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Capitellum Fractures

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Topic updated on 03/04/14 9:35pm
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 excison
      • 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
  • Nonunion (1-11% with ORIF)
  • Ulnar nerve injury
  • Heterotopic ossification (4% with ORIF)
  • AVN of capitellum
  • Nonunion of olecranon osteotomy

 

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Qbank (2 Questions)

TAG
(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 Figures A and B. A CT scan is obtained to better characterize the injury, and representative images are shown in Figures C and D. The patient is legally blind and ambulates with the assistance of a guide dog. 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? Topic Review Topic
FIGURES: A   B   C   D    

1. Open reduction internal fixation of the distal humerus fracture
2. Nonsurgical management with early passive range of motion exercises
3. Initial nonsurgical management followed by interpositional arthroplasty when the fracture has healed
4. Total elbow arthroplasty
5. Excision of the capitellar fragments and fixation of the trochlear fragments

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Coronoid fracture
2. Capitellum fracture with extension into the trochlea
3. Radial head and capitellum fracture
4. Isolated capitellum fracture
5. Trochlea fracture

PREFERRED RESPONSE ▶



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