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Introduction
  • Coronal fracture of the distal humerus at capitellum
  • Epidemiology 
    • 1% of elbow fractures
    • 6% of all distal humerus fractures
  • Pathophysiology
    • mechanism of injury
      • typically, low-energy fall on outstretched hand
      • direct, axial compression with the elbow in a semi-flexed position creates shear forces
    • pathoanatomy
      • radiocapitellar joint is an important static stabilizer of the elbow
      • capitellar fracture can cause potential block to motion and instability due to loss of the radiocapitellar articulation
  • Associated conditions
    • concomitant injuries to radial head and/or LUCL can occur up to 60% of the time
  • 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% (mostly due to stiffness)
Anatomy
  • Radiocapitellar articulation
    • essential to longitudinal and valgus stability of the elbow
      • can also lead to coronal plane instability with capitellar excision if medial structures are not intact
    • integral relationship with the posterolateral ligamentous complex of the elbow (i.e. LUCL)
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 (typically fall from standing)
    • typically, elbow is in semi-flexed elbow position
  • Symptoms
    • elbow pain, deformity
    • swelling 
    • wrist pain may also occur
  • Physical exam
    • inspection and palpation
      • ecchymosis, swelling
      • diffuse tenderness
    • range of motion & instability
      • may have mechanical block to flexion/extension and/or rotation
    • neurovascular exam
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 fractures  (<2 mm displacement)
        • nondisplaced Type II fractures  (<2 mm displacement)
  • Operative
    • open reduction and internal fixation
      • indications
        • displaced Type I fractures  (<2 mm displacement) 
        • Type IV fractures 
      • technique
        • ORIF with lateral column approach
          • indications
            • isolated capitellar fractures
            • type IV fractures that can have trochlear involvement
        • ORIF with posterior approach with or without olecranon osteotomy
          • indications
            • capitellar fractures with associated fractures/injuries to distal humuers/olecranon and/or medial side of the elbow
    • arthroscopic-assisted ORIF
      • indications
        • isolated type I fractures with good bone stock
    • fragment excision
      • indications
        • displaced Type II fractures (<2 mm displacement)
        • displaced Type III fractures (<2 mm displacement)
    • total elbow arthroplasty
      • indications
        • unreconstructable capitellar fractures in elderly patients with associated medial column instability
Technique
  • ORIF with lateral column approach
    • approach
      • lateral approach recommended for isolated Type I and Type IV fx 
      • supine positioning
      • lateral skin incision centered over the lateral epicondyle extending to 2cm distal to the radial head 
    • technique
      • headless screw fixation
      • minifragment screw using posterior to anterior fixation
        • counter sink screw using anterior to posterior fixation 
      • mini-fragment or capitellar plates can be used to capture fractures with proximal extension  
      • avoid disruption of the blood supply that comes from the posterolateral aspect of the elbow 
      • do not destabilize LUCL
  • ORIF with posterior approach with or without olecranon osteotomy
    • approach
      • indicated when more extensive articular work is needed   
      • can also be used when concomitant medial sided injuries and/or distal humeral fractures require more fixation
      • lateral decubitus positioning
      • long-posterior based incision along the elbow
        • radial and ulnar based flaps allow access to both medial and lateral sides of elbow
    • technique
      • fracture-pattern specific
        • independent headless compression/cannulated screws for capitellar component
        • supplemental fixation for concomitant pathology
          • parallel or orthoogonal distal humerus plates
          • radial head arthroplasty/ORIF
        • LUCL/UCL repair via bone tunnels or suture anchors
  • Arthroscopic-assisted ORIF
    • approach
      • definitive indications not fully known
      • experienced arthroscopists, indicated for isolated capitellar fractures
      • supine or lateral positioning (dependent on desire for anterior or posterior access)  
      • 70 degree scope can be helpful in gaining access
      • can be combined with limited open technique for fracture manipulation
    • technique
      • standard portals (anteromedial, anterolateral, posterolateral)
      • proximal anterolateral portal established under fluoroscopic guidance to place trocar to allow for reduction of fracture fragment 
        • extend elbow and push fragment with trocar for reduction 
        • flex radial head past 90 to lock reduction
      • anteromedial and posterolateral portals allow for fracture debridement
      • freer elevator can help maintain reduction while cannulated/headless compression screws are placed under fluoroscopic guidance (typically posterior to anterior in direction) 
Complications
  • Elbow contracture/stiffness (most common) 
  • Nonunion (1-11% with ORIF)
  • Ulnar nerve injury
  • Heterotopic ossification (4% with ORIF)
  • AVN of capitellum
  • Nonunion of olecranon osteotomy
  • Instability
  • Post-traumatic arthritis
  • Cubital valgus
  • Tardy ulnar nerve palsy
  • Infection
 

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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

10%

(224/2215)

2

Nonsurgical management with early passive range of motion exercises

9%

(190/2215)

3

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

2%

(34/2215)

4

Total elbow arthroplasty

76%

(1682/2215)

5

Excision of the capitellar fragments and fixation of the trochlear fragments

4%

(78/2215)

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.


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Question COMMENTS (9)

(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%

(5/322)

2

Capitellum fracture with extension into the trochlea

42%

(135/322)

3

Radial head and capitellum fracture

4%

(12/322)

4

Isolated capitellum fracture

50%

(160/322)

5

Trochlea fracture

3%

(9/322)

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:

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