• Coronal shear injury
• elbow
• rare fracture triad

• Distal humerus
• coronal shear fractures
• lateral combined approach
• surgical treatment

• Humans
• Male
• Female
• Fracture Fixation, Internal/methods
• Humeral Fractures/surgery
• Middle Aged
• Adult
• Range of Motion, Articular
• Retrospective Studies
• Aged
• Elbow Joint/surgery
• Elbow Joint/physiopathology
• Treatment Outcome
• Young Adult
• Open Fracture Reduction/methods

• T-condylar fracture
• lateral condyle fracture
• lateral epicondyle fracture
• medial condyle fracture
• medial epicondyle fracture
• olecranon fracture
• pediatric elbow dislocations
• pediatric elbow fractures
• proximal radius fracture
• supracondylar humeral fracture

• anterior approach for elbow
• capitellum fracture
• dubberley classification
• mal-united fracture
• trochlea fracture

• Coronal shear fracture of the distal humerus
• Distal humeral osteotomy
• Posterior approach

• Humans
• Aged
• Humeral Fractures/diagnostic imaging
• Humeral Fractures/surgery
• Humeral Fractures/etiology
• Elbow
• Fracture Fixation, Internal/methods
• Prospective Studies
• Treatment Outcome
• Elbow Joint/diagnostic imaging
• Elbow Joint/surgery
• Humerus
• Fractures, Comminuted/surgery
• Range of Motion, Articular
• Retrospective Studies

• capitellum
• coronal fractures
• distal humerus
• shear fractures
• trochlea

• Coronal shear fracture
• distal humerus
• elbow
• modified Dubberley classification

• Bone Plates
• Elbow Joint/diagnostic imaging
• Elbow Joint/surgery
• Fracture Fixation, Internal
• Humans
• Humeral Fractures/diagnostic imaging
• Humeral Fractures/surgery
• Humerus
• Range of Motion, Articular
• Retrospective Studies
• Treatment Outcome

• capitellum
• coronal shear fracture
• distal humeral fractures
• elbow injury
• trochlea

• capitellum
• coronal shear fracture
• distal humerus fracture
• elbow fracture
• trochlea

• Case report
• Coronal shear fracture
• Distal humerus fracture
• Lateral epicondyle
• Osteotomy
• Surgical approach

Introduction

This study aimed to evaluate the clinical outcomes of 16 patients with capitellum and trochlea fractures that were treated using isolated headless compression screws or a combination of dorsolateral locking plates and anterior-to-posterior screws. We also investigated the presence of lateral epicondyle fragments because this fragment is especially important when making decisions regarding the surgical approach and implants.

Materials and methods

We conducted a retrospective analysis of 16 patients with capitellum and trochlea fractures. Clinical, radiographic (based on CT scans), and elbow-specific outcomes, including the Mayo Elbow Performance Index (MEPI), were evaluated at a mean of 23.5 months postoperatively.

Results

The average MEPI scores in patients with Dubberley type A (non-posterior comminution) and type B (posterior comminution) fractures were 88 and 78, respectively (p=0.08). Headless compression screws were used in 10 cases of type A fracture and one case of type B fracture. A combination of dorsolateral locking plates and anterior-to-posterior screws was used in five cases of type B fracture. Hardware loosening was seen in one case of type B fracture with isolated screw fixation. The presence of a lateral epicondyle fragment was significantly associated with the type B group (6/6 patients; 100%). In contrast, patients in the type A group rarely had posterior comminution of the lateral epicondyle fragment (2/10 patients; 20%).

Conclusions

Capitellum and trochlea fractures with posterior comminution, which typically presented with lateral epicondylar fragments, were safely and effectively treated with a combination of dorsolateral locking plates and anterior-to-posterior screws through lateral approaches. Cases without posterior comminution were treated with headless compression screws with no complications. The Dubberley classification system provides helpful information to determine the fixation strategy.

• capitellum and trochlea fracture
• coronal shear fracture
• distal humerus
• dubberley
• lateral epicondyle fragment
• posterior comminution

Based on the complex intra-articular nature of capitellum fractures, it has been sometimes difficult to formulate a universally accepted method of surgical treatment. The purpose of this study is to present the functional outcomes of capitellum fractures after fixation with Herbert screw including the safety and tips of the surgical approach.

This descriptive cross-sectional study was done from December 2014 to November 2019. Ethical approval was taken. The study included 22 capitellum fractures treated by open reduction and internal fixation with Herbert screws either lateral or anterolateral approach. Functional outcomes were assessed with Mayo elbow performance index scores at the latest follow-up visit. Convenient sampling was done. Data entry was done using the Statistical Package for the Social Sciences (version16.0).

Out of 22 surgeries, the average time to unite the fracture was 11.13±1.20 weeks (range 9 to 15). The mean range of movement for flexion and extension was 138.41±8.22 degree while the mean supination and pronation range was 161.59±6.79 degree. The average time of follow-up in this series was 37.45±9.43 weeks (range 22 to 58 weeks). Similarly, the mean Mayo elbow performance index score at the latest follow-up was 90.22±8.65 (range 70 to 100).

Careful assessment and radiological evaluation, anatomical reduction, and stable fixation with Herbert screws maintaining the minimal damage to the articular cartilage can maximize the functional outcomes and minimize the incidence of complications.

• fracture;surgery;treatment.

• Adult
• Bone Plates
• Elbow Joint/diagnostic imaging
• Elbow Joint/physiopathology
• Elbow Joint/surgery
• Female
• Fracture Fixation, Internal/adverse effects
• Fracture Fixation, Internal/instrumentation
• Fracture Fixation, Internal/methods
• Humans
• Humeral Fractures/diagnosis
• Humeral Fractures/surgery
• Humerus/diagnostic imaging
• Humerus/injuries
• Humerus/surgery
• Male
• Radiography/methods
• Range of Motion, Articular
• Retrospective Studies
• Treatment Outcome

• Elbow anterior approach
• Lateral humeral condyle fracture
• Pediatric elbow

• coronal shear fracture
• distal humerus fracture
• fracture site approach
• olecranon fracture

• anterolateral approach
• capitellum
• coronal shear fracture
• herbert screw
• internal fixation
• open reduction

For coronal shear fractures of humeral capitellum, the lateral approach is the most commonly used surgical approach. However, exposure range of the anterior aspect of the distal humerus is inadequate. The anterolateral approach has also been adopted to overcome this disadvantage. However, this approach seems anatomically complex due to the risk of iatrogenic injury to the radial nerve. So far, the optimal approach for the treatment of capitellar shear fractures remains inconclusive. The purpose of this study is to prospectively review and compare the early clinical and radiographic outcomes of treated with open reduction and Herbert screw internal fixation through the lateral approach or the anterolateral approach.

Twenty-six patients with isolated capitellar shear fractures were enrolled from January 2013 to December 2017, and randomly assigned to lateral approach group or anterolateral approach group. All the fractures were treated with open reduction and Herbert screw internal fixation through lateral approach or anterolateral approach. Operation time, wound healing complication, elbow joint function, and radiographic evidence were evaluated and compared between two groups.

The operation via the anterolateral approach took significantly shorter time than via lateral approach (p < 0.05). There were no wound healing problems and infection for both groups. One patient from anterolateral approach group sustained incomplete posterior interosseous nerve palsy, which recovered completely in 4 weeks without residual compromise. All fractures healed well in their normal anatomic position as seen on radiographs. At the final follow-up, no significant difference was found between two groups with respect to the ROM in supination-pronation, ROM in pronation-supination, loss of flexion-extension motion, or loss of pronation-supination motion (p > 0.05). There is no significant difference with respect to MEPI score of elbow joint between two groups (p > 0.05).

Based on our findings, both lateral approach and anterolateral approach with Herbert screw internal fixation are suitable for coronal shear fractures of capitellum with satisfactory early outcomes. Compared with the lateral approach, the anterolateral approach made the surgical procedure easier and time saving in current series. When the medial aspect of the trochlea is involved for capitellar coronal fractures, the anterolateral lateral approach should be preferred.

• Capitellum
• Fracture
• Herbert screw
• Internal fixation
• Surgical approach

• Anterolateral approach
• Capitellum fracture
• Chronic radial head dislocation

• Capitellum
• distal humerus
• elbow
• fracture
• open reduction and internal fixation
• trochlea

• Kirschner wire
• elbow joint
• external fixator
• fracture fixation
• trauma

• Associated injuries
• Capitellum and trochlea fractures
• Fracture classification
• Functional outcomes
• Open reduction and internal fixation

Due to the intraarticular and complex nature of the coronal shear fracture of the humeral capitellum and its rarity, it has been difficult to formulate a universally accepted method of surgical management. The purpose of this study is to retrospectively evaluate the clinical outcomes of 15 patients with isolated coronal shear fractures of the capitellum treated by Herbert screw fixation through anterolateral approach, and to address the safety and tips for this surgical procedure.

This retrospective study included 15 isolated coronal shear fractures of the capitellum without posterior involvement, which were classified according to the Dubberley classification as 11 type 1A fractures and 4 type 3A fractures. All fractures were treated with Herbert screws fixation via the anterolateral approach. Clinical and radiographic evaluation was performed regularly, with a mean follow-up of 29 months.

The mean operative time was 81 min. There were no wound healing problems or infection. One incomplete posterior interosseous nerve injury occurred, which recovered soon without residual compromise. All fractures healed well. At the final follow-up, the average range of motion was 134°in flexion-extension and 172°in supination-pronation. There was no significant difference between the affected and the unaffected elbows with regard to motion in flexion-extension or flexion-extension. The average Mayo Elbow Performance Index Score was 93 with 11 excellent and 4 good. No evidence of avascular necrosis, posttraumatic osteoarthritis, or heterotrophic ossification was found.

Open reduction and internal fixation using Herbert screws through a anterolateral approach is a reliable and effective treatment for coronal shear fractures of capitellum, and able to achieve stable fixation and restoration of a functional range of motion.

• Anterolateral approach
• Capitellum
• Fracture
• Herbert screw
• Internal fixation

Introduction: Coronal plane distal humeral injuries are relatively rare. Numerous classification systems have been proposed as the complexity of these fractures has been realized. We in the present series of ten patients describe the surgical technique of Open Reduction and Internal Fixation of Coronal plane fractures of the distal humerus with headless compression screws performed using the anterolateral approach.

Material and method: It was a retrospective study, the data collected from March 2010 to 2015 was analysed and the final outcome was assessed using the DASH score. Out of a total of 13 patients with distal humerus coronal plane fractures, 10 patients were available for follow up. The X-rays and CT scans were reviewed and the fractures were classified according to Dubberley and Bryan and Morrey classification. Radiographic were evaluated for presence of union or nonunion, avascular necrosis, joint line step-off (none/1-mm/>1-mm), hardware failure and instability.

Results: The average age was 41 years. The average DASH score in our study was around 24. The time to union ranged between 8–12 weeks with the average time being around 10 weeks. One patient had post traumatic Arthritis radiologically classified as Broberg and Morrey Type 2 and one patient had Heterotrophic ossification Brooker Grade 1.

Conclusion: Open reduction and internal fixation of coronal shear fractures of capitellum and trochlea using headless screw compression via the antero-lateral approach is a reliable treatment modality and results in stable fixation with restoration of a functional arc of motion.

Level of evidence: IV

• Capitellum
• complications
• coronal plane
• fracture
• open reduction and internal fixation
• trochlea

Coronal shear fractures of distal humerus involving the capitellum and the trochlea are rare injuries with articular complexity, and are technically challenging for management. With better understanding of the anatomy and imaging advancements, the complex nature of these fractures is well appreciated now. These fractures involve metaphysealcomminution of lateral column and associated intraarticular injuries are common. Previously, closed reduction and excision were the accepted treatment but now preference is for open reduction and internal fixation with an aim to provide stable and congruent joint with early range of motion of joint. Various approaches including extensile lateral, anterolateral and posterior approaches have been described depending on the fracture pattern and complexity. Good to excellent outcome have been reported with internal fixations and poor results are noted in articular comminution with associated articular injuries. Various implants including headleass compression screws, minifragment screws, bioabsorbable implants and column plating are advocated for reconstruction of these complex fractures. Inspite of articular fragments being free of soft tissue attachments the rate of osteonecrosis and osteoarthritis is reported very less after internal fixation. This article summarizes the diagnostic and treatment strategies for these rare fractures and recommendations for management.

• Capitellum
• Trochlea
• Elbow
• Fracture
• Distal humerus
• Treatment

Coronal shear fractures of the distal humerus are rare, complex fractures that can be technically challenging to manage. They usually result from a low-energy fall and direct compression of the distal humerus by the radial head in a hyper-extended or semi-flexed elbow or from spontaneous reduction of a posterolateral subluxation or dislocation. Due to the small number of soft tissue attachments at this site, almost all of these fractures are displaced. The incidence of distal humeral coronal shear fractures is higher among women because of the higher rate of osteoporosis in women and the difference in carrying angle between men and women. Distal humeral coronal shear fractures may occur in isolation, may be part of a complex elbow injury, or may be associated with injuries proximal or distal to the elbow. An associated lateral collateral ligament injury is seen in up to 40% and an associated radial head fracture is seen in up to 30% of these fractures. Given the complex nature of distal humeral coronal shear fractures, there is preference for operative management. Operative fixation leads to stable anatomic reduction, restores articular congruity, and allows initiation of early range-of-motion movements in the majority of cases. Several surgical exposure and fixation techniques are available to reconstruct the articular surface following distal humeral coronal shear fractures. The lateral extensile approach and fixation with countersunk headless compression screws placed in an anterior-to-posterior fashion are commonly used. We have found a two-incision approach (direct anterior and lateral) that results in less soft tissue dissection and better outcomes than the lateral extensile approach in our experience. Stiffness, pain, articular incongruity, arthritis, and ulnohumeral instability may result if reduction is non-anatomic or if fixation fails.

• Coronal
• Shear
• Fractures
• Distal
• Humerus
• Management
• Approach
• Two-incision

When treating a distal humeral shear fracture, comminution of the lateral column may preclude the reconstruction of the lateral articular fragments.

In this article a new strategy for the management lateral column comminuted shear-fractures (LCCSF) is presented, called the “built-on” surgical technique. Three goals are obtained by this technique: (1) Restoration of the lateral column bone stock; (2) Provision of a solid scaffold for the repair of the lateral ulnar collateral ligament (LUCL); and (3) Provision of a sable platform for the reconstruction and fixation of the articular fragments.

We will obtain these goals through the following surgical steps:

1/ Reconstruction of the lateral trochlea.

2/ Reconstruction of the lateral column

3/ Fixation of the Capitellum

4/ Reconstruction of the LUCL

• Capitellar and trochlear fractures
• distal humerus
• fractures
• lateral column
• shear fractures

• Arthroplasty
• Distal humerus
• Elbow
• Fracture
• Hemiarthroplasty
• Plate

• Capitellum
• Coronal shear fracture
• Internal fixation
• Screw placement

• Arthroscopy
• Elbow Joint/diagnostic imaging
• Fracture Fixation, Internal/methods
• Fractures, Comminuted/surgery
• Humans
• Humeral Fractures/classification
• Humeral Fractures/diagnostic imaging
• Humeral Fractures/surgery
• Radiography
• Elbow Injuries

• Arthroplasty
• Arthroscopy
• Elbow Joint/physiopathology
• Elbow Joint/surgery
• Epiphyses/injuries
• Epiphyses/physiopathology
• Epiphyses/surgery
• Fracture Fixation, Internal
• Humans
• Humeral Fractures/classification
• Humeral Fractures/therapy
• Postoperative Care
• Elbow Injuries

• Aged
• Aged, 80 and over
• Biomechanical Phenomena
• Bone Plates
• Equipment Design
• Fracture Fixation, Internal/instrumentation
• Fracture Fixation, Internal/methods
• Humans
• Humeral Fractures/physiopathology
• Humeral Fractures/surgery
• Materials Testing
• Middle Aged

• Adult
• Bone Screws
• Female
• Follow-Up Studies
• Fracture Fixation, Internal
• Humans
• Humeral Fractures/diagnostic imaging
• Humeral Fractures/physiopathology
• Humeral Fractures/surgery
• Middle Aged
• Outcome Assessment, Health Care
• Radiography
• Recovery of Function/physiology
• Retrospective Studies
• Shear Strength
• Trauma Severity Indices