Capitellar Fractures Treatment & Management

Updated: Jul 10, 2020
  • Author: Janos P Ertl, MD; Chief Editor: Harris Gellman, MD  more...
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Treatment

Approach Considerations

Treatment of capitellar fractures is similar to that of any intra-articular fracture. Every effort should be made to repair and stabilize displaced capitellar fractures. However, should a significant amount of comminution be present, fixation may not be possible, and excision of the fragments may prove necessary instead. No contraindications for surgical treatment exist, other than those imposed by the patient's medical status, ability to tolerate anesthesia, and activity level. (See Surgical Therapy.)

The development of smaller screws and absorbable implants has led to more successful results with open reduction and internal fixation (ORIF). All efforts should be made to reduce a displaced capitellar fragment, whether by closed or by open techniques.

Closed reduction can be attempted for type I fractures (see Nonoperative Therapy). However, soft-tissue attachments are rare, and stability allowing early motion may not be achieved. The most appropriate treatment of type I capitellar fractures is ORIF. [13] If closed reduction is unsuccessfully attempted, open reduction is indicated.

Open reduction is indicated in all displaced fractures of the capitellum and in those for which closed reduction fails. The presence of significant comminution may preclude fixation; surgical excision of the comminuted fragments is then recommended.

With the evolution of smaller implants, absorbable implants, and biologic surgical techniques, more aggressive attempts at fixation of capitellar fractures will continue to be made. Arthroscopically assisted reduction and percutaneous fixation will also be options.

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Nonoperative Therapy

Closed reduction can be attempted for type I fractures (see Classification) with the patient under general anesthesia, as described by Ochner et al. [14] The elbow is extended, distracted, and gently flexed in an attempt to capture the fragment and lock it into place. The elbow is manipulated with fluoroscopic assistance (or permanent radiographs may be obtained to confirm reduction). Closed reduction is best performed under muscle-relaxing anesthesia with fluoroscopic control.

Attempts should not be repeated, to avoid additional damage or comminution of the fragment. Should the reduction be unsuccessful or nonanatomic, open reduction is indicated.

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Surgical Therapy

Surgical techniques and implants have evolved to the point where fixation of small fractures is feasible and reproducible. The literature supports anatomic reduction and the initiation of early motion as the treatment of choice for capitellar fractures. Efforts should be made to reduce and stabilize displaced fractures that block extension. When an attempt at closed reduction is unsuccessful, immediate progression to open reduction is recommended. [7, 15, 8, 16]  The choice of surgical approach may be influenced by the pathoanatomy of the particular fracture. [17]

Preparation for surgery

Preoperative planning involves the following steps:

  • Review the anatomy and the surgical approach between the anconeus and the extensor carpi ulnaris (ECU)
  • Have radiographs present in the operating room
  • Use a radiolucent hand table
  • Use a fluoroscope (C-arm)
  • Ensure that the following items are available: minifragment standard screw set, Kirschner wires (K-wires), small/minifragment Herbert screws, absorbable pins, and prophylactic antibiotics (usually 1 g cephalosporin)
  • Apply a tourniquet

Operative details

Position the patient supine on the operating room table, and place the injured extremity on the radiolucent hand table. Perform standard extremity preparation and draping. Flex the elbow. Exsanguinate with an Esmarch bandage, 200-250 mm Hg.

Use a lateral approach to the elbow, between the anconeus and the ECU. An anterolateral approach has been described for isolated coronal shear fractures of the humeral capitellum and appears to offer comparable early outcomes. [18]

Begin the incision 2 cm proximal to the lateral epicondyle, and extend it 2-3 cm distal to the radial head.

The common extensor origin can be osteotomized from the lateral epicondyle or incised longitudinally with minimal subperiosteal elevation of the origin. Expose the lateral elbow joint. Avoid posterior dissection. Be aware of the course of the radial nerve between the brachioradialis and the brachialis. An extensile lateral exposure can also be used. [7]  Vaishya et al reported good results with ORIF done via an anterolateral approach with headless double-threaded compression screws. [19]

Irrigate the joint. The fracture fragment often has no soft-tissue attachments. Reduce the fracture fragment, and temporarily secure it with K-wires.

Internal fixation options include the following:

  • Herbert screws [18]  or headless compression-type screws [7] inserted through the articular surface - Headless compression screws are commonly composed of titanium, but biodegradable magnesium-based equivalents have also been developed [20]
  • Countersunk 2.0-mm minifragment interfragmentary compression screws
  • Standard or cannulated minifragment interfragmentary compression screws placed posteriorly, with care taken to avoid significant posterior dissection
  • Absorbable pins for type II and III fractures, placed as needed
  • Excision if the fragment is too small or comminuted

Check the range of motion (ROM) and the fracture stability. Reattach the origin of the common extensor tendons.

Release the tourniquet; achieve hemostasis. Close the wound.

Apply a removable posterior splint. If the fixation is stable, institute early motion; if it is less stable, delay ROM (3-4 weeks).

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Postoperative Care

Check neurovascular status in the recovery room. Place ice on the lateral elbow. Instruct the patient regarding limb elevation.

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Complications

As with any osteochondral fractures and with intra-articular fractures in general, complications of treatment include the following [21] :

Loss of ROM may arise from closed reduction with immobilization and, often, from surgical excision of the fragment.

As a consequence of the rapid revascularization of the fragment, AVN occurs more often than is recognized. Should the avascular fragment become symptomatic, delayed excision is recommended.

Malunion is uncommon and is often caused by delayed identification by the patient and the physician. When malunion occurs, elbow flexion is usually severely restricted. Anterior elbow soft-tissue release and fragment excision are indicated. Yu et al described the use of arthrolysis, late internal fixation, and a hinged external fixator to treat patients with a stiff elbow associated with malunion or nonunion after delayed treatment of capitellar fracture. [22]

Nonunion may be isolated or may be associated with AVN. If the fragment is large enough and viable, an attempt at refixation may be made. If the fragment is small and symptomatic, excision is indicated. In treating these complications, an anterior capsular release in conjunction with the proposed procedure should be considered.

The results of one study concluded that patients with operatively treated comminuted fractures of the capitellum and trochlea have a greater risk of nonunion than other types of capitellum and trochlea fractures, notably when a posterior comminution is noted (Dubberley type 3B) and multiple articular fragments are created. [23]

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Long-Term Monitoring

Depending on the fixation achieved, the patient should be scheduled for physical therapy for progressive and protected single-plane elbow motion. A removable plastic splint may be made.

The follow-up schedule with the physician, with radiographs at each visit, is as follows:

  • 7-10 days
  • 14-20 days
  • 4-6 weeks
  • 3 months
  • 6-12 months
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