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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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