Updated: 4/10/2022

Capitellum Fractures

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  • summary
    • Capitellum Fractures are traumatic intra-articular elbow injuries involving the distal humerus at the capitellum.
    • Diagnosis is made using plain radiographs of the elbow.
    • Treatment may be nonoperative for nondisplaced fractures but any displacement generally requires anatomic open reduction and internal fixation.
  • Epidemiology
    • Incidence
      • 1% of elbow fractures
      • 6% of all distal humerus fractures
  • Etiology
    • 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
  • 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
            • "double arc" sign created from subchondral bone of capitellum and lateral part of trochlea
    • 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
  • 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)
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Questions (13)
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(SBQ18TR.43) A 29-year-old male falls down a flight of 10-stairs while intoxicated. He presents to the ED the following afternoon with increased difficulty using his right arm and associated pain. Radiographs of the right elbow are demonstrated in Figure A. What is a potential complication of the surgical approach to address this injury?

QID: 211573

Loss of sensation of ring and small finger, weakness of hand intrinsic muscles



Inability to flex the thumb and index finger IP joints



Inability to extend the thumb



Brachial artery injury



Laceration of the extensor indicis proprius tendon



L 4 E

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(SBQ18TR.42) A 38-year-old man falls from a ladder and presents with the injury depicted in Figure A. On examination, his skin is intact, with moderate swelling, and limited elbow range of motion due to pain/swelling. He elects to undergo surgical intervention. A CT is obtained for preoperative planning and there are no signs of trochlear involvement or posterior comminution. Which of the following provides ideal visualization and least morbidity for this fracture pattern with respect to patient positioning and surgical approach for his injury?

QID: 211562

Prone with olecranon osteotomy



Lateral decubitus with olecranon osteotomy



Lateral decubitus with triceps elevation



Supine with medial epicondylectomy



Supine with Kaplan approach



L 2 A

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(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 functional outcome can be expected with which of the following definitive treatment options?

QID: 4555

Open reduction internal fixation of the distal humerus fracture



Nonsurgical management with early passive range of motion exercises



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



Total elbow arthroplasty



Excision of the capitellar fragments and fixation of the trochlear fragments



L 3 B

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(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?

QID: 1087

Coronoid fracture



Capitellum fracture with extension into the trochlea



Radial head and capitellum fracture



Isolated capitellum fracture



Trochlea fracture



L 4 C

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(OBQ04.157) Which of the following elbow injuries as found in Figures A-E best characterizes the radiographic "double-arc" sign?

QID: 1262

Figure A



Figure B



Figure C



Figure D



Figure E



L 1 B

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Evidence (16)
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