Fractures of the capitellum

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.

Good outcomes of elbow arthroscopy-assisted absorbable screw fixation for capitellum fracture of the humerus in children: a case series

Background

Capitellum fractures are rare coronal fractures of the distal humerus which accounts for 6% of all distal humeral fractures and only 1% of all elbow fractures. The purpose of this study was to investigate the efficacy and complications of arthroscopically assisted reduction and fixation with absorbable screws for capitellar fracture of the humerus in children.

Methods

This was a retrospective case series study, which considered four patients (4 elbows), ranging from 10 to 15 years old, who were treated by arthroscopic-assisted percutaneous absorbable screw between 2018 and 2020. The elbow flexion-extension and forearm supination-pronation ranges of motion (ROM) were measured at the preoperative examination and last follow-up examination. Finally, the clinical and radiological results were assessed.

Results

The result of operations is satisfactory. The mean follow-up was 3.0 years (range 2-3.8 years). Average range of motion significantly improved from pre- to postoperation, with forearm supination from 60°(50°-60°) to 90°(90°) and pronation improved from 75°(70°-80°) to 90°(90°). The postoperative elbow flexion-extension range of motion was significantly higher compared with range of motion before surgery (P < 0.001; r = 0.949). At the final follow-up examination, the Mayo Elbow Performance Score was excellent. Satisfactory clinical results were achieved in all patients, and no postoperative complications were observed.

Conclusions

It is an effective and safe surgical option to use arthroscopic-assisted percutaneous absorbable screw fixation for treating capitellum fracture of the humerus without any complications in children.

Level of evidence

Level IV; case series.

Arthroscopic reduction and internal fixation of capitellar and trochlear fractures: A case series

Background

In a simple isolated capitellar/trochlear fracture without extensive posterior comminution, arthroscopic reduction and internal fixation (ARIF) can provide an alternative option to open reduction internal fixation. The purpose of this retrospective case series was to report on the technique and outcomes of arthroscopic reduction and internal fixation of capitellar/trochlear fractures.

Methods

All patients that underwent ARIF at a single upper extremity referral centre in the last twenty years were reviewed. Patient demographics, preoperative, intraoperative, and postoperative records were obtained through chart review and telephone followup.

Results

Ten cases of ARIF were identified over a twenty year period performed by two surgeons. The average age of patients was 37 years (17-63 years), with nine females and one male. With an average followup of eight years, nine of ten patients had a mean range of motion from 0 to 142 degrees. Their average MEPI and PREE score were 93 ± 7 and 8 ± 14, respectively. Four patients had focal cartilage collapse with three that required a reoperation. There were no infections, nonunions, or arthroscopy related complications.

Conclusion

ARIF offers an alternative to ORIF for capitellar/trochlear fractures producing good results while providing better visualization of the fracture reduction and minimizing soft tissue dissection.

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.

A Peculiar Case of Open Complex Elbow Injury with Critical Bone Loss, Triceps Reinsertion, and Scar Tissue might Provide for Elbow Stability?

Background

Complex elbow injuries (CEIs) are severe and rare lesions, difficult to treat correctly due to the different patterns of clinical presentations. Standard methods cannot often be applied. The main goals of the treatment are performing a stable osteosynthesis of all fractures, obtaining a concentric and stable reduction of the elbow by repairing the soft tissue constraint lesions, and allowing early motion. Since the introduction of virtual reality (VR) approaches in clinical practice, three-dimensional (3D) computed tomography (CT) and 3D printing have revolutionised orthopaedic surgeries, thus helping to understand the anatomy and the pathology of complex cases.

Case description

We discussed a case of CEI, characterised by an extended soft tissue (IIIB Gustilo classification) and neurovascular lesions associated with bone loss in a young female patient. Olecranon fracture was type IIIB according to Mayo classification. We outlined the steps of a pluri-tissue reconstructive approach and stressed the importance of 3D printing in the preoperative planning for such cases. Finally, peculiar final functional patient outcomes were reported.

Conclusion

In this case, we found out that triceps reinsertion and scar process may provide for the joint stability in a low-demanding patient. 3D printing and VR approaches in clinical practice can be useful in the management of CEIs associated with an important bone and soft tissue loss.

How to cite this article

Facco G, Politano R, Marchesini A, et al. A Peculiar Case of Open Complex Elbow Injury with Critical Bone Loss, Triceps Reinsertion, and Scar Tissue might Provide for Elbow Stability? Strategies Trauma Limb Reconstr 2021;16(1):53-59.

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.

Capitellum Fracture Open Reduction and Internal Fixation With Headless Screws

Partial articular fractures involving the capitellum represent an injury to the lateral column of the distal humerus. Capitellum open reduction and internal fixation restores this portion of the distal humerus articular surface and biomechanical integrity to the lateral column. This video demonstrates open reduction and internal fixation of a type I capitellar fracture with headless compression screws through an extensile lateral approach.

Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients

INTRODUCTION

Only few case series of capitellar and trochlear fractures have been reported. Some of them assume that the presence of a posterior comminution (type B according to Dubberley classification) can represent a negative risk factor for treatment and prognosis respect to the type A cases (without posterior comminution). Nevertheless, how this parameter impacts the treatment and the prognosis has never been quantified before.

MATERIALS AND METHODS

All the capitellar and trochlear fractures treated from 2007 to 2015 have been retrospectively reviewed. The presence of posterior comminution on a pre-operative CT-scan was correlated to the surgical technique, to the timing of initiation of rehabilitation and to clinical outcomes.

RESULTS

45 Consecutive patients have been selected, 17 not presenting a posterior comminution (type A), and 28 with posterior comminution (type B). In all the type A fractures a lateral approach (Kocher o Kocher extensile) was used and the fragment fixation was always performed using only screws. Elbow replacement or olecranon osteotomy were performed only to treat type B fractures. Augmented fixations, using plates and k-wires, or prosthetic replacement have been used only in type B fractures. The post-operative immobilization was significantly inferior for type A fracture. Better results have been obtained in type A fractures: mean MEPI score was 86 in type A and 73 in type B, the range of motion was significatively higher in type A both in flexion-extension and in pronation-supination. In type B fractures a significant higher number of complications have been observed (64% vs 29%) along with more reoperations.

DISCUSSION

The study has confirmed that, even without considering the extension of the fracture on the coronal plane, the presence of posterior comminution represents an evident negative risk factor, influencing the surgical approach and treatment, the fixation technique, the post-operative rehabilitation, the clinical outcomes, the complications and re-operation rates.

CONCLUSIONS

The analysis of the present case series shows how the treatment and the outcomes can be significantly anticipated based on the presence or absence of posterior comminution. Patients with type A fracture are more likely treated with a Kocher approach, screw fixation, an early rehabilitation is performed. In type A fractures better outcomes and low complications rate are expected.

Treatment of Fractures of the Humeral Capitellum Using Herbert Screws

Isolated fractures of the capitellum are rare injuries and account for 1% of all elbow injuries. The purpose of this study is to evaluate the clinical outcomes of 11 Type I capitellum fractures treated by open reduction and internal fixation using at least two standard Herbert screws between 1998 and 2003. The average age of the patients was 27.5 years. The mean follow-up time was 23.4 months. The final postoperative assessment was made at the 12th month. The results were evaluated according to the Mayo Elbow Performance Index. We obtained excellent result in eight patients and good result in three patients. We recommend open reduction and fixation with Herbert screws inserted from the posterior surface of the lateral epicondyle and early mobilization in Type I fractures of the capitellum.

Capitellum Fracture Fragment Excision: a Case Series

BACKGROUND

Fractures of the capitellum are rare injuries, and few studies have reported the results of fragment excision.

QUESTIONS/PURPOSES

The purpose of this study was to determine range of motion and short-term clinical outcomes for patients treated with capitellum excision.

METHODS

A retrospective review was performed to identify all patients with an isolated capitellum fracture who underwent excision as definitive treatment at our institutions. Mechanism of injury, associated elbow injuries, type of capitellum fracture, complications, and postoperative outcomes including final elbow range of motion (ROM), elbow instability, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded.

RESULTS

Four patients met the inclusion and exclusion criteria of this study. All patients were female with an average age of 69 years (range 42-85). Based on the Bryan and Morrey classification system, three (75%) fractures were classified as type I and one (25%) fracture as type III. The average clinical follow-up was 11 months. Final examination demonstrated a mean elbow range of motion from 14° (range 0-30) of extension to 143° (range 130-160) of flexion. All patients had full forearm rotation, and there was no clinical evidence of elbow instability. The average DASH score was 18.3 (12.5-24.2) at final follow-up.

CONCLUSION

Excision of the capitellum, much like excision of the radial head, results in acceptable short-term outcome scores and elbow range of motion in patients with fractures that are not amenable to open reduction and internal fixation.

Capitellar fractures-is open reduction and internal fixation necessary?

OBJECTIVE

The purpose of this retrospective study was to evaluate the medium-term to longer-term results of type 1 displaced capitellar fractures treated with closed reduction.

DESIGN

Retrospective case series.

PATIENTS

Eight consecutive cases (7 adults; 1 child) with type 1 capitellar fractures.

INTERVENTION

Closed reduction of type 1 capitellar fractures and 4 weeks of postreduction immobilization.

OUTCOME MEASURES

Complications (including radiographic), Disabilities of the Arm, Shoulder, and Hand Score, and active elbow range of motion.

RESULTS

Average follow-up was 41.6 months (range, 18-77 months). All 8 fractures were united. The patients obtained near full return of the range of motion when compared with the uninjured contralateral side. Mean average Disabilities of the Arm, Shoulder, and Hand Score scores were 4.36 (SD, 2.68; Range, 0-9). No complications were observed.

CONCLUSIONS

This study demonstrated that type 1 capitellar fractures can be treated successfully with closed reduction and cast immobilization.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Capitellum excision: Mechanical implications and clinical consequences

Controversy exists regarding the optimal treatment of isolated fractures of the capitellum that are not amenable to open reduction and internal fixation. Excision of the capitellum could result in instability of the elbow, though only limited the clinical or laboratory evidence exists to support this outcome. The aim of our study was to determine if capitellum excision leads to significant instability by measuring the relative change in varus-valgus displacement of the elbow. The varus-valgus displacement was recorded in 11 cadaveric elbows before and after isolated excision of the capitellum. Specimens were testing in varus-loaded and valgus-loaded positions with and without a 1 kg weight on the forearm. The varus-valgus displacement at the elbow was measured using a 3D motion capture system. Capitellum excision did not significantly change varus-valgus displacements in either the adducted, varus, or valgus position of the elbow (p = 0.80, p = 0.28, p = 0.51). Furthermore, the addition of the 1 kg external functional load to the forearm did not produce a significant change in the varus and valgus loaded positions (p = 0.16, p = 0.36). Our results demonstrate that excision of the capitellum in the setting of intact ligamentous structures does not result in significant instability in either the adducted varus loaded or valgus loaded positions of the elbow.

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.

Fractures of the radial head and neck

The majority of simple fractures of the radial head are stable, even when displaced 2 mm. Articular fragmentation and comminution can be seen in stable fracture patterns and are not absolute indications for operative treatment. Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the elbow and forearm. Partial and complete articular fractures of the radial head should be differentiated. Important fracture characteristics impacting treatment include fragment number, fragment size (percentage of articular disc), fragment comminution, fragment stability, displacement and corresponding block to motion, osteopenia, articular impaction, radiocapitellar malalignment, and radial neck and metaphyseal comminution and/or bone loss. Open reduction and internal fixation of displaced radial head fractures should only be attempted when anatomic reduction, restoration of articular congruity, and initiation of early motion can be achieved. If these goals are not obtainable, open reduction and internal fixation may lead to early fixation failure, nonunion, and loss of elbow and forearm motion and stability. Radial head replacement is preferred for displaced radial head fractures with more than three fragments, unstable partial articular fractures in which stable fixation cannot be achieved, and fractures occurring in association with complex elbow injury patterns if stable fixation cannot be ensured.

Internal fixation for coronal shear fracture of the capitellum with polylactide resorbable fixation

A 24-year-old woman with pain in the right elbow after a fall demonstrated a coronal shear fracture on radiographic studies. Perioperative a coronal shear fracture was seen and treated successfully with a polylactide Rigid fix resorbable pin. The operative correction resulted in normal function at 6 months follow-up. We state that a capitellum shear fracture can be fixated with a single resorbable pin, leading to successful fusion.

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.

Capitellar excision and hemiarthroplasty affects elbow kinematics and stability

INTRODUCTION

Capitellar hemiarthroplasty is proposed as a reconstructive option for isolated capitellar deficiency, but there is limited data on its effect on elbow biomechanics. This study assessed the effect of capitellar excision with and without replacement on elbow kinematics and stability, and evaluated 2 different implant surface shapes.

MATERIALS AND METHODS

Ten cadaveric arms were tested with an upper extremity joint simulator. Each arm underwent computer tomography scanning for implant sizing and computer-assisted implantation. Kinematic data were obtained using an electromagnetic tracking system during elbow flexion, with the arm oriented in the valgus, varus, and vertical positions. Implants were placed through an extended lateral epicondylar osteotomy using computer-assisted techniques. A repeated-measures design compared 2 implants (anatomical and spherical) to the native capitellum control and capitellar excision states. Outcomes were maximum varus-valgus laxity and rotation of the ulna with respect to the humerus.

RESULTS

Excision of the capitellum increased the varus-valgus laxity up to 3.1° in active elbow flexion, with the forearm in pronation but not in supination. Both capitellar implant designs maintained normal varus-valgus laxity in both active and passive elbow flexion. Excision of the capitellum increased external ulnar rotation during active flexion in the vertical and valgus positions up to 1.5°, while both implants restored normal ulnar rotation. The kinematics and stability of the elbows were similar for both implant designs.

CONCLUSION

The capitellum appears to have a role as a valgus and external rotational stabilizer of the ulnohumeral joint. This instability was corrected by both designs of capitellar hemiarthroplasty.

Fragility fractures of the distal humerus

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.

Closed reduction and early mobilization in fractures of the humeral capitellum

Seven consecutive patients with an isolated fracture of the humeral capitellum were treated by a single surgeon at a Level II care facility according to a simple treatment algorithm. Closed reduction was attempted in all cases using a standard technique. After reduction, the arm was splinted at 90° of flexion and mobilized at 14 days. All patients completed a clinical and radiographic follow-up consisting of a radiographic evaluation of reduction, elbow range of motion, Disabilities of the Arm, Shoulder and Hand Questionnaire, and a subjective rating of patient satisfaction. None of the patients required conversion to open reduction internal fixation or excision. Disabilities of the Arm, Shoulder and Hand Questionnaire scores ranged from 6 to 13 points (out of 100; mean, 9). The mean flexion/extension arc of motion obtained was 126° with minimal loss of rotation. Patient satisfaction was rated as excellent in five patients and good in two. All fractures appeared united at the most recent clinical and radiographic review. Closed reduction and early mobilization appears to be a safe and effective method of treating displaced fractures of the humeral capitellum with clinical results comparable to that of open reduction internal fixation.

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.

Osteochondral lesions of the capitellum do not affect elbow kinematics and stability with intact collateral ligaments: an in vitro biomechanical study

PURPOSE

Osteochondritis dissecans (OCD) of the capitellum most commonly affects adolescent pitchers and gymnasts, who present with pain and mechanical symptoms. Patients with larger lesions have poorer outcomes, possibly related to increased contact pressures on the surrounding articular surface with or without instability. The purpose of this in vitro study was to determine whether displaced OCD lesions of the capitellum lead to altered kinematics and stability of the elbow.

METHODS

We mounted 9 fresh-frozen cadaveric arms in an upper extremity joint testing system, with cables attaching the tendons of the major muscles to motors and pneumatic actuators. An electromagnetic receiver on the ulna enabled quantification of the kinematics of the radius and ulna with respect to the humerus. We used 3-dimensional computed tomography scans and computer-assisted techniques to navigate sequential osteochondral defects ranging in size from 12.5% to 100% of the capitellum. The arms were subjected to active and passive flexion in both the vertical and valgus positions with the forearm in both pronation and supination.

RESULTS

We found no significant differences in valgus angulation or ulnar rotation between any of the OCD lesions and the intact elbow during flexion, regardless of arm position or forearm rotation.

CONCLUSIONS

Osteochondritis dissecans lesions of the capitellum, both small and large, did not alter the ulnohumeral kinematics and stability with intact collateral ligaments. Therefore, excision of unfixable osteochondral fragments of the capitellum in the setting of intact collateral ligaments can be considered without the risk of creating instability.

Effect of coronal shear fractures of the distal humerus on elbow kinematics and stability

BACKGROUND

Coronal shear fractures of the distal humerus can include some or all of the cartilaginous and bony surface. Fixation is preferred, but severe comminution, nonunion, and avascular necrosis may mandate excision. The amount of distal humerus that is safe to excise is unknown. This study examined the effect of excision of the capitellum and trochlea on elbow kinematics and stability with intact collateral ligaments.

METHODS

Eight cadaveric arms were mounted in an upper extremity joint testing system. Electromagnetic receivers on the radius and ulna enabled quantification of ulnohumeral and radiocapitellar kinematics. The distal humeral articular surface was sequentially excised to replicate clinically relevant coronal shear fractures, leaving the collateral ligaments undisturbed. The arms underwent simulated active flexion in vertical and valgus-loaded positions, and passive forearm rotation in the vertical position.

RESULTS

In the vertical position, sequential excision of the articular surface increased valgus angulation during active flexion (P < or = .04), and excision of the entire articular surface increased ulnar external rotation compared to the intact elbow (P < or = .02). In the valgus position, excisions involving the trochlea increased valgus angulation for active flexion (P < or = .04). The radial head moved distal, posterior, and medial on the capitellum with some or all of the trochlea excised (P < or = .02).

DISCUSSION

While the capitellum alone does not contribute to elbow stability, the trochlea has an important role. Excision of the trochlea resulted in multiplanar instability of the ulnohumeral and radiocapitellar joints. Therefore, excision of an irreparable capitellum fracture may be considered if collateral ligaments are intact, while excision of some or all of the trochlea may not.

Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures

BACKGROUND AND PURPOSE

The current surgical treatment for displaced fracture of the capitellum and trochlea is open reduction and internal fixation (ORIF), but the results are often unsatisfactory, particularly with complex fractures. Furthermore, the surgical approach, the kind of osteosynthesis, and postoperative management are controversial. We evaluated the results of internal fixation combined with hinged external fixation.

METHODS

We analyzed 15 patients with a mean age of 47 (18-65) years. Based on the Bryan-Morrey-McKee classification, the fractures were identified as type I in 6 cases and type IV in 9. Active and passive motion was started and activities of daily living were permitted on the second postoperative day. The mean follow-up time was 29 (12-49) months.

RESULTS

In 13 cases, functional range of motion was obtained within 6 weeks of surgery. At final follow-up, 14 patients had a stable, pain-free elbow with a mean active range of motion of 13 degrees to 140 degrees . The average score on the Mayo elbow performance score was 98.

INTERPRETATION

The use of the hinged fixator allows early motion of the elbow while preserving joint stability. It may have additional value in complex articular fractures when stable internal fixation cannot be obtained with ORIF, and in the presence of severe ligamentous injuries.

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 emerging role of elbow arthroscopy in chronic use injuries and fracture care

Arthroscopy is emerging as an invaluable tool for diagnosing and treating elbow pathology. In addition to the advantages of less scarring, decreased risk of infection, less postoperative pain, and a more thorough visualization of the elbow joint, arthroscopy is particularly well suited to the treatment of athletes trying to minimize rehabilitation and inactivity. Indications for elbow arthroscopy now extend well beyond diagnosis and loose body removal, and include the treatment of impingement, arthritis, contractures, fragment stabilization for osteochondritis dessicans, and treatment of certain fractures. This article reviews the basic principles and techniques of elbow arthroscopy and their application to common sports-related conditions, such as valgus overload syndrome, medial collateral ligament insufficiency, and the various causes of lateral elbow pain. Newer applications of elbow arthroscopy in fracture care are addressed as well.

Open reduction and internal fixation of an apparent capitellar fracture using an extended lateral exposure

Apparent fractures of the capitellum are often more complex involving the trochlea and the posterior aspect of the lateral column. Many of these fractures can be addressed through an extended lateral exposure, but fixation techniques specific to small, nearly entirely articular fragments will be necessary. When the fracture fragments do not fit, there is usually posterior impaction of the lateral column and sometimes the posterior trochlea.

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.

Type 4 capitellum fractures: Diagnosis and treatment strategies

BACKGROUND

Fractures of the capitellum are rare injuries of the elbow usually seen in the adolescents. This fracture is often missed in the emergency room if a proper radiograph is not available. Recent reports have described many modalities of treatment favoring headless screw for fixation. The facility for headless screw fixation, however, is not available in most centers. This paper presents the diagnosis and management of type 4 capituller fractures (Mckee) with gadgets available in a district hospital.

MATERIALS AND METHODS

Between 2004 and 2007 three patients with right sided type IV capetullar fracture were treated in a district hospital. There were two boys aged 15 and 17 and one 33 years old lady. In one case, the fracture was missed in the emergency room. A double arc sign in the lateral views of the X-rays of the elbow was seen in all the cases. In each case a preoperative CT scan was done and a diagnosis of Mckee type IV fracture of the capitellum was made. Under tourniquet, using extended lateral approach, open reduction and internal fixation was done using 4mm partially threaded AO cancellous screws (n=2) and 2.7 mm AO screws (n=1), under vision from posterior to anterior direction from the posterior aspect of lateral condyle of humerus avoiding articular penetration.

RESULTS

All the fractures united uneventfully. At the end of one year follow-up, two cases had excellent elbow function; implants were removed and there were no signs of AVN or arthritis. The third case had good elbow ROM at 11 months without AVN.

CONCLUSION

Double arc sign on lateral X-rays of the elbow along with pre-operative CT scan evaluation is important to avoid a missed diagnosis and analysis of type IV capitellur fracture. Fixation with non-cannulated ordinary AO screws using extended Kocher's lateral approach has given good results.

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.

Apparent capitellar fractures

Isolated capitellar fractures are rare but are identified as such, even when they are more complex, because the displaced capitellar fracture is usually the most obvious and identifiable radiographic finding and because teaching has traditionally underemphasized the involvement of the trochlea in such fractures. The author prefers the term 'apparent capitellar fractures' and draws on his experience to explain why he favors three-dimensional CT for depicting fracture detail. This article discusses treatment options, emphasizing open reduction and internal fixation to restore the native elbow. Operative techniques, including extensile lateral exposure and olecranon osteotomy; fixation techniques; and elbow arthroplasty, are described. Complications, such as ulnar neuropathy and infection, are also covered.

Fractures of the distal humeral articular surface

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100,000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age.

Technique for internal fixation of capitellum and lateral trochlea fractures

Internal fixation for fractures of the humeral capitellum is a technically challenging procedure. Controversy exists regarding the optimal surgical approach and fixation technique. The benefit of stable fixation of the capitellum fragment is early mobilization. Our preferred technique involves anatomic reduction of the capitellar fragment and fixation with headless screws placed from anterior to posterior. When possible, the surgical exposure employed preserves the lateral ulnar collateral ligament (LUCL) and minimizes disruption of the soft tissues posterior to the capitellum.

[Bilateral capitulum humeri fracture, a case report and review of the literature]

Fracture of the capitellum is an intra-articular fracture of the distal humeral metaphysis and usually occurs in the frontal plane. It is a rare fracture and even more unusual when bilateral. The authors report a case of bilateral isolated fracture of the capitellum (Hahn-Steinthal type I) in a woman aged 28 years, treated surgically. A posterolateral approach was used for both elbows. Internal fixation was performed using two Herbert screws in the right elbow, and AO screws in the left elbow. Both elbows were immobilised for 3 weeks before commencing an intensive mobilization program guided by a physiotherapist. The end result was very satisfactory: both elbows were pain-free, with a complete range of movement on the right and a 10 degrees loss of extension on the left. Radiologically, consolidation was complete and there were no signs of avascular necrosis. Based on a review of the literature, the authors favour the use of Herbert screws in the treatment of capitellar fractures. They give good inter-fragmentary compression and reduce the risk of damaging the articular surface due to their subarticular position.

Absorbable implants in surgical correction of a capitellar malunion in an 11-year-old: a case report

We present the case of an 11-year-old girl who had a corrective osteotomy reconstruction using absorbable implants for a malunited capitellar fracture 3-1/2 months after a dislocation of her elbow joint. This operative stabilization enabled early joint mobilization and, finally, excellent results in terms of anatomy and function at a 2-year follow-up. We were not able to find any similar report in the English literature dealing with corrective osteotomy reconstruction using absorbable implant fixation for a malunited capitellum in a child.

Coronal shear fractures of the distal humerus: the capitellum and trochlea

Fractures of the capitellum and trochlea are uncommon and multiple options have been advocated for the treatment of this injury. A single management technique has not emerged as the superior technique, and a complement of interventions is necessary to manage the continuum of injuries that can be observed. In general, open reduction and internal fixation is advocated for healthy and active patients with satisfactory bone quality to allow for the insertion of stable fixation. In the geriatric population, total elbow arthroplasty may emerge as the treatment of choice particularly for the more comminuted fracture patterns. Postoperative rehabilitation is important and is guided by fracture stability, ligament integrity, and the ability of the patient to cooperate with the treatment protocol. Gratifying results can be achieved in most patients with even the most complex injuries.

Bilateral capitellum humeri fracture: a case report and review of the literature

We report a case of a 37-year-old woman who sustained a bilateral Hahn-Steinthal type fracture of her capitellum humeri. Open reduction and internal fixation, using extra-articular insertion of Herbert screws, were performed. Both elbows were immobilised for 3 weeks postoperatively. Radiographic signs of union were present at week 8. Within the observation period of 18 months, no signs of avascular necrosis were detected. At the end of the recovery period, despite intensive physiotherapy, the patient was left with a 20 degrees loss of flexion in her right elbow and a 15 degrees loss of extension in her left elbow. We found the use of Herbert screws particularly suitable for this type of injury: it allows good inter-fragmentary compression due to the sub-articular positioning that avoids the risk of damaging the articular surface. Mobilisation should start early to prevent joint stiffness and long-term disability.

Arthroscopic treatment of capitellum fracture of the humerus

This case report presents a type I Hahn-Steinthal capitellum fracture treated by screw fixation under arthroscopic control. It is the first published case of the use of this technique. The 3 types of capitellum fractures and different methods for treatment are described: functional treatment, open surgery, and arthroscopic surgery. The arthroscopic approach allows a precise reduction and fixation of the articular fragment with a better evaluation of associated lesions compared with the open surgery. Arthroscopic fixation minimizes the damage to periarticular soft tissues and has a lower morbidity compared with open surgery.

Fractures of the elbow's lateral column radial head and capitellum

Fractures of the lateral column of the elbow involve radial head fractures or capitellum fractures. As the biomechanics of the elbow have become better understood, the importance of the radiocapitellar joint in stabilizing the elbow has been emphasized. Preservation of the radial head has gained importance. For nondisplaced radial head fractures, good results are generally obtained with a short period of immobilization followed by early range of motion. In managing displaced radial head fractures, improved techniques and more versatile instrumentation have helped make preservation more feasible. Excellent results can be achieved with ORIF. In cases in which ORIF is impossible, prosthetic replacement of the radial head is a sound alternative. Successful results have been obtained with arthroplasty, and with second-generation modular systems, the facility of performing this procedure should increase. Treatment of capitellar fractures has also benefited from improved fixation systems. If the fragment is large enough, reduction and fixation with small screws or Kirschner wires have had good success. Excision works well in patients with fragments that are too small or not amenable to fixation, especially if the other structures of the medial elbow and forearm axis are competent.