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Images steinthal 3.jpg steinthal 2.jpg steinthal 1a.jpg
  • 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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