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.

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

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. 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. 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. 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.
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