The effect of surgery on functional outcomes of the elbow in adults with isolated capitellar fractures

Abstract

Objectives. The aim of this study was to evaluate the factors affecting the functional outcomes together with the clinical and radiological findings obtained from the treatment of adult capitellar fractures through open reduction and internal fixation. Methods. Patients who applied our clinic between 2008 and 2013 with a mean age of 37.5 (range: 17-77) were treated surgically. A total of 11 patients, seven male, and four female, were included in the study. In the study, fracture types of the patients were determined according to McKee modification of the Bryan and Morrey classification. After the operation, patients were followed for an average 26 (15-63) months. In the radiological and clinical evaluations, carrying angle of the operated elbow was compared with the carrying angle values of the healthy elbow. Clinical assessment was made of the Mayo Elbow Performance Index (MEPI). Results. Patients were clinically assessed according to the MEPI scoring over 100 points. It was seen that five patients got 100 points (excellent) while 6 got 85 points (good). No significant difference was observed between fracture types regarding elbow flexion. Type III fractures were found to be significantly more limited than type I and type IV fractures regarding elbow extension degrees (p=0.040). Conclusions. This study yielded inferences that we considered important. Degenerative changes observed in type III fractures only show that this fracture type poses the risk of osteoarthritis development The fact that heterotopic ossification ossification causes movement restriction affect clinical findings adversely. We believe that degenerative arthritis would decrease, joint range could be maintained better, and functional results will be better by avoiding challenging passive exercise and suggesting active practice instead.

Keywords

• Capitellum,elbow fractures; heterotopic ossification; osteoarthritis; elbow

References

1. Bryan RS, Morrey BF. Fractures of the distal humerus. In The elbow and its disorders. Edited by: Morrey BF. Philadelphia: WB Saunders; 1985;302-39.
2. Pogliacomi F, Concari G, Vaienti E. Hahn-Steinthal fracture: report of two cases. Acta Biomed. 2005 Dec;76(3):178-84.
3. Alvarez E, Patel MR, Nimberg G. Fracture of the capitellum humeri. J Bone Joint Sur Am. 1975 Dec;57(8):1093-6.
4. Grantham SA, Norris TR, Bush DC. Isolated fracture of the humeral capitellum. Clin Orthop. 1981 Nov-Dec;(161):262-9.
5. Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. (4th Ed);2010.
6. Guitton TG, Zurakowski D, van Dijk NC, Ring D. Incidence and risk factors for the development of radiographic arthrosis after traumatic elbow injuries. J Hand Surg Am. 2010 Dec;35(12):1976-80.
7. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003 Feb;85-A(2):232-8.
8. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Coronal plane partial articular fractures of the distal humerus: current concepts in management. J Am Acad Orthop Surg. 2008 Dec;16(12):716-28.

9. 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 Jan;88(1):46-54.
10. Bryan RS,Morrey BF. Fractures of the distal humerus. In:Morrey BF,ed. The elbow and its disorders. Philadelphia:WB Saunders,1985;302-39.
11. Mehdian H, McKee MD. Fractures of capitellum and trochlea. Orthop Clin North Am. 2000 Jan;31(1):115-27.
12. Mckee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996 Jan;78(1):49-54.
13. Trinh TQ, Harris JD, Kolovich GP, Griesser MJ, Schickendantz MS, Jones GL. Operative management of capitellar fractures: a systematic review. J Shoulder Elbow Surg. 2012 Nov;21(11):1613-22.
14. Ong KL, Mahadev A. Cannulated cancellous screw fixation for capitellum fractures in adolescents. J Orthop Surg (Hong Kong). 2011 Dec;19(3):346-9.
15. Dushuttle RP, Coyle MP, Zawadsky JP, Bloom H. Fractures of the capitellum. J Trauma. 1985 Apr;25(4):317-21.
16. Ochner RS, Bloom H, Palumbo RC, Coyle MP. Closed reduction of coronal fractures of the capitellum. J Trauma. 1996 Feb;40(2):199-203.
17. Puloski S, Kemp K, Sheps D, Hildebrand K, Donaghy J. Closed reduction and early mobilization in fractures of the humeral capitellum. J Orthop Trauma. 2012 Jan;26(1):62-5.
18. Fowles JV, Kassab MT. Fracture of the capitulum humeri treatment by excision. J Bone Joint Surg Am. 1974 Jun;56(4):794-8.
19. Mighell M, Virani NA, Shannon R, Echols EL Jr, Badman BL, Keating CJ. Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws. J Shoulder Elbow Surg. 2010 Jan;19(1):38-45.
20. Giannicola G, Sacchetti FM, Greco A, Gregori G, Postacchini F. Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures. Acta Orthop. 2010 Apr;81(2):228-33.
21. Werner CM, Zimmermann SM, Würgler-Hauri CC, Lane JM, Wanner GA, Simmen HP. Use of imatinib in the prevention of heterotopic ossification. HSS J. 2013 Jul;9(2):166-70.
22. Koh KH, Lim TK, Lee HI, Park MJ. Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification.J Shoulder Elbow Surg. 2013 Aug;22(8):1128-34.
23. Shukla DR, Pillai G, McAnany S, Hausman M, Parsons BO. Heterotopic ossification formation after fracture-dislocations of the elbow. J Shoulder Elbow Surg. 2015 Mar;24(3):333-8.
24. Foruria AM, Lawrence TM, Augustin S, Morrey BF, Sanchez-Sotelo J. Heterotopic ossification after surgery for distal humeral fractures. Bone Joint J. 2014 Dec;96-B(12):1681-7.
25. Terra BB, Silva BCM, Carvalho HBF, Dobashi ET, Pinto JA, Ishida A. Evolution of the carrying angle of the elbow: a clinical and radiographic study. Acta Ortop Bras 2011 Mar-Apr;19(2):79-82.
26. Letts M, Rumball K, Bauermeister S, McIntyre W, D’Astous J. Fractures of the capitellum in adolescents. J Pediatr Orthop. 1997 May-Jun;17(3):315-20.
27. Nithyananth M.J, Cherian VM, Venkatesh K, Amritanand R: Bilateral Hahn-Steinthal fracture: a case report and review of literature. Eur J Orthop Surg Traumatol. 2008 July;18(5):395-7.
28. De Boeck H, Pouliart N. Fractures of the capitellum humeri in adolescents. Int Orthop. 2000;24(5):246-8.
29. SS Suresh : Type 4 capitellum fractures: Diagnosis and treatment strategies. Indian J Orthop. 2009 Jul-Sep;43(3):286-91.
30. Bilsel K, Atalar AC, Erdil M, Elmadag M, Sen C, Demirhan M. Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation. Arch Orthop Trauma Surg. 2013 Jun;133(6):797-804.
31. Rockwood and Green’s. Fractures in adults (6th ed) volume 1;1101-7.
32. Cutbush K, Andrews S, Siddiqui N, Brown LM, Ross M. Capitellar fractures-is open reduction and internal fixation necessary? J Orthop Trauma. 2015 Jan;29(1):50-3.
33. Lambert SM, Pike J, Railton GT. Fractures of humeral capitellum:Herbert screw fixation. J R Coll Surg Edinb. 1994 Oct;39(5):321-3.
34. Elkowitz S J,Polatsch DB, Egol K A. Capitellum fractures: A biomechanical evaluation of three fixation methods. J Orthop Trauma. 2002 Aug;16(7):503-6.
35. Poynton AR, Kelly IP, O’Rourke SK. Fractures of the capitellum-A comparison of two fixation methods. Injury. 1998 Jun;29(5):341-3.
36. Clough TM, Jago ER, Sidhu DP, Markovic L. Fractures of the capitellum: a new method of fixation using a maxillofacial plate. Clin Orthop Relat Res. 2001 Mar;(384):232-6.
37. Kurtulmus T, Saglam N, Saka G, Avci C, Kucukdurmaz F, Akpinar F. Posterior fixation of type IV humeral capitellum fractures with fully threaded screws in adolescents. Eur J Trauma Emerg Surg.2014;40:379-85.
38. Johansson J, Rosman M. Fracture of the capitulum humeri in children: A rare injury, often misdiagnosed. Clin Orthop. 1980 Jan-Feb;(146):157-60.
39. Root CG, Meyers K, Wright T, Hotchkiss R. Capitellum excision: Mechanical implications and clinical consequences. J Orthop Res. 2014 Feb;32(2):346-50.
40. Simpson LA, Richards RR . Internal fixation of a capitellar fracture using Herbert screws. A case report. Clin Orthop. 1986 Aug;(209):166-8.
41. Feldman MD. Arthroscopic excision of typ II capitellar fractures. Arthroscopy. 1997 Dec;13(6):743-8.
42. Shukla DR, Thoreson AR, Fitzsimmons JS, An KN, O'Driscoll SW. The effect of capitellar impaction fractures on radiocapitellar stability. J Hand Surg Am. 2015 Mar;40(3):520-5.
43. Rosenberg ZS, Blutreich SI, Schweitzer ME, Zember JS, Fillmore K. MRI features of posterior capitellar impaction injuries. AJR Am J Roentgenol. 2008 Feb;190(2):435-41.
44. Hall MJ, Fullilove SM, Keenan J. Hills-sachs type lesion of the capitellum. J Tauma. 2010 Jan;68(1):E30-1.
45. Faber KJ, King GJ. Posterior capitellum impression fracture: a case report associated with posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg.1998 Mar-Apr;7(2):157-9.
46. Feldman DR, Schabel SI, Friedman RJ, Young JW. Translational injuries in posterior elbow disloc ation. Skeletal Radiol. 1997 Feb;26(2):134-6.
47. Ring D. Apparent capitellar fractures. Hand Clin. 2007 Nov;23(4):471-9.
48. Snoecx M, De Muynck M, Van Laere M. Association between muscle trauma and heterotopic ossification in spinal cord injured patients: reflections on their causal relationship and the diagnostic value of ultrasonography. Paraplegia. 1995 Aug;33(8):464-8.
49. Daud O, Sett P, Burr RG, Silver JR. The relationship of heterotopic ossification to passive movements in paraplegic patients. Disabil Rehabil. 1993 Jul-Sep;15(3):114-8.
50. Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty.J Bone Joint Surg Am. 1990 Apr;72(4):601-18.
51. Murnaghan M, Li G, Marsh DR. Nonsteroidal anti-inflammatory drug-induced fracture nonunion: an inhibition of angiogenesis? J Bone Joint Surg Am. 2006 Nov;88 Suppl 3:140-7.