Open reduction and internal fixation of capitellar fractures with headless screws

Intermediate-term outcomes for floating elbow and floating elbow variant injuries

BACKGROUND

There are limited outcome studies describing floating elbow injuries. The purpose of this report is to describe patient outcomes after floating elbow injury using the American Shoulder and Elbow Surgeons (ASES) elbow assessment form.

MATERIALS AND METHODS

From 1994 to 2004, 19 patients were retrospectively identified at 3 Level I trauma centers and returned for follow-up evaluation after treatment of their floating elbow injury. Patient outcomes were assessed based on physical examination and the ASES elbow form.

RESULTS

The 19 patients were evaluated at a mean of 6.7 years (range, 2.3-13.4 years) after treatment of their floating elbow injuries. The mean ASES elbow score was 89 (range, 13-99), and the mean visual analog scale satisfaction with elbow surgery was 8.7 (range, 7-10). Fifteen of 19 patients reported continued pain in the elbow. Patient age, arm dominance, type of humeral fixation, type of forearm fixation, open fracture, multiple surgeries, and fracture pattern were not significantly associated with outcomes. Nerve injury was associated with lower ASES elbow scores (P = .03). There was also a significant correlation between the ASES elbow score and follow-up time, indicating that patients with a longer duration of follow-up had better subjective outcomes (Spearman coefficient = 0.55; P = .02).

CONCLUSION

Floating elbow fractures represent high-energy trauma and have significant associated injuries. Nerve injury is correlated with lower subjective outcomes. Patients continue to improve for several years with acceptable mid-term results.

Operative management of capitellar fractures: a systematic review

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Coronal shear fractures of the distal humerus

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

Reconstruction of a Bryan and Morrey type I capitellar fracture in a sawbone model with four different fixation devices: an experimental study

BACKGROUND

We evaluated 4 different fixation devices for the reconstruction of a standardised Bryan and Morrey capitellar shear fracture in a sawbone model. Outcome measurements were the quality of reduction, time for reconstruction and stability.

METHODS

80 standardised Bryan and Morrey type I fractures were created for 5 different orthopaedic surgeons in 80 sawbones. Each surgeon reconstructed 16 fractures with 2mm K-wires, 3mm Herbert screws, 2.7 mm AO screws and 2.2mm fine-threaded wires (Fragment Fixation System: FFS). 4 fractures were allocated to each method with a standardised reconstruction procedure. Quality of reduction and time for reconstruction were measured after definitive fixation. Biomechanical testing was performed using a shear loading model with the application of monocyclic or polycyclic stress to the reconstructed capitulum.

RESULTS

There was no difference in the quality of reduction with the different fixation devices. Herbert and AO screw fixation was slower than the other implants (p<0.05). No difference in the time for reconstruction was observed with K-wires and FFS. Failure load was less for K-wires compared to FFS, Herbert screws and AO screws (p<0.05). With polycyclic loading, residual deformation was higher with K-wire reconstruction compared to FFS, Herbert screws and AO screws (p<0.05).

CONCLUSION

When using four different fixation devices, the fixation of standardised Bryan and Morrey type I fractures in the sawbone model differs when it comes to the time needed for reduction, but not in the quality of reduction. Stability was the same for the implants used, except for the K-wires. There is no argument in favour one of the screw implants over another in clinical use.

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

INTRODUCTION

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

CASE PRESENTATION

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

CONCLUSION

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

Reconstruction of radial capitellar fractures using fine-threaded implants (FFS)

Fractures of the capitulum humeri are rare and challenging injuries to the elbow and outcome results are limited to case series, often with different fixation devices. This article aims to present 15 patients with a fracture of the capitulum humeri treated with the same implant, fine-threaded Kirschner wires (FFS). Besides range of motion and grip strength, outcome measurements include the following scores: the Mayo Elbow Performance index (MEPI); the American Shoulder and Elbow Surgeons' Elbow Assessment (ASES) Form; the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and the Broberg-Morrey score. Using the modified Bryan and Morrey classification, there were seven type-I injuries, three type-II, two type-III and three type-IV fractures. In addition to fractures of the capitellum, five patients were diagnosed with a complex ligamentous injury and three had suffered radial head fractures. After a minimum follow-up of 12 months, we obtained a range of motion in flexion and extension of 124° and a pro- and supination of 173°. The mean DASH showed 10.84 and the Broberg-Morrey score reached 90.8. ASES and MEPI scores were 91.5 and 90, respectively. The mean grip strength of the injured side was 217.9N versus 236.4N on the healthy side. The use of FFS for capitellar fractures of the humerus achieved good clinical results and these implants can be considered as a treatment option for this fracture entity.

Nonunion of operatively treated capitellum and trochlear fractures

PURPOSE

To test the hypothesis that comminuted fractures of the capitellum and trochlea with posterior comminution (Dubberley type 3B) have a greater risk of nonunion than other types of capitellum and trochlea fractures.

METHODS

We observed 30 patients with operatively treated fractures of the capitellum and trochlea for an average of 34 months (range, 12-75 mo). We compared 18 fractures with comminution of the capitellum and trochlea and posterior comminution (type 3B according to Dubberley and colleagues) with 12 fractures consisting of single large anterior fracture fragments with (6 patients; Dubberley type 2B) or without (6 patients; Dubberley type 2A) posterior comminution.

RESULTS

Of 18 patients, 8 with type 3B fractures were noted to have nonunion. No patients with type 2 fractures had a nonunion.

CONCLUSIONS

Fractures of the capitellum and trochlea are prone to nonunion when they create multiple articular fragments and there is posterior comminution (Dubberley type 3B).

Distal humeral fractures in adults

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

Coronal shear fracture of the distal humerus in an 11-year-old patient

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.

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

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

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

INTERPRETATION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4.

Transarticular shear fractures of the distal humerus

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level 4; Case series, treatment study.

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

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

The often-missed Kocher-Lorenz elbow fracture

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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