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

doi:10.1016/j.jse.2016.01.034

Journal of Shoulder and Elbow Surgery

Volume 25, Issue 7, July 2016, Pages 1182-1188

https://doi.org/10.1016/j.jse.2016.01.034 Get rights and content

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.

Section snippets

Materials and methods

This is a case series of 16 consecutive patients with capitellar fractures who were treated with open reduction and internal fixation with 2 HCSs using the anterolateral approach. All patients with a capitellar fracture presenting to the tertiary referral center were included in the study, with 18 patients included from June 2010 to July 2013. Two patients were lost to follow-up. The patients were a mean age of 32 years (range, 18-50 years).

Ten patients had a history of fall on an outstretched

Results

Sixteen patients (10 men, 6 women) were available for follow-up and were included in the study. Fractures were on the right side in 12 patients and on the left in 4. Ten fractures were noted in the dominant hand. Associated olecranal fracture was seen in 2 patients, who had type I capitellar fractures according to the Bryan and Morrey classification.² The average tourniquet time was 50 minutes (range, 40-70 minutes), and mean operating time was of 60 minutes (range, 50-70 minutes).

The average

Discussion

Capitellar fracture is a rare injury in adults that usually presents with deformity in the elbow after a history of fall on the outstretched hand or on the flexed elbow. It is commonly missed on AP radiographs; therefore, careful evaluation should be done in the lateral view.¹⁰ In lateral view, the “double arc sign” may be seen, which is a characteristic feature in patients with a capitellar fracture that extends to the trochlea, the type IV fracture as seen in 1 patient in our study (Fig. 6).

Conclusion

Good results after the capitellar fracture can be expected by keeping a high index of suspicion, timely management, accurate reduction, and adequate fixation, and finally, early ROM. All of these can be easily achieved by the use of the HCS for fixation through the anterolateral approach to the elbow.

Disclaimer

The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (31)

The Effect of Buttress Plating on Biomechanical Stability of Coronal Shear Fractures of the Capitellum: A Cadaveric Study
2023, Journal of Hand Surgery
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.
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.
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).
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.
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.
Long-Term Outcomes and Return to Work After Isolated Coronal Shear Fractures of the Capitellum
2023, Journal of Hand Surgery Global Online
The purpose of this study was to analyze the ability of patients to return to work after ORIF of isolated capitellar shear fractures and assess long-term functional outcomes.
We retrospectively reviewed the cases of 18 patients with isolated capitellar shear fractures with or without lateral trochlear extension and investigated demographic data, occupation, worker’s compensation status, injury characteristics, surgical details, motion, radiographic appearance at final in-person follow-up, complications, and return to work status via in-person and long-term telemedicine follow-ups.
Final follow-up was at an average of 76.6 (7–222.6) months or 6.4 (0.58–18.6) years. Of the 14 patients working at the time of injury, 13 patients had returned to work at final clinical follow-up. The work status of the remaining patient was not documented. Mean elbow motion at final follow-up was 4° (range, 0–30) to 138° (range, 130–145) of flexion, 83° of supination, 83° of pronation. Two patients had complications that required reoperation but had no further complications. For the 13 of 18 patients with long-term telemedicine follow-up, the average Quick Disabilities of the Arm, Shoulder, and Hand score was 6.8 (0–25).
In our series, rates of return to work were high after ORIF of coronal shear fractures of the capitellum with or without lateral trochlear extension. This was true across all occupational classes including manual labor, clerical, and professional. With anatomic restoration of articular congruity, stable internal fixation, and postoperative rehabilitation, these patients had excellent ROM and functional scores at an average of 7.9 years of follow-up.
After ORIF of isolated capitellar shear fractures with or without lateral trochlear extension, patients can expect a high rate of return to work with excellent ROM and functionality and low long-term disability.
Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members
2023, Injury
Citation Excerpt :
In the previous series good to excellent outcomes have been reported with ORIF in the majority of patients with coronal shear fracture of the distal humerus. Anatomical reduction, stable fixation and early mobilization are the reasons for these good results obtained with the ORIF technique [36–39]. For type 1 and 2 fractures according to Dubberley classification, a lateral approach is most commonly used and it can be performed through various intervals, including between the anconeus and the extensor carpi ulnaris (Kocher approach) or between the extensor digitorum communis and extensor carpi radialis (Kaplan approach).
Coronal shear fractures of the distal humerus are uncommon injuries representing 6% of distal humeral fractures. There is no univocal consensus about the correct management of this type of fracture. A national survey was conducted to gain more insight into the current classification, diagnosis and treatment of coronal shear fractures in Italy.
A postal survey was sent to all AO Italian members including residency orthopaedic surgeons. The survey consisted of general questions about personal experience in the management of these fractures: types of classification systems used, surgical approaches, treatment options and rehabilitation programs.
114 orthopaedic surgeons answered a 13-items questionnaire. The most used classification system was AO/OTA (72,8%). Independent screws and if necessary plates were the most answered regarding surgical treatment (81,6%). The most encountered post-surgical complication was stiffening of the elbow (81,6%).
An algorithm of treatment has been proposed. To better classify coronal shear fractures, the authors recommended the integration of two classification systems: AO and Dubberley classifications. In the case of posterior wall comminution, a Kocher extensile approach is recommended, otherwise, if a posterior wall is intact, Kocher or Kaplan approach can be used. The posterior transolecranic approach can be reserved to Dubberley type III or AO 13B3.3. The best treatment choice is represented by independent screws and plates placed according to fracture patterns while arthroplasty is indicated when a stable ORIF is not possible. Mobilization is postponed for about 2 weeks.
Rate of Complications After Capitellum Fracture Fixation: A Systematic Review and Meta-Analysis
2023, Journal of Hand Surgery
This systematic review aimed to determine the incidence of complications following surgical fixation of an acute capitellum fracture. We secondarily aimed to compare the complication rate between anterior-to-posterior (A-P) versus posterior-to-anterior (P-A) screw insertion.
PubMed, EMBASE, and Scopus were searched to identify studies on surgical fixation of capitellum fractures in skeletally mature patients. The main outcome was the rate of complication after fracture fixation. Subgroup analysis was performed to assess the impact of the fixation technique on the outcomes after surgery. An inverse variance method using random or fixed effects models was used to perform a meta-analysis based on the degree of heterogeneity between studies. Study heterogeneity was evaluated using Q statistics to calculate the I² index.
We included 42 studies in the final analysis. The most reported complications after surgical fixation of capitellum fractures included elbow pain (21%), radiocapitellar arthritis (19%), hardware removal (17%), and heterotopic ossification (13%). When groups were stratified based on the direction of screw insertion, the mean rate of avascular necrosis was higher in the P-A direction (29% vs 11%). In comparison, the rate of revision fixation (2.9% vs 6.7%) and heterotopic ossification (7.3% vs 22%) were higher in the A-P direction. Transient posterior interosseous nerve palsy was reported in four patients in four studies, of whom three patients had A-P screw fixation.
Fixation of a displaced capitellum fracture is recommended when possible. However, patients should be counseled about the potential risk of complications and chances of undergoing an unplanned surgery.
Therapeutic IV.
Are outcomes after fixation of distal humerus coronal shear fractures affected by surgical approach? A systematic review and meta-analysis
2022, JSES International
Surgical management of coronal shear fractures of the distal humerus is associated with a high rate of complications. Several surgical approaches have been described to address these fractures. The complication profiles associated with each approach have not previously been compared, and that is the aim of the present study.
A systematic review of the literature was performed to identify all studies addressing coronal shear fractures of the distal humerus published between 2001 and January 2022. Of the 189 articles identified, 45 met the criteria for inclusion. Summaries of continuous data were calculated using the inverse variance method for pooling with random effects models. Fixed effects model estimates were reported unless significant heterogeneity was observed between studies. A subset of 6 studies reported the surgical approach and complications associated with the operative management of capitellar shear fractures without posterior comminution. The complication profiles of the extended lateral and anterolateral approaches were compared.
The 45 studies included yielded 899 patients. The average age was 44.9 years (95% confidence interval [CI]: 39.7 to 50.2). The fracture type was Dubberley A in 38% (n = 342), Dubberley B in 33% (n = 300), and not reported in the remainder. The reoperation rate was 13.8% (95% CI: 9.6% to 19.5%). Pooled complication rates included post-traumatic arthritis in 21.2% (95% CI: 18.0% to 24.9%), heterotopic ossification in 12.0% (95% CI: 9.2% to 15.6%), nerve injury in 7.8% (95% CI: 5.6% to 10.9%), and avascular necrosis in 7.4% (95% CI: 5.3% to 10.2%). The complication rate in noncomparative studies was 25.8% following the lateral approach and 16.7% following the anterolateral approach. Reported complications following the anterolateral approach were pain (9.5%) and nerve injury (7.1%). Reported complications following the lateral approach included arthritis (9.1%), heterotopic ossification (6.1%), avascular necrosis (4.5%), instability (3.0%), nerve injury (1.5%), and wound issues (1.5%).
Complications are common following operative management of capitellar shear fractures. In noncomparative studies, the complication rate was higher following the extended lateral compared to the anterolateral approach for Dubberley A fractures. Additionally, the reported complications following the extended lateral approach may impact long-term outcomes. Insufficient comparative evidence currently exists to recommend one approach over the other. High-quality comparative studies are needed.
Humeral capitellum fracture combined with humeral lateral column injury: A novel classification system and treatment algorithm
2020, Injury
Citation Excerpt :
However, neither of these two classification systems summarized the morphological characteristics of LHC comminution. Anatomically, for classic CFs, countersunk screws are biomechanically sufficient to provide compression between the intact LHC and the capitellar fragment [12–15]. When the LHC is biomechanically compromised, this critical osseous buttress for the capitellar fragment is lost.
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.
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.
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.
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.
Level IV; Case Series; Treatment Study

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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

Background

Materials and methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Conclusion

Disclaimer

J Hand Surg Am

J Hand Surg Eur

J Shoulder Elbow Surg

Fracture of the capitellum humeri

J Bone Joint Surg Am

Fractures of the distal humerus

Anterolateral Approach for an unusual pediatric capitellar fracture: a Case Report and Review of the Literature

Iowa Orthop J

Capitellum fractures: a biomechanical evaluation of three fixation methods

J Orthop Trauma

Isolated fracture of the humeral capitellum

Clin Orthop Relat Res

On osteochondrosis deformas juvenilis capituli humeri including investigation of intra-osseous vasculature in distal humerus

Acta Orthop Scand Suppl