Capitellum Fracture Fragment Excision: a Case Series

The Operative Management of Capitellum Fractures

Capitellum fractures represent fewer than 1% of elbow fractures. Most commonly, these fractures occur secondary to either axial loading with the elbow fully extended or direct impact to the lateral aspect of the elbow. Numerous classification systems exist, with many types and subtypes. Since capitellum fractures are uncommon and fracture type varies widely, there is a lack of consensus with regard to treatment recommendations. We present a case series of seven patients with capitellum fractures, who presented between January 2016 and August 2020 to Addenbrooke's Hospital (Cambridge, the United Kingdom). All patients were female, with an average age of 33 years. In each case, the affected elbow joint was immobilised using a backslab before open reduction and internal fixation (ORIF) was performed. Joint mobility was recorded both on the day of the injury and at clinic review postoperatively (first at two weeks and then at between four and eight weeks). The Oxford Elbow Score (OES) was measured retrospectively, relating to (1) before the injury and (2) six months after fracture reduction. ORIF was associated with a near-full return of pronation and supination by eight weeks, with flexion-extension also improving significantly. The Oxford Elbow Score at six months reached 82.0% of pre-injury scores. Overall, our results suggest that ORIF is a well-tolerated and effective treatment strategy for capitellum fractures. Future studies with a greater sample size are required to assess the outcomes across a longer period, to determine whether outcomes are maintained and continue to improve.

Coronal Shear Fractures of the Distal Humerus

Coronal shear fractures of the distal humerus are rare, frequently comminuted, and are without consensus for treatment. The aim of this paper is to review the current concepts on the diagnosis, classification, treatment options, surgical approaches, and complications of capitellar and trochlear fractures. Computed Tomography (CT) scans, along with the Dubberley classification, are extremely helpful in the decision-making process. Most of the fractures necessitate open reduction and internal fixation, although elbow arthroplasty is an option for comminuted fractures in the elderly low-demand patient. Stiffness is the most common complication after fixation, although reoperation is infrequent.

Arthroscopic osteosynthesis of capitellum fractures: Feasibility study and clinical study on 2 cases

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.

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

Background

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

Case description

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

Conclusion

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

How to cite this article

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

Coronal shear fractures of the distal humerus: Current concepts and surgical techniques

Coronal shear fractures of the distal humerus are a unique subset of distal humeral fractures which entail partial or complete articular fractures of the distal humerus without involvement of the columns. The very distal nature of these fragments, their small size and propensity for comminution render them challenging to treat surgically. The purpose of this article is to describe the classification, outcomes and surgical techniques currently used for the treatment of these fractures using the available literature and authors' clinical experience.

Treatment of capitellar and trochlear fractures with posterior comminution: minimum 2-year follow-up

HYPOTHESIS

This study aimed to evaluate the safety and efficacy of the fixation of Dubberley type B capitellar and trochlear fractures using dorsolateral anatomic plates with support of the distal humerus (DAPSDHs).

METHODS

Fifteen patients with Dubberley type B capitellar and trochlear fractures (two type 1B, five type 2B, and eight type 3B) were treated through the extended lateral approach, and fixation was achieved with DAPSDHs. Radiographic evaluation was performed, and range of motion of the elbow and forearm was recorded. Functional outcomes were assessed using the Mayo Elbow Performance Score and Disabilities of the Arm, Shoulder and Hand score.

RESULTS

The mean follow-up period was 32.5 months (range, 24-54 months). Fracture union was achieved in all cases. At the final follow-up, range of motion was as follows: flexion, 123.7° ± 8.1° (range, 110°-135°); lack of extension, 11.0° ± 7.1° (range, 5°-30°); pronation, 81.7° ± 5.6° (range, 70°-90°); and supination, 78.7° ± 5.2° (range, 70°-85°). At the final follow-up, the mean Disabilities of the Arm, Shoulder and Hand score was 11.9 ± 4.0 (range, 4.2-20.8) and the mean Mayo Elbow Performance Score was 89.0 ± 7.1 (range, 70-95). The outcome was rated as excellent in 12 patients (80.0%), good in 2 (13.3%), and fair in 1 (6.7%). Avascular necrosis of the capitellum developed in 1 patient. One patient had implant irritation. Heterotopic ossification developed in 1 patient. Ten patients returned to their previous activity levels.

CONCLUSION

Capitellar and trochlear fractures with posterior comminution are safely and effectively treated through the extended lateral approach using DAPSDHs, resulting in good radiographic and functional outcomes.