without involvement of the columns. The very distal nature of these fragments, their small size and propensity for comminution render them challenging to treat surgically. The purpose of this article is to describe the classification, outcomes and surgical techniques currently used for the treatment of these fractures using the available literature and authors' clinical experience.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Combined use of Kirschner wires and hinged external fixator for capitellar and trochlear fractures: a minimum 24-month follow-up

BACKGROUND

Open reduction and internal fixation is the adequate treatment for capitellar and trochlear fractures. Given the low incidence of this type of fractures, it is difficult to constitute a universally accepted method for fixation. Thus, we hypothesised that combined use of Kirschner wires (K-wires), absorbable rods and sutures for fixation and post-operative hinged external fixator for early rehabilitation exercise can restore elbow joint function well.

METHODS

This retrospective study included 20 patients with a mean age of 48.3 (range 16-76) years. According to the Dubberley classification, fractures were classified on plain radiographs, computed tomography images and intra-operative findings. All patients were evaluated by the range of motion of the elbow and the Broberg-Morrey score.

RESULTS

All fractures had healed without non-union, and the average time was 13.6 (range 8-17) weeks. The mean follow-up was 42.5 (range 24-80) months. The mean flexion was 117.1° (range 90°-135°), and the mean extension was 17.5° (range 0°-45°). The mean pronation was 74.4° (range 45°-85°), and the mean supination was 84.3° (range 60°-90°). The average Broberg-Morrey score was 86.2 (range 68-98) points with 10 excellent, 7 good and 3 fair results.

CONCLUSION

K-wires, absorbable rods and sutures combined with hinged external fixator are feasible for fixation of capitellar and trochlear fractures. However, due to the absence of a control group (such as Herbert screw fixation), comparative studies are still needed to demonstrate the safety and reliability of K-wires for fixation.

Missed Capitellar Fracture Caused by Avoidance of Radiological Evaluation in Pregnancy

In this paper, we report a pregnant woman with a missed capitellar fracture of the elbow, who was treated successfully with open reduction and internal fixation using two headless screws. A 29-year-old 6-month pregnant woman presented to the emergency department due to a history of falling on her outstretched hand. A long-arm splint was applied without radiological evaluation due to pregnancy. She came to the orthopaedics and traumatology outpatient clinic 6 weeks after trauma and her examination after splint removal revealed pain and restriction in the elbow joint movements. Radiography was taken by using a lead shield in order to protect the fetus. Radiographs showed a displaced osteochondral capitellar fracture. Using the posterolateral approach as described by Kocher, the fracture was fixed using headless canulated compression screws. The follow-up examination showed excellent functional and radiological results. Radiological evaluation should not be avoided in case of obvious fracture findings after trauma even in case of pregnancy. It is also highlighted that good results in terms of union and functional recovery can be achieved with open reduction and headless compression screw fixation followed by early rehabilitation even in delayed treatment of capitellum fractures.

The impact of associated injuries and fracture classifications on the treatment of capitellum and trochlea fractures: A systematic review and meta-analysis

BACKGROUND

Capitellum and trochlea fractures are truly rare and the treatment is not fully appreciated. So we evaluate the impact of associated injuries and fracture classifications on elbow functional outcomes after open reduction and internal fixation.

MATERIALS AND METHODS

PubMed, Embase, Ovid Medline, and the Cochrane Library were searched from January 1, 1974 to January 1, 2017. All English literature with the treatment of capitellum and trochlea fractures by open reduction and internal fixation were included.

RESULTS

For associated injuries, the results suggested that the MEPI score of patients without associated injuries was higher than that of patients with associated injuries (P = 0.001). However, there was no significant difference in the arc of motion between the two groups (P = 0.052). For Bryan and Morrey classification, there was no significant difference in the MEPI score (P = 0.622) and in the arc of motion (P = 0.652) between type-I fractures and type-IV fractures. For Dubberley classification, there was significant difference only in the MEPI score between subtype-A fractures and subtype-B fractures (P = 0.005).

CONCLUSION

The associated injury of fracture may have a negative impact on the functional outcomes of elbow. And Dubberley classification is more suitable to classify this kind of fracture. Furthermore, high-quality studies are required to attain robust evidence.

Conservative treatment in displaced fractures of the humeral capitellum: a reduction technique under local anaesthesia

We report the case of a 46-year-old woman who struck her right elbow on the ground after a fall on ice. Radiography showed a right humeral capitellar fracture, and CT further confirmed a Dubberley type 1A fracture. Closed reduction was performed under local anaesthesia, and an anatomical position was obtained. After the reduction, her right elbow was casted for 18 days. Three months after the injury, bone union was achieved without displacement, and the active range of motion of her right elbow recovered similar to the unaffected side. At 1 year postinjury, the Grantham score was excellent, and she obtained a two-point score on the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire. Although surgical treatment is recommended for a displaced humeral capitellar fracture, a Dubberley type 1A (no posterior column fracture of a distal humerus) can be effectively treated by early closed reduction.

Fractures of the capitellum humeri and their associated injuries

Objective

Fractures of the capitellum are rare injuries but are often more complex and of a greater extent than assumed from conventional radiographs. Classification is usually based on their extension in relation to the trochlea the trochlea and on the number of fragments. Information on associated injuries is limited and only reported in small case series. The aim of this retrospective study was to report on our experience with capitellar fractures and their associated injuries.

Methods

We retrospectively reviewed all patients treated for fractures of the capitellum humeri at our institute between 2005 and 2017. Fractures were classified according to the Bryan–Morrey and the Dubberley classification and analyzed for their associated injuries depending on the fracture type using the chi-squared test.

Results

A total of 27 capitellar fractures were treated at our institute between 2005 and 2017. The median age of the patients was 57 years (range, 4–78) and they were all treated operatively. Associated injuries of the elbow were found in 12 cases (ten radial head fractures, two elbow dislocations, two tears of the radial collateral ligament). The injury mechanism was known for 26 patients (four fell on their outstretched arm, 19 suffered a direct blow to their elbow, two had a traffic accident).

Conclusion

The incidence of radial head fractures is high in patients with capitellar fractures. Patients suffering a fracture of the capitellum humeri should be thoroughly examined for such associated injuries since a missed diagnosis can lead to poor outcomes.

Distal Humeral Fractures-Current Concepts

Background:

Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation.

Methods:

A literature search was performed and the authors’ personal experiences are reported.

Results:

This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate orientation, transposition of the ulnar nerve and the role of elbow arthroplasty.

Conclusion:

Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes.

Resurfacing arthroplasty as an alternative to the posttraumatic sequelae of fractures of the external column of the humerus in the young adult

Symptomatic posttraumatic arthritis of the elbow in young patients is a disorder for which there is currently no satisfactory solution. In this case report we show the evolution of a comminuted fracture of the capitellum with trochlear extension (McKee typeIV) treated initially with open reduction and internal fixation that eventually required a resurfacing hemiarthroplasty of the capitellum and reconstruction of the lateral ligament complex. After this surgical procedure, the patient had evident improvement of pain and of elbow range of motion, keeping the possibility of performing other rescue techniques open if they were to be necessary in the future.

Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients

BACKGROUND

Fracture of the capitellum is an often missed or inadequately treated serious elbow injury. Anatomic reduction and proper stabilization are essential to obtain articular congruity so that late-onset arthritis can be avoided. The main areas of interest in this intriguing fracture are the choice of implant and the surgical approach. We describe the use of anterolateral approach and headless double-threaded compression screws for the fixation of this fracture.

MATERIALS AND METHODS

This prospective study included 16 capitellar fractures. A computed tomography scan was done for delineating the fracture line and planning the fixation technique. All fractures were treated with headless double-threaded compression screws using an anterolateral approach, over a period of 3 years, with a mean follow-up of 2.3 years (range, 1.5-4 years).

RESULTS

The average time to bony union was 3.5 months (range, 2.5-5 months) with no malunion or nonunion. The mean range of flexion was 132° (range, 125°-135°). The average extensor lag was 10° (range, 0°-25°), but the range of motion remained functional in all patients. On the final follow-up, no evidence of osteonecrosis, post-traumatic osteoarthritis, or heterotrophic ossification was seen. The outcome was excellent in 10 patients, and 6 patients had a good result.

CONCLUSIONS

The success of management of a capitellar fracture depends on an early diagnosis by keeping a high index of suspicion and timely management. Adequate exposure of the fracture is of paramount importance to achieve accurate reduction. This can be satisfactorily achieved by an anterolateral approach to the elbow. An adequate fixation of the fractured fragments can be achieved by the use of headless double-threaded compression screws.

Clinical outcome and osteoarthritic changes after surgical treatment of isolated capitulum humeri fractures with a minimum follow-up of five years

PURPOSE

The aim of this study was to evaluate the functional outcome of patients treated for a fracture of the capitulum humeri and to analyze the grade of osteoarthritic changes.

METHODS

Patients undergoing surgical reconstruction of isolated capitulum humeri fractures were included in a retrospective comparative analysis. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) and Dubberley and were functionally evaluated by the American Shoulder and Elbow Surgeons Score (ASES) and the Mayo Elbow Performance Index (MEPI). Levels of arthritic changes were measured with the Broberg and Morrey Score. Frequency of complications was evaluated whereby all results were compared to the ipsilateral, unaffected side.

RESULTS

Thirteen patients, ten females (76.9 %) and three males (23.1 %), with a mean age of 48.7 ± 13.3 years were included in the study. Long-term follow-up range of motion (ROM) in the sagittal plane was significantly influenced by time of surgery (p < 0.001), and long-term follow-up with respect to pronation and supination by ROM of the healthy control (p < 0.05). The average ASES score was 37.8, and the Mayo Elbow Performance Index (MEPI) was 92.7. The mean level of degenerative arthritic changes was 1.9 ± 0.6 on the fractured side and significantly less (0.8 ± 0.8) on the healthy side (p_F-test < 0.001). At a mean follow-up of 118.5 ± 52.4 months neither nonunion nor avascular necrosis were observed in any case. However, six cases of heterotopic ossification were identified.

CONCLUSIONS

Satisfying functional outcomes and a low rate of osteoarthritic changes can be expected after the presented open reduction and internal fixation of capitulum humeri fractures.

LEVEL OF EVIDENCE

Level IV - Case series; therapeutic study.

Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years

BACKGROUND

The aim of this study was to describe the fracture patterns of capitellum coronal fractures and to evaluate the complications and functional and radiographic outcomes of open reduction and internal fixation in patients older than 65 years.

METHODS

A retrospective study of 23 patients with a mean follow-up of 48 months (36-105) was performed. Fractures were classified according to the Dubberley classification. All patients were evaluated by the Mayo Elbow Performance Index (MEPI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) scores.

RESULTS

Three patients were lost to follow-up. There were 16 type 1 and 4 type 2 fractures. The mean age was 71 years (66-79), and 65% were women. The mean MEPI score was 92 (60-100), and the mean DASH score was 9 (0-75). Either a concomitant fracture or an elbow dislocation was present in 50% of the patients. Mean sagittal plane range of motion at last follow-up was 122° ± 8°, with lower extension in type 2 and worse scores on MEPI (91 vs. 97) and DASH (3 vs. 0) scales. Placement of the screws in the posteroanterior direction was associated with better range of motion in flexion (130° vs. 122°) and better outcomes in functional scores (MEPI, 97 vs. 89; QuickDASH, 0 vs. 4). Complications were post-traumatic osteoarthritis in 3 patients, avascular necrosis in 1 patient, and heterotopic ossification in 5 patients. One patient required reoperation.

CONCLUSIONS

Patients older than 65 years have no substantial risk of complex fracture patterns, but they have a large number of concomitant injuries. Open reduction and internal fixation with cannulated screws allow stable fixation and provide satisfactory functional results with a lower complication rate.

Capitellar and Trochlear Fractures

Fractures of the capitellum and trochlea account for a small proportion of elbow trauma. Clinicians need to be vigilant in their assessment as they are commonly associated with other injuries about the elbow. To optimize outcomes, the goals of management include a stable, anatomic reduction and early range of motion. Closed reduction of noncomminuted fractures may be successful but requires close follow-up. Open reduction and internal fixation is the preferred management of displaced capitellum-trochlear fractures. Elbow stiffness is the most commonly reported complication in operatively treated fractures. Arthroscopic-assisted reduction and internal fixation and arthroplasty are evolving management options.

[Neglected capitellum fracture in an adult: report of a case and review of literature]

Les auteurs rapportent un cas de fracture du capitellum négligée chez une femme de 36 ans ayant des limitations fonctionnelles. Après revue de la littérature, ils discutent le problème de la prise en charge thérapeutique et le pronostic de la lésion.

Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation

INTRODUCTION

Coronal plane fractures of the distal humerus involving the capitellum and trochlea are rare. Treatments have evolved from closed reduction to open reduction and internal fixation (ORIF) to achieve a stable joint that allows early mobilization.

BACKGROUND

We determined the functional outcomes of treating coronal plane fractures of the distal humerus with ORIF.

METHODS

We reviewed the records of all patients with coronal plane fractures of the distal humerus treated by ORIF. Fractures were classified according to Bryan and Morrey. Cannulated screws were used for fixation. All patients were evaluated using the Mayo Elbow Score Performance Index (MEPI) and disabilities of the arm, shoulder, and hand (DASH) scores at least 1 year later.

RESULTS

Of the 18 patients evaluated (12 women), the mean (SD) age was 45.3(16.5) years (range 16-70). There were seven Type-I, five Type-III, and six Type-IV fractures. Mean follow-up was 43.6 (38.1) months (range 12-120). The mean elbow range of motion in sagittal plane at last follow-up ranged from 8.9° to 132.8°. The mean MEPI score was 86.7 (15.2) points (range 60-100), corresponding to 12 excellent, 2 good, and 4 fair outcomes. The mean DASH score was 15.3 (13.5) points (range 17-35.8). Heterotrophic ossification developed in one patient with delayed fixation; 14 patients with excellent or good results returned to their previous activity levels. Functional scores did not differ by age, sex, or fracture types (P > 0.05 for all comparisons).

CONCLUSION

ORIF with cannulated screws, which maintain a stable anatomic articular position, provides satisfactory results in coronal plane fractures of the distal humerus.

LEVEL OF EVIDENCE

Level IV case series.

Corrective osteotomy through fracture site and internal fixation with headless screws for type I (Hahn-Steinthal) capitellar malunion

A 20-year-old woman presented 6 months after an initial injury to her left elbow with pain and restricted movements. She was diagnosed with a type I malunited (Hahn-Steinthal) type of capitellum fracture through radiographic studies. Classically, the treatment has been excision of the fragment, which carries a risk of valgus instability of the elbow and late osteoarthrosis. We report a case of malunited type I capitellum fracture, for which corrective osteotomy through fracture site, open reduction and internal fixation was done 6 months following missed trauma. At 24 months follow-up the capitellum fracture had united and the patient has a stable elbow and excellent range of motion. Our case demonstrates that for type I malunited capitellum fractures corrective osteotomy through fracture site and internal fixation rather than excision of the fragment in young can result in successful union and stable elbow.

Distal humeral coronal plane fractures: management, complications and outcome

BACKGROUND

Coronal plane fractures of the distal humerus have special characteristics in classification, imaging, surgical approaches, materials used, treatment modalities, and complications. The purpose of this study is to comment on these topics.

MATERIALS AND METHODS

A retrospective analysis was done for patients with distal humeral coronal plane fractures. They were classified according to Dubberley and functionally evaluated by Mayo Elbow Performance Index (MEPI). The long-term complications were evaluated.

RESULTS

There were 15 patients, with type 1 fractures in 2, type 2 in 6, and type 3 in 7. All patients were treated by open reduction and internal fixation either by lateral or posterior approach. The average MEPI score was 83.3 (range, 60-100) points with 7 excellent, 2 good, and 6 fair results. The MEPI scores of type 3 fractures were significantly lower than those of types 1 and 2 fractures (P = .037 and P = .002, respectively). The complications were avascular necrosis in 4 (27%) patients, degenerative arthritis in 6 (40%), joint step-off in 6 (40%), heterotopic ossification in 7 (47%), nonunion in 1 (7%), and implant failure in 1 (7%). The presence of avascular necrosis and joint step-off were significantly associated with degenerative arthritis (P = .004 and P = .005, respectively). Heterotopic ossification was significantly associated with presence of lateral epicondyle fracture (P = .004).

CONCLUSION

Type 1A and 2A coronal plane fractures typically had an excellent outcome. However, type 3 and subtype B fractures are prone to developing complications which are primarily avascular necrosis, degenerative arthritis and heterotopic ossification.

Operative management of capitellar fractures: a systematic review

PURPOSE

This study was conducted to evaluate reports of clinical outcomes of isolated capitellar fractures.

MATERIALS AND METHODS

We conducted a systematic review of medical databases reporting clinical outcomes of patients undergoing nonoperative and operative management of isolated capitellar fractures.

RESULTS

We identified 28 studies for inclusion comprising 174 patients. All included studies were level IV evidence. Capitellar fractures were more common among women than men and were more likely to involve the nondominant arm. Type I fractures (84%) were more common than type II (14%) and III fractures (2%). Operative and nonoperative management both led to satisfactory clinical outcomes. No significant difference in outcomes was observed in those undergoing operative management compared with those undergoing closed reduction and immobilization.

CONCLUSIONS

Nonoperative and operative management of isolated capitellar fractures leads to satisfactory clinical outcomes as determined by postoperative range of motion, improvement in pain, and a return to previous levels of function. No statistical difference in outcomes was observed between those undergoing operative management compared with those treated with closed reduction and immobilization.

Coronal shear fractures of the distal humerus

Management of coronal shear fractures of the distal humerus has evolved considerably over the past 3 decades, with an increased appreciation of the complexity of these fractures, improvements in internal fixation techniques, and the use of more extensile exposures. Nearly all of these fractures are displaced, given the paucity of soft tissue attachments and correspondingly, nonsurgical management is fraught with complications including chronic pain, mechanical symptoms, and instability and is not recommended. Good to excellent outcomes can be achieved in the majority of patients with open reduction internal fixation, particularly when the fracture is limited to the radiocapitellar joint. Outcomes are worst for those with considerable medial extension or comminution. Computed tomography is highly recommended to guide surgical planning. The presence of posterior comminution or extension to the medial column might require more extensile exposures and supplemental fixation for adequate stability. Arthroscopic reduction and fixation techniques have been described for the simple fracture. Those not amenable to fixation might do better with total elbow arthroplasty in a select population. Long-term data demonstrate the durability of these elbows following open reduction internal fixation. Complications other than stiffness are rare. Radiographic avascular necrosis does not appear to affect outcome. Radiographic mild to moderate arthritis was observed in half of patients at 17-year follow-up.

Distal humeral fractures in adults

Distal humeral fractures in adults are relatively uncommon injuries that require operative intervention in the majority of cases. Dual plate fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90° or 180° to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus. Acute total elbow arthroplasty is the preferred treatment for elderly patients with a displaced, comminuted, intra-articular distal humeral fracture that is not amenable to stable internal fixation. Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach.

Arthroscopic-assisted reduction and percutaneous fixation for coronal shear fractures of the distal humerus: report of two cases

Two patients with fractures of the capitellum and trochlea were treated with arthroscopic-assisted reduction and percutaneous fixation. This option may only be appropriate for straightforward fractures with no posterior comminution that can be reduced and visualized adequately.

Transarticular shear fractures of the distal humerus

BACKGROUND

Capitellar fractures result from shearing and wedging forces transmitted to the elbow that create complex injury patterns that are difficult to stabilize. The fracture often extends into the trochlea and is associated with posterior comminution of the humerus and soft tissue injury. Diverse fixation techniques are required to restore the anatomy perfectly to ensure elbow function is regained.

MATERIALS AND METHODS

This study presents the results of treatment of 26 patients followed up prospectively and treated within a week of injury. Clinical and radiographic evaluations were done annually by an independent reviewer, and the Mayo Elbow Performance Index (MEPI) was calculated.

RESULTS

Results were excellent in 9 patients, good in 9, and fair in 8 when assessed at an average of 46 months (range, 19-94 months) postoperatively using the MEPI, which averaged 81.3 (range 65-100). The poorer results occurred in patients with severe injuries associated with posterior comminution of the humerus and who required more extensive reconstructive procedures. All pain scores improved significantly and activities of daily living were restored in all groups, All returned to employment within 6 months, but 6 (3 type 2 and 3 type 3) had altered their roles from manual to administrative work.

CONCLUSION

This series reflects the challenges in reconstructing precisely this cartilage-covered sphere, especially when there are multiple fragments. Modern techniques of fracture stabilization that concentrate on restoring a circular structure may require a different approach and engineering solutions.

LEVEL OF EVIDENCE

Level 4; Case series, treatment study.

Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws

Fourteen patients with displaced fractures of the humeral capitellum were treated by open reduction and internal fixation of the capitellar fragments with Herbert screws. As per Bryan and Morrey classification, there were seven type I fractures, one type II fracture, three type III fractures, and three non-unions. Patient outcomes were evaluated using the Mayo elbow performance score. The follow-up period ranged from three to seven years (mean 4.8 years). All patients had a stable, pain-free elbow with good range of motion at follow-up. There was no evidence of avascular necrosis or degenerative change.

The often-missed Kocher-Lorenz elbow fracture

The authors report a case of an undiagnosed Kocher-Lorenz fracture in a 12-year-old adolescent. The Kocher-Lorenz type fracture involves a superficial osteochondral shell of the capitellum with little underlying bone. Three years after trauma, the patient still complained of throbbing and occasional elbow pain. Radiographic examination revealed a large intra-articular bone fragment mimicking the shape of a "second radial head", between the lateral condyle's ossification center and the radial head. Surgical treatment by fragment excision was performed. Eight years postoperatively, the patient had fully recovered with complete relief of pain. The patient demonstrated full range of motion in all planes. The authors offer a review of the literature on this rare fracture which diagnosis is often delayed.

Open reduction and internal fixation of capitellar fractures with headless screws. Surgical technique

BACKGROUND

The outcome of operatively treated capitellar fractures has not been reported frequently. The purpose of the present study was to evaluate the clinical, radiographic, and functional outcomes following open reduction and internal fixation of capitellar fractures that were treated with a uniform surgical approach in order to further define the impact on the outcome of fracture type and concomitant lateral column osseous and/or ligamentous injuries.

METHODS

A retrospective evaluation of the upper extremity database at our institution identified sixteen skeletally mature patients (mean age, 40 +/- 17 years) with a closed capitellar fracture. In all cases, an extensile lateral exposure and articular fixation with buried cannulated variable-pitch headless compression screws was performed at a mean of ten days after the injury. Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated at a mean of 27 +/- 19 months postoperatively.

RESULTS

Six Type-I, two Type-III, and eight Type-IV fractures were identified with use of the Bryan and Morrey classification system. Four of five ipsilateral radial head fractures occurred in association with a Type-IV fracture. The lateral collateral ligament was intact in fifteen of the sixteen elbows. Metaphyseal comminution was observed in association with five fractures (including four Type-IV fractures and one Type-III fracture). Supplemental mini-fragment screws were used for four of eight Type-IV fractures and one of two Type-III fractures. All fractures healed, and no elbow had instability or weakness. Overall, the mean ulnohumeral motion was 123 degrees (range, 70 degrees to 150 degrees ). Fourteen of the sixteen patients achieved a functional arc of elbow motion, and all patients had full forearm rotation. The mean Mayo Elbow Performance Index score was 92 +/- 10 points, with nine excellent results, six good results, and one fair result. Patients with a Type-IV fracture had a greater magnitude of flexion contracture (p = 0.04), reduced terminal flexion (p = 0.02), and a reduced net ulnohumeral arc (p = 0.01). An ipsilateral radial head fracture did not appear to affect ulnohumeral motion or the functional outcome.

CONCLUSIONS

Despite the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV fractures or fractures with an ipsilateral radial head fracture, good to excellent outcomes with functional ulnohumeral motion can be achieved following internal fixation of these complex fractures. Type-IV injuries may be more common than previously thought; such fractures often are associated with metaphyseal comminution or a radial head fracture and may require supplemental fixation.

Coronal plane partial articular fractures of the distal humerus: current concepts in management

Partial articular fractures of the distal humerus commonly involve the capitellum and may extend medially to involve the trochlea. As the complex nature of capitellar fractures has become better appreciated, treatment options have evolved from closed reduction and immobilization and fragment excision to a preference for open reduction and internal fixation. The latter is now recommended to achieve stable anatomic reduction, restore articular congruity, and initiate early motion. More complex fracture patterns require extensile surgical exposures. The fractures are characterized by metaphyseal comminution of the lateral column and have associated ipsilateral radial head fracture. With advanced instrumentation, elbow arthroscopy may be used in the management of these articular fractures. Though limited to level IV evidence, clinical series reporting outcomes following open reduction and internal fixation of fractures of the capitellum, with or without associated injuries, have demonstrated good to excellent functional results in most patients when the injury is limited to the radiocapitellar compartment. Clinically significant osteonecrosis and heterotopic ossification are rare, but mild to moderate posttraumatic osteoarthrosis may be anticipated at midterm follow-up.

Open reduction and internal fixation of capitellar fractures with headless screws

BACKGROUND

The outcome of operatively treated capitellar fractures has not been reported frequently. The purpose of the present study was to evaluate the clinical, radiographic, and functional outcomes following open reduction and internal fixation of capitellar fractures that were treated with a uniform surgical approach in order to further define the impact on the outcome of fracture type and concomitant lateral column osseous and/or ligamentous injuries.

METHODS

A retrospective evaluation of the upper extremity database at our institution identified sixteen skeletally mature patients (mean age, 40 +/- 17 years) with a closed capitellar fracture. In all cases, an extensile lateral exposure and articular fixation with buried cannulated variable-pitch headless compression screws was performed at a mean of ten days after the injury. Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated at a mean of 27 +/- 19 months postoperatively.

RESULTS

Six Type-I, two Type-III, and eight Type-IV fractures were identified with use of the Bryan and Morrey classification system. Four of five ipsilateral radial head fractures occurred in association with a Type-IV fracture. The lateral collateral ligament was intact in fifteen of the sixteen elbows. Metaphyseal comminution was observed in association with five fractures (including four Type-IV fractures and one Type-III fracture). Supplemental mini-fragment screws were used for four of eight Type-IV fractures and one of two Type-III fractures. All fractures healed, and no elbow had instability or weakness. Overall, the mean ulnohumeral motion was 123 degrees (range, 70 degrees to 150 degrees). Fourteen of the sixteen patients achieved a functional arc of elbow motion, and all patients had full forearm rotation. The mean Mayo Elbow Performance Index score was 92 +/- 10 points, with nine excellent results, six good results, and one fair result. Patients with a Type-IV fracture had a greater magnitude of flexion contracture (p = 0.04), reduced terminal flexion (p = 0.02), and a reduced net ulnohumeral arc (p = 0.01). An ipsilateral radial head fracture did not appear to affect ulnohumeral motion or the functional outcome.

CONCLUSIONS

Despite the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV fractures or fractures with an ipsilateral radial head fracture, good to excellent outcomes with functional ulnohumeral motion can be achieved following internal fixation of these complex fractures. Type-IV injuries may be more common than previously thought; such fractures often are associated with metaphyseal comminution or a radial head fracture and may require supplemental fixation.

Open reduction and internal fixation of coronal fractures of the capitellum

In this article, we describe a technique for internal fixation of coronal shear fractures of the distal humerus. It follows basic AO principles utilizing lag screw fixation combined with an antiglide plate to neutralize shearing forces. We have used this technique successfully for the treatment of isolated shear fractures of the capitellum, including those with extension into the trochlea.