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Wright D, Meyer Z, Goldfarb CA, Wall LB. Adolescent Coronal Shear Fractures of the Distal Humerus: Surgical Approach and Outcomes. J Hand Surg Am 2025:S0363-5023(24)00597-5. [PMID: 39818649 DOI: 10.1016/j.jhsa.2024.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 10/31/2024] [Accepted: 11/28/2024] [Indexed: 01/18/2025]
Abstract
PURPOSE Isolated coronal shear fractures of the distal humerus in adolescents are rare injuries with unique surgical challenges. Respect for the posterior blood supply, open physes, and need for direct visualization to achieve anatomic reduction are critical considerations in surgical fixation. This study presents a case series and a surgical approach used in treating these patients. METHODS A retrospective review of patients aged 10-19 presenting to a single quaternary-care academic center from 2016 to 2023 with isolated capitellar and trochlear shear fractures was performed. Demographic data, injury mechanism, fracture classification, and surgical approach were recorded. Outcomes included elbow range of motion at the final follow-up, visual analogue scale pain scores, pediatric Patient-Reported Outcome Measurement Information System (PROMIS) scales, radiographic and clinical union, return to sport, and postoperative complications. RESULTS Eight patients were included, four of whom were treated through a single-incision anterolateral approach. Average age was 13 years. Average time of the final clinical follow-up was 21 months, with a radiographic follow-up of 11 months. Five fractures were classified as Dubberly type 2A, two as type 3A, and one as type 3B. At the final follow-up, average elbow range of motion and visual analogue scale pain scores were 3-137 degrees and 0.28 (range: 0-2), respectively. PROMIS scores demonstrated an average mobility score of 55 (SD: 8), pain interference of 35 (SD: 5), and pediatric upper-extremity score of 55 (SD: 4). One patient with sickle cell disease developed avascular necrosis of the capitellum. There were no other postoperative complications. CONCLUSIONS Short-term clinical outcomes reveal low pain scores, near normal elbow motion, radiographic and clinical union, and normal patient-reported outcome measures in operatively treated coronal shear fractures of the distal humerus in adolescent patients. A single-incision anterolateral approach offers visualization of the anterior articular surface while respecting posterior soft tissues and the olecranon apophysis. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V, case series.
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Affiliation(s)
- David Wright
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Zachary Meyer
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO.
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Kholinne E, Gani KS, Mitchel, William, Wonggokusuma E, Pribadi A. Elbow stiffness due to malunited capitellum fracture: A case report and the role of 3D printing in surgical management. Int J Surg Case Rep 2024; 124:110398. [PMID: 39395254 PMCID: PMC11562399 DOI: 10.1016/j.ijscr.2024.110398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 09/26/2024] [Accepted: 09/29/2024] [Indexed: 10/14/2024] Open
Abstract
INTRODUCTION Elbow stiffness is an uncommon condition that significantly impacting a patient's daily activities. Trauma is the most frequent cause of elbow stiffness. However, capitellum fractures are rare, accounting for approximately 1 % of elbow fractures. They are often misdiagnosed due to nonspecific symptoms and the complex anatomy of the elbow joint. CASE PRESENTATION We report the case of a 54-year-old female who presented with left elbow stiffness eight months after a traumatic incident. On physical examination, her left elbow extension was +10°, and flexion was restricted to 65°, with no limitation in pronation or supination. Imaging studies revealed a malunited capitellum with osteophytes at the posterolateral site of the olecranon. A 3D-printed model of her elbow was created based on a CT scan to aid surgical planning. She underwent capsulectomy and osteotomy and was stabilized with two bioabsorbable P(L/DL)LA pins. Six months postoperatively, the patient's elbow range of motion was fully restored, and no complications were observed. CLINICAL DISCUSSION Elbow stiffness resulting from the malunion of a capitellum fracture typically necessitates surgical intervention to restore functional movement in the elbow. CONCLUSION Capitellum fractures are uncommon and frequently underdiagnosed, leading to complications such as elbow stiffness and reduced functionality. Early detection is crucial, as delayed diagnosis can result in complex management due to malunion. 3D printing from CT scans helps surgeons accurately evaluate malunions and plan precise surgical interventions.
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Affiliation(s)
- Erica Kholinne
- Gatam Institute, Eka Hospital, Indonesia; Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia.
| | | | - Mitchel
- Gatam Institute, Eka Hospital, Indonesia
| | - William
- Gatam Institute, Eka Hospital, Indonesia
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Patel UJ, Dondapati A, Carroll T, Soin S. Technical trick: buttress plate fixation of comminuted capitellum fractures with combined suture repair of the lateral ulnar collateral ligament. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:576-582. [PMID: 37929000 PMCID: PMC10624994 DOI: 10.1016/j.xrrt.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Urvi J. Patel
- University of Rochester Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Akhil Dondapati
- University of Rochester Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas Carroll
- University of Rochester Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Sandeep Soin
- University of Rochester Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
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You C, Cheng Z, Xia Y, Deng C, Zhou Y, Sun Y, Fu G. Good outcomes of elbow arthroscopy-assisted absorbable screw fixation for capitellum fracture of the humerus in children: a case series. Front Pediatr 2023; 11:1202537. [PMID: 37334220 PMCID: PMC10272462 DOI: 10.3389/fped.2023.1202537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
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.
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Affiliation(s)
- Chao You
- Correspondence: Chao You Guibing Fu
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Ulery DJ, Stegelmann SD, Phillips SA. Open Reduction and Internal Fixation of a Type IV Capitellum Fracture Through a Transolecranon Tunnel: A Case Report. JBJS Case Connect 2023; 13:01709767-202306000-00037. [PMID: 37235705 DOI: 10.2106/jbjs.cc.23.00144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
CASE A 60-year-old woman sustained a type IV capitellum fracture from falling on an outstretched arm. Open reduction internal fixation (ORIF) was performed using an anconeus approach, and a transolecranon tunnel was created to place a trochlear screw. The patient showed good clinical outcomes with almost full range of motion at 6 months. CONCLUSION With type IV capitellum fractures, the olecranon often obstructs the screw trajectory necessary for anterior-to-posterior fixation of trochlear fragments. Drilling a transolecranon tunnel through the proximal olecranon with the elbow flexed creates a viable pathway for screw placement from a more medial starting point than what is possible with traditional techniques.
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Affiliation(s)
- David J Ulery
- Mercy Health St Vincent Medical Center, Toledo, Ohio
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Kim BS, Jung KJ, Kim KB, Park SS. Treating AO Type C2-3 Distal Humerus Fractures With the Anconeus Flap Transolecranon Approach. Orthopedics 2022; 45:e326-e334. [PMID: 35947456 DOI: 10.3928/01477447-20220805-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We evaluated the outcomes of precontoured locking plate fixation with the anconeus flap transolecranon (AFT) approach to treating AO type C2-3 comminuted intra-articular distal humerus (IDH) fractures among active patients. Thirty-six patients (age <65 years) with IDH fractures treated with precontoured distal humerus locking plate fixation were divided into 2 groups: group 1 (n=18; transolecranon [TO] approach) and group 2 (n=18; AFT approach). The radiographic examination included assessments of implant failure, fracture site union, and olecranon osteotomy site union. Clinical examination included assessments of operating time, range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disability of the Arm, Shoulder and Hand (DASH) score, and complications. The mean follow-up time was 25.2 months (range, 18-79 months). The mean operating time was 134.3 minutes and was significantly longer for group 2 (AFT; 141.2 minutes) than for group 1 (TO; 124.2 minutes). The mean olecranon osteotomy site union time was significantly longer in group 2 (7.4 weeks) than in group 2 (4.0 weeks). Olecranon osteotomy site resorption occurred among 6 of 18 patients only in group 2. No significant difference in ROM (flexion, 130°; extension, -0.7°), MEPS (85.7 points), DASH score (20.0 points), or frequency of major complications (TO, 5; AFT, 6) was observed between the groups. Our results showed no advantage of the AFT approach over the TO approach, despite preserving the anconeus. Prospective randomized trials will be necessary to compare the AFT and TO approaches for treating comminuted IDH fractures. [Orthopedics. 2022;45(6):e326-e334.].
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Li J, Martin VT, Li DT, Su ZW, Wu YH, Gan JY, Liu QL, Yu B. Lateral epicondyle osteotomy approach vs. olecranon osteotomy approach: an anatomic study of cadavers. J Shoulder Elbow Surg 2022; 31:2339-2346. [PMID: 35613695 DOI: 10.1016/j.jse.2022.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Jie Li
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Vidmi Taolam Martin
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Dong-Tai Li
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Wen Su
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - You-Hui Wu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jing-Yue Gan
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qiao-Lan Liu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
| | - Bo Yu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
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Nolte PC, Midtgaard K, Miles JW, Tanghe KK, Provencher MT. The Effect of Buttress Plating on Biomechanical Stability of Coronal Shear Fractures of the Capitellum: A Cadaveric Study. J Hand Surg Am 2022:S0363-5023(21)00801-7. [PMID: 35153076 DOI: 10.1016/j.jhsa.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 10/21/2021] [Accepted: 12/02/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare, using a cadaveric model, the biomechanical properties of headless compression screws (HCSs) and HCSs augmented with a buttress plate (BP) in capitellar fractures. METHODS Twenty pairs of fresh-frozen humeri (mean age, 46.3 years; range, 33-58 years) were used. The soft tissue was removed, and a Dubberley type IA capitellar fracture was created. One specimen in each pair was randomly assigned to receive either two 2.5-mm HCSs (HCS group) or two 2.5-mm HCSs augmented with an anterior 2.4-mm BP (HCS + BP group). This resulted in a similar distribution of the left and right humeri between the groups. Cyclic loading was performed, and displacement of the capitellum at 50, 100, 250, 500, 1,000, and 2,000 cycles was assessed using a motion capture system. This was followed by load-to-failure testing, wherein the load at a displacement of 1 and 2 mm was recorded. Failure was defined as 2-mm displacement. RESULTS During cyclic loading, there were no significant differences in the displacement between the HCS and HCS + BP groups at any of the assessed cycles. During load-to-failure testing, no significant strength differences were observed in the load at 1-mm displacement between the HCS (mean: 449.8 N, 95% CI: 283.6-616.0) and HCS + BP groups (mean: 606.2 N, 95% CI: 476.4-736.0). However, a significantly smaller load resulted in a 2-mm displacement of the fragment in the HCS group (mean: 668.8 N, 95% CI: 414.3-923.2) compared with the HCS + BP group (mean: 977.5 N, 95% CI: 794.1-1,161.0). CONCLUSIONS Anterior, low-profile buttress plating in addition to HCSs results in a significantly higher load to failure compared with HCSs alone in a biomechanical Dubberley type IA capitellar fracture model. CLINICAL RELEVANCE The addition of an anterior BP may be considered to improve initial stability in select cases such as osteoporotic patients or when the posterolateral column is frail.
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Affiliation(s)
- Philip C Nolte
- Steadman Philippon Research Institute, Vail, Colorado; BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwigshafen, Germany
| | - Kaare Midtgaard
- Steadman Philippon Research Institute, Vail, Colorado; Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Norwegian Armed Forces Joint Medical Services, Forsvarsvegen, Norway
| | - Jon W Miles
- Steadman Philippon Research Institute, Vail, Colorado
| | - Kira K Tanghe
- Steadman Philippon Research Institute, Vail, Colorado
| | - Matthew T Provencher
- Steadman Philippon Research Institute, Vail, Colorado; Steadman Clinic, Vail, Colorado.
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Coronal Shear Fractures of the Distal Humerus. J Funct Morphol Kinesiol 2022; 7:jfmk7010007. [PMID: 35076551 PMCID: PMC8788494 DOI: 10.3390/jfmk7010007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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BAYDAR MEHMET, AYKUT SERKAN, MERT MUHAMMED, KESKINBIÇKI M, AKDENIZ H, ÖZTÜRK KAHRAMAN. ISOLATED CAPITELLAR FRACTURE FIXATION WITH HEADLESS SCREWS IN DIFFERENT CONFIGURATIONS. ACTA ORTOPEDICA BRASILEIRA 2022; 30:e244357. [PMID: 35431622 PMCID: PMC8979352 DOI: 10.1590/1413-785220223001e244357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
Introduction We evaluated the clinical and radiological outcomes of capitellar fractures treated with modified screw insertion (inserting the first fixation screw anteroposteriorly and the second screw posteroanteriorly), a technique that can be applied with a minimally invasive lateral elbow approach. Materials and Methods Twenty-one isolated capitellum fractures that were surgically treated were included in the study. Fixation was achieved with two headless cannulated compression screws placed in anteroposterior and posteroanterior order using the modified lateral elbow approach. The Broberg-Morrey rating system was used to assess the post-operative functional status of the patients. Results According to the Broberg-Morrey criteria, the mean score was 92.7 (77-100) and 13 cases had excellent, 7 had good, and 1 had fair results. None of the patients developed avascular necrosis or heterotopic ossification. According to the Broberg-Morrey arthrosis score, two cases had Grade 1 and one had Grade 2 arthrosis. One patient had a superficial wound site infection that was treated with antibiotics, and in one case a 60° extension loss was observed in the elbow. Conclusion Treatment of isolated capitellar fractures with 2 headless screws placed anteroposteriorly and posteroanteriorly can provide stable fixation and is less traumatic for the elbow joint. Level of Evidence IV; Therapeutic Studies - Investigating the results of treatment.
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Fram BR, Seigerman DA, Ilyas AM. Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes. Hand (N Y) 2021; 16:577-585. [PMID: 31625402 PMCID: PMC8461205 DOI: 10.1177/1558944719878817] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Fractures of the capitellum and trochlea are uncommon fractures of the elbow and can be challenging to treat due to their size, location, and articular nature. Because of their intra-articular nature and predilection toward displacement, these fractures are typically treated operatively. Furthermore, capitellum fractures have high rates of associated injuries, including radial head fractures or lateral collateral ligament injury in ~30% to 60% of patients. In addition to open reduction internal fixation, operative options include fragment excision, arthroscopic assisted reduction and fixation, and elbow arthroplasty. In this article, we undertake a comprehensive literature review of capitellum fractures of the distal humerus, in an attempt to summarize the existing body of evidence and propose areas of future study.
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Affiliation(s)
| | | | - Asif M. Ilyas
- Thomas Jefferson University Hospital, Philadelphia, PA, USA,Asif M. Ilyas, Rothman Institute of Orthopedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5 Floor, Philadelphia PA 19107, USA.
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Matter-Parrat V, Eichler D, Sommaire C, Gicquel P, Clavert P. Arthroscopic osteosynthesis of capitellum fractures: Feasibility study and clinical study on 2 cases. J Orthop Sci 2021; 26:604-609. [PMID: 32814660 DOI: 10.1016/j.jos.2020.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/12/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The current management of displaced capitellum fractures is traditionally surgical. Most authors perform open reduction and internal fixation. The working hypothesis was that closed reduction and internal fixation of capitellum fractures is achievable by arthroscopy. METHODS We carried out a cadaveric study on six fresh frozen elbows. We performed two Bryan and Morrey type I fractures of the capitellum, three type II and one type IV using a 15 mm osteotome. Fracture reduction was performed under arthroscopy using a probe hook and an aiming femoral instrument set. Fixation with a lag screw was performed under arthroscopy and radioscopic control. We reviewed, two patients who had been operated on for a type I and type II capitellum fracture and osteosynthesized under arthroscopy with a 7.5 years follow-up. RESULTS In our cadaveric study, we obtained anatomical reduction and stable osteosynthesis in four cases. We had two failures (2 type II fractures) due to a fracture of the fragment during screwing. In our clinical study, range of motion was very satisfactory with only a 5° extension deficit. The x-rays did not reveal any signs of osteoarthritis or periarticular ossification. One patient had minimal signs of osteonecrosis. CONCLUSIONS Arthroscopic osteosynthesis of capitellum fractures is feasible and reproducible. We recommend cannulated lag screws for Bryan and Morrey type I and IV fractures and adjustable lock pins for type II fractures. We have shown that this technique gives good results on two patients with a 7.5-year follow-up. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Valérie Matter-Parrat
- Shoulder and Elbow Service, CHRU Strasbourg, Avenue Molière, 67098, Strasbourg Cedex, France
| | - David Eichler
- Shoulder and Elbow Service, CHRU Strasbourg, Avenue Molière, 67098, Strasbourg Cedex, France
| | - Christian Sommaire
- Institut of Anatomy, Faculté de Médecine, 4, Rue Kirschleger, 67085, Strasbourg Cedex, France
| | - Philippe Gicquel
- ICube-GEBOAS, CNRS, UMR 7357, Faculté de Médecine, 4, Rue Kirschleger, 67085, Strasbourg Cedex, France; Hôpitaux Universitaires de Strasbourg, Centre de Chirurgie Pédiatrique, Strasbourg, France
| | - Philippe Clavert
- Shoulder and Elbow Service, CHRU Strasbourg, Avenue Molière, 67098, Strasbourg Cedex, France; Institut of Anatomy, Faculté de Médecine, 4, Rue Kirschleger, 67085, Strasbourg Cedex, France; Hôpitaux Universitaires de Strasbourg, Centre de Chirurgie Pédiatrique, Strasbourg, France.
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Optimal Fixation of the Capitellar Fragment in Distal Humerus Fractures. J Orthop Trauma 2021; 35:e228-e233. [PMID: 33252446 DOI: 10.1097/bot.0000000000002012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if orthogonal or parallel plate position provides superior fixation of the separate capitellar fragment often present in intra-articular distal humerus fractures. We hypothesized that orthogonal plating would provide stiffer fixation given a greater number of opportunities for capitellar fixation and screw trajectories perpendicular to the fracture plane offered by a posterolateral plate compared with a parallel plate construct. METHODS Ten matched pairs of cadaveric distal humeri were used to compare parallel and orthogonal plating in a fracture gap model with an isolated capitellar fragment. The capitellum was loaded in 20 degrees of flexion using a cyclic, ramp-loading protocol. Fracture displacement was measured using video tracking software. The primary outcome was axial stiffness for each construct. Secondary outcomes included maximum axial and angular fracture displacement. RESULTS The parallel plate construct was more than twice as stiff as the orthogonal plate construct averaged across all loads (1464.8 ± 224.0 N/mm vs. 526.3 ± 90.8 N/mm, P < 0.001). Average axial fracture displacement was 0.15 ± 0.03 mm versus 0.53 ± 0.10 mm for parallel versus orthogonal plating, respectively (P = 0.003). Angular fracture displacement was minimal for both constructs (0.009 ± 0.001 degrees vs. 0.028 ± 0.006 degrees for parallel vs. orthogonal constructs). CONCLUSIONS Despite fewer points of fixation, a parallel plate construct provided stiffer fixation with less displacement of the simulated capitellar fracture fragment than an orthogonal plate construct in this biomechanical study. In the setting of an articular fracture, in which absolute stability and primary bone healing are desirable, parallel fixation should be considered even in fractures with a separate capitellar fragment if the size of fragment and fracture orientation allows.
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Li J, Martin VT, Su ZW, Li DT, Zhai QY, Yu B. Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature. World J Clin Cases 2021; 9:4318-4326. [PMID: 34141796 PMCID: PMC8173410 DOI: 10.12998/wjcc.v9.i17.4318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/24/2021] [Accepted: 04/02/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Jie Li
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Vidmi Taolam Martin
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Zhi-Wen Su
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Dong-Tai Li
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Qi-Yi Zhai
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Bo Yu
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
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Abdoli A, Farhoud AR, Kamrani RS. Treatment of Distal Humerus Articular Fracture with Pin-and-Plate Technique. J Hand Surg Asian Pac Vol 2020; 25:332-339. [PMID: 32723041 DOI: 10.1142/s242483552050037x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Distal Humerus Articular Fracture (classified by Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association as 13-B3) is an uncommon fracture with significant complications. We report results of 14 patients treated by open reduction and pin-and-plate fixation technique. Methods: In this retrospective study, we applied pin-and-plate fixation to 14 distal humerus articular fractures, in which screw fixation alone was inefficient or inadequate to provide stable fixation. After anatomical reduction of articular fragments, multiple Kirschner wires were inserted through the fragments. To prevent migration of Kirschner wires a small plate was placed proximally on the bent end of the pins. Results: The average age of 14 patients (8 males and 6 females) was 36.4 years (range: 16-57) and the mean follow up period was 43 months (range: 12-80). At last follow up the average quick Disabilities of the Arm, Shoulder and Hand score was 18.9 (range: 2.3-42.5) and the mean points for Mayo Elbow Performance Index was 75.3 (range: 50-100). Mean final arc of flexion-extension was 97° (range: 40-131). Conclusions: Distal humerus articular fracture is sometimes difficult to fix with conventional methods. We used pin-and-plate technique that could make a stable fixation and allow early range of motion with acceptable results.
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Affiliation(s)
- Abbas Abdoli
- Department of Orthopedics, Shahid Sadoughi Hospital, Shahaid Sadoughi (Yazd) University of Medical Sciences, Yazd, Iran
| | - Amir Reza Farhoud
- Department of Orthopedics, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.,Joint Reconstruction Research Center, Tehran, Iran
| | - Reza Shahryar Kamrani
- Joint Reconstruction Research Center, Tehran, Iran.,Department of Orthopedics, Dr Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Demir MT, Ertan Birsel S, Salih M, Pirinçci Y, Birsel O, Kesmezacar H. Outcome after the surgical treatment of the Dubberley type B distal humeral capitellar and trochlear fractures with a buttress plate. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:364-371. [PMID: 32554364 DOI: 10.5152/j.aott.2020.20092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Muhammed Taha Demir
- Clinic of Orthopaedics and Traumatology, İstanbul Medicine Hospital, İstanbul, Turkey
| | - Sema Ertan Birsel
- Clinic of Orthopaedics and Traumatology, İstanbul Medicine Hospital, İstanbul, Turkey
| | - Muhammet Salih
- Clinic of Orthopaedics and Traumatology, İstanbul Medicine Hospital, İstanbul, Turkey
| | - Yusuf Pirinçci
- Clinic of Orthopaedics and Traumatology, İstanbul Medicine Hospital, İstanbul, Turkey
| | - Olgar Birsel
- Department of Orthopaedics and Traumatology, Koç University, School of Medicine, İstanbul, Turkey
| | - Hayrettin Kesmezacar
- Clinic of Orthopaedics and Traumatology, Florence Nightingale Hospital, İstanbul, Turkey
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Zhang Y, Hu J, Li X, Qin X. Humeral capitellum fracture combined with humeral lateral column injury: A novel classification system and treatment algorithm. Injury 2020; 51:955-963. [PMID: 32169276 DOI: 10.1016/j.injury.2020.02.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Shear humeral capitellum fracture (CF) treatment can be complicated by comminution of the distal lateral humeral column (LHC). Although treatment with a 3.5 mm posterolateral distal humerus plate with support (PDHPWS) has been proposed, its indications have not yet been outlined. The purpose of this study was to describe a classification system for this fracture pattern and provide a therapeutic algorithm to avoid complications associated with PDHPWS fixation. METHODS Thirty-four patients who underwent surgical treatment for CF with LHC comminution were enrolled. The humeral capitellum angle (α angle) measured on the sagittal view of computed tomography reconstructions corresponded to the height of the LHC fracture line; based on this height, the severity of LHC injury was categorized as subtype L (low fracture line, 60° < α < 90°), subtype M (moderate fracture line, 45° < α < 60°) or subtype H (high fracture line, α < 45°). The therapeutic algorithm was countersunk compression screws for subtype L, lateral buttressing combined with/without an anterior antiglide mini-fragment plate for subtype M and a dorsolateral anatomical locking plate for subtype H. At the end of the follow-up period, the treatment outcome was evaluated by radiography and an assessment of the range of motion. A functional assessment was carried out using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS The mean age of patients in this cohort was 49.6 ± 14.6 years, and the mean follow-up duration was 48.9 ± 34.6 months. There were 10 cases classified as subtype L, with a mean α angle of 80.6 ± 8.8°. The mean α angle for the 13 cases classified as subtype M was 52.1 ± 4.6° and that for the 11 cases classified as subtype H was 24.1 ± 22.4°. All fractures healed uneventfully, and implant removal was required in 8 cases (one subtype M and seven subtype H). The average MEPS in the three subgroups was 84.5 (subtype L), 87.3 (subtype M) and 78.2 (subtype H), while the average DASH score was 13.9 (subtype L), 11.6 (subtype M) and 21.5 (subtype H). Compared with the other subtypes, subtype H showed the smallest improvement in mean elbow function (112.7° in flexion, 13.6° in extension, 66.4° in pronation and 71.4° in supination). No cases of heterotopic ossification or avascular necrosis of the capitellum developed in any group. CONCLUSION By analyzing the fracture morphology, a substantial portion of CFs with mild to moderate LHC comminution could be successfully managed by a simpler and less aggressive method with fewer complications than PDHPWS. LEVELS OF EVIDENCE Level IV; Case Series; Treatment Study.
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Affiliation(s)
- Yu Zhang
- The First Affiliating Hospital of Nanjing Medical University &Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China
| | - Jun Hu
- The First Affiliating Hospital of Nanjing Medical University &Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China
| | - Xiang Li
- The First Affiliating Hospital of Nanjing Medical University &Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China
| | - Xiaodong Qin
- The First Affiliating Hospital of Nanjing Medical University &Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China.
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Garg S, Sain A, Sharma V, Farooque K, Rangaswamy N. Functional Outcome of a Coronal Shear Fracture of the Capitellum Managed by Herbert Screw Fixation Using the Anterolateral Surgical Approach. Cureus 2020; 12:e6578. [PMID: 31956467 PMCID: PMC6946593 DOI: 10.7759/cureus.6578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Fractures of the capitellum, particularly coronal shear fractures, are difficult to manage. The challenges are adequate surgical exposure, proper anatomic reduction, and stable fixation of these fractures. Our study included 10 patients with a coronal shear fracture of the capitellum without any involvement of the posterior condyle. All patients underwent open reduction and Herbert screw fixation using the anterolateral approach, with good functional outcome. In our opinion, this is a good option for the treatment of coronal shear fractures of the capitellum.
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Affiliation(s)
- Sitender Garg
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
| | - Arnab Sain
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
| | - Vijay Sharma
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
| | - Kamran Farooque
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
| | - Namith Rangaswamy
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
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Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients. Injury 2018; 49 Suppl 3:S84-S93. [PMID: 30415675 DOI: 10.1016/j.injury.2018.09.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/28/2018] [Accepted: 09/30/2018] [Indexed: 02/02/2023]
Abstract
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.
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Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients. J Shoulder Elbow Surg 2016; 25:1182-8. [PMID: 27052272 DOI: 10.1016/j.jse.2016.01.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/14/2016] [Accepted: 01/22/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Fracture of the capitellum is an often missed or inadequately treated serious elbow injury. Anatomic reduction and proper stabilization are essential to obtain articular congruity so that late-onset arthritis can be avoided. The main areas of interest in this intriguing fracture are the choice of implant and the surgical approach. We describe the use of anterolateral approach and headless double-threaded compression screws for the fixation of this fracture. MATERIALS AND METHODS This prospective study included 16 capitellar fractures. A computed tomography scan was done for delineating the fracture line and planning the fixation technique. All fractures were treated with headless double-threaded compression screws using an anterolateral approach, over a period of 3 years, with a mean follow-up of 2.3 years (range, 1.5-4 years). RESULTS The average time to bony union was 3.5 months (range, 2.5-5 months) with no malunion or nonunion. The mean range of flexion was 132° (range, 125°-135°). The average extensor lag was 10° (range, 0°-25°), but the range of motion remained functional in all patients. On the final follow-up, no evidence of osteonecrosis, post-traumatic osteoarthritis, or heterotrophic ossification was seen. The outcome was excellent in 10 patients, and 6 patients had a good result. CONCLUSIONS The success of management of a capitellar fracture depends on an early diagnosis by keeping a high index of suspicion and timely management. Adequate exposure of the fracture is of paramount importance to achieve accurate reduction. This can be satisfactorily achieved by an anterolateral approach to the elbow. An adequate fixation of the fractured fragments can be achieved by the use of headless double-threaded compression screws.
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Lopiz Y, Rodríguez-González A, García-Fernández C, Marco F. Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years. J Shoulder Elbow Surg 2016; 25:369-75. [PMID: 26927432 DOI: 10.1016/j.jse.2015.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 11/28/2015] [Accepted: 12/04/2015] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Yaiza Lopiz
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery and Traumatology, Clínico San Carlos Hospital, Madrid, Spain.
| | - Alberto Rodríguez-González
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery and Traumatology, Clínico San Carlos Hospital, Madrid, Spain
| | - Carlos García-Fernández
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery and Traumatology, Clínico San Carlos Hospital, Madrid, Spain
| | - Fernando Marco
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery and Traumatology, Clínico San Carlos Hospital, Madrid, Spain
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Singh AP, Singh AP. Coronal shear fractures of distal humerus: Diagnostic and treatment protocols. World J Orthop 2015; 6:867-876. [PMID: 26716083 PMCID: PMC4686434 DOI: 10.5312/wjo.v6.i11.867] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 09/02/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Coronal shear fractures of distal humerus involving the capitellum and the trochlea are rare injuries with articular complexity, and are technically challenging for management. With better understanding of the anatomy and imaging advancements, the complex nature of these fractures is well appreciated now. These fractures involve metaphysealcomminution of lateral column and associated intraarticular injuries are common. Previously, closed reduction and excision were the accepted treatment but now preference is for open reduction and internal fixation with an aim to provide stable and congruent joint with early range of motion of joint. Various approaches including extensile lateral, anterolateral and posterior approaches have been described depending on the fracture pattern and complexity. Good to excellent outcome have been reported with internal fixations and poor results are noted in articular comminution with associated articular injuries. Various implants including headleass compression screws, minifragment screws, bioabsorbable implants and column plating are advocated for reconstruction of these complex fractures. Inspite of articular fragments being free of soft tissue attachments the rate of osteonecrosis and osteoarthritis is reported very less after internal fixation. This article summarizes the diagnostic and treatment strategies for these rare fractures and recommendations for management.
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Garner MR, Schottel PC, Hotchkiss RN, Daluiski A, Lorich DG. Capitellum Fracture Fragment Excision: a Case Series. HSS J 2015; 11:204-8. [PMID: 26981054 PMCID: PMC4773682 DOI: 10.1007/s11420-015-9452-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/29/2015] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Matthew R. Garner
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY 10065 USA
| | | | - Robert N. Hotchkiss
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY 10065 USA
| | - Aaron Daluiski
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY 10065 USA
| | - Dean G. Lorich
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY 10065 USA
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Yu SY, Wang W, Liu S, Ruan HJ, Liu JJ, Li XJ, Zhan YL, Fan CY. Arthrolysis and delayed internal fixation combined with hinged external fixation for elbow stiffness associated with malunion or nonunion of capitellum fracture. J Shoulder Elbow Surg 2015; 24:941-6. [PMID: 25818519 DOI: 10.1016/j.jse.2015.01.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/22/2015] [Accepted: 01/31/2015] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Shi-Yang Yu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shen Liu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hong-Jiang Ruan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jun-Jian Liu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xu-Jun Li
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yu-Lin Zhan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cun-Yi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Yari SS, Bowers NL, Craig MA, Reichel LM. Management of distal humeral coronal shear fractures. World J Clin Cases 2015; 3:405-417. [PMID: 25984515 PMCID: PMC4419104 DOI: 10.12998/wjcc.v3.i5.405] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/15/2015] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
Coronal shear fractures of the distal humerus are rare, complex fractures that can be technically challenging to manage. They usually result from a low-energy fall and direct compression of the distal humerus by the radial head in a hyper-extended or semi-flexed elbow or from spontaneous reduction of a posterolateral subluxation or dislocation. Due to the small number of soft tissue attachments at this site, almost all of these fractures are displaced. The incidence of distal humeral coronal shear fractures is higher among women because of the higher rate of osteoporosis in women and the difference in carrying angle between men and women. Distal humeral coronal shear fractures may occur in isolation, may be part of a complex elbow injury, or may be associated with injuries proximal or distal to the elbow. An associated lateral collateral ligament injury is seen in up to 40% and an associated radial head fracture is seen in up to 30% of these fractures. Given the complex nature of distal humeral coronal shear fractures, there is preference for operative management. Operative fixation leads to stable anatomic reduction, restores articular congruity, and allows initiation of early range-of-motion movements in the majority of cases. Several surgical exposure and fixation techniques are available to reconstruct the articular surface following distal humeral coronal shear fractures. The lateral extensile approach and fixation with countersunk headless compression screws placed in an anterior-to-posterior fashion are commonly used. We have found a two-incision approach (direct anterior and lateral) that results in less soft tissue dissection and better outcomes than the lateral extensile approach in our experience. Stiffness, pain, articular incongruity, arthritis, and ulnohumeral instability may result if reduction is non-anatomic or if fixation fails.
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Bilsel K, Atalar AC, Erdil M, Elmadag M, Sen C, Demirhan M. Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation. Arch Orthop Trauma Surg 2013; 133:797-804. [PMID: 23494115 DOI: 10.1007/s00402-013-1718-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Kerem Bilsel
- Orthopaedic and Traumatology Department, Bezmialem Vakif University, Fatih, 34093, Istanbul, Turkey.
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Jeevannavar SS, Shenoy KS, Daddimani RM. Corrective osteotomy through fracture site and internal fixation with headless screws for type I (Hahn-Steinthal) capitellar malunion. BMJ Case Rep 2013; 2013:bcr-2013-009230. [PMID: 23709538 DOI: 10.1136/bcr-2013-009230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
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.
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Distal humeral coronal plane fractures: management, complications and outcome. J Shoulder Elbow Surg 2013; 22:560-6. [PMID: 22981357 DOI: 10.1016/j.jse.2012.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 07/13/2012] [Accepted: 07/16/2012] [Indexed: 02/01/2023]
Abstract
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.
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Ong KL, Mahadev A. Cannulated cancellous screw fixation for capitellum fractures in adolescents. J Orthop Surg (Hong Kong) 2011; 19:346-9. [PMID: 22184168 DOI: 10.1177/230949901101900317] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To review the outcome of 9 adolescents treated with 2 to 3 cannulated cancellous screws for type-1 capitellum fractures. METHODS Records of 8 boys and one girl aged 12 to 14 (mean, 14) years with type-1 capitellum fractures were reviewed. The mechanism of injury was a fall on the flexed elbow. No patient had associated injuries or neurovascular compromise. In 2 patients, the fracture was minimally displaced and treated with a cast. The remaining 7 patients with displaced fractures underwent open reduction and internal fixation using 4.0-mm cannulated partially threaded cancellous screws inserted in a posterior-to-anterior direction. In one patient, a Kirschner wire was added to fix a small comminuted fragment. Elbow pain, range of motion, stability, and function were evaluated using the Mayo Elbow Performance Index. RESULTS The mean follow-up period was 7 (range, 2-18) months. The mean Mayo Elbow Performance Index score was 100, indicating excellent outcome. No patient developed avascular necrosis or heterotrophic ossification. All patients achieved anatomic bone union. All implants were removed after a mean of 4.7 (range, 2-7) months. CONCLUSION The fixation of type-1 capitellum fractures with 2 to 3 cannulated cancellous screws inserted posteroanteriorly achieved excellent functional outcome.
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Abstract
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.
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Affiliation(s)
- Aaron Nauth
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Coronal shear fractures of the distal humerus are uncommon in the pediatric population. We present the case of an 11-year-old girl who sustained a coronal shear fracture of the distal humerus, requiring open reduction and internal fixation with the use of headless screws. At the time of the latest follow-up, she had fully recovered the range of motion on the affected limb, had returned to full physical activities without limitations, radiographs showed a completely healed fracture with restoration of the articular line, and there was no signs of avascular necrosis of the capitellum.
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Singh AP, Singh AP, Vaishya R, Giannicola G, Sacchetti F. Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures. Acta Orthop 2010; 81:518; author reply 518-9. [PMID: 20809748 PMCID: PMC2917578 DOI: 10.3109/17453674.2010.504612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Ajay Pal Singh
- D-13, UCMS, Guru Teg Bahadur Hospital, Dilshad GardenNew Delhi, India,
| | - Arun Pal Singh
- D-13, UCMS, Guru Teg Bahadur Hospital, Dilshad GardenNew Delhi, India
| | - Raju Vaishya
- D-13, UCMS, Guru Teg Bahadur Hospital, Dilshad GardenNew Delhi, India
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Singh AP, Singh AP. Regarding "Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws". J Shoulder Elbow Surg 2010; 19:e25; author reply e25-6. [PMID: 20036581 DOI: 10.1016/j.jse.2009.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 09/20/2009] [Indexed: 02/01/2023]
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Ashwood N, Verma M, Hamlet M, Garlapati A, Fogg Q. Transarticular shear fractures of the distal humerus. J Shoulder Elbow Surg 2010; 19:46-52. [PMID: 19884023 DOI: 10.1016/j.jse.2009.07.061] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 07/07/2009] [Accepted: 07/23/2009] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Neil Ashwood
- Queens Hospital NHS Foundation Trust, Staffordshire, United Kingdom
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Singh AP, Singh AP, Vaishya R, Jain A, Gulati D. Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws. INTERNATIONAL ORTHOPAEDICS 2009; 34:897-901. [PMID: 19894049 DOI: 10.1007/s00264-009-0896-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2009] [Revised: 08/28/2009] [Accepted: 10/07/2009] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Arun Pal Singh
- Department of Orthopaedics, University College of Medical Sciences & associated Guru Teg Bahadur Hospital, Shahdara, Delhi, India
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Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. Surgical technique. J Bone Joint Surg Am 2009; 91 Suppl 2 Pt 1:38-49. [PMID: 19255199 DOI: 10.2106/jbjs.h.01195] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- David E Ruchelsman
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, 14th Floor, New York, NY 10003, USA.
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Abstract
A distal humerus fracture can be a debilitating and difficult injury to treat. The anatomy of the distal humerus is highly complex, as it articulates with both the radius and ulna and allows for motion in multiple planes. Furthermore, comminution and osteopenia may render the metaphyseal-diaphyseal junction weak, making adequate stabilization difficult. Various methods of surgical fixation have been described, with bicolumnar plating being the most popular. Controversy over fixation techniques and the introduction of recently developed implants, including precontoured plates and locking plates, have led to renewed focus on biomechanical testing of various fixation constructs. Failure of adequate reconstruction or fixation can be addressed with adjunctive measures such as incorporation of structural bone grafts, external fixation, or, in certain instances, salvage with total elbow arthroplasty. The articular surface can also be injured from a shear force, resulting in fractures of the capitellum and trochlea in the coronal plane. This article presents a review of current literature concerning the diagnosis, classification, treatment, and outcome of distal humerus fractures.
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Affiliation(s)
- Andrew S Wong
- Allegheny General Hospital, Pittsburgh, PA 15212, USA
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Abstract
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.
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Affiliation(s)
- SS Suresh
- Department of Orthopaedics, Ibri Regional Referral Hospital, PO Box 46, Ibri 516, Sultanate of Oman,Address for correspondence: Dr. S S Suresh, PO Box 396, Ibri 516, Sultanate of Oman. E-mail:
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Abstract
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.
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Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am 2008; 90:1321-9. [PMID: 18519327 DOI: 10.2106/jbjs.g.00940] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- David E Ruchelsman
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003, USA.
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Charissoux JL, Mabit C, Fourastier J, Beccari R, Emily S, Cappelli M, Malingue E, Mansat P, Hubert L, Proust J, Bratu D, Veillard D, Grandmaison FLD, Apard T, Martinel V, Bonnevialle N. Fractures articulaires complexes de l’extrémité distale de l’humérus chez le sujet âgé. ACTA ACUST UNITED AC 2008; 94:S36-62. [DOI: 10.1016/j.rco.2008.03.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sen MK, Sama N, Helfet DL. Open reduction and internal fixation of coronal fractures of the capitellum. J Hand Surg Am 2007; 32:1462-5. [PMID: 17996785 DOI: 10.1016/j.jhsa.2007.08.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Accepted: 08/22/2007] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Milan K Sen
- University of California, San Francisco, San Francisco, CA, USA.
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Abstract
Fractures of the capitellum account for less than 1% of all elbow fractures. Because they may be difficult to visualize on plain radiographs, the clinician must have a high index of suspicion for their diagnosis. Anatomic alignment of these fractures is imperative; slight residual displacement may result in significant loss of elbow motion. Surgical management is described with open reduction internal fixation using variable pitch headless screws, precontoured plates, or bioabsorbable pins. The optimal method of fixation depends on the fracture pattern and degree of comminution. If the fracture fragments are too small for stable fixation, excision of the fragments is recommended. Osteonecrosis, as well as, end-stage arthrosis requiring total elbow arthroplasty, has been reported as a rare, but potential, complication.
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Affiliation(s)
- Emilie V Cheung
- Department of Orthopedic Surgery, Stanford University, Stanford, CA 94305, USA.
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