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FOR CITATION PURPOSES: Raju et al. Functional outcome of capitellar fracture fixation with cannulated cancellous screws. OA Orthopaedics 2014 Aug 10;2(2):15.
Research study
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Tra
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Functional outcome of capitellar fracture fixation with cannulated
cancellous screw
KV Puttakemparaju1*, BR Vivekanada1*, H Manjunatha1, KS Sreekantha1, A Vishwanatha1
Abstract Introduction Management of capitellar fractures is a challenge to the orthopaedic surgeons considering the complications they pose. They are rare injuries and fewer studies have been published, in view of this the present study was done over a span of 9 years in order to obtain and study adequate number of cases. The purpose of this study was to evaluate the functional outcome of capitellar fracture fixation with cannulated cancellous screws. Materials and methods Eighteen patients with capitellum fractures were studied between March 2002 and October 2010 (15 men and 3 women). Sixteen cases were operated within 9 days of injury. Patients were treated with open reduction and internal fixation using cannulated cancellous screws. All patients were followed up for a mean period of 49 months. Functional outcome was measured using Mayo elbow performance index and by radiology. Results The mean Mayo elbow performance index score was 95. All patients except one had excellent functional ratings according to this evaluation. The mean range of movements at elbow in flexion\extension was 1240 (1140-1340) while range of movements in pronation\supination was 1720 (1240- 1800). Radiologically no evidence of avascular necrosis was noted in any of the patients at 1 year of follow up. One patient had secondary arthritis.
Conclusion Cannulated cancellous screws fixation of capitellar fractures have very good functional outcome.
Introduction Fractures of the capitellum of humerus are rare1,2,3. They account for approximately 1% of the elbow fractures and 6% of distal humerus fractures2,3. They result from a direct force transmitted through the radial head that provides a shearing and/or compressive load to the capitellum and occasionally to the trochlea. Displaced fractures invariably lead to poor outcome if left untreated. The displaced fragment can migrate superiorly and unite with anterior humerus and cause mechanical block to elbow flexion by obstructing the radial and/or coronoid fossa. Capitellar fractures may also be associated with medial and lateral collateral ligament injury and an ipsilateral radial head fracture1,2,3,4,5. Capitellar fractures have been variously classified in the past which include Bryan and Morrey classification3, Mckee et al. classification6,7, Ring classification8, AO classification1,2,4. Dubberley classification considers posterior condylar comminution and also recognizes fractures splitting the trochlea and capitellum into different fragments as a separate entity4. It classifies capitellar fractures into 3 types, Type 1 – injuries involving primarily the capitellum with or without lateral trochlear ridge. Type 2 – injuries involving the capitellum and trochlear as one piece. Type 3 – injuries involving capitellum and trochlear as separate piece. Type 3 is again sub classified into A and B, A – without posterior communition, B –
with posterior communition. According to AO classification capitellar fractures can be grouped as B3 – Distal aspect of the humerus, partial articular and frontal. B31 – capitellar fractures, B32 – trochlear fractures, B33 – capitellar and trochlear fracture. Bryan and Morrey classification includes Type 1 injuries consisting of coronal shear fractures of the capitellum that had little to no involvement of the trochlea; Type 2 injuries were shear fracture of the capitellum with minimally attached subchondral bone; and Type 3 injuries were essentially comminuted fractures of the capitellum. McKee et al. subsequently added a 4th type that involved a large coronal shear fracture of the distal humerus, where the capitellum and trochlea consisted as 1 single fragment.9,10
Treatment strategies for these injuries have also evolved over time. At present, open reduction and internal fixation is the preferred method in comparison
*Corresponding author Email: [email protected] [email protected]
1 BANGALORE MEDICAL COLLEGE AND
RESEARCH INSTITUTE, BANGALORE, INDIA
Table 1: Mayo elbow performance index (MEPI).
Variable Definition No of points
Pain None
Mild
Moderate
Severe
45
30
15
0
Range of motion
Arc > 100
Arc 50 – 100
Arc <50 degrees
20
15
5
Stability Stable
Moderately unstable
Grossly unstable
10
5
0
Function Able to comb hair
Able to feed oneself
Able to perform personal
hygiene tasks
Able to on shirt
Able to put on shoes
5
5
5
5
5
Page 2 of 6
Licensee OAPL (UK) 2014. Creative Commons Attribution License (CC-BY)
FOR CITATION PURPOSES: Raju et al. Functional outcome of capitellar fracture fixation with cannulated cancellous screws. OA Orthopaedics 2014 Aug 10;2(2):15.
Research study
Co
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with conservative methods and fragment excision with respect to early mobilisation, stable anatomical reduction and maintenance of articular congruity3,4,5,6. Given the rarity of these fractures, it has been difficult to formulate a universally accepted method of fixation. The purpose of the present study was to obtain a comprehensive and objective evaluation of the patients with capitellar fractures that were treated with open reduction and internal fixation. To evaluate the functional and radiological outcome of 18 patients treated by open reduction and internal fixation with cannulated cancellous screws.
Materials and methods This work conforms to the values laid down in the Declaration of Helsinki (1964). The protocol of this study has been approved by the relevant ethical committee related to our institution in which it was performed. All subjects gave full informed consent to participate in this study. Eighteen patients with capitellar fractures were evaluated in this study between March 2002 and October 2010. All the patients were operated on an elective basis after evaluating thoroughly for their medical ailments and obtaining fitness for the surgical procedure and written informed consent. 16 cases were operated within 9 days of injury. 2 cases were operated 90 days after injury as they presented late and were initially treated conservatively with splinting. Cannulated cancellous screws (4 mm) were used in all the 18 patients. Patients were followed up for a minimum of 12 months for clinical and radiological outcomes. No patients was excluded or lost during follow-up. Fractures in this study were classified according to Dubberley classification.
Evaluation of the patients post operatively was done according to the Mayo elbow performance index (MEPI) (Table 1). It is one of the most commonly used physician based elbow rating systems. The total score ranges from 5-100 points, with larger scores indicating better function. If the total score is included between 90 and 100 points, it can be considered excellent; between 75 and 89, good; between 60 and 74 points, fair; less than 60 points, poor11. Surgical technique All cases were operated under general anaesthesia, sterile tourniquet was applied in all cases and assessment for ligament instability was done. Lateral
Kaplan approach was used in all the patients. Incision was taken approximately 5 cm proximal to the lateral epicondyle of the humerus; it was carried distally approximately 5 cm distal to the epicondyle along the lateral surface of the forearm. Subcutaneous tissues were dissected and retracted. Interval between the triceps posteriorly and origins of the extensor carpi radialis longus and brachioradialis anteriorly was
Table 2: Tabulation of capitellum fractures classification, mechanism of injury and handedness in selected cases (n=18).
Handedness Number
Right 18
Side of injury Number
Right 15 (3 females; 12 males)
Left 3 (males)
Mechanism of injury
Number
Indirect trauma 16
Direct trauma 2
Type of fracture Number
Class I 2
Class II 6
Class III 7
Figure 1: case 1 - preoperative image. Figure 2: Intraoperative c arm view.
Figure 3: CASE 1 - 1 year follow up X ray image.
Figure 4: CASE 1 - Clinical photographs at 1 year a) flexion and extension range of movement.
Figure 5: CASE 1 - Clinical photographs at 1 year b) supination/pronation range of movement.
Page 3 of 6
Licensee OAPL (UK) 2014. Creative Commons Attribution License (CC-BY)
FOR CITATION PURPOSES: Raju et al. Functional outcome of capitellar fracture fixation with cannulated cancellous screws. OA Orthopaedics 2014 Aug 10;2(2):15.
Research study
Co
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developed. The forearm was kept in full pronation in order to avoid injury to the radial nerve in the proximal aspect of the incision where it enters the interval between brachialis and brachioradialis muscles. The brachioradialis and extensor carpi radialis muscles along with the anterior capsule were subperiosteally elevated to create an anterior full thickness flap which was connected distally to the Kocher interval. This exposed the capitellum and the lateral aspect of the humerus. A full thickness flap was raised posteriorly which was also required for the placement of cannulated cancellous screws. Fracture site was cleared of haematoma and soft tissue debris for better identification of the fracture fragments which were reduced and fixed temporarily with Kirschner wires (K wires). Reduction was confirmed under image intensifier, definitive fixation was done using 4 mm cannulated cancellous screws which were directed from posterior to anterior direction, head of the screw was placed in such a manner so as to avoid the olecranon fossa with certain amount of countersinking. Bone grafts were not used in any of the patients. Postoperatively, patients were immobilised in an above elbow slab for 5 -7 days following which gentle active mobilization was started. None of the patients were subjected to passive mobilization. Patients were followed up regularly for a minimum of 6 months to assess the functional (MEPI) and radiological outcome.
Results In the present study, we evaluated eighteen cases of capitellar fracture. Out of them, fifteen were males and three females. Mean age of subjects was 44.89 (±13.8) years. All patients were right handed (Figure 5,6,7,8). Mean time delay for surgery was 5.39 days in 16 patients. Two patients had delayed surgery (90 days from the date of injury). Average follow up duration was 49 months with range of
36 months to 60 months. Fractures were classified based on Dubberley’s classification, 13 patients were with class II and III (Figure 1,2,3,4). The mean MEPI was 95 points (92 – 97) with 17 excellent outcomes and one poor rating. The mean range of movements at elbow in flexion\extension was 1240 (1140-1340) while range of movements in pronation\supination was 1720 (1240- 1800). Radiologically no evidence of avascular necrosis was noted in any of the patients at 1 year of follow up. One patient showed osteoarthritic changes. There were no instances of instability or non-union. All the patients returned to their previous levels of activity. There was secondary arthritis in one patient noted after one year of surgical intervention and his MEPI was 45. Though he had mild pain (30 points) his movements were severely restricted (5 points) which hampered his daily life activities (10 points, totally 45). This has resulted in poor rating in terms of MEPI.
Statistically, there were significantly more males (15/18) than females. There were fractures in dominant upper limb. There were no notable differences in outcomes between subtypes of capitellum fractures in terms of MEPI and radiological evaluation (Table 2).
Discussion Nowadays Herberts screws and cannulated cancellous screws are widely used for fixation of capitellum fractures. In the present study which was spread over 8 years, we have used canulated cancellous screws and the results are comparable to other studies. Eighteen patients were evaluated prospectively for an average period of 49 months. Several studies using headless compression screws have shown mostly good to excellent results (using varying rating systems) for all types of capitellum fractures over a wide range of follow-up. Our study is unique because we have reported relatively large numbers of cases, with follow up of four years in Indian subcontinent.
Figure 6: CASE 2 - Preoperative radiographs anteroposterior and lateral views.
Figure 7: CASE 2 - C T images.
Figure 8: CASE 2 - Post operative radiograph Anteroposterior and Lateral views.
Figure 9: CASE 2 - 1 year follow up radiograph AP and Lateral views.
Page 4 of 6
Licensee OAPL (UK) 2014. Creative Commons Attribution License (CC-BY)
FOR CITATION PURPOSES: Raju et al. Functional outcome of capitellar fracture fixation with cannulated cancellous screws. OA Orthopaedics 2014 Aug 10;2(2):15.
Research study
Co
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With a quick look at the previous literature we can conclude that we have good number of cases for comparison (Figure 9, 10, 11, 12, 13). We have used Extensile Lateral approach for all the cases for fixing the fracture and elevation of anterior and posterior soft tissue attachments as flap subperiosteally provided adequate exposure and a separate medial approach or olecranon osteotomy was not necessary in any of the cases. The exposure was adequate to deal with trochlear extension or posterior communition also. The extensile lateral approach was used by most of authors for exposure of fracture. Olecranon osteotomy and medial approach were associated with higher flexion contracture rates and hardware problems associated with olecranon osteotomy necessitating re-surgery for hardware removal. And these exposures were used for higher classes of fracture classification for better exposure. The absence of such complications in our study supports lateral approach as safe exposure for capitellum fractures. And lateral approach was used even in type 3 fractures which included seven patients and none of patients required olecranon
osteotomy and adequate reduction and fixation was achieved and there were no significant complication rates in these patients (Table 3). Despite using CC screws for stabilisation of fracture and the range of motion achieved was comparable to the other implants as the implants were placed over the lateral column.
Ruchelsman et al. and Mighell et al. have used cannulated headless compression screws for stabilisation and the range of motion in flexion extension averaging around 125° with contracture less than 10° with almost full rotation1,2. The results with our study are nearly equal to the above with no contracture noted in any patient. The MEPI scores too are
Table 3: Previous studies on capitellar fractures, number of cases studied (n), material used for fixation, assessment method, and outcome of the study with complications reported.
Study N Duration of follow up
Material used Assessment method
Outcome Complications
Ring8 21 Herbert screws MEPI 12 – good
5 – fare
4 – excellent
Dubberley4 28 56 months Canulated cancellous
screws in type I and bone grafting in type II & III
MEPI Overall mean score in MEPI – 91
9 osteoarthritis
3 osteonecrosis
Ruchelsman2 16 24 months Herbert screws MEPI 9 – excellent
6 – good
1 – fair
Mighell1 18 26 months Headless Compression
Screws Broberg Morrey 12 – excellent
5 – good
1 – poor
Bilsel12 18 43.6 months MEPI 12 – excellent
2 – good
4 – poor
Present
study 18 49 Cannulated cancellous
screws MEPI 17 – excellent
1 - poor 1 Osteoarthritis
Figure 10: CASE 3 - Preoperative Radio-graph Anteroposterior and Lateral Radio-graph. Figure 11: CASE 3 - One and half
month follow up radiograph AP and Lateral views.
Figure 12: CASE 3 - 1 year follow up radio-graph AP and Lateral views.
Figure 13: CASE 3 - Clinical photograph at end of 1 year.
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Licensee OAPL (UK) 2014. Creative Commons Attribution License (CC-BY)
FOR CITATION PURPOSES: Raju et al. Functional outcome of capitellar fracture fixation with cannulated cancellous screws. OA Orthopaedics 2014 Aug 10;2(2):15.
Research study
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comparable. The results with Herberts screws used by Ring et al. are low with 123° flexion with an average of 27° contracture with poorer MEPI scores8. CC screws were also used by Dubberley et al. in Type I fractures with 144° flexion in type Ia and 124.5° of flexion in type Ib noted4. Hence, CC screws and Headless compression have got good and comparable results and either of the two can be used in these fractures. In 2003 Ring et al. reported the results of 21 open reduction and internal fixation of capitellum and trochlear fractures using Herbert screws and followed them up for 40 months8. They identified five patterns of injury, all of which healed with no residual instability or weakness. The results according to the MEPI were excellent in four, good in twelve, and fair in five. There was no radiographic evidence of arthritis or osteonecrosis. It was mainly a retrospective study with sixteen of twenty one being evaluated through data from records. Dubberley et al. studied outcome of open reduction and internal fixation of capitellum and trochlear fractures in 28 patients prospectively with mean follow up period of 56 ± 33 months4. Implants used were dependant on the complexity of fracture, cannulated cancellous screws used in Type I fractures in seven patients and bone grafting used in fractures with posterior communition in ten patients. All the patients were within 2 weeks of trauma. The average flexion of 138° and extension of 19° and supination of 74° and pronation of 82° were observed. The average loss of motion in flexion and extension was 25° and supination and pronation was 4°. The average MEPI score of 91 corresponding to excellent outcome. Nine patients had radiographic evidence of osteoarthritis and three patients had evidence of osteonecrosis. Re-surgery was required in twelve patients, six of them for olecranon hardware removal
due to pain, seven patients for elbow capsulectomy and hardware removal for loss of function and two for total elbow arthroplasty for non union or osteonecrosis. Ruchelsman et al. reported outcome of Open Reduction and Internal Fixation of Capitellum fractures fixed with Herberts screws in 16 patients, followed up for a maximum period of 2 years2. Extensile lateral Approach with lateral incision and Kocher exposure was used in all cases with fracture fixed with cannulated screws buried under the articular surface with delay of 10 days. Bone grafting or plating were not used in any case. The average ulnohumeral arc was 123° with average flexion of 133° and average contracture of 10° with full forearm rotations. Nine were excellent, six good and one fair outcome according to MEPI scores. Four patients had radiographic evidence of osteoarthritis and osteonecrosis was not noted in any patient. The study had a small cohort with limited duration follow up and is a retrospective study. Mighell et al. studied large coronal shear fractures of capitellum and trochlea treated with Headless Compression Screws which included 18 patients with an average delay of 10 days, followed prospectively for a period of 26 months1. There were 11 type 1 and 7 type 2 cases according to Dubberley classification. Lateral Kaplan approach was used in all cases; fracture stabilized with cannulated headless compression screws. The average ROM in flexion extension was 128° and in pronation supination 176°. Broberg Morrey score was used in the study with average score of 93.3 points; 12 excellent, 5 good and 1 poor result13. Five patients had radiographic evidence of osteoarthritis, 3 had osteonecrosis and 3 cases of heterotopic ossification noted. He also reported that no difference in BM score and Range of movements (ROM) of type 1 and 2 fractures.
Bilsel et al. reported 18 cases in 2013; they treated coronal plane fractures of the distal humerus involving the capitellum and trochlea with open reduction and internal fixation with cancellous screws with a mean follow up period of 43.6 months12. There were seven type I, five type-III, and six type-IV fractures according to Bryan Morrey Classification13. The mean elbow range of motion in sagittal plane at last follow-up ranged from 8.9° to 132.8°. The mean MEPI score was 86.7, corresponding to 12 excellent, 2 good, and 4 fair outcomes. In our study there was one case of secondary osteoarthritis noted after 1 year follow up in a case operated after a time delay of 90 days. There was a poor MEPI score in the same case. He was intervened with 2 doses of 40 mg methylprednisolone which was administered at a gap of 6 months following which the MEPI score improved to 70 and hw was able to return to his routine activities. The other case operated after 90 days had good result with no complications. The reason for the complication in the first case hence cannot be explained by the time delay alone as playing a major role. There was no case of AVN even though the exposure involved more soft tissue dissection and periosteal stripping. There were higher incidences of osteonecrosis and osteoarthritis in other studies particularly in those where headless compression screws were used. One thing to note here is Mighelle et al. evaluated 18 patients with type I and II Dubberley classes and lateral approach used in all cases with lesser time delay, but there were higher incidence of osteoarthritis and osteonecrosis1. Hence higher classes of fractures play a minor role in complication rate. And even though lateral approach was used in their study, the reasons for higher rate of osteonecrosis could not be explained. In our study, we have evaluated 18 patients with capitellum fractures all being unilateral. 16 out of 18 patients were male showing male predominance of the fracture contradicting other relevant studies where there was a
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FOR CITATION PURPOSES: Raju et al. Functional outcome of capitellar fracture fixation with cannulated cancellous screws. OA Orthopaedics 2014 Aug 10;2(2):15.
Research study
Co
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female predominance. The reasons explaining the same are post traumatic insufficiency fractures due to low bone mineral density in women and increased valgus carrying angle of 5° leading to greater impact forces to the lateral column in fall on an outstretched hand. Hence there are reasons other than above deciding the sex predominance which needs to be evaluated. There is an increased predominance in dominant extremity i.e.15 out of 18 patients and this even is contradicting the previous studies1. The reason for this was unclear and need to be assessed.
Conclusion Open reduction and internal fixation using cannulated cancellous screws via a lateral approach is a reliable treatment for capitellum fractures and results in stable fixation and restoration of a functional arc of motion. With proper technique mechanical obstruction can be avoided and the results are comparable to earlier literature using headless screws.
References 1. Mighell M, Virani NA, Shannon R, Jr ELE, Badman BL, Keatingf CJ. Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws. J Shoulder Elbow Surg. 2010;19:38–45. 2. Ruchelsman DE, Tejwani NC, Kwon YW EK. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am. 2008;90:1321–9. 3. Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, editor. The elbow and its disorders. Philadelphia, PA: WB Saunders; 1985. p. 302-39. 4. Dubberley JH, Faber KJ, Macdermid JC, Patterson SD, King GJ. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am 2006;88:46-54. 5. OS Schindler. Bilateral capitellum humeri fracture: A case report and
review of the literature. Journal of Orthopaedic Surgery. 2003;11(2): 207–12. 6. Guitton TG, Doornberg JN, Raaymakers EL, Ring D, Kloen P. Fractures of the capitellum and trochlea. J Bone Joint Surg Am 2009;91:390-7. 7. Harrington JP, McKee MD. Coronal shear fractures of the capitellum and trochlea. Tech Shoulder Elbow Surg 2000;1:240-6. 8. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003;85-A:232-8. 9. Guitton TG, Doornberg JN, Raaymakers EL, Ring D, Kloen P. Fractures of the capitellum and trochlea. J Bone Joint Surg Am 2009;91:390-7. 10. McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am 1996;78:49-54. 11. Longo UG, Franceschi F, Loppini M, Maffulli N, Denaro V. Rating systems for evaluation of the elbow. British Medical Bulletin. 2008;87:131–61. 12. K Bilsel, AC Atalar, M Erdil, M Elmadag CS and MD. Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation. Arch Orthop Trauma Surg. 2013;133(6):797–804. 13. Broberg MA MB. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am. 1986;68:669–74.
