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

Clinical Outcomes and Management Strategies for Capitellum and Trochlea Fractures: A Systematic Review

Purpose

Capitellum and trochlea fractures, also referred to as coronal shear fractures of the distal humerus, are infrequent yet challenging intra-articular fractures of the elbow. There are a variety of surgical approaches and fixation methods with often variable outcomes. This systematic review investigates interventions, outcomes and complications of capitellum and trochlea fractures.

Methods

A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the clinical outcomes of capitellum and trochlea fractures managed surgically. Data on patient demographics, surgical approach, implant usage, postoperative outcomes and complications were compiled.

Results

Forty-one studies met the inclusion criteria with a total of 700 patients. Surgical interventions primarily utilized either the lateral (79%) or antero-lateral (15%) approaches with headless compression screws as the most common fixation method (68%). Clinical outcomes were measured using the Mayo Elbow Performance Index (MEPI) with a mean score of 89.9 (±2.6) and the DASH score with a mean of 16.9 (±7.3). Elbow range of motion showed a mean flexion of 126.3° (±19.4), extension of 5.71° (±11.8), pronation of 75.23° (±12.2), and supination of 76.6° (±9.8). The mean flexion-extension arc was 113.7° (±16.9), and the mean pronation-supination arc was 165.31° (±9.41). Complications occurred in 19.8% of cases, with re-interventions required in 8.3% of cases, mainly due to symptomatic implants and elbow stiffness requiring surgical release. Other complications included implant removal (10.4%), overall reported stiff elbows (6%), nerve palsies (2%), non-union (1.5%), and infection (1.2%).

Conclusion

The treatment of capitellum and trochlea fractures yields satisfactory outcomes but has a considerable rate of complications and reoperations primarily due to symptomatic implants and elbow stiffness. There is noteworthy variability in the achieved range of motion, suggesting unpredictable outcomes. Deficits in functionality and range of motion are common after surgery, especially with more complex injury patterns.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomechanical stability of complex coronal plane fracture fixation of the capitellum

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Biomechanical study.

Biomechanical stability of simple coronal shear fracture fixation of the capitellum

BACKGROUND

Coronal shear fractures of the capitellum are rare, and their surgical management is challenging, without a defined gold standard. The purpose of this study was to compare the biomechanical stability of 3 different internal fixation techniques for simple coronal shear fractures of the capitellum without posterior comminution.

METHODS

Dubberley type IA fractures of the capitellum were created in 18 cadaveric elbows, which were age and sex matched to the following 3 internal fixation groups: (1) two anteroposterior cannulated headless compression screws (HCSs), (2) two anteroposterior HCSs with an additional anterior antiglide plate (antiGP), and (3) a posterolateral distal humeral locking plate (LP). All fixation techniques were cyclically loaded with 75 N over 2000 cycles and ultimately until construct failure. Data were analyzed for displacement, construct stiffness, and ultimate load to failure.

RESULTS

Fragment displacement under cyclic loading with 2000 cycles did not show a significant difference (P = .886) between the 3 groups. The HCS group showed the highest stiffness compared with the HCS-antiGP and LP groups (602 N/mm vs. 540 N/mm vs. 462 N/mm, P = .417), without reaching a statistically significant difference. Ultimate load to failure was also not significantly different on comparison of all 3 groups (P = .297).

CONCLUSIONS

Simple coronal shear fractures of the capitellum are biomechanically equally stabilized by HCSs compared with HCSs with an additional antiGP or a posterolateral distal humeral LP. In view of the advantages of less (invasive) metalware, the clinical use of 2 isolated anteroposterior HCSs appears reasonable.

Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis

BACKGROUND

Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years.

METHODS

We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating.

RESULTS

Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01).

CONCLUSIONS

This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.

Surgical tips and tricks for coronal shear fractures of the elbow

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic III.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Type IV capitellum fractures in children

Capitellum fractures represent 1% of elbow fractures. A coronal shear fracture which involves the trochlea is classified as a type IV McKee fracture. The combination of its rarity in the paediatric population as well as its unique appearance on X-ray make diagnosis of this fracture a challenge. We present the case of a 14-year-old boy who sustained this fracture falling from his bike. It was diagnosed from the double arc sign on X-ray. In addition, a CT scan was obtained to aid preoperative planning. It was treated by open reduction and fixation with two headless compression screws. Follow-up at 6 months showed no avascular necrosis. The patient could achieve full extension, while flexion was reduced only by 5°. Final follow-up was conducted at 15 months. Anatomic reduction and stable internal fixation are essential for a good outcome in these uncommon paediatric fractures.

Comparison of lateral approach versus anterolateral approach with Herbert screw fixation for isolated coronal shear fractures of humeral capitellum

Background

For coronal shear fractures of humeral capitellum, the lateral approach is the most commonly used surgical approach. However, exposure range of the anterior aspect of the distal humerus is inadequate. The anterolateral approach has also been adopted to overcome this disadvantage. However, this approach seems anatomically complex due to the risk of iatrogenic injury to the radial nerve. So far, the optimal approach for the treatment of capitellar shear fractures remains inconclusive. The purpose of this study is to prospectively review and compare the early clinical and radiographic outcomes of treated with open reduction and Herbert screw internal fixation through the lateral approach or the anterolateral approach.

Methods

Twenty-six patients with isolated capitellar shear fractures were enrolled from January 2013 to December 2017, and randomly assigned to lateral approach group or anterolateral approach group. All the fractures were treated with open reduction and Herbert screw internal fixation through lateral approach or anterolateral approach. Operation time, wound healing complication, elbow joint function, and radiographic evidence were evaluated and compared between two groups.

Results

The operation via the anterolateral approach took significantly shorter time than via lateral approach (p < 0.05). There were no wound healing problems and infection for both groups. One patient from anterolateral approach group sustained incomplete posterior interosseous nerve palsy, which recovered completely in 4 weeks without residual compromise. All fractures healed well in their normal anatomic position as seen on radiographs. At the final follow-up, no significant difference was found between two groups with respect to the ROM in supination-pronation, ROM in pronation-supination, loss of flexion-extension motion, or loss of pronation-supination motion (p > 0.05). There is no significant difference with respect to MEPI score of elbow joint between two groups (p > 0.05).

Conclusion

Based on our findings, both lateral approach and anterolateral approach with Herbert screw internal fixation are suitable for coronal shear fractures of capitellum with satisfactory early outcomes. Compared with the lateral approach, the anterolateral approach made the surgical procedure easier and time saving in current series. When the medial aspect of the trochlea is involved for capitellar coronal fractures, the anterolateral lateral approach should be preferred.

The impact of associated injuries and fracture classifications on the treatment of capitellum and trochlea fractures: A systematic review and meta-analysis

BACKGROUND

Capitellum and trochlea fractures are truly rare and the treatment is not fully appreciated. So we evaluate the impact of associated injuries and fracture classifications on elbow functional outcomes after open reduction and internal fixation.

MATERIALS AND METHODS

PubMed, Embase, Ovid Medline, and the Cochrane Library were searched from January 1, 1974 to January 1, 2017. All English literature with the treatment of capitellum and trochlea fractures by open reduction and internal fixation were included.

RESULTS

For associated injuries, the results suggested that the MEPI score of patients without associated injuries was higher than that of patients with associated injuries (P = 0.001). However, there was no significant difference in the arc of motion between the two groups (P = 0.052). For Bryan and Morrey classification, there was no significant difference in the MEPI score (P = 0.622) and in the arc of motion (P = 0.652) between type-I fractures and type-IV fractures. For Dubberley classification, there was significant difference only in the MEPI score between subtype-A fractures and subtype-B fractures (P = 0.005).

CONCLUSION

The associated injury of fracture may have a negative impact on the functional outcomes of elbow. And Dubberley classification is more suitable to classify this kind of fracture. Furthermore, high-quality studies are required to attain robust evidence.

Management of isolated coronal shear fractures of the humeral capitellum with Herbert screw fixation through anterolateral approach

Background

Due to the intraarticular and complex nature of the coronal shear fracture of the humeral capitellum and its rarity, it has been difficult to formulate a universally accepted method of surgical management. The purpose of this study is to retrospectively evaluate the clinical outcomes of 15 patients with isolated coronal shear fractures of the capitellum treated by Herbert screw fixation through anterolateral approach, and to address the safety and tips for this surgical procedure.

Methods

This retrospective study included 15 isolated coronal shear fractures of the capitellum without posterior involvement, which were classified according to the Dubberley classification as 11 type 1A fractures and 4 type 3A fractures. All fractures were treated with Herbert screws fixation via the anterolateral approach. Clinical and radiographic evaluation was performed regularly, with a mean follow-up of 29 months.

Results

The mean operative time was 81 min. There were no wound healing problems or infection. One incomplete posterior interosseous nerve injury occurred, which recovered soon without residual compromise. All fractures healed well. At the final follow-up, the average range of motion was 134°in flexion-extension and 172°in supination-pronation. There was no significant difference between the affected and the unaffected elbows with regard to motion in flexion-extension or flexion-extension. The average Mayo Elbow Performance Index Score was 93 with 11 excellent and 4 good. No evidence of avascular necrosis, posttraumatic osteoarthritis, or heterotrophic ossification was found.

Conclusion

Open reduction and internal fixation using Herbert screws through a anterolateral approach is a reliable and effective treatment for coronal shear fractures of capitellum, and able to achieve stable fixation and restoration of a functional range of motion.

Double-locking precontoured plating system for malunited fractures of the distal end of humerus

BACKGROUND

Distal humeral malunions are uncommon injuries, often associated with limited elbow motion, pain, instability, weakness, and sometimes ulnar neuritis. The complex anatomy of the elbow joint makes this condition one of the most complex elbow injuries to treat.

MATERIALS AND METHODS

Four patients were treated by the same surgeon between 2011 and 2013 using a double-locking precontoured plating system for malunited intra-articular or extra-articular fractures of the distal end of the humerus.

RESULTS

At a mean 3 years of follow-up, a significant improvement in the elbow motion and functional outcome, evaluated with the Mayo Elbow Performance Index and the Disability of the Arm, Shoulder, and Hand, were observed. Articular reduction obtained after the surgery was maintained in all patients without evidence of avascular necrosis. No other complications (i.e., infection, nervous iatrogenic lesions) were reported.

CONCLUSIONS

Corrective osteotomy using double-locking precontoured plating system preceded by preoperative planning using a CT scan allowed an improvement in the functional outcome and elbow motion, without complications.