http://upload.orthobullets.com/topic/1023/images/43b_moved.jpg
http://upload.orthobullets.com/topic/1023/images/classification illustration jaaps..jpg
http://upload.orthobullets.com/topic/1023/images/hahn steinthal 3.jpg
http://upload.orthobullets.com/topic/1023/images/hahn steinthal 2.jpg
Introduction
  • Coronal fracture of the distal humerus at capitellum
  • Epidemiology 
    • 1% of elbow fractures
  • Mechanism of injury
    • fall on outstretched hand
  • Prognosis
    • most patients will gain functional range of motion but have residual stiffness
    • surgical treatment results are generally favorable
      • reoperation rates as high as 48%
Classification
 
 Bryan and Morrey Classification (with McKee modification)  
Type I Large osseous piece of the capitellum involved
Can involve trochlea 
  
Type II Kocher-Lorenz fracture
Shear fracture of articular cartilage
Articular cartilage separation with very little subchondral bone attached
 
Type III Broberg-Morrey fracture
Severely comminuted
Multifragmentary
 
Type IV McKee modification
Coronal shear fracture that includes the capitellum and trochlea

 
Presentation
  • History
    • fall on outstretched arm
  • Symptoms
    • elbow pain
    • swelling 
  • Physical exam
    • may have mechanical block to flexion and extension
Imaging
  • Radiographs
    • recommended
      • AP and lateral of the elbow
        • best demonstrated on lateral radiograph
  • CT
    • delineates fracture anatomy and classification  
Treatment
  • Nonoperative
    • posterior splint immobilization for < 3 weeks
      • indications
        • nondisplaced Type I and Type II fractures (<2 mm displacement)
  • Operative
    • open reduction and internal fixation
      • indications
        • displaced Type I fractures (>2mm) 
        • Type IV fractures 
    • fragment excision
      • indications
        • displaced (>2mm) Type II fractures
        • displaced (>2mm) Type III fractures
    • total elbow arthroplasty
      • indications
        • unreconstructable capitellar fractures in elderly patients with associated medial column instability
Technique
  • ORIF
    • approach
      • lateral approach recommended for Type IV fx 
      • posterior approach can be used if associated with other elbow injuries
    • screw fixation 
      • headless screw fixation
      • minifragment screw using posterior to anterior fixation
        • counter sink screw using anterior to posterior fixation
    • avoid disruption of the blood supply that comes from the posterolateral aspect of the elbow 
Complications
  • Elbow contracture (most common) 
  • Nonunion (1-11% with ORIF)
  • Ulnar nerve injury
  • Heterotopic ossification (4% with ORIF)
  • AVN of capitellum
  • Nonunion of olecranon osteotomy
 

Please rate topic.

Average 3.8 of 28 Ratings

Questions (2)

(OBQ12.195) An 88-year-old female presents after a fall onto her left arm. She reports isolated left elbow pain, and radiographs are shown in Figure A. She lives in an assisted living facility, and reports no other major medical problems. The best outcome can be expected with which of the following definitive treatment options? Review Topic

QID:4555
FIGURES:
1

Open reduction internal fixation of the distal humerus fracture

11%

(207/1831)

2

Nonsurgical management with early passive range of motion exercises

9%

(159/1831)

3

Initial nonsurgical management followed by interpositional arthroplasty when the fracture has healed

1%

(27/1831)

4

Total elbow arthroplasty

74%

(1358/1831)

5

Excision of the capitellar fragments and fixation of the trochlear fragments

4%

(75/1831)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

This elderly, low demand patient is presenting with a distal and comminuted distal humerus fracture in the setting of poor bone quality. These are extremely difficult to reconstruct and rehabilitate from, and therefore in this particular case total elbow arthroplasty is the best option.

Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humerus fractures in patients older than age 70. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight more than 10-15 pounds must be followed to avoid loosening.

Kamineni et al. retrospectively reviewed 49 acute distal humerus fractures in 48 patients who were treated with total elbow arthroplasty as the primary option. Forty-three of these fractures were followed for 2 years. At the latest follow-up examination, the average flexion arc was 24 degrees to 131 degrees and the Mayo elbow performance score averaged 93 of a possible 100 points. This review supports a recommendation for total elbow arthroplasty for the treatment of an acute distal humerus fracture when strict inclusion criteria are observed.

Frankle et al. compared open reduction and internal fixation (ORIF) with total elbow arthroplasty (TEA) for intraarticular distal humerus fractures in women older than 65 years of age. Follow-up was a minimum of two years. Using the Mayo Elbow Performance score, the outcomes of the 12 patients treated with ORIF were as follows: 4 excellent, 4 good, 1 fair, and 3 poor. Outcomes of the 12 patients treated with TEA were as follows: 11 excellent and 1 good. There were no fair or poor outcomes in the TEA group, and no patients treated with TEA required revision surgery.

The AP and lateral elbow radiographs shown in Figures A demonstrate a severely comminuted and displaced distal humerus fracture.

Incorrect Answers:
Answer 1: Stable ORIF is nearly impossible to attain in the setting of a very distal fracture of the humerus with comminution and poor bone quality.
Answer 2: Although nonsurgical management of these injuries showed some favor in the past, range of motion and pain control are ultimately better with TEA in the appropriate patient.
Answer 3: Interpositional arthroplasty is indicated in younger patients who may not be able to comply with the strict weight lifting restrictions of a TEA.
Answer 5: Fixation of the trochlear fragments would be extremely difficult in this case, and capitellar excision would likely lead to an unstable elbow joint in the setting of a compromised ulnohumeral articulation.


Please rate question.

Average 2.0 of 21 Ratings

Question COMMENTS (8)

(OBQ05.201) A 20-year-old man falls from his bicycle. He is going to be scheduled for open reduction internal fixation. What best describes the injury shown in Figure A and B? Review Topic

QID:1087
FIGURES:
1

Coronoid fracture

2%

(5/289)

2

Capitellum fracture with extension into the trochlea

43%

(125/289)

3

Radial head and capitellum fracture

3%

(10/289)

4

Isolated capitellum fracture

49%

(142/289)

5

Trochlea fracture

2%

(6/289)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The radiographs shows a coronal shear fracture of the capitellum with extension into the trochlea, which would be classified as a Type IV fracture under the Bryan and Morrey classification system which was modified by McKee to include this specific injury. The lateral radiograph in Figure B and Illustration A is an example of the "double arc" sign representing an injury to both the trochlea and capitellum. The treatment of choice for a displaced Type IV fracture is open reduction internal fixation.

Dushuttle et al demonstrated that absence of the capitellum did not lead to valgus instability unless the medial collateral ligament was injured, suggesting that excision of highly comminuted fractures could be performed.

The reference by Grantham et al looked at a series of capitellum fractures and recommended the choice of treatment should be selective and individualized depending on age, character of the bone, and type of fracture.

McKee et al in their case review described this coronal injury pattern and their results for ORIF of these fractures.

ILLUSTRATIONS:

Please rate question.

Average 3.0 of 38 Ratings

Question COMMENTS (12)
Sorry, this question is available to Virtual Curriculum members only.

Click HERE to learn more and purchase the Virtual Curriculum today!


This is a Never-Been-Seen Question that can only be seen in Milestone Exams
for Virtual Curriculum members.

Click HERE to learn more and purchase the Virtual Curriculum today!


CASES (4)
GROUPS (1)
EVIDENCE & REFERENCES (13)
Topic COMMENTS (11)