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

Outcome determinants for coronal shear fractures of the distal humerus

PURPOSE

Coronal shear fractures of the distal humerus involving the capitellum and trochlea are rare injuries. Internal fixation with headless compression screws provides a stable construct facilitating early mobilisation. Our study aimed to identify the key determinants of both radiological and functional outcomes of patients with distal humerus coronal shear fractures treated with internal fixation.

METHODS

A retrospective analysis of 61 patients with distal humerus coronal shear fractures who were treated surgically was done. Demographics, fracture morphology, time to surgery, operative details such as surgical approach and implant used, quality of reduction, time to union, and associated complications from hospital records. Radiological outcomes were assessed using plain radiographs, and the functional outcomes were by Oxford Elbow Score (OES) and Mayo Elbow Performance Index (MEPI).

RESULTS

Patients with anatomical reduction of the fracture had better functional outcomes and range of motion. The presence of posterior comminution of capitellum resulted in poorer outcomes (p = 0.03). Delayed presentation did not alter the outcome when the anatomical reduction was achieved. Myositis ossificans was noted in nine patients and non-union in five patients. Two patients developed avascular necrosis of the capitellum and arthritis of the elbow joint.

CONCLUSION

Anatomical reduction and posterior comminution are the two key determinants of the functional outcome in these coronal shear fractures of the distal humerus. Early mobilisation following a stable fixation is crucial in achieving a good outcome.

Surgical treatment of Hahn-Steinthal fracture using Herbert screws

Hahn-Steinthal fractures are rare and often neglected. Their initial management should be early, given the relatively high complication rate. We report eight cases of type I capitellum fractures treated by Herbert screw fixation. Between 2019 and 2022, we selected eight patients (six men and two women) with a mean age of 25 years (18-40 years). The mean follow-up was 2 years (1-3 years). Clinical results were assessed using the Mayo Clinic Elbow Performance Score (MEPS). The mean arc of mobilitý was 135° (105°-150°) for flexion/extension and 161° (150°-175°) for pronosupination. The mean MEPS was 90.6 points, with seven excellent results and one good result. The aim of this study was to highlight the good results of Herbert screw fixation technique in the management of Hahn-Steinthal fractures.

Capitellum and Capitellar-Trochlear Shear Injury in Children

OBJECTIVES

We report our clinical results following surgical intervention for capitellar fractures in a pediatric population, highlighting approaches, surgical instruments, and possible prognostic factors.

DESIGN

Retrospective descriptive case-series study.

SETTING

A tertiary referral hospital.

PATIENTS

Twelve pediatric patients with capitellar or capitellar-trochlear injuries were treated between 2017 and 2021.

INTERVENTION

Open reduction and internal fixation primarily using cannulated headless screws.

MAIN OUTCOME MEASUREMENTS

The mean follow-up period was 22 months (range: 10-35 months). Functional outcomes were assessed using the Mayo Elbow Performance Score. Post-traumatic elbow arthrosis was assessed using the Bromberg and Morrey rating system.

RESULTS

All fractures healed within 5-7 weeks. The mean Mayo Elbow Performance Score value was 98 (range, 85-100). Three patients developed arthrosis, and one had capitellar osteonecrosis.

CONCLUSIONS

Based on our experience, the Kocher approach and fixation of 2-3 retrograde cannulated screws together represent an appropriate surgical technique for isolated capitellar fractures, whereas good functional outcomes are attainable for capitellar-trochlear shear fractures using the transolecranon approach with 3 cannulated screw fixations. Further injuries to the osseoligamentous structures around the elbow joint are suspected to be an unfavorable prognostic factor.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A new attempt to treat coronal plane fractures of the elbow joint with salvage via an anterior approach

Background

Existing approaches for treating elbow fractures include lateral, medial, anterior and posterior approaches, though the anterior approach is often not chosen by surgeons to avoid damage to important nerves and blood vessels. However, the anterior approach has unique advantages. The purpose of this study was to report outcomes of 38 patients with coronal plane elbow fractures treated through the anterior approach.

Methods

We retrospectively analyzed 38 cases of coronal plane elbow fracture treated through an anterior approach at our institution between March 2015 and July 2019. The length of the surgical incision, operation time, and postoperative complications were recorded. The range of flexion, extension, and rotation of the affected elbow and the healthy elbow were collected at follow-up. Functional outcomes were evaluated using the Mayo Elbow Function Score (MEPS).

Results

All 38 patients were followed up for a mean of 21.26 months (range 12–36 months). Intraoperatively, the mean surgical incision length was 8 ± 2 cm and the mean operative time was 123 ± 59 min. At the final follow-up, solid osseous union was confirmed for all coronal plane elbow fractures. The mean elbow flexion arc was 129 ± 7°, and the extension arc was 9 ± 6°. The mean pronation arc was 83 ± 3°, and the supination arc was 80 ± 3°. The mean MEPS was 90 ± 8 points, with 18 excellent cases and 20 cases of excellent and good results, respectively. In 31 cases, there was no significant difference in elbow extension, flexion, or pronation between the single-fracture and healthy elbows (P > 0.05), though the arc of supination was slightly worse than that of the healthy elbow (P < 0.05). VAS pain scores before the operation, at three months after the operation, and during follow-up were compared, and pain was significantly reduced after treatment (P < 0.05). Two patients experienced transient postoperative median nerve paralysis, from which they recovered within three months. One patient had mild heterotopic ossification and was not treated because it did not affect the function of the elbow joint. All patients returned to work and were satisfied with the treatment.

Conclusion

The anterior approach has the benefits of simplicity, safety, minimal invasiveness, excellent exposure, and satisfactory prognosis for coronal plane elbow fracture.

The Effect of Buttress Plating on Biomechanical Stability of Coronal Shear Fractures of the Capitellum: A Cadaveric Study

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.

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.

ISOLATED CAPITELLAR FRACTURE FIXATION WITH HEADLESS SCREWS IN DIFFERENT CONFIGURATIONS

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.

Treatment of Capitellum and Trochlea Fractures Using Headless Compression Screws and a Combination of Dorsolateral Locking Plates

Introduction

This study aimed to evaluate the clinical outcomes of 16 patients with capitellum and trochlea fractures that were treated using isolated headless compression screws or a combination of dorsolateral locking plates and anterior-to-posterior screws. We also investigated the presence of lateral epicondyle fragments because this fragment is especially important when making decisions regarding the surgical approach and implants.

Materials and methods

We conducted a retrospective analysis of 16 patients with capitellum and trochlea fractures. Clinical, radiographic (based on CT scans), and elbow-specific outcomes, including the Mayo Elbow Performance Index (MEPI), were evaluated at a mean of 23.5 months postoperatively.

Results

The average MEPI scores in patients with Dubberley type A (non-posterior comminution) and type B (posterior comminution) fractures were 88 and 78, respectively (p=0.08). Headless compression screws were used in 10 cases of type A fracture and one case of type B fracture. A combination of dorsolateral locking plates and anterior-to-posterior screws was used in five cases of type B fracture. Hardware loosening was seen in one case of type B fracture with isolated screw fixation. The presence of a lateral epicondyle fragment was significantly associated with the type B group (6/6 patients; 100%). In contrast, patients in the type A group rarely had posterior comminution of the lateral epicondyle fragment (2/10 patients; 20%).

Conclusions

Capitellum and trochlea fractures with posterior comminution, which typically presented with lateral epicondylar fragments, were safely and effectively treated with a combination of dorsolateral locking plates and anterior-to-posterior screws through lateral approaches. Cases without posterior comminution were treated with headless compression screws with no complications. The Dubberley classification system provides helpful information to determine the fixation strategy.

Some outcomes of patients treated operatively for distal humerus fractures are affected by hand dominance

PURPOSE

This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm.

METHODS

A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed.

RESULTS

Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314).

CONCLUSION

Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair.

LEVEL OF EVIDENCE

Level III.

Heterotopic ossification formation after fractures about the elbow

INTRODUCTION

Heterotopic ossification (HO) is a well-known sequela after an elbow injury and is widely studied given the associated morbidity. The anatomic location of HO development for specific elbow injuries has not been reported. The purpose of this study was to describe the precise, anatomic location of HO development after different peri-articular elbow injuries.

METHODS

A retrospective chart review was performed for patients with peri-articular elbow fracture and/or dislocation who underwent an elbow contracture release. The injuries were grouped into coronal shear distal humerus/AO 13.B3 (CSDH), distal humerus/AO 13.A, 13.B1, B2 or 13.C (DH), olecranon/AO 21.B1 (OL), radial head/AO 21.B2 (RH), extra-articular proximal radius and ulna/AO 21.A (EAPRU) fractures and elbow dislocations (DL). The HO location was determined by reviewing elbow radiographs and CT scans and were classified as anterior capsule, medial or lateral collateral ligaments, and posterior capsule/triceps insertion.

RESULTS

The study consisted of 49 patients, such as 6 CSDH, 13 DH, 6 OL, 21 RH, 4 EAPRU fractures and 20 elbow DL. All CSDH and RH fractures and 19/20 elbow DL developed HO in the collateral ligaments, while 12/13 DH fractures developed an anterior capsule HO. All 6 OL fractures developed HO posteriorly, and 3/4 EAPRU fractures developed a proximal radioulnar synostosis.

CONCLUSIONS

Our findings suggest that the location of HO development is specific to the injury type and is influenced by the soft tissues involved. This is consistent with the understanding that HO is the abnormal ossification of normal structures.

Coronal shear fractures of the capitellum and trochlea: interobserver variability in classifying the fracture and the need for a computed tomography scan for the correct surgical planning

Background

To determine interobserver agreement in the classification by X-rays and by computed tomography (CT) scan of the coronal shear fractures of the capitellum and trochlea as well as the agreement between these two tests.

Methods

Patients with coronal shear fractures of the capitellum who were managed at our center between January 2008 and December 2017 were included. This retrospective cohort study was carried out with the approval of the ethics committee of our institution (Nº: IIBSP-Cod-2019-02, Ref. 19/070). Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated. Three observers analyzed the preoperative X-rays from all the cases. Each one of them independently classified the fractures according to the Bryan and Morrey classification (with the modification of McKee et al). The interobserver agreement was calculated by Cohen kappa coefficient. The same methodology was used to analyze the CT scan. Thereafter, one single value was determined for each X-ray and CT scan, from the good interobserver agreements. Finally, the agreement between the global X-ray classification and the global CT scan classification was calculated using the agreement percentage and the Cohen kappa coefficient.

Results

There were 3 males and 6 females, with a mean age of 47 years (range, 18-83). The mean follow-up period was 18 months (12-40). The average Mayo Elbow Performance Index score was 85 (range, 65-100) points. The complications were nonunion in one patient (11 %), degenerative arthritis in 7 (78 %), joint step-off in 5 (55%), and heterotopic ossification in 7 (78%). The agreement analysis between the global X-ray classification and the global CT scan classification showed a 57.1% agreement, with a kappa coefficient of −0.167. These values imply the absence of agreement.

Conclusion

Our results demostrated that simple X-rays do not allow for the adequate interpretation of distal humeral coronal plane fractures. Although an acceptable interobserver agreement was found, there is no agreement when the same fractures were analyzed by CT scan. The authors routinely recommend CT scan to assess the extent of the fracture and perform surgical planning.

Treatment of Distal Humerus Articular Fracture with Pin-and-Plate Technique

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.

Capitellum fractures: Treatment with headless screws and outcomes

Objectives

This study aims to present the results of 21 patients with capitellum fractures treated with open reduction and headless screws by a single experienced surgeon.

Patients and methods

Twenty-one patients (13 males, 8 females; mean age 39 years; range, 18 to 63 years) who were admitted to our clinic between June 2011 and January 2018 with the diagnosis of capitellum fracture and followed-up for a mean period of 45 months (range, 12 to 90 months) were included in this retrospective study. The fractures were fixed with headless cannulated screws by a single surgeon.

Results

The mean range of motion was 102° (range, 65° to 140°) during flexion-extension and 165° (range, 130° to 180°) during supination-pronation. The mean preoperative visual analog scale (VAS) score was 8.5 (range, 6 to 10), whereas the mean postoperative VAS score was 2.2 (range, 0 to 6). According to the Mayo Elbow Performance score, nine patients were evaluated as excellent, six patients as good, four patients as fair, and two as poor. The mean Quick-Disabilities of the Arm, Shoulder and Hand score was 25.1 (range, 4 to 57). Avascular necrosis developed in three patients (14%) and heterotopic ossification was detected in one patient (4%).

Conclusion

Capitellum fractures are difficult to diagnose and treat, and good results can only be achieved by an accurate diagnosis, careful surgical technique, and stable fixation. Larger and more comprehensive studies are required to establish a generalization and more accurate inferences on this limitedly studied subject.

The anterior limited approach of the elbow for the treatment of capitellum and trochlea fractures: Surgical technique and clinical experience in eight cases

When a coronal fracture affects the capitellum and the trochlea, the Kocher lateral approach may be inadequate for the correct visualisation, reduction and fixation of the fracture. In such cases an associated medial elbow approach may be required, or a posterior transolecranon approach may be preferred. The anterior limited approach to the elbow (ALAE) could be a valid option when treating these types of fracture, as it does not involve the detachment of any muscle group or ligament, thereby facilitating the recovery process. We can also treat associated injuries such as fractures of the radial head or coronoid process with this approach. We describe the surgical technique and the functional outcome of eight patients with a mean of 66 years of age (range, 53-76) who where treated with open reduction and internal fixation for capitellar and trochlear fractures through the ALAE. Patient outcomes were assessed with physical and radiological evaluation, range-of-motion measurements with a follow-up from 24 to 60 months. Two different quality of life questionnaires were carried out: the EuroQol Five Dimensions Questionnaire (EQ-5D) and the patient-answered questionnnaire of the Liverpool Elbow Score patient (PAQ-LES). Four fractures involved the capitellum, one involved the capitellum with the lateral ridge of the trochlea, and three involved the capitellum and trochlea as separate fragments. The patients presented a favorable clinical evolution at a median of 33 months (range, 24-60), with an average of motion of 10-138°. Four patients presented a fracture of the head of the radius (Mason type 2) and 3 fractures of the coronoid (Bryan-Morrey Type 1) associated. All the patients presented radiological consolidation without signs of osteonecrosis, being the average EQ-5D 0.857 (range, 0.36-1.0) and the PAQ-LES of 35 (range 17 to 36). Patients with isolated capitellar fractures had better results than those with trochlear involvement. The presence of associated fractures does not seem to worsen the results. We believe that the ALAE is a technical option to consider for the open surgical treatment of a capitellar fracture with or without involvement of the trochlea. LEVEL OF EVIDENCEIS: Therapeutic Level III.

Functional Outcome of a Coronal Shear Fracture of the Capitellum Managed by Herbert Screw Fixation Using the Anterolateral Surgical Approach

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.

Lateral Trochlear Ridge: A Non-Articulating Zone for Anterior-to-Posterior Screw Placement in Fractures Involving the Capitellum and Trochlea

BACKGROUND

Coronal shear fractures of the distal aspect of the humerus that involve the capitellum and the trochlea are rare; nevertheless, they are difficult to treat because of the complex fracture patterns and osteochondral nature of the fragments, limiting optimal screw placement. The use of anterior-to-posterior screw fixation by a lag technique (without countersinking) could potentially improve the strength of the construct. Our primary research question was to anatomically determine if there is a non-articulating zone for screw placement along the anterior aspect of the lateral trochlear ridge (aLTR) throughout normal elbow range of motion.

METHODS

Eight fresh-frozen cadaveric elbows were used. The region of interest was defined with 3 polymeric pins inserted in the inferior, middle, and superior-most aspects of the aLTR of each elbow, with use of an extensor digitorum communis (EDC) split approach. The elbows were then mounted on a magnetic resonance imaging (MRI)-compatible compression frame and subjected to high-resolution 7-T MRI at 90°, 120°, and 145° of flexion (positions of potential impingement), and at neutral and maximal pronation and maximal supination for each position of flexion. Portions of the aLTR that had free adjacent space were identified using the sagittal and coronal scans. This non-articulating region was identified as the "non-articulating zone" (NAZ).

RESULTS

The NAZ was found to encompass the proximal 38.2% (range, 30.2% to 48.9%) of the aLTR, measuring, on average, 5.2 mm in width. It was consistently located either directly adjacent to the apex of the ridge or just medial to it. The distal 61.8% of the aLTR articulated with either the ulna or the radial head in some of the elbows.

CONCLUSIONS

Our results suggest that there is a portion of the aLTR that, despite being covered with articular cartilage, is non-articulating throughout normal elbow range of motion.

CLINICAL RELEVANCE

In situations in which headless anterior-to-posterior and posterior-to-anterior screw insertion results in inadequate fixation of capitellar-trochlear fractures, anterior-to-posterior lag screw instrumentation along the non-articulating portion of the aLTR may provide a location for additional fixation in some patients. However, because of variation between patients, each case must be individualized.

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.

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.

An anterior neurovascular interval approach to coronal shear fractures of the distal humerus: a prospective clinical study with short- to mid-term follow-up

SUMMARY OBJECT: To explore the treatment effect of the anterior medial neurovascular interval approach to coronal shear fractures of the distal humerus. METHODS: This prospective study included two female patients who were 30-64 years old, with a mean age of 47 years. Fractures were caused by falling from a bicycle. The time between the injury and operation was 1-2 days, with a mean time interval of 1.5 days. Two patients with coronal shear fracture of the distal humerus were treated with open reduction and internal fixation using anterior neurovascular interval approach. RESULTS: There were no intraoperative and postoperative neurological and vascular complications or infections, and the fracture was united. At 12 months after the surgery, the patient returned to work without pain, and with a normal range of motion for elbow and forearm rotation. The X-rays revealed excellent fracture union, no signs of heterotopic ossification, and no traumatic arthritis. According to Mayo's evaluation standards for elbow function, a score of 100 is excellent. CONCLUSIONS: The application of the anterior neurovascular interval approach of the elbow in the treatment of shear fracture of the articular surface of the distal humerus, particularly the trochlea of the humerus, can reduce the stripping of the soft tissue.

Combined use of Kirschner wires and hinged external fixator for capitellar and trochlear fractures: a minimum 24-month follow-up

BACKGROUND

Open reduction and internal fixation is the adequate treatment for capitellar and trochlear fractures. Given the low incidence of this type of fractures, it is difficult to constitute a universally accepted method for fixation. Thus, we hypothesised that combined use of Kirschner wires (K-wires), absorbable rods and sutures for fixation and post-operative hinged external fixator for early rehabilitation exercise can restore elbow joint function well.

METHODS

This retrospective study included 20 patients with a mean age of 48.3 (range 16-76) years. According to the Dubberley classification, fractures were classified on plain radiographs, computed tomography images and intra-operative findings. All patients were evaluated by the range of motion of the elbow and the Broberg-Morrey score.

RESULTS

All fractures had healed without non-union, and the average time was 13.6 (range 8-17) weeks. The mean follow-up was 42.5 (range 24-80) months. The mean flexion was 117.1° (range 90°-135°), and the mean extension was 17.5° (range 0°-45°). The mean pronation was 74.4° (range 45°-85°), and the mean supination was 84.3° (range 60°-90°). The average Broberg-Morrey score was 86.2 (range 68-98) points with 10 excellent, 7 good and 3 fair results.

CONCLUSION

K-wires, absorbable rods and sutures combined with hinged external fixator are feasible for fixation of capitellar and trochlear fractures. However, due to the absence of a control group (such as Herbert screw fixation), comparative studies are still needed to demonstrate the safety and reliability of K-wires for fixation.

Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients

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.

Mid-term and Long-term Functional and Radiographic Results of 13 Surgically Treated Adolescent Capitellum Fractures

BACKGROUND

Capitellum fractures are rare in adolescents, and information in literature is still limited. The purpose of this study was to report the mid-term and long-term functional and radiographic results of 13 surgically treated adolescent capitellum fractures in a level I trauma center.

METHODS

This retrospective study included patients aged 10 to 16 years, who underwent surgery for a capitellum fracture and were followed up for at least 12 months. Fractures were classified according to the McKee modification of the Bryan and Morrey classification, and elbow arthritis was classified using the Broberg and Morrey system. Functional outcomes were assessed with the Mayo Elbow Performance Index (MEPI) and the Turkish-language version of the shortened version of the Disabilities of Arm, Shoulder, and Hand (QuickDASH) scale.

RESULTS

The mean time to surgical intervention was 4.5 days (range, 1 to 18 d). The mean flexion-extension range of motion arc was measured as 115 (range, 45 to 150) degrees. The mean restriction for extension and flexion compared with the uninjured side was measured as 10.7 (range, 0 to 45) and 11.5 (range, 0 to 45) degrees, respectively. The mean MEPI was 87.7 points (range, 50 to 100 points) with 9 patients as excellent, 1 good, 1 fair, and 2 poor results. The mean QuickDASH score was 11 (range, 0 to 57). The mean MEPI score was 95.6 and 75 and the mean QuickDASH score was 2.62 and 25.0 for early surgery group (≤3 d) and late surgery group (>3 d), respectively (P=0.073, 0.024). Elbow joint contracture developed in 4 patients. Implant removal and open release of joint contracture was applied to 2 patients. Elbow arthritis of grade 3 was observed in 2 patients and grade 2 in 1 patient.

CONCLUSIONS

Capitellum fractures may be easily missed on conventional radiographs, if not suspected. Delayed diagnosis may lead to a worsening of the functional outcomes. Computerized tomography is helpful in the determination of these fractures. Early diagnosis and a well-performed surgery is essential for successful outcome.

LEVEL OF EVIDENCE

Level IV-case series.

Missed Capitellar Fracture Caused by Avoidance of Radiological Evaluation in Pregnancy

In this paper, we report a pregnant woman with a missed capitellar fracture of the elbow, who was treated successfully with open reduction and internal fixation using two headless screws. A 29-year-old 6-month pregnant woman presented to the emergency department due to a history of falling on her outstretched hand. A long-arm splint was applied without radiological evaluation due to pregnancy. She came to the orthopaedics and traumatology outpatient clinic 6 weeks after trauma and her examination after splint removal revealed pain and restriction in the elbow joint movements. Radiography was taken by using a lead shield in order to protect the fetus. Radiographs showed a displaced osteochondral capitellar fracture. Using the posterolateral approach as described by Kocher, the fracture was fixed using headless canulated compression screws. The follow-up examination showed excellent functional and radiological results. Radiological evaluation should not be avoided in case of obvious fracture findings after trauma even in case of pregnancy. It is also highlighted that good results in terms of union and functional recovery can be achieved with open reduction and headless compression screw fixation followed by early rehabilitation even in delayed treatment of capitellum fractures.

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.

The limited anterior approach of the elbow for open reduction and internal fixation of capitellum fractures. Surgical technique and clinical experience in 2 cases with more than 2 years follow-up

OBJECTIVE

Fractures involving the capitellum can be treated surgically by excision of the fragment, or by reduction and internal fixation with screws, with or without heads. The lateral Kocher approach is the most common approach for open reduction. We believe that the limited anterior approach of the elbow, could be a valid technique for treating these fractures, as it does not involve the detachment of any muscle group or ligament, facilitating the recovery process.

MATERIAL AND METHOD

A description is presented of the surgical technique, as well as of 2cases with a Bryan-Morrey type 1 fracture (Dubberley type 1A). Two different final quality of life evaluation questionnaires were completed by telephone: the EuroQol Five Dimensions Questionnaire (EQ-5D), and the patient part of the Liverpool Elbow Score (PAQ-LES) questionnaire.

RESULTS

The 2patients showed favourable clinical progress at 36 and 24 months, respectively, with an extension/flexion movement arc of -5°/145° and -10°/145°, as well as a pronosupination of 85°/80° and 90°/90°. The 2patients showed radiological consolidation with no signs of osteonecrosis. The EQ-5D score was 0.857 and 0.910 (range: 0.36-1), and a PAQ-SLE of 35 and 35 (range: 17-36), respectively.

CONCLUSIONS

We believe that the limited anterior approach of the elbow is a technical option to consider for the open surgical treatment of a capitellum fracture, although further studies are needed to demonstrate its superiority and clinical safety compared to the classical lateral Kocher approach.

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

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.

Capitellum Fracture Fragment Excision: a Case Series

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.

Triceps tendon rupture: the knowledge acquired from the anatomy to the surgical repair

Triceps injuries are relatively uncommon in most traumatic events, and the distal triceps tendon ruptures are rare. Recently, the knowledge of this tendon lesion has increased, and it seems to be related to more precise diagnostic and clinical assessments. The most common mechanism of injury remains a forceful eccentric contraction of the muscle, while several other risk factors have been studied as chronic renal failure, endocrine disorders, metabolic bone diseases as well as steroid use. Olecranon bursitis and local corticosteroid injections may also play a role. The commonest site of rupture is at the tendon's insertion into the olecranon and rarely at the myotendinous junction or intramuscularly. The surgical intervention is recommended in acute complete ruptures, and non-operative treatment is reserved for patients with major comorbidities, as well as for partial ruptures with little functional disability and in low demanding patients. Various techniques and approaches as the direct repair to bone, the tendon augmentation, the anconeus rotation flap and the Achilles tendon allograft have been proposed for the management of these challenging injuries. The goal of surgical management should be an anatomical repair of the injured tendon by selection of a procedure with a low complication rate and one that allows early mobilization. This manuscript focuses the triceps tendon ruptures starting from the anatomy to the diagnosis and entity of the triceps tendon injuries, as well as the indications and guidelines for the management.

Arthrolysis and delayed internal fixation combined with hinged external fixation for elbow stiffness associated with malunion or nonunion of capitellum fracture

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.

Posterior fixation of type IV humeral capitellum fractures with fully threaded screws in adolescents

PURPOSE

Humeral capitellum fractures comprise approximately 1% of all elbow fractures. In this study, we examined the clinical, radiographic, and functional outcomes following operative stabilization of Bryan and Morrey type IV fractures of the capitellum in adolescents. We applied headless cannulated screws in a posteroanterior direction without damaging the articular cartilage surface of the fractures.

METHODS

Eight adolescent patients (six male, two female) with a mean age of 15 ± 2.1 years (range 13-18 years) were treated for type IV (McKee) humerus capitellum fractures. In the preoperative radiological evaluation, anteroposterior and lateral radiographs and computed tomography (CT) images were performed. A lateral surgical approach was used, and cannulated fully threaded headless screws were applied in a posteroanterior direction as fixation materials in the fracture reduction. The Mayo Elbow Performance Score was used in the evaluation of elbow joint functions.

RESULTS

Patients were followed up for a mean of 24.6 months. Fracture union was achieved at a mean of 5 ± 0.92 weeks (range 4-6 weeks). The mean elbow extension flexion arc was 135° ± 13.47° (range 110°-150º) and the mean pronation supination arc was 156° ± 4.43° (150°-160°). In one patient, there was nonconformity in the humerus trochlea and in another patient, there was keloid formation on the surgical scar. All patients attained excellent results according to the Mayo Elbow Performance Score.

CONCLUSIONS

In the treatment of type IV capitellum fractures in adolescents, open reduction with a lateral surgical approach and fixation using posteroanterior directed, cannulated, fully threaded, headless screws is a reliable method to achieve a pain-free functional elbow joint.

Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation

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.

Distal humeral coronal plane fractures: management, complications and outcome

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.

Fractures of the capitellum concomitant with avulsion fractures of the triceps tendon

We present 2 cases of a capitellum fracture with concomitant triceps avulsion fracture. Common radiologic features of these injuries include a comminuted fracture of the capitellum with extension to the lateral portion of the trochlea, absence of posterior lateral condyle comminution, and a triceps avulsion fragment that is avulsed in a posterolateral direction.

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.

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.

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.