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Abstract
We report a case of a 16-year-old boy who sustained a bilateral
fracture of his capitellum humeri following a fall from bicycle.
Open reduction and internal fixation, using extra-articular
insertion of Cancellous screws, were performed. Both elbows were
immobilised for 3 weeks postoperatively. Radiographic signs of
union were present at week 7. Within the observation period of
18 months, no signs of avascular necrosis were detected. At the
end of the recovery period, despite intensive physiotherapy, the
patient was left with a 10° loss of flexion in his right elbow
and a 5° loss of flexion in his left elbow. Mobilisation should
start early to prevent joint stiffness and long-term disability.
Key words:
bone; capitellum; fractures; humerus; internal fixation
J.Orthopaedics 2007;4(1)e13
Introduction:
Fractures of the capitellum humeri are rare injuries and usually
a result of axial loading of the capitellum by forces
transmitted through the radial head.1-3 Although Bohler4
postulated that the fracture could only occur in patients with
increased cubitus valgus and hyperextension of the elbow, which
is reflected by a female predominance (male to female ratio of
about 1:4) reported in most series5-9, but here we report this
fracture in a male patient. As an isolated injury, fractures of
the capitellum humeri account for 0.5% to 1% of all elbow
injuries and often result in significant long-term morbidity if
treatment is delayed.2,6,10,11
In 1853 Hahn,12 a German surgeon, provided the first description
of an isolated capitellum humeri fracture in the medical
literature. After further reports by Kocher13 in 1896,
Steinthal14 in 1898, and Lorenz15 in 1905, a systematic
classification of capitellum fractures into 2 types evolved. The
Hahn-Steinthal, or type I fracture, characterises a shear
fracture involving a large osseous portion of the capitellum in
the coronal plane of the distal humerus (Figs. 1 and
2).1,7,12,14,16-19 The Kocher-Lorenz, or type II fracture,
merely involves a superficial osteochondral shell with little
osseous bone, and is usually referred to as an 'uncapping' of
the capitellum (Fig. 1).13,15 In more recent decades, comminuted
fractures of the capitellum humeri have been referred to as type
III injuries (Fig. 1).2,10
The standard treatment of the Kocher-Lorenz type injury is
excision of the fragment because refixation is difficult and in
most cases not feasible.2,6,21 A similar approach is generally
adopted for treating comminuted type III fractures.2,10
Controversy, however, exists regarding the management of
fractures of the Hahn-Steinthal type. Before the advent of
modern internal fixation techniques, closed reduction or early
excision of the capitellum fragment were the adopted
treatments.1,4,11,20,22,24,25 Clinical results after reduction
or resection of the capitellum were frequently complicated by
elbow instability, decreased range of motion, and arthritis
unless anatomical positioning of the fragment was
attained.5,6,8,22,26,27 Reports of avascular necrosis (AVN) of
the capitellum fragment, on the other hand, are surprisingly
rare, and such cases are not necessarily associated with a poor
outcome.23,25,27
In order to provide a better and more predictable outcome after
treating capitellum fractures, a variety of internal fixation
methods have been tried over the past 3 decades, including
Kirschner wires, staples, bone pegs, Arbeitsgemeinschaft fur
Osteosynthesefragen (AO) small fragment screws, and Herbert
screws.5,7-9,17,19,28 The use of Herbert screw fixation in
particular has gained international popularity since early
reports confirmed its successful application in the fixation of
capitellum fractures.16-18,29-31
Case report:
A 16-year-old boy was admitted to our hospital after having
sustained a fall from his bicycle on his outstretched arms.He
complained of pain around the outer aspects of both of his
elbows, which was triggered by palpation and movement.
Clinically he presented with bilateral elbow haemarthrosis and
localised tenderness over the lateral epicondyles. Elbow
movements were restricted to a range of 60° to 40° bilaterally.
The stability of his elbow was considered normal. No neuro-vascular
abnormalities were noted. Radiographs confirmed the diagnosis of
bilateral capitellum fractures of the Hahn-Steinthal type (Figs.
1 and 2).
A posterolateral Kocher-type approach was used to facilitate
open reduction. The fixation was performed with 2 AO cancellous
screws, which were inserted through the posterior aspect of the
lateral epicondyle into the centre of the capitellum; hence the
articular cartilage was not damaged. Postoperatively, his elbows
were immobilised for 3 weeks before commencing an intensive
mobilisation programme guided by a physiotherapist. Both
fractures presented convincing signs of unification by week 7 on
the basis of radiographic appearance of the fracture, and
absence of pain on movement. Functionally his right elbow
presented a residual,with flexion being limited by 10° on the
right compared to 5° on the left. Supination/ pronation were
measured at 90°/80° in the right and 65°/70° in the left elbow.
Fig: 1. Pre op and Post
Op x-rays. Right Side.
 
Fig: 2. Pre op and Post
Op x-rays. Left Side.
 
Discussion:
The move towards open reduction and internal fixation in the
late 1970s can be considered a direct reflection of the
dissatisfaction with the inconsistent results achieved with
closed reduction or excision of the capitellum fragment. Hahn12
was the first to report on the unsatisfactory outcome after
conservative management of a coronal shear fracture of the
capitellum humeri. At autopsy he found that the capitellum had
been displaced superiorly and consequently united to the
anterior aspect of the humerus, causing restriction of elbow
flexion. However, there are authors who have shown that
excellent results are achievable if closed anatomical reduction
can be attained, and subsequently maintained until fracture
consolidation is guaranteed.22 It is generally agreed that if
manipulative reduction is impossible, operative fragment removal
or fixation is unavoidable. Authors who are in favour of
fragment excision argue that complications inherent in the
conservation of the capitellum, such as redisplacement,
imperfect reduction, and the risk of AVN are entirely
eliminated.1-11 Mazel,33 for example, was of the opinion that
excessive pressure in attempting a reduction may break up the
fragment and that the small fragments left behind could
seriously damage the joint.
The use of screws in the fixation of capitellum fractures is an
attractive alternative to the application of Kirschner wires.
Although the best alternative can be use of Herbert Screw with
the advantage of not causing soft tissue irritation and witout a
need to remove the metal.Problems might arise if AVN or
chondrolysis occurs, exposing metal implants to the adjacent
radial head, and possibly leading to erosion or arthritic
changes within the joint. Fortunately there are only a few
reports in the literature commenting on the development of AVN
after open fracture reduction of the capitellum.24,26,27 Despite
AVN, most of the described cases appeared to have had a
reasonably satisfactory outcome.26,27
On balance, efforts to re-create normal anatomy are rewarded
with elbow stability and more favourable elbow and forearm
biomechanics. Hence, long-term sequelae such as reduction in
forearm rotation, proximal migration of the radius, cubitus
valgus, triangular fibrous cartilage complex disruption or wrist
osteoarthritis, all of which may lead to chronic elbow and wrist
pain, might be avoidable or at least diminished. Modern fixation
methods, such as the use of intra-osseous screws, provide
instant fracture stability without compromising articular
integrity, which are prerequisites for achieving good functional
results.34 Depending on the quality of the fixation and in the
absence of any concomitant injuries, early mobilisation can be
commenced, thereby avoiding the problems of elbow stiffness and
disability that are commonly caused by prolonged plaster cast
immobilisation. Intra-osseous screws also bear the inherent
advantage of not requiring metal removal at a later date. It
remains to be investigated whether upcoming devices like the
cannulated Martin screw or biodegradable screws will provide
equal or superior results to the fixation with Herbert screws.
Since fractures of the capitellum humeri are uncommon, most of
the information in the available literature is based on only a
few cases.28,31 This fact also implies that it is practically
impossible, although highly desirable, for a medical centre to
conduct a larger trial in order to compare different treatment
options in a randomised and controlled fashion.
Reference:
-
Alvarez E, Patel MR, NimbcrgG, Pearlman HS. Fracture of the
capitulum humeri. J Bone Joint Surg Am 1975;57:1 093-6.
-
DeLee JC, Green DP, Wilkins KE. Fractures and dislocations of
the elbow. In: Rockwood CA Jr, Green DP, Bucholz RW, editors.
Rockwood and Green's fractures in adults. 3rd edition.
Philadelphia: Lippincott; 1991:768-74.
-
Milch H. Unusual fractures of the capitulum humeri and the
capitulum radii. J Bone Joint Surg Am 1931;13:1882-6.
-
Bohler J. Conservative treatment of fractures of the
capitulum of humerus [in German). Arch Orthop Unfallchir
1956;48: 323-5.
-
Collert S. Surgical management of fracture of the capitulum
humeri. Acta Orthop Scand 1977;48:603-6.
-
Grantham SA, Morris TR, Bush DC. Isolated fracture of the
humeral capitellum. Clin Orthop 1981;161:262-9.
-
Hirvensalo E, Bostman O, Partio E, Tormala P, Rokkanen P.
Fracture of the humeral capitellum fixed with absorbable
polyglycolide pins. 1-year follow-up of 8 adults. Acta Orthop
Scand 1993;64:85-6.
-
l.ansinger O, Mare K. Fracture of the capitulum humeri. Acta
Orthop Scand 1981;52:39-44.
-
Mosheiff R, Liebergall M, Elyashuv O, Mattan Y, Segal D.
Surgical treatment of fractures of the capitellum in adults: a
modified technique. J Orthop Trauma 1991;5:297-300.
-
Bryan RS, Morrey BF. Fractures of the distal humerus. In:
Morrey BF, editor. The elbow and its disorders. Philadelphia: WB
Saunders; 1985:302-39.
-
Fowles JV, Kassab MT. Fracture of the capitulum humeri.
Treatment by excision. J Bone Joint Surg Am 1974;56:794-8.
-
Hahn NF. Fall von einer besonderen Varietat der Frakturen des
Ellenbogens. Zeitschrift fur Wundarzte und Geburtshelfer
1853;6:185-9.
-
Kocher T. Beitrage zur Kenntniss einiger praktisch wichtiger
Frakturformen. Basel: Carl Sallmann; 1896:585-91.
-
Steinthal D. Die isolierte Fraktur der Eminentia Capitata im
Ellenbogengelenk. Zentralbl Chirurgie 1898;15:1.
-
Lorenz H. Zur Kenntniss der Fractura Capitelulm Humeri
(Eminentia Capitata). Deutsche Zeitschr f Chir 1905;78:531-45.
-
Poynton AR, Kelly IP, O'Rouke SK.
Fractures of the capitellum-a comparison
of two fixation methods. Injury 1998;29: 341-3.
-
Silveri CP, Corso SJ, Roofeh J. Herbert screw fixation of a
capitellum fracture. A case report and review. Clin Orthop 1994;
300:123-6.
-
Simpson EA, Richards RR. Internal fixation of a capitellar
fracture using Herbert screws. A case report. Clin Orthop 1986;
209:166-8.
-
Stansbury NA, Bosacco SJ. Answer please. Capitellum
fractures. Orthropedics 1994;17:11 62-3.Bohler L. The treatment of fractures. Bristol: John Wright
and Sons Ltd; 1936:197-8.
-
Mancini GB, Fiacca C, Picuti G. Resection of the radial
capitellum. Long term results, Ital J Orthop Traumatol 1989;
15:295302.
-
Christopher F, Bushnell LF. Conservative treatment of
fractures of the capitellum. J Bone Joint Surg Am 1
935;17:489-92.
-
Gejrot W. On intra-articular fractures of the capitellum and
trochlea of the humerus with special reference to the treatment.
Acta Chir Scand 1932;71:253-70.
-
Judet J, Raynal L. Fractures of capitellum; uncapping of
eminentia capitata [in French]. Acta Orthop Belg 1957;23:5-22.
-
Smith FM. Surgery of the elbow. Springfield: Thomas, 1954:11
6-20.
-
Bryan RS. Fractures about the elbow in adults. In: Murray
DG, editor. American Academy of Orthopaedic Surgeons
instructional course lectures XXX. St. Louis: CV Mosby;
1981:200-23.
-
Dushuttle RP, Coyle MP, Zawadsky JP, Bloom H. Fractures of
the capitellum. J Trauma 1985;25:317-21.
-
Mckee MD, Jupiter JB, Bamberger HB. Coronal shear fractures
of the distal end of the numerus. J Bone Joint Surg 1996;78;
49-54.
-
Lambert SM, Pike J, Railton GT. Fractures of the humeral
capitellum: Herbert screw fixation. J R Coll Surg Edinb 1994;39:
321-3.
-
Liberman N, Katz T, Howard CB, Nyska M. Fixation of
capitellar fractures with the Herbert screw. Arch Orthop Trauma
Surg 1991;110:155-7.
-
Richards RR, Khoury GW, Burke FD, Waddell JP. Internal
fixation of capitellar fractures using Herbert screws: a report
of four cases. Can J Surg 1987;30:188-91.
-
Muller ME, Allgower M, Schneider R, Willeneger H, editors.
Manual of internal fixation: techniques recommended by the AO-ASIF
Group. 3rd edition. Berlin: Springer-Verlag; 1991.
-
Mazel MS. Fracture of the capitellum: A report of a case. J
Bone Joint Surg Am 1 935;17:483-8.
-
Mehdian H, McKee MD. Fractures of the capitellum and
trochlea. Orthop Clin North Am 2000;3:11 5-27.
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