Chinese Journal of Traumatology 19 (2016) 231e234

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Chinese Journal of Traumatology

journal homepage: http://www.elsevier.com/locate/CJTEE

Case report

Operative management of a shear fracture of the bilateral capitellum: A case

report and review of the literature
Alessandro Are a, Ignazio Tornatore a, Emmanouil Theodorakis b, *
a
Department of Orthopedics, Policlinico Casilino Hospital, Rome, Italy
b
Department of Orthopedics, Aurelia Hospital, Rome, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Fracture of bilateral capitulum humeri is a very rare injury. We present a case of a 38-year-old woman,
Received 6 April 2015 affected by a shear fracture of bilateral capitellum after a motorcycle accident. Intervention was carried
Received in revised form out through a lateral approach on both sides and direct fixation of the fragment with headless screws.
8 October 2015
Consolidation was achieved and no signs of avascular necrosis occurred at 24 months of follow-up. The
Accepted 10 November 2015
Available online 4 March 2016
patient returned to her previous activities with no functional limitations. To the best of our knowledge,
only four cases are reported describing different types of treatment and postoperative period of cast
immobilization. According to our review of the literature regarding capitellar fractures, we preferred an
Keywords:
Elbow joint
immediate postoperative rehabilitation of the elbow, following the stable osteosynthesis.
Fracture of capitulum humeri © 2016 Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of
Fracture fixation Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND
Internal license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Recovery of functional

Introduction with only four case reports found in literature. Here, we present a
case of a bilateral capitellar shear fracture treated with ORIF,
Fractures of capitulum humeri in the coronal plane are rare reporting the surgical management as well as the clinical and the
injuries, accounting for nearly 1% among all elbow fractures.1 radiographic outcome.
These injuries usually occur after an axial loading force to the
capitellum through the radial head. Bryan and Morrey1 described
Case report
three types of capitellar fractures. These fractures were further
characterized with respect to the absence (A) or presence (B) of a
A 38-year-old female fell onto both her outstretched hands after
posterior condylar comminution. X rays in the standard AP and
a motorcycle accident. Clinical examination at the emergency
lateral views should be performed including forearm and wrist
department in our hospital found diffuse swelling of both elbows,
radiographs for associated injuries; moreover, a CT scan is neces-
together with intense pain and impairment of any elbow joint
sary for a detailed preoperative planning. These fractures often
motion. Radiographs in the AP and lateral planes showed a bilateral
result in significantly high long-term morbidity if the surgical
fracture of the capitellum humeri without evidence of elbow
treatment is delayed. Open reduction and internal fixation (ORIF)
dislocation (Figs. 1a and 2a). Subsequent X-rays to the forearm and
is mandatory in order to obtain the best restoration of the articular
wrist did not reveal concomitant fractures or distal radio-ulnar
surface and allow an early joint mobilization. The integrity of the
(DRUJ) joints. The next day, a CT scan was performed with a 3D
lateral collateral ligament (LCL) must be assessed during the sur-
reconstruction (Figs. 1b and 2b) in the sagittal and coronal planes
gical exposure and the stability of the elbow joint must be tested
for a detailed preoperative evaluation. Both capitellar fractures
during the intervention after proper fixation. An isolated, bilateral
were classified as type 1A. Type “1” refers to the Bryan and Morrey's
shear fracture of the capitulum humeri is an extremely rare event
classification, describing a shear fracture in the coronal plane
involving most of the capitellum and none of the trochlea. “A” type,
according to Dubberley et al, refers to the absence of posterior
* Corresponding author. Tel.: þ39 3407444861.
E-mail address: drtheodorakis@gmail.com (E. Theodorakis).
condylar comminution. At the third day after trauma, our patient
Peer review under responsibility of Daping Hospital and the Research Institute underwent bilateral same-day surgery (ORIF), simultaneously for
of Surgery of the Third Military Medical University. both capitellar fractures, by two surgical equips.

http://dx.doi.org/10.1016/j.cjtee.2015.11.017
1008-1275/© 2016 Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
232 A. Are et al. / Chinese Journal of Traumatology 19 (2016) 231e234

Fig. 1. A: Preoperative X-rays of the right elbow in AP and lateral view. The capitular fracture is easily identified on the lateral projection. B: CT 3D scan reconstruction.
C: Postoperative X-rays after headless screw osteosynthesis.

A lateral approach was performed bilaterally with the elbow Postoperative radiographic exam confirmed anatomic reduction
already been flexed at 90 . Skin incision began 2 cm proximally to of the capitellar fractures and the correct hardware positioning
the tip of the lateral epicondyle and extended distally and for (Figs. 1c and 2c). The patient was held in flexion at 90 in a provi-
approximately 4 cm towards the Lister's tubercle. We used the sionary cast. Starting from the second postoperative day, a func-
superficial interval between the extensor digitorum communis tional brace for the elbow was positioned with a free range of
and the extensor carpi radialis longus and brevis, as described by motion (ROM) between 100 and 20 of flexion. The hinged brace
Kaplan. At the deep level, we proceeded by splitting the lateral protected the elbow joint from any varus/valgus deviation stress.
annular ligament complex, remaining anterior to the LCL. No LCL No load-bearing or strengthening exercises were allowed until
avulsion and/or disruption were detected at any of the two sites. early fracture healing was established, within approximately 2
Particular attention was paid in order to preserve the LCL and the months after surgery. Upon removal of the sutures at 14 days after
posterior interosseous nerve. At this point, there was no need to surgery, the patient was also allowed to come out of the brace and
release the lateral ligamentous complex from the distal aspect of perform gravity-aided and assisted flexion/extension-supination/
the humerus to achieve a better visualization of the fracture. An pronation exercises of the elbow joint.
excellent exposure of the capitellar fractures was achieved Clinical and radiographic evaluation was performed at 1, 2, 3, 6,
showing no impact and/or fragmentation of the capitulum 12 and 24 months after surgery. At each follow-up ROM in flexion/
humeri. extension and supination/pronation was recorded. After 6 months
Debridement of the free capitellar fragment was performed, and during the final follow-up, the American Shoulder and Elbow
removing any residual fibrous tissue and hematoma. The fragments Surgeons (ASES) score was also obtained. At the first month flexion/
were reduced in direct visualization, held with a dental pick and extension range was found to be 100 e5 on the right and 95 e10
then temporally fixed with the guide wires of the mini Acutrac on the left. Supination/pronation was measured 120 on the right
(Acumed, Hillsboro, OR, USA) headless screws. Definitive osteo- and 110 on the left elbow. After the second month, the fracture site
synthesis from anterior to posterior, with one headless Acutrac was considered healed, based on radiographic appearance of the
mini compression screw was realized at both sites, achieving a fracture and absence of pain on movement in both sides during
stable and anatomical reconstruction of the articular surface with clinical evaluation. ROM in flexion/extension was found to be
screws buried underneath the cartilage. During the procedure, the 140 e0 on the right and 130 e0 in the left. Supination/pronation
tip of a guide wire used for temporary fixation was previously was measured at 180 on both sides. Three months after surgery,
broken and intentionally left into the distal right humerus, result- there was 145 of flexion with full extension on the right (0 e145 ),
ing in no interference with fracture's definitive osteosynthesis. and 135 of flexion and full extension on the left side (0 e135 )
Upon fixation, elbow joint was tested in varus/valgus stress under (Fig. 3). No variation was detected for ROM at the 6, 12 and 24
fluoroscopy and found to be stable in both sides. months follow-up and the ASES score resulted 100.
 A. Are et al. / Chinese Journal of Traumatology 19 (2016) 231e234 233

Fig. 2. A: Preoperative X-rays of the left elbow in AP and lateral view. B: CT scan and 3D reconstruction. Capitulum humeri in the sagittal and coronal plane. C: Postoperative X-rays.

Fig. 3. Functional outcome at three months after surgery for both elbows.
234 A. Are et al. / Chinese Journal of Traumatology 19 (2016) 231e234

Discussion weeks of cast immobilization, the patient was put into hinged
braces. Eight weeks after surgery, a 15 extension lag on the right
Type 1 fractures were found to be the most common (84%) and 30 on the left elbow were detected. Three months after sur-
among capitellar fractures.2 Fractures of the capitulum humeri are gery, the patient lacked of 10 extension bilaterally.
difficult to recognize in the AP view and a true Lateral film is In our case, ORIF with headless screws offered a stable fixation
essential for diagnosis.3 Moreover, a CT scan including both a to the osteochondral fragment in both sides. Early physical reha-
sagittal and a coronal 3D reconstruction, provides more informa- bilitation beginning from the second postoperative day was pro-
tion regarding articular impaction and metaphyseal comminution. tected with a hinged brace for the first month. Clinical recovery was
Various methods and fixation techniques have been described for found more promising in our patient comparing to ROM reported
capitellar fractures. Closed manipulation and conservative treat- for bilateral fractures by the first three authors.8e10 In the above
ment of these injuries has been reported in some case series. This mentioned cases, elbow was immobilized for a three-week period
approach has the disadvantage of a long immobilization period that and rehabilitation of the joint was unable to restore a complete
could lead to an incomplete clinical recovery. ROM, even when a stable ORIF was achieved.10 In the most recent
ORIF with headless compression screws has shown good to case reported,11 cast was maintained for two weeks following a
excellent results.3,4 Despite the fact that closed manipulation and bilateral stable osteosynthesis of the capitulum humeri. Eight
cast immobilization seemed to be criticized, Trinh et al2 in a sys- weeks after surgery, the patient showed a 15 extension lag on the
tematic review found no statistical difference in the clinical right and 30 on the left elbow. Only at the third year during
outcome, comparing nonoperative (close reduction and immobili- postoperative follow up, ROM was found to be restored with
zation) and operative management of isolated capitellar fractures. absolutely no loss of function. Our patient experienced an excellent
Avascular necrosis (AVN), a degenerative joint disease, and het- clinical recovery, based on ROM restore, fracture healing and
erotopic ossifications are some of the complications that can occur absence of pain on both elbows, after two months of surgery with
after surgical treatment of capitulum humeri fractures.3,5 However, full extension and supination/pronation bilaterally. Moreover,
McKee et al3 found that AVN is uncommon after ORIF of these having both joints mobilized within the range of a hinged brace
fractures. In addition, even if AVN occurs, clinical outcome can still offered to our patient absolute independence in daily activities.
be satisfactory. In conclusion, in accordance with most of the authors, we
In the case of a delayed diagnosis associated with a high risk of believe that ORIF of capitellar fractures adopting headless screws is
complete osteonecrosis, excision of the fragment could be recom- the best way to achieve a stable and anatomic reconstruction in
mended. Alternatively, ORIF should be the best option using bone order to restore an early joint movement. In our opinion, if reduc-
graft augmentation.6 Humeral shear fractures have been reported tion and satisfactory stability of the fragment is achieved, rehabil-
by Giannicola et al7 as a potential pattern of complex elbow itation should be started within the second postoperative day. In
instability where eventual associated injuries of the LCL and medial the very rare case of a bilateral injury, this concept appears
collateral ligament (MCL) should be assessed. In our case, type 1A mandatory with the purpose to offer immediate functional auton-
fractures were exposed with a lateral (according to Kaplan) omy in the patient's daily living activities.
approach and the LCL was found to be intact. After fixation, stability
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