|Year : 2022 | Volume
| Issue : 1 | Page : 9-12
Functional outcome of delayed surgical fixation of capitellar fractures treated by open reduction and internal fixation with herbert screw
Sanjay Keshkar, Riddhideb Barman, Mohammad Nasim Akhtar
Department of Orthopaedics, ESIC Medical College and Hospital, Kolkata, West Bengal, India
|Date of Submission||07-May-2022|
|Date of Acceptance||12-May-2022|
|Date of Web Publication||15-Jun-2022|
Dr. Mohammad Nasim Akhtar
Department of Orthopaedics, ESIC Medical College and Hospital, Joka, Kolkata - 700 104, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Capitellar fractures are rare injuries and difficult to manage, especially so if the patient presents late. Treatment is almost always operative. The purpose of this study is to evaluate the functional outcome of capitellar fractures in adults treated by open reduction and internal fixation (ORIF) with cannulated compression headless screws (Herbert screw) with an inadvertent delay of 2 weeks or more. Materials and Methods: Twelve patients (4 males and 8 females) of capitellum fracture who were reported after an inadvertent delay of at least 2 weeks, with near-normal elbow range of motion, operated by ORIF with Herbert screw, were studied retrospectively from April 2013 to March 2019. All cases were operated between 2 to 3 weeks of injury. All patients had a follow-up for a mean period of 34 months, and the final functional outcome was assessed using Mayo Elbow Performance Index (MEPI) and by radiology. Results: The mean MEPI score was 92.9 points, and as per this evaluation of the functional rating, all but one patient had excellent results. The mean range of elbow flexion/extension was 125 (90–140), while the range of movement in supination/pronation was 170 (130–180). Conclusion: ORIF of capitellum fractures with Herbert screw was found to be superior and gives excellent result, even with a delay of around 2 weeks. Preoperative computed tomography is helpful not only to know clear picture of fracture configuration but also to choose right surgical approach and right implant. Apart from stable internal fixation, early mobilization and rehabilitation are the keys for optimum functional outcome.
Keywords: Capitellum fracture, distal humerus fracture, elbow joint, headless cannulated compression screw, Herbert screw
|How to cite this article:|
Keshkar S, Barman R, Akhtar MN. Functional outcome of delayed surgical fixation of capitellar fractures treated by open reduction and internal fixation with herbert screw. J Orthop Traumatol Rehabil 2022;14:9-12
|How to cite this URL:|
Keshkar S, Barman R, Akhtar MN. Functional outcome of delayed surgical fixation of capitellar fractures treated by open reduction and internal fixation with herbert screw. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Aug 19];14:9-12. Available from: https://www.jotr.in/text.asp?2022/14/1/9/347364
| Introduction|| |
Capitellar fractures are not uncommon injuries. It accounts for approximately 6% of distal humerus fractures and 1% of all elbow fractures., If left untreated, the outcome is invariably poor, particularly in displaced fractures. Due to social, cultural, or socioeconomic issues, there may be a delay in surgical fixation of these crucial injuries, and a delay up to 2 weeks after trauma may not be uncommon. Superior migration and union with anterior humerus are not infrequent, causing mechanical block to elbow flexion by obstructing the radial and/or coronoid fossa.
Various classification systems have been given for capitellar fracture, for example, Bryan and Morrey classification, Dubberley classification, Harrington and Mckee classification, Ring classification, and AO classification., Dubberley classification is popular among all, which classifies capitellar fractures into three 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; and Type 3, injuries involving the capitellum and trochlear as separate piece. Type 3 is again subclassified into A and B: A, without posterior comminution and B, with posterior comminution. This classification considers posterior condylar comminution and also recognizes fractures splitting the trochlea and capitellum into different fragments as a separate entity.
Although various treatment options available for these injuries, e. g., conservative methods and fragment excision, open reduction and internal fixation (ORIF) is the preferred method for early mobilization, stable anatomical reduction, and maintenance of articular congruity.,,,
The ORIF can be done using various implants (e.g., simple K-wires, cannulated cancellous screws, and headless screws like Herbert screw), but Herbert screw was found to be superior among all and is an accepted method of fixation. The purpose of this study is to evaluate the functional outcome of delayed fixation of capitellar fractures in adults treated by ORIF with Herbert screw.
| Materials and Methods|| |
Twelve patients (4 males and 8 females) of capitellum fracture, presenting after an inadvertent delay of at least 2 weeks due to social, cultural, or socioeconomic issues, operated by ORIF with Herbert screw, were studied retrospectively from April 2013 to March 2019. The cases were selected from the medical record department of this institution by review of the case files. Patients having isolated fracture of the capitellum confirmed by preoperative radiograph and/or computed tomography (CT) scan were included in this study. Patients having other associated fractures around the elbow along with capitellar fracture, compound fractures, or grossly restricted elbow flexion of <120° were excluded from the study.
All cases were operated between 2 to 3 weeks of initial trauma and had a follow-up for a mean period of 34 months. Dubberley classification was used to classify fractures in this study, and the final functional outcome was assessed using Mayo Elbow Performance Index (MEPI) and by radiology. MEPI [Table 1] is one of the most popular elbow rating systems where the total score ranges from 5 to 100 points, with larger scores indicating better function. The result can be considered excellent, if the total score is between 90 and 100 points; good, between 75 and 89; fair, between 60 and 74 points; and poor, <60 points.
All cases were operated under general anesthesia, under tourniquet control by lateral approach. Fracture site was cleared of hematoma 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 an image intensifier, and then definitive fixation was done using Herbert screws. We have not used bone grafts in any of our patients as it was not required. Postoperatively, an above-elbow slab was given to patients to immobilize the elbow for 10–15 days, following which gentle active mobilization was started. Regular monthly follow-up was done for all patients for a minimum of 12 months to assess the functional (MEPI) and radiological outcome.
| Results|| |
In the present study, 12 cases of capitellar fracture operated by ORIF with Herbert screw were evaluated. There were four males and eight females with male/female ratio of 1:2. The mean age of patients was 37 years ranging from 20 to 60 years. Eight patients had involvement of the right (dominant) side and 4 had the left (nondominant) side. As per Dubberley classification, nine patients had type I fracture and 3 had type II fracture. One case had a missed fracture [Figure 1]a in the initial radiograph taken in the extended elbow, which became evident in the subsequent radiograph taken in the flexed elbow [Figure 1]b and in CT scan [Figure 1]c. The mean time delay for surgery was 16.8 days. The average follow-up duration was 34 months with a range of 20 months to 48 months.
|Figure 1: Showing initial missed diagnosis due to radiograph in extended elbow (a), but finally diagnosed with radiograph in flexed elbow (b) and CT scan (c), with excellent outcome with good union (d) and full range of motion (e and f)|
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The mean MEPI score was 92.9 points [Table 2], and as per this evaluation of the functional rating, all but one patient had excellent result [Figure 1], showing excellent result with good union [Figure 1]d, full flexion [Figure 1]e, and near full extension [Figure 1]f. Despite excellent union, 1 case had mild stiffness of the elbow due to poor compliance with physiotherapy with mild functional disability and was graded as good result. This patient presented 2 weeks after trauma and had 120° of elbow flexion preoperatively. The mean range of elbow flexion/extension was 125 (90–140) and supination/pronation was 170 (130–180). None of the patients in this series had complications such as avascular necrosis, myositis ossificans, and osteoarthrosis. All the patients returned to their previous levels of activity.
| Discussion|| |
| Review of literature|| |
In 2003, Ring et al. did a retrospective study of outcome of 21 cases of capitellum and trochlear fractures treated by ORIF using Herbert screws. With an average follow-up of 40 months, the MEPI was excellent in four, good in twelve, and fair in five without any evidence of radiographic arthritis or osteonecrosis.
Ruchelsman et al. reported outcome of ORIF by Herbert screws in 16 patients of capitellum fractures and followed up for a maximum period of 2 years. The average ulno-humeral arc was 123° with an average flexion of 133° and average flexion 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 a limited duration of follow-up and was a retrospective study.
Mighell et al. did a prospective study of 18 patients of large coronal shear fractures of capitellum and trochlea, stabilized with cannulated headless compression screws with an average delay of 10 days, followed prospectively for a period of 26 months. There were 11 type 1 and 7 type 2 cases according to Dubberley classification. Lateral Kaplan approach was used in all cases. The average range of movement (ROM) in flexion extension was 128° and in pronation supination 176° after a follow-up period of 26 months. Broberg–Morrey score was used in the study with an average score of 93.3 points; 12 excellent, 5 good, and 1 poor result. Five patients had radiographic evidence of osteoarthritis, 3 had osteonecrosis, and 3 cases of heterotopic ossification noted. He also reported that there was no difference in BM score and ROMs of type 1 and 2 fractures.
At present, not much literature is available to define a suitable delay in fixation or outcome assessment in delayed fixation, but for few case reports. Wilharm et al. reported satisfactory outcome in bilateral capitellum fracture fixed after delay of 6 weeks.
Discussion related to the present study
ORIF by Herbert screws/headless cannulated compression screw is the implant of choice for capitellum fractures. 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. In the present study, we also used Herbert screws in 12 patients and were evaluated for an average period of 34 months. The results of our study are comparable to other studies [Table 2] and [Table 3].
|Table 3: Comparison of present study of capitellar fractures (treated by Herbert Screws) with previous studies|
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The extensile lateral approach was used by most of the 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 resurgery for hardware removal. Moreover, these exposures were used for higher classes of fracture classification for better exposure. In the present study, we have used extensile lateral approach for all the cases for fixing the fracture, and a separate medial approach or olecranon osteotomy was not necessary in any of the cases as most of our cases were type I (isolated capitellar fracture).
In most of the studies, there is a female predominance of this capitellum fracture and is true for our study also. The cause behind the same is increased valgus carrying angle of 5° compared to males, leading to greater impact forces to the lateral column in fall on an outstretched hand. Low bone mineral density in women compared to men could be another contributing factor for the same. The only contradicting observation of our study with previous studies was increased predominance in dominant extremity, i.e., 8 out of 12 patients. The reason for this was unclear and needs to be assessed.
In our study, one case had a missed fracture [Figure 1]a in the initial radiograph taken in the extended elbow, which became evident in the subsequent radiograph taken in the flexed elbow [Figure 1]b and in CT scan [Figure 1]c. This shows that fracture becomes more evident in the lateral radiograph in the flexed elbow.
| Conclusion|| |
ORIF of capitellum fracture with Herbert screw was found to be superior and gives excellent result even in delayed cases. Preoperative CT is helpful not only to know clear picture of fracture configuration but also to choose right surgical approach and right implant. Apart from stable internal fixation, early mobilization and rehabilitation are the keys for optimum functional outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am 2008;90:1321-9.
Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, ed., the Elbow and Its Disorders. Philadelphia, PA: WB Saunders; 1985. p. 302-39.
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.
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Wilharm A, Marintschev I, Gras F, Hofmann GO. Delayed diagnosis of fractures of the capitulum of the humerus. Successful internal fixation 6 weeks after the accident. Unfallchirurg 2010;113:1042-6.
[Table 1], [Table 2], [Table 3]