Outcome After Open Reduction and Internal Fixation of Capitellar and Trochlear Fractures

Author(s): Dubberley JH, Faber KJ, MacDermid JC, Patterson SD, King GJW

Source:   Journal of Bone and Joint Surg 88A:1, 46-54, 2006.

Summary:


This retrospective review includes 28 patients treated with open reduction and internal fixation for a capitellar and/or trochlear fracture using a patient questionnaire, interview, physical examination, radiographic evaluation and strength testing.  Mean patient age is 43 years (range, 20-71 years) with a mean duration of follow-up of 56 months (range, 14-121 months). The authors proposed a new classification with Type 1 being primarily a capitellar fracture with or without lateral trochlear ridge involvement; Type 2 involving the capitellum and the trochlea as one piece, and Type 3 consisting of fractures of both the capitellum and the trochlea as separate fragments.  These fractures were further classified with respect to the absence (A) or presence (B) of posterior condylar comminution.  There were no isolated trochlear fractures in this series.  A posterior midline incision was used for 24 patients and lateral skin incisions for the other 4 by four different surgeons which included the Boyd, Kocher and Kaplan exposure.  The majority of fractures were treated with cancellous screws and some required supplemental bone grafting and/or plating, especially if posterior comminution was present.  Twenty-six patients were treated with early active assisted range of motion exercises commencing on the first or second postoperative day with daytime resting splints at 90 degrees and nighttime extension splints.  Passive stretching and strengthening exercises commenced at six weeks postoperatively.  Eighteen of the 28 patients were prescribed indomethacin.  As expected, at final follow-up there were deficits in average motion compared to the contralateral unaffected elbow with average loss of motion of 25 degrees of the flexion-extension arc and 4 degrees of the supination-pronation arc.  The average strength of the affected and unaffected elbows was significantly less in flexion and extension.  For the Mayo elbow performance index, Type 1 fractures had a significantly better outcome than Type 2 and 3 injuries.  Subsequent surgical procedures were required in 12 patients with most interventions required for olecranon osteotomies.  Seven patients with a Type 2 or 3 fractures had an elbow capsulectomy and hardware removal for loss of motion and two patients with a Type 3-B fracture had a total elbow arthroplasty for nonunion or osteonecrosis of the capitellum and trochlea.  One patient developed a frozen shoulder.  Posttraumatic arthrosis was noted in 9 patients with 5 having slight joint space narrowing and minimal osteophyte formation whereas 4 had moderate joint space narrowing and osteophyte formation, but no patient had severe joint space narrowing with gross destruction, except for 2 patients who had already undergone a total elbow arthroplasty.  Overall, patients with more complex fractures required more extensive surgery, had fewer complications, less secondary procedures, and poor outcomes compared with those with simple fractures.

This study is the largest reported series to evaluate capitellar and trochlear fractures and includes subjective and objective outcomes.  Overall,  Type 1 fractures faired best as all went on to heal without complications and none required a second operative.  Two of the four Type 2 fractures required subsequent capsulotomies and hardware removal to treat residual elbow contractures and both of these patients had radiographic mild posttraumatic arthritis.  Type 3 fractures involving the capitellum and trochlea typically required olecranon osteotomy for exposure and subsequently resulted in higher complication rates due to painful hardware and residual contracture.  This study, although retrospective, does provide intermediate-term follow up for intra-articular capitellar and trochlear fractures.  These shear injuries to the distal humeral articular surface may be the most difficult of any periarticular fracture about the elbow to treat, especially the Type 2 and 3 patterns with greater articular involvement and comminution.

 

Related Links
Journal of Bone and Joint Surgery