Closed reduction of coronal 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.

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.

Lateral epicondyle osteotomy approach vs. olecranon osteotomy approach: an anatomic study of cadavers

BACKGROUND

Exposure of the articular surface is the key to successful open reduction and internal fixation treatment for coronal shear fractures of the distal humerus. The olecranon osteotomy approach has previously been described as one of the most effective exposure approaches. Nevertheless, this approach cannot expose the anterior trochlea, and it is impossible to reduce and fix the capitellum under direct vision. The purpose of this study was to compare the exposure of the articular surface of the distal humerus between the lateral epicondyle osteotomy approach (group L) and the olecranon osteotomy approach (group O).

METHODS

Each approach was performed on 8 freshly frozen upper limbs of adult cadavers. After each approach was completed, a 0.5-mm Kirschner wire is inserted along the edge to mark the visible part of the articular surface. Then, the soft tissue of each elbow is removed, and a surface-scanning system is used to create a digital 3-dimensional model. The visible part of the articular surface obtained by each surgical approach was mapped and quantified using markers created by Kirschner wires.

RESULTS

The lateral epicondyle osteotomy approach and the olecranon osteotomy approach exposed 0.8 ± 0.0 and 0.6 ± 0.0 of the distal humeral articular surface (P < .001), 1.0 ± 0.0 and 0.3 ± 0.1 of the capitellum (P < .001), 0.6 ± 0.0 and 0.7 ± 0.0 of the trochlea (P < .001), 0.7 ± 0.0 and 0.5 ± 0.1 of the anterior trochlea (P < .001), and 0.5 ± 0.0 and 1.0 ± 0.0 of the posterior trochlea, respectively (P < .001).

CONCLUSION

Compared with the olecranon osteotomy approach, the lateral epicondyle osteotomy approach could more fully expose the total articular surface of the distal humerus, capitellum, and anterior trochlea, but the olecranon osteotomy approach could more fully expose the trochlea and posterior trochlea.

Trans-fracture approach for ORIF of coronal shear fractures of the distal humerus

INTRODUCTION

Open reduction and internal fixation (ORIF) of comminuted coronal shear fractures of the distal humerus is challenging. When a concomitant lateral condyle fracture is present, it may be used for a trans-fracture approach to facilitate exposure and fracture reduction. This study aimed to investigate the frequency of lateral condyle fractures in coronal shear fractures of the distal humerus and analyze fracture reduction, fracture union and clinical results following ORIF through a trans-fracture approach.

MATERIALS AND METHODS

All adult patients who underwent treatment for an acute distal humerus fracture during a three-year period in our level-one trauma center were identified. All fractures were classified according to the Orthopaedic Trauma Association (OTA/AO) fracture classification system and all B3 fractures were classified according to the Dubberley classification. B3 fractures with a concomitant radial condyle fracture were identified. The clinical and radiological results, (Mayo Elbow Performance Score = MEPS, Visual Analogue Scale = VAS, range of motion), complications and revision surgeries were analyzed.

RESULTS

53 patients (mean age 52 ± 19 years) were identified. 13 fractures (24.5%) were B3 fractures. Four of them (30.8%) had a concomitant radial condyle fracture. All of these patients underwent ORIF with headless cannulated compression screws and a (postero-)lateral locking plate through a trans-fracture approach. At a minimum follow-up of 24 months, the MEPS was 88 ± 12 points, the VAS was 2 ± 1 and the range of motion was 118° ± 12°. All fractures showed anatomic reduction. One patient developed partial avascular necrosis and underwent arthrolysis at 6 months. One patient underwent partial hardware removal and lateral collateral ligament bracing at 6 months.

CONCLUSIONS

Lateral condyle fractures are present in about one third of coronal shear fractures of the distal humerus. This injury can be used for a trans-fracture approach to facilitate exposure and to reliably achieve anatomic fracture reduction.

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.

Biomechanical stability of complex coronal plane fracture fixation of the capitellum

INTRODUCTION

Coronal plane fractures of the distal humerus are relatively rare and can be challenging to treat due to their complexity and intra-articular nature. There is no gold standard for surgical management of these complex fractures. The purpose of this study was to compare the biomechanical stability and strength of two different internal fixation techniques for complex coronal plane fractures of the capitellum with posterior comminution.

MATERIALS AND METHODS

Fourteen fresh frozen, age- and gender-matched cadaveric elbows were 3D-navigated osteotomized simulating a Dubberley type IIB fracture. Specimens were randomized into one of two treatment groups and stabilized with an anterior antiglide plate with additional anteroposterior cannulated headless compression screws (group antiGP + HCS) or a posterolateral distal humerus locking plate with lateral extension (group PLP). Cyclic testing was performed with 75 N over 2000 cycles and ultimately until construct failure. Data were analyzed for displacement, construct stiffness, and ultimate load to failure.

RESULTS

There was no significant difference in displacement during 2000 cycles (p = 0.291), stiffness (310 vs. 347 N/mm; p = 0.612) or ultimate load to failure (649 ± 351 vs. 887 ± 187 N; p = 0.140) between the two groups.

CONCLUSIONS

Posterolateral distal humerus locking plate achieves equal biomechanical fixation strength as an anterior antiglide plate with additional anteroposterior cannulated headless compression screws for fracture fixation of complex coronal plane fractures of the capitellum. These results support the use of a posterolateral distal humerus locking plate considering the clinical advantages of less invasive surgery and extraarticular metalware.

LEVEL OF EVIDENCE

Biomechanical study.

Surgical outcomes of coronal shear fractures of the distal humerus in the elderly

BACKGROUND

The purpose of this study is to evaluate the clinical outcomes of the elderly with coronal shear fractures (CSFs) of the distal humerus who had undergone open reduction and internal fixation (ORIF).

METHODS

Between April 2002 and March 2019, eight elderly patients (76.3 ± 5.1 years)with CSFs of the distal humerus were investigated retrospectively. Postoperative complications, the range of motion (ROM) of the elbow joint, and functional elbow scoring (Mayo elbow performance score; MEPS) were assessed.

RESULTS

The mean follow-up duration was 23.6 ± 13.9 months. CSFs were treated by a buried implantable headless screw or Kirshner wires or bioresorbable screw with/without lateral locking plates. There were no superficial or deep infections, or elbow joint instability. Seven patients obtained fracture healing, but one patient showed non-union. Osteochondritis dissecans was present in one patient. Three patients showed step-off deformity (> 2 mm) of the articular surface. Two patients displayed a collapse of the fractured articular surface. A patient with severe comminution of both the capitellum and the trochlear showed the collapse of the whole articular surface with osteonecrosis of the capitellum and trochlea. Mean the range of motion of the elbow were flexion, 116.3±12.7° and extension, -28.8±14.1°. The mean MEPS was 78.8±10.2 points, representing patients who scored an excellent (n=1), good (n=3), and fair (n=4).

CONCLUSION

ORIF yielded satisfactory outcomes for theelderly with noncomminuted CSF of the distal humerus. However, the cases with comminuted articular fragment or complex posterior fractures were still challenging.

Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature

BACKGROUND

Coronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage. Open reduction and internal fixation (ORIF) has become the preferred treatment because it provides anatomical reduction, stable internal fixation, and early motion, but the optimal surgical approach remains controversial.

CASE SUMMARY

We report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach, in which lateral epicondyle osteotomy was performed based on the extended lateral approach. We named the novel surgical approach the lateral epicondyle osteotomy approach. All patients underwent surgical treatment and were discharged successfully. All patients had excellent functional results according to the Mayo elbow performance score. The average range of motion was 118° in flexion/extension and 172° in pronation/ supination. Only case 2 had a complication, which was implant prolapse.

CONCLUSION

We demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.

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.

Surgical tips and tricks for coronal shear fractures of the elbow

INTRODUCTION

Coronal shear fractures of the distal humerus represent an uncommon lesion and could be burdened by high complications. This complex lesion requires an accurate reduction and surgical fixation for a better outcome. Different techniques have been described, however no standard protocol have been proposed. Purpose of this retrospective study, is to evaluate the clinical and radiological outcome with posterior cannulated self-tapping headless screws followed by an early-active-motion protocol and to outline the surgical tips and tricks for different fracture patterns.

MATERIALS AND METHODS

From 2013 to 2019, a consecutive series of 24 patients with coronal shear fracture undergoing ORIF were included in the study. Fractures were classified according to Dubberley's classification. Cannulated self-tapping headless screws were used to fix the fragments. When necessary, additional cannulated half-threaded screws on the lateral edge of the humerus were used, as well as bone chips and fibrin sealant on severe comminution. All patients underwent an assisted early-active-motion rehabilitation protocol. Mean follow-up was 30 months; patients underwent standard X-rays and clinical outcome assessment with range of motion, Broberg and Morrey score and MEPI score.

RESULTS

Surgical fixation with headless screw guaranteed complete healing of all shear fractures examined, no loss of reduction were reported. ROM assessment showed good results with an average arc of 113.1°. Excellent to good Broberg-Morrey and MEPI score were reported. No cases of avascular necrosis nor post-traumatic osteoarthritis resulted in our series. Complications occurred in 16.6% of the patients.

CONCLUSION

Coronal shear fracture represents a challenging injury to treat. Anatomical reduction and the use of cannulated self-tapping headless screws from posterior provide a stable fixation, high union rates and good elbow function, with a low cartilage damage and risks of necrosis over 2 years of follow-up.

LEVEL OF EVIDENCE

Therapeutic III.

Outcome after the surgical treatment of the Dubberley type B distal humeral capitellar and trochlear fractures with a buttress plate

OBJECTIVE

This study aimed to evaluate the functional outcomes of the surgical treatment performed with a buttress plate for the trochlear and distal capitellum fractures with posterior extension in the humerus.

METHODS

The data belonging to 6 female and 4 male patients with a mean age of 43.8±11.1 (34-72) years were retrospectively evaluated. The mean follow-up period was 59.6±38.79 (22-127) months. The trochlear extension and posterior comminution of the fractures were assessed through the initial X-rays and computerized tomography images. Ten patients were classified as Dubberley type B. All fractures were treated surgically, with open reduction and internal fixation using a lateral buttress plate, headless cannulated screws, and Kirschner (K)-wires. The passive flexion and extension exercises were initiated at the first postoperative day. The patients were evaluated clinically and radiographically at the final follow-up. The outcomes were quantified using the Mayo Elbow Performance Index (MEPI), visual analog scale (VAS) pain score, and the patient's opinion.

RESULTS

At the final follow-up, the mean elbow flexion was 137.5°±3° (132°-140°), extension was -17.9°±9.2° (10°-35°), pronation was 72.2°±2.6° (68°-75°), and supination was 78.9°±4.09 (72°-85°). The mean MEPI score was calculated as 95.5±5.98 (85-100). According to the MEPI score, 8 patients were evaluated as excellent and 2 as good. The mean VAS pain score was 0.8±1.03 (0-2). The subjective patient evaluation was recorded as excellent in 5 patients, good in 3 patients, and moderate in 2 patients. One patient developed avascular necrosis and 2 patients had elbow joint arthrosis. K-wire migration was observed in one patient. Loss of reduction, nonunion, malunion, reflex sympathetic dystrophy, or heterotopic ossification were not encountered.

CONCLUSION

The management of distal humeral fractures is challenging, and favorable outcomes are closely associated with early joint motion. A solid fixation grants early mobilization. An internal fixation using lateral buttress plate, headless cannulated screws, and interfragmentary K-wires provides a solid and secure construction that allows early postoperative joint motion.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

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.

Anti-sliding plate technique for coronal shear fractures of the distal humerus

PURPOSE

The purpose of this study is to discuss the surgical strategy, technical feasibility, and clinical efficacy of coronal shear fractures of the distal humerus using the anti-sliding plate technique.

METHODS

Fifty-two patients (35 males and 17 females) were treated with the anti-sliding plate technique in our hospital from January 2012 to January 2017. The average age of the patients was 40.4 years. They were classified according to the Dubberley classification system and treated with the anti-sliding plate technique. The long-term functional scores represented by the Mayo Elbow Performance Index and complications were evaluated.

RESULTS

Fractures were classified as follows: 11 type-IA, 5 type-IB, 16 type-IIA, 4 type-IIB, 13 type-IIIA, and 3 type-IIIB according to the Dubberley classification system. All patients were treated with open reduction and internal fixation by the extensile lateral approach and completed a clinical and radiographic follow-up (average, 17.6 months). The average Mayo elbow performance score was 90.6 points, with 36 excellent, 11 good, and 5 fair results. The average range of movement of the elbow joint was 3° (0-15°) for extension and 136° (90-150°) for flexion.

CONCLUSIONS

The anti-sliding plate technique follows basic AO principles and neutralizes the shearing force combined with lag screws and/or Kirschner wires after the anatomic reduction of the fracture. It allows for the stable internal fixation of the fracture, which is critical for early mobilization and a good functional outcome.

LEVEL OF EVIDENCE

Level IV, Case Series, Treatment Study.

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.

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.

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.

Outcomes of Concomitant Fractures of the Radial Head and Capitellum: The "Kissing Lesion"

BACKGROUND

Radial head compression against the capitellum may cause concomitant fracture of the capitellum. The purpose of this study was to investigate if radial head fracture type is associated with a concomitant fracture of the capitellum.

PATIENTS AND METHODS

Data were identified from five area hospitals. We retrieved records of patients older than 18 years of age who underwent treatment for concomitant capitellum fracture and radial head fracture between January 2002 and January 2013. Patients with olecranon fractures or trochlea fractures were excluded.

RESULTS

A total of 10 patients with a radial head fracture and a concomitant capitellum fracture were included. Based on the operative reports, nine radial head fractures were classified as Hotchkiss modification of the Mason classification type II, and one was classified as type I. Based on the available radiographs and computed tomography, three capitellum fractures were type I, and seven were type II according to the Grantham classification.

CONCLUSION

Surgeons have to be alert to capitellar damage in case of a Hotchkiss type II radial head fracture.

LEVEL OF EVIDENCE

This is a level IV, therapeutic, retrospective study.

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.

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.

Shear fractures of the distal humerus: Is the use of intra-articular screws a safe treatment?

BACKGROUND

Coronal shear fractures of the distal humerus are uncommon injuries and are not exempt from complications. The aim of this research is to evaluate the possible advantages and drawbacks using cannulated compression headless screws.

MATERIALS AND METHODS

We performed a prospective study including all the consecutive patients who were treated with cannulated screws for coronal shear fractures of the distal humerus between 2010 and 2013. Following the Dubberley's classification, three patients were type 1A, one patient was 1B, three patients were 2B, and one patient was 3B. The mean follow-up was 30 months. The clinical and radiological evaluation included analysis of passive range of motion, functional outcome, radiological evaluation of fracture healing and reduction maintenance, and the occurrence of possible adverse events.

RESULTS

All fractures healed, and radiographic union was observed at an average of 3 months. The average elbow range of motion was 125°, with 125° of flexion and 20 of extension. According to the Broberg and Morrey score, there were four excellent and four good results. Using the Mayo Elbow Performance Index, five cases achieved excellent scores and three reported good results. Adverse events reported in three cases were as follows: heterotopic ossification, complex regional pain syndrome and delayed lateral collateral ligament disruption.

CONCLUSIONS

The use of cannulated compression headless screws has given satisfactory results, allowing a strong inter-fragmentary compression, early mobilization, with high union rates and good elbow function. However, patients should be counseled about the high proportion of adverse events following these injuries.

Arthrolysis and delayed internal fixation combined with hinged external fixation for elbow stiffness associated with malunion or nonunion of capitellum fracture

BACKGROUND

This study assessed outcomes after treatment of patients with capitellum fracture diagnosed >4 weeks after the trauma (delayed) who presented with stiff elbow.

METHODS

We reviewed 7 patients with stiff elbows after delayed diagnosis of capitellum fractures between February 2007 and February 2012. They were treated with arthrolysis by twin incisions, late open reduction and internal fixation, and a hinged external fixator. According to the Bryan-Morrey-McKee classification, 3 patients had type I capitellum fractures and 4 patients had type IV.

RESULTS

Mean follow-up was 28 months (range, 24-38 months). The mean delay from the initial trauma was 3.7 months. The flexion arc improved from a preoperative mean of 24° to a postoperative mean of 122°. The Mayo Elbow Performance Score increased from a mean of 56 points to 93 points. Anatomic fracture union occurred in all cases, and there was no secondary displacement.

CONCLUSIONS

Arthrolysis, late internal fixation, and use of a hinged external fixator can solve problems associated with stiff elbow after delayed diagnosis of capitellum fracture. Combined use of these techniques may be a safe and effective treatment option.

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.

Posterior fixation of type IV humeral capitellum fractures with fully threaded screws in adolescents

PURPOSE

Humeral capitellum fractures comprise approximately 1% of all elbow fractures. In this study, we examined the clinical, radiographic, and functional outcomes following operative stabilization of Bryan and Morrey type IV fractures of the capitellum in adolescents. We applied headless cannulated screws in a posteroanterior direction without damaging the articular cartilage surface of the fractures.

METHODS

Eight adolescent patients (six male, two female) with a mean age of 15 ± 2.1 years (range 13-18 years) were treated for type IV (McKee) humerus capitellum fractures. In the preoperative radiological evaluation, anteroposterior and lateral radiographs and computed tomography (CT) images were performed. A lateral surgical approach was used, and cannulated fully threaded headless screws were applied in a posteroanterior direction as fixation materials in the fracture reduction. The Mayo Elbow Performance Score was used in the evaluation of elbow joint functions.

RESULTS

Patients were followed up for a mean of 24.6 months. Fracture union was achieved at a mean of 5 ± 0.92 weeks (range 4-6 weeks). The mean elbow extension flexion arc was 135° ± 13.47° (range 110°-150º) and the mean pronation supination arc was 156° ± 4.43° (150°-160°). In one patient, there was nonconformity in the humerus trochlea and in another patient, there was keloid formation on the surgical scar. All patients attained excellent results according to the Mayo Elbow Performance Score.

CONCLUSIONS

In the treatment of type IV capitellum fractures in adolescents, open reduction with a lateral surgical approach and fixation using posteroanterior directed, cannulated, fully threaded, headless screws is a reliable method to achieve a pain-free functional elbow joint.

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.

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.

An unusual case of an isolated capitellar fracture of the right elbow in a child: a case report

INTRODUCTION

Although elbow fractures have a high incidence in the pediatric population, fractures of the capitellum are almost exclusively observed in individuals older than 12 years of age. Due to their rarity in children, reports with large numbers of cases are lacking in the literature and the surgical treatment options are poorly defined.

CASE PRESENTATION

We present the case of an 11-year-old Portuguese girl with a displaced fracture of the capitellum of the right elbow, a typical Hahn-Steinthal or Type 1 fracture, which was followed for one year. The treatment and outcome of this fracture are described. Our patient underwent an open reduction and internal fixation with two cannulated screws. There were no complications and normal elbow function was recovered.

CONCLUSION

The authors believe that cannulated screw fixation is a reliable method of treatment for Type 1 capitellar fracture in children because it enables good interfragmentary compression, early mobilization, faster functional elbow recovery and implant removal is rarely necessary.

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.

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.

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.

Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws

BACKGROUND

The purpose of this study is to retrospectively evaluate the clinical outcomes of 18 patients with large coronal shear fractures of the capitellum and lateral trochlea that underwent open reduction and internal fixation with headless compression screws.

METHODS

Eighteen patients were identified (16 women, 2 men) with an average age of 45 years and an average follow-up of 26 months. Fractures were classified according to the Dubberley classification as 11 type-1A injuries and 7 type-2A injuries.

RESULTS

All patients, with the exception of 1, had good to excellent functional results by the Broberg-Morrey scale (mean score, 93.3). Average arc of motion was 128 degrees in flexion/extension and 176 degrees in pronation/supination. Radiographically, 3 patients had subsequent development of avascular necrosis and 5 developed arthrosis. No significant negative correlation was noted between the development of avascular necrosis and clinical outcome. Minor complications occurred in 2 patients, but there were no re-operations.

CONCLUSION

Headless compression screw fixation allows for stable fixation in patients with large coronal shear fractures of the distal humerus without posterior comminution.

LEVEL OF EVIDENCE

4.

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.

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.

Hahn-Steinthal fracture: a case report

Isolated fracture of the capitellum is rare. We present clinical and radiological data on a single case of a fracture of capitellum. We came across a 31 year old woman who sustained an isolated Hahn Steinthal type of fracture. It was treated operatively by open reduction and internal fixation using mini fragment screws. The elbow was immobilized for 4 weeks. The patient regained full range of movement at 12 weeks post operatively. We reiterate that anatomical reduction and fixation is the right way to treat this injury.

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.

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.