Internal fixation of fractures of the capitellum and trochlea - Retrospective analysis of 26 cases

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Fractures of capitellum and trochlea account for 0.5-1% of elbow fractures and 6% of distal humerus fractures. These usually occur due to axial loading of the distal humerus by forces transmitted across the joint producing a coronal shear fracture of the capitellum or the trochlea. Internal fixation is the best modality to restore articular congruity in these fractures.




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Internal fixation of fractures of the capitellum and trochlea - Retrospective analysis of 26 cases

  1. 1. Internal fixation of fractures of the capitellum and trochlea - Retrospective analysis of 26 cases
  2. 2. Review Article Internal fixation of fractures of the capitellum and trochlea e Retrospective analysis of 26 cases Yatinder Kharbanda a , Mrinal Sharma b, *, Anand Vadhera c , Vivek Srivastava d a Senior Consultant Orthopaedics, Indraprastha Apollo Hospital, New Delhi, India b Consultant Orthopaedic Surgeon, Indraprastha Apollo Hospital, New Delhi, India c Clinical Associate, Indraprastha Apollo Hospital, New Delhi, India d DNB Orthopaedics Student, Indraprastha Apollo Hospital, New Delhi, India a r t i c l e i n f o Article history: Received 1 October 2012 Accepted 17 May 2013 Available online 14 June 2013 Keywords: Internal fixation Capitellum Trochlea Herbert screw a b s t r a c t Introduction: Fractures of capitellum and trochlea account for 0.5e1% of elbow fractures and 6% of distal humerus fractures. These usually occur due to axial loading of the distal hu- merus by forces transmitted across the joint producing a coronal shear fracture of the capitellum or the trochlea. Internal fixation is the best modality to restore articular con- gruity in these fractures. Material and methods: Twenty-six cases of fresh trauma operated for capitellum (n ¼ 22), trochlea (n ¼ 2) or capitello-trochlear (n ¼ 2) fractures using Herbert screws between 2005 and 2011 were evaluated retrospectively. Patients between age group of 19and 58 years were followed up for mean 3.6 years (1.8e7 years). Fractures were classified according to the classification of Bryan and Morrey. Patients were evaluated using the Mayo elbow performance score. Results: The mean time to union was 5 weeks (4e7weeks). Patients were followed for mean 3.7 years (1.8e7years).No patient was lost to follow-up.Mean extension was50(range00e150) and mean flexion was 132 degree (range 1200e1400). Excellent results were seen in 18, good in 6, satisfactoryin1andpoorin1case. Noneofthepatients showedevidenceofavascularnecrosis. Discussion: Anatomic reduction, stable internal fixation and early post-operative moblisation leads to best results. Headless compression screws with differential pitch afford rigid sta- bility and compression at the fracture site. It can be sunk into the bone and does not need removal later. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Coronal shear fractures of the articular surface of distal hu- merusnamelythe capitellum and thetrochleaare a challengeto the orthopaedic surgeon as restoration of articulate congruity is the primary aim of internal fixation. Intra-articular fractures of distalhumerushaveawelldeserved reputation ofbeing difficult to manage with a poor prognosis.1 These fractures account for 0.5e1% of elbow fractures and 6% of distal humerus fractures. Internal fixation is the best modality to restore articular con- gruity in these fractures.2,3 These usually occur due to axial loading of the distal humerus by forces transmitted across the * Corresponding author. E-mail address: dr.mrinalsharma@gmail.com (M. Sharma). Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 6 e2 7 9 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.05.015
  3. 3. joint producing a coronal shear fracture of the capitellum or the trochlea.4 Herbert screw fixation provides stable fixation and compression at the fracture site, least damage to the cartilage and there is no need for implant removal.5,6 We retrospectively analysed 22 cases of capitellum, trochlea (2) and capitello-trochlear fractures (2) treated by open reduction and internal fixation using Herbert screws and K-wires in the past 7 years. 2. Material and methods Twenty-six cases of fresh trauma operated for capitellum (n ¼ 22), trochlea (n ¼ 2) or capitello-trochlear (n ¼ 2) fractures using Herbert screws between 2005 and 2011 were evaluated retrospectively. Patients between age group of 19 and 58 years were followed up for mean 3.6 years (1.8e7 years). Fourteen of them were males and 12 were females. Sixteen of them had a fall on the outstretched hand. Others could not recollect the mechanism of injury. All the injuries were closed and there was no associated injury in other bones except for one case with ipsilateral olecranon fracture. Anteroeposterior (AP) and lateral views of the elbow were taken and fractures were classified according to the classification of Bryan and Morrey.7 Computed tomography (CT) was done in cases where the fracture pattern was not clearly defined on radiographs. All cases were operated under single tourniquet time. The mean time of surgery was 42 min (36e55 min). The fracture was exposed using Kaplan’s approach (between extensor carpi radialis longus and brevis) to the elbow for capitellar and capitello-trochlear fractures. Fracture fragments were defined and reduced. Provisional fixation was done using K-wires. Drilling was done over the guide wires and Herbert screws of measured sizes were placed to achieve inter-fragmentary compression. Mini-fragment screws and K-wires were used to stabilise small fragments in complex patterns. Trochlear fractures were exposed from the medial side and fixed with headless compression screws directed from posterior to ante- rior (preferred) or anterior to posterior. We preferred to pass two Herbert screws in each fragment to provide rigid rotational stability. Ligamentous avulsion of the epicondyles were stabi- lised using K-wires. Wound closure was done in layers. Post-operatively elbow was immobilised in a slab at 90 of elbow flexion for 7 days. Passive range of motion exercises was started after one week when pain and swelling settled. Active assisted exercises were started at 3 weeks. Patients were recalled for clinical evaluation and X-rays at 2 weeks, 1 month, 3 month and 6 monthly thereafter. Patients were evaluated for pain, range of motion, stability and activities of daily living using the Mayo elbow performance score. Radio- graphs were evaluated for union, heterotrophic ossification, avascular necrosis and osteoarthritis. 3. Results Fractures were classified as Bryan and Morrey type 1 (n ¼ 22), type 2 (n ¼ 2) and type 4 (n ¼ 4). All fractures showed union. There was no intra-operative or immediate post-operative complications. The mean time to union was 5 weeks (4e7weeks). Even fragments devoid of soft tissues united. Patients were followed for mean 3.7 years (1.8e7years). No patient was lost to follow-up. Patients were evaluated using Mayo elbow performance score (90 points).8 Mean extension was 5 (range 0 -15 ) and mean flexion was 132 (range 120 e140 ). Excellent results were seen in 18, good in 6, satisfactory in 1 and poor in 1 case. None of the patients showed evidence of avascular necrosis. One patient had elbow stiffness and poor result for which an arthrolysis was per- formed. None of the patients had an intra-articular screw. K-wire migration and soft tissue irritation was seen in two patients. This was managed with K-wire removal. Heterotro- phic ossification was seen in one case with resultant restric- tion of motion. Excision of new bone was performed after complete maturation at one year. Arthrosis and elbow insta- bility was not seen in any of our cases. 3.1. Illustrative case reports 3.1.1. Case 1 A 28-year male injured his left elbow after a slip on the floor. His CT scan 3d reconstructed images showed a fracture of the capitello-trochlear fragment (Fig. 1aec). Fixation was done using a headless compression screw from the lateral side and a K-wire from the medial side. Post-operative radiographs at 2.5-year follow-up (Fig. 1d,e). Full supination and pronation achieved with 15 extension lag at the elbow (Fig. 1feh). 3.1.2. Case2 A 32-year male injured his right elbow and sustained a frac- ture of capitellum, lateral epicondyle and part of trochlea (Fig. 2a,b). Intraoperative picture showing the capitellum fracture and provisional fixation with K-wires (Fig. 2c). Post- operative follow-up radiographs at 2-year follow-up showing complete union (Fig. 2d,e). 4. Discussion Coronal shear fractures of distal humerus are sometimes missed on routine radiographs. Radiographs of type IV frac- tures may show a double arc sign (case 1) which is pathoge- nomic of a trochlea and capitellum fracture.4 But this sign may not be visible in all cases due to rotation of the fragments.6 CT scans with 3D reconstructions clearly defines the fracture pattern.9 Neglected or untreated fractures lead to adhesions, limitation of motion and early arthrosis.10,11 Closed reduction of these fractures results in stiffness and resultant loss of motion.11,12 Excision of fragments leads to adhesions on the raw area and elbow instability, valgus deformity at the elbow and ulnar neuritis at a later date.5,6,10 Anatomic reduction, stable internal fixation and early post- operative mobilisation lead to best results.5,13e15 Fixation with K-wires although provides stability but does not provide compression at the fracture site. K-wires also need removal at a later date. AO compression screw head irritates the cartilage of the radial head leading to radio-humeral arthrosis.5 Head- less compression screws with differential pitch afford rigid stability and compression at the fracture site. It is sunk into the bone, does not need removal and can be used a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 6 e2 7 9 277
  4. 4. Fig. 1 e a, b: 3 D reconstructed CT scan images of the injured elbow. c: Axial CT image showing the capitello-trochlear fragment. d, e: Post-operative AP, lateral radiographs of the elbow at 2.5-year follow-up. f, g, h: Clinical photographs showing full supination and pronation and 15 extension lag. Fig. 2 e a: Ap view of the elbow joint showing the capitellum, part of trochlea and lateral epicondyle fracture. b: lateral view of elbow showing the double ring sign suggestive of capitello-trochlear fracture. c: Kaplan lateral exposure of elbow joint. The brachialis, Extensor digitorum longus and brevis, the anterior joint capsule and the extensor digitorum communis split (vertical arrow) and a raised as an anterior flap. The horizontal arrow shows the fractured lateral epicondyle. The capitellum fracture is shown being stabilized provisionally with K-wires. d, e: Ap and lateral post-operative views at 2 years follow-up showing stable fracture fixation and no features of avascular necrosis. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 6 e2 7 9278
  5. 5. both from anterior-posterior or posterior-anterior direction (preferred).5,13e16 Fracture fragments are usually displaced anteriorly and superiorly into the anterior capsular space of elbow joint. These are usually devoid of any soft tissue fragments. We had such fragments in six of our cases. These usually revascular- ise themselves. All were fixed and achieved union. Avascular necrosis was not seen in any cases. Avascular necrosis although rare, is less appreciated clinically and radiologically has a reported incidence of 0e30%.5 Delayed excision is the treatment of choice. Internal fixation of a free fragment has been encouraged by Mehdian et al and Singh et al.6,17 Ruchelsmann et al showed good results in a retrospective analysis of 14 cases followed over 24 months and fixed using lateral extensile approach and Herbert screws. Eight of these wereBryan and Morreytype IV with radial headfractures(n ¼ 5), comminuted metaphysis (n ¼ 5) and lateral collateral injury (n ¼ 1). He also used supplemental mini-fragment screws for fixation.3 We have also used mini-fragment screws to fix the small fragments and bony ligament avulsions. Anchor sutures can be used instead. Ring et al have reported no osteoarthrosis in their series of 21 patients followed up for 44 months.18 Mckee etalreportedmildosteoarthrosis inone patient out of6 patients followed for 22 months.4 Arthrosis was not seen in any of our patients and has not been reported by others also.6,18,19 Duber- ley et al in their study of 38 cases reported postetraumatic arthrosis in 11 patients (commonly type III fractures).20 Heterotrophic new bone formation was seen in one of our cases for which excision of the bone was done after its matu- ration at one year. Functional range of motion was achieved in this case. Duberley et al reported minor peri-articular calcifi- cations in 4 cases without any loss of function or motion.20 Coronal shear fractures are rare injuries and need high degree of precision and experience on the part of the oper- ating surgeon. Anatomic stabilisation and fixation with headless compression screws followed by early mobilisation achieves excellent results. Conflicts of interest All authors have none to declare. r e f e r e n c e s 1. Jupiter J. Master Techniques in Orthopaedic Surgery: Elbow. Lippincot Williams and Wilkins; 2002:65e80. Part II. 2. Jupiter JB, Morrey BF. Fractures of the distal humerus in the adult. In: Morrey BF, ed. The Elbow and Its Disorders. 2nd ed. Philadelphia: WB Saunders; 1993:328e366. 3. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Jt Surg [Am]. 2008;90:1321e1329. 4. McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Jt Surg [Am]. 1996;78:49e54. 5. Mahirogullari M, Kiral A, Solakoglu C, Pehlivan O, Akmaz I, Rodop O. Treatment of fractures of the humeral capitellum using Herbert screws. J Hand Surg (Br Eur Vol). 2006;31:320e325. 6. Singh AP, Singh AP, Vaishya R, Jain A, Gulati D. Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws. Int Orthopaedics (SICOT). 2010;34:897e901. 7. Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, ed. The Elbow and Its Disorders. Philadelphia: Saunders; 1985:325e333. 8. Morrey BF. Functional evaluation of the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. 3rd ed. Philadelphia: WB Saunders; 2000:82. 9. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Coronal plane partial articular fractures of the distal humerus: current concepts in management. J Am Acad Orthop Surg. 2008;16(12):716e728. 10. Alvarez E, Patel MR, Nimberg G, Pearlman HS. Fracture of the capitellum humeri. J Bone Jt Surg Am. 1975;57:1093e1096. 11. Dushuttle RP, Coyle MP, Zawadsky JP, Bloom H. Fractures of the capitellum. J Trauma. 1985;25:317e321. 12. Ochner RS, Bloom H, Palumbo RC, Coyle MP. Closed reduction of coronal fractures of the capitellum. J Trauma. 1996;40:199e203. 13. Silveri CP, Corso SJ, Roofeh J. Herbert screw fixation of a capitellum fracture: a case report and review. Clin Orthop. 1994;300:123e126. 14. Simpson LA, Richards RR. Internal fixation of capitellar fractures using Herbert screws: a case report. Clin Orthop. 1986;209:166e168. 15. Sano S, Rokkaku T, Saito S, Tokunaga S, Abe Y, Moriya H. Herbert screw fixation of capitellar fractures. J Shoulder Elbow Surg. 2005;14(3):307e311. 16. Liberman N, Katz T, Howard CB, Nyska M. Fixation of capitellar fractures with the Herbert screw. Arch Orthop Trauma Surg. 1991;110:155e157. 17. Mehdian H, McKee MD. Fractures of capitellum and trochlea. Orthop Clin North Am. 2000;31:115e127. 18. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Jt Surg [Am]. 2003;85:232e238. 19. Lansinger O, Mare K. Fracture of the capitulum humeri. Acta Orthop Scand. 1981;52:39e44. 20. Dubberley JH, Faber KJ, Macdermid JC, Patterson SD, King GJ. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Jt Surg (Am). Jan 2006;88(1):46e54. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 6 e2 7 9 279
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