Internal fixation of a capitellar fracture using Herbert screws. A case report

Fractures of the capitellum can involve a significant portion of the articular surface, rendering the elbow joint unstable. In this situation it is desirable to reduce and internally fix the capitellar fragment, because this restores the articular surface and augments joint stability. A 35-year-old woman sustained a posterolateral dislocation of the left elbow associated with a capitellar fracture. Fixation of the capitellar fragment with Herbert screws stabilized the joint, allowed anatomic reduction, and gave good fixation. Active motion was possible at three weeks. When the patient was evaluated at one year, the fracture had united and there was no evidence of avascular necrosis.     

Articular cartilage injuries of the capitellum interposed in radial head fractures: a report of ten cases

Ten cases of Mason type I and type II isolated radial head fractures are reported, in which an unexpected cartilaginous fragment of the capitellum trapped within the radial head fracture was identified at the time of surgery. In no case was this injury pattern identified on preoperative imaging, including computed tomography in 2 cases. Five patients did have preoperative mechanical findings with forearm rotation. At surgery, all capitellar fragments were found to originate from the posterolateral capitellum. Excision of the capitellar fragment and internal fixation of the radial head fracture were performed in all cases. No sequelae were identified on short-term follow-up. This series highlights an injury pattern that should be considered in isolated nondisplaced and minimally displaced fractures of the radial head. The natural history of this finding, when treated conservatively, is unknown.     

A lateral fracture step-off of 2mm increases intra-articular pressure following tibial plateau fracture

IntroductionThe aim of this study was to evaluate the effects of increasing posttraumatic step-offs after lateral tibial plateau fracture reduction on the intra-articular pressure.Materials and MethodsIn eight fresh-frozen human cadaveric knees with intact menisci, a standardized sagittal osteotomy of the lateral tibial condyle was performed as an OTA/AO type 41-B1 fracture-model. The fragment was fixed by a customized sled including an angular stable tibia plate to evaluate step-offs from 0 mm to 8 mm in 1mm increments. In a servo-hydraulic testing machine, an axial force was applied to the tibial plateau in 0° (700N), 15° (700N), 30° (700N), 60° (350N), and 90 ° (350N) of flexion while the joint pressure was recorded by two pressure sensors.ResultsA 1mm step-off did not result in an increased joint pressure. At 60° of flexion a 2mm step-off increased the lateral joint pressure by 61.84kPa (P = 0.0027). In 30° of flexion, a 3mm step raised the lateral joint pressure by 66.80kPa (p = 0.0017), whereas in 0°, 15° and 90° of flexion, a 4mm step increased the pressure by >50kPa (P < 0.05). Concomitant medial joint pressure increments were lower than those in the lateral plateau. A significant increase of 19-24kPa in the medial joint pressure was detected in 90° of flexion with a 1mm lateral step (P = 0.0075), in 15° and 60° of flexion with a 2mm step (P < 0.05), in 0° of flexion with a 4mm step (P = 0.0215) and in 30° of flexion with a 7mm step (P = 0.0487).ConclusionLateral fracture step-offs of 2mm or larger should be reduced intraoperatively to avoid large increases in lateral joint pressure.     

Choice of surgical approach for capitellar fractures based on pathoanatomy of fractures: outcomes of surgical management

The understanding of the anatomic configuration of the fractures of the capitellum has enhanced in the last few years, and the classification of these fractures continues to evolve. It is essential to tailor the surgical approaches to these fractures based on the state-of-the-art classifications. Thirty-three patients with fractures of the capitellum were included in this retrospective study. The mean age of the patients was 37.9 years, and the mean follow-up period was 24.6 months. Seventeen patients had Bryan–Morrey type I fracture, three had type II fracture, two had type III fracture and eleven had type IV fracture. Of the 11 patients with Bryan–Morrey type 4 fracture, 5 patients belonged to Dubberley 2A and 3A category and 6 patients belonged to Dubberley 2B and 3B category. Bryan–Morrey type 1, 2 and 3 fractures were approached via extended lateral approach. Bryan–Morrey type 4 was further classified using the Dubberley classification. Dubberley 2A and 3A fractures were approached via the anterolateral approach, and Dubberley 2B and 3B fractures were approached via the posterior transolecranon approach. Fracture united in all patients. Three patients showed slight delay in union, but union was achieved eventually. Two patients had avascular necrosis of the capitellar fragment. The mean range of flexion/extension was 133° (SD ± 8.0°), and pronation/supination was 151° (SD ± 6.7°). The mean Mayo Elbow Performance Index at final follow-up was 80.9 (SD ± 13.9). Based on the MEPI score, 14 patients had excellent, 10 patients had good, 6 patients had fair and 3 patients had poor results (Dubberley type 3B fractures). Correct choice of surgical approach facilitates the accuracy of reduction and fixation of these difficult fractures. It also helps to minimize the requirement of two-incision approach. Anterolateral approach is an excellent approach for Dubberley 2A and 3A fractures. Level of evidence: Level IV.     

Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating

Background

The volar lunate facet fragment of a distal radius fracture may not be stabilized with volar-locked plating alone due to the small size and distal location of the fragment. Identification and stabilization of this small fragment is critical as unstable fixation may result in radiocarpal and radioulnar joint subluxation. The addition of spring wire fixation with volar plating can provide stable internal fixation of this critical fracture fragment.

Methods

A retrospective review (2006–2011) identified nine patients with distal radius fractures with an associated volar lunate facet fragment that were treated with volar-locked plating and spring wire fixation of the volar lunate facet fragment. Radiographic indices, range of motion, grip strength, and postoperative Patient-related wrist evaluation (PRWE) scores were obtained to assess pain and function.

Results

All distal radius fractures healed, and the volar lunate facet fragment reduction was maintained. The mean follow-up was 54 weeks. Mean active range of motion was 46° wrist flexion, 51° wrist extension, 80° pronation, and 68° supination. The mean grip strength was 21 Kg, achieving 66 % of the uninjured limb. The average PRWE score was 17. No patient required removal of hardware or had evidence of tendon irritation.

Conclusions

The addition of spring wire fixation to volar-locked plating provided stable fixation of the volar lunate facet fragment of distal radius fractures without complication. This technique addresses a limitation of volar-locked plating to control the small volar lunate facet fragment in distal radius fractures otherwise amenable to volar plating.

Level of Evidence

A retrospective case series, Level IV.     

Capitellar fracture with bony avulsion of the lateral collateral ligament in a child: Case report

IntroductionIsolated capitellar fracture is a rare injury accounting for 1% of all elbow fractures Bryan and Morrey (1985) and Poynton et al. (1998). In children, a fall on an outstretched hand, before the fusion of the epiphysis, usually leads to lateral condyle physeal fractures. Very few cases of capitellar fractures in the paediatric population have been reported.Presentation of caseOur patient, a 9-year-old girl presented with a capitellar fracture and lateral collateral ligament (LCL) avulsion of her left elbow. A type IV capitellar fracture, indicated by the double arc sign on the radiogram, was confirmed with 3-dimensional computed tomography. The patient underwent open reduction through a lateral approach and fixation with 2 Herbert’s screws. The lateral collateral ligament (LCL) avulsion was repaired with 2 suture anchors. Early mobilization and rehabilitation were started soon after the surgery. Follow-up radiography showed union of the fracture with no signs of osteonecrosis.DiscussionCapitellum fracture in children is easily overlooked due to its rarity. And hereby, meticulous history, clinical examination and proper radiological views with high index of suspicion is crucial in order diagnose these injuries. Our patient had type IV capitellar fracture with lateral collateral ligament avulsion. Principles of management of these intra articular fractures include accurate reduction, stable fixation and early mobilization. We used an extensile lateral approach to expose, reduce and fix the fracture. LCL avulsion was fixed with 2 suture anchors.ConclusionCapitellum fractures are rare injuries in children. Careful evaluation and proper stable fixation are the cornerstones of good functional results.     

肱骨小头移位骨折手术治疗的疗效分析

目的 探讨手术治疗肱骨小头骨折的固定方法和疗效.方法 自2004年12月至2006年12月手术治疗肱骨小头骨折16例,男8例,女8例;年龄16～65岁,平均44.9岁;按Bryan-Money分型:Ⅰ型8例,Ⅲ型1例,Ⅳ型7例.手术时间为伤后5天以内.手术经外侧入路,骨折复位后,AO拉力螺钉固定.所有患者均为新鲜闭合性骨折,无神经、血管损伤.术后根据Broberg-Money肘关节功能评分标准进行疗效评价,同时记录肘关节的屈伸活动度,前臂旋转度以及内侧稳定性.同时进行影像学评估.结果 16例手术中未发现合并有外侧副韧带损伤,均无血管、神经损伤,术后伤口一期愈合.全部病例均获得随访,随访时间24～36个月,平均29个月.骨折临床愈合时间6～11周,平均7.9周.无一例骨折畸形愈合及延迟愈合,未见肱骨小头缺血性坏死.1例有创伤性关节炎表现.术后随访肘关节屈伸活动度平均为125.8°±16.8°,前臂旋转度平均为163.1°±10.62°.术后Broberg-Money评分平均92.0分,优8例,良7例,差1例.15例患者恢复到受伤前日常的活动水平,9例患者报告可重新继续以往的健身运动.1例术后出现肘关节僵硬.结论 肱骨小头骨折的治疗需按分型计划手术;术中解剖复位和牢固固定,早期肘关节功能锻炼,近期疗效满意.     

Fatigue fractures in the area of the hip joint in joggers

An increased incidence of fatigue fractures of the lower extremities has been observed as a result of the jogging craze. The authors describe a fatigue fracture of the neck of the femur and a fracture dislocation (not described to date) of the hip joint with fracture of the posterior acetabular margin and avulsion of a femoral head fragment.     

Surgical outcomes of retrograde nailing enhanced with minimally invasive cerclage cable fixation for infra-isthmal femoral fracture

BackgroundInfra-isthmal femoral fracture has been known as one of the risk factors for femoral nonunion. Retrograde intramedullary nailing can provide reliable stability of the distal fragment in infra-isthmal femoral fracture, but adequate reduction is required to achieve a successful outcome. This study aimed to evaluate the surgical outcomes of retrograde nailing enhanced with minimally invasive cerclage cable fixation for infra-isthmal femoral fracture.MethodsBetween March 2013 and July 2017, 15 patients with infra-isthmal fractures treated with retrograde nailing and minimally invasive cerclage cable fixation were included in this study. Cerclage cable was applied for reduction aid (reduction cable) or prevention of further displacement in non-displaced extension of the distal spiral fracture (prevention cable). Number and function of cerclage cables, operation time, additional surgery, and complications were assessed. Further displacement of the wedge after nailing, coronal and sagittal alignment, displacement of the main fragment, and time from injury to union were evaluated as radiologic outcomes.ResultsOf the 15 patients in this study, 14 were treated with reduction cables. Average postoperative coronal and sagittal angulation was 1.7° (1° varus to 4° valgus) and 1.6° (2° flexion to 11° extension). Mean displacement between the main fragments was 3.5 mm (range 0–22 mm). Four of the 14 cases used additional prevention cables combined with reduction cable. Only one case was treated solely with a prevention cable. A total of five prevention cables were maintained without further displacement. All patients achieved bone union, and the average time to union was 22.7 weeks (range 9–44 weeks). There were no complications as a result of surgery, such as infection or major neurovascular injury.ConclusionsThe minimally invasive cerclage cable technique could be a useful and safe enhancement in retrograde nailing for infra-isthmal femoral fracture in order to prevent further displacement and to reduce the main fracture.     

Mini hook plate fixation for palmar fracture-dislocation of the proximal interphalangeal joint

Fracture-dislocations of the proximal interphalangeal joint are challenging to treat, since it is difficult to achieve both rigid fixation and early joint motion simultaneously. Palmar fracture-dislocations of the proximal interphalangeal joint are less frequent injuries and a small number of treatment methods have been reported. We describe here a patient with a chronic palmar fracture-dislocation of the proximal interphalangeal joint, who was treated with a new surgical technique. In the surgery, a mini hook plate that was made by adapting a 1.5 mm AO hand modular system straight plate was used. Despite the thinness of the fragment, rigid fixation was achieved, resulting in early active motion. At final follow up, the active ranges of motion were 0°–100° at the proximal and 0°–80° at the distal interphalangeal joint, and there were no complications. This technique may become a useful surgical method to treat palmar fracture-dislocations of the proximal interphalangeal joint.     

Absorbable implants in surgical correction of a capitellar malunion in an 11-year-old: a case report

We present the case of an 11-year-old girl who had a corrective osteotomy reconstruction using absorbable implants for a malunited capitellar fracture 3-1/2 months after a dislocation of her elbow joint. This operative stabilization enabled early joint mobilization and, finally, excellent results in terms of anatomy and function at a 2-year follow-up. We were not able to find any similar report in the English literature dealing with corrective osteotomy reconstruction using absorbable implant fixation for a malunited capitellum in a child.     

Treatment of type III middle phalangeal neck fractures through a palmar approach: a case report

Phalangeal neck fractures occur almost exclusively in children. We present the case of a 49 years old man with a dislocated fracture of the neck of the middle phalanx with the distal fragment rotated at 180°, due to a traumatic circular saw injury to the left index, which was solved by anatomical reduction and bone fixation with two 1.5 mm Synthes screws and a temporary transarticular Kwire at the distal interphalangeal joint. Zone Iflexor digitorum profundus repair was performed using a modification of the Kessler 4-strands core suture and a full-thickness skin graft from the hypothenar eminence was taken to cover the skin gap. At 6-month follow-up the patient was pain-free and with a total active movement equivalent to 190°. No radiological signs of avascular necrosis of the head of the middle phalanx or nonunion of the distal fragment was detectable with recovery to the previous manual work. Owing to the position of the phalangeal head maintained in position by the collateral ligaments an anatomic reduction from dorsal approach is difficult to be performed and a longitudinal traction can render the reduction harder too. The volar approach permits an easier reduction of the fracture through a derotation of the distal fragment facing palmar.     

Neue Möglichkeiten in der operativen Therapie von Fersenbeinfrakturen

Operative management of intra-articular calcaneal fractures is becoming increasingly widely established. Such treatment can only be successful if exact anatomical repositioning of the fracture fragments with reconstruction of the length and the angle of the joint of the tuber calcanei and, especially, of the subtalar joint is achieved. The mobile Siremobil^® Iso-C3D is the first device to permit intraoperative 3D visualization of the fracture, and it has become an important aid to exact anatomical repositioning of the fracture fragments. Any dislocation that persists after realignment can be detected and corrected at a very early stage. The realignment achieved can be maintained in the long term with the use of a fixed-angle implant. From October 2002 to May 2004, a total of 49 patients had fractures of the calcaneus treated surgically by internal fixation with fixed-angle plates. 3D Imaging was used during all these operations. On average, the angle of the tuber was improved by 16°. In 18 cases the intraoperative 3D imaging revealed dislocations by more than 1 mm, which we were able to correct. Secondary dislocation of the central fragment did not occur in any of these cases.     

Fixation of capitellar fractures with the Herbert screw

Summary Five fractures of the capitellum were fixed with a Herbert screw. Three patients had a type 1 fracture and two patients had a type 2 fracture. In four patients the fragment was fixed by insertion of the screw from the lateral epicondyle towards the joint line, with good clinical and radiological results. In one patient the fragment was fixed from the joint line. The fragment underwent avascular necrosis with poor clinical result.     

Neglected isolated fracture of the trochlea humeri

A 15 years old girl was found to have isolated trochlea fracture 10 weeks after an injury caused by a fall on her left elbow. Movement of the elbow was severely restricted. Radiographs showed a half moon-shaped and anterosuperiorly displaced osteochondral fragment. Medial approach capsulotomy of the elbow and excision of the intraarticular adhesions were done to expose the isolated trochlea fracture. Headless screws were used for fixation, combined with bone grafting. The follow-up showed union and excellent functional recovery of the elbow. Isolated trochlea fracture in adults is rare and usually associated with capitellar fractures and/or elbow dislocations. A neglected trochlea fracture is rarely reported in the English language literature to the best of our knowledge. Recognition of isolated trochlea fracture is vital to apprehend the pathomechanics of the injury and to devise a suitable treatment approach.     

Fracture–luxation complexe de l’articulation interphalangienne proximale. À propos d’un cas et mise au point sur les fractures–luxations palmaires interphalangiennes proximales

The palmar fracture-dislocation of the proximal interphalangeal (PIP) joint of fingers is an uncommon injury. We report a complex form in a 16-year old teenager, associating a palmar fracture-dislocation and a fracture of the base of the middle phalanx with the dorsal fragment dislocated between the neck of the proximal phalange and the palmar plate. The management was surgical with open reduction and fixation of the fragments by K-wires and temporary PIP arthrorisis. The result at 6 months of follow- up after removal of the wires and physiotherapy was satisfactory. The patient was painless with a range of motion of 115°. Clinically, the sagittal and frontal stability of the joint both in flexion and extension was maintained. Osseous healing was obtained on X-ray control. The patient went back to his usual activities. A focus on palmar fracture-dislocations of PIP joint is presented through incidence, mechanism and treatment.     

Surgical treatment of type I capitellar-humeral fractures using the Henry ventral approach approach. Short- and medium-term results

Capitellar fractures are rare. Despite adequate surgical treatment, patients suffer frequently from limited range of motion, osteonecrosis, and neurological deficits. The purpose of this retrospective study was to evaluate short- and medium-term surgical results in seven patients who had type I capitellar fractures according to Bryan and Morrey. All patients were treated via an anterior approach, according to Henry, and open reduction and internal fixation with two screws.Seven patients were examined clinically, neurologically, and radiologically after 10-65 months. The fracture healed in all patients. None of the patients had a neurological deficit. According to the Morrey Score, five of seven patients had an excellent or good functional result. Open reduction and internal fixation with two screws via the Henry approach is a suitable option for surgical treatment for type I capitellar fractures.     

Anterior approach for fixation of isolated type III coronoid process fracture

Authors chose anterior approach through the antecubital fossa for better exposure in that case of isolated coronoid process fracture. The objective of the study was to report validity of anterior approach for the Regan and Morrey type III, isolated fracture of the coronoid process of the ulna without residual valgus or varus instability. From January 2007 and January 2010, we evaluated eleven consecutive patients (7 men, 4 women; mean age 44 years; range 25–67 years) who underwent surgical fixation through the anterior approach. The mean follow-up period was 21 months (range 15–34 months). Preoperative and follow-up roentgenograms were evaluated for assessment of the fracture configuration and confirmation of fracture union. Clinical evaluation included an analysis of surgical complication, range of motion, Mayo elbow performance score, and DASH (disability of the arm, shoulder, and hand) score. Fractures were mainly fixed with plate and screws in 8 cases, cannulated screws in 3 cases. There was no residual joint instability after fracture fragment fixation. All fractures were united, and the average union time was 15.2 weeks with a range of 11–20 weeks. Mean flexion contracture of the elbow was 3.6° (range 0°–10°), and further flexion was 130.9° (range 125°–140°) at the last follow-up. Mean Mayo elbow performance score was 92.3 (range 80–100 points), and mean DASH score was 5.9 (range 1.6–8.3 points). In conclusion, Primary fixation of the coronoid process fractures through the anterior approach could be particularly useful in the Regan and Morrey type III isolated coronoid process fractures.     

Operative Versorgung von Capitulum-humeri-Typ-I-Frakturen über den ventralen Zugang nach Henry

Capitellar fractures are rare. Despite adequate surgical treatment, patients suffer frequently from limited range of motion, osteonecrosis, and neurological deficits. The purpose of this retrospective study was to evaluate short- and medium-term surgical results in seven patients who had type I capitellar fractures according to Bryan and Morrey. All patients were treated via an anterior approach, according to Henry, and open reduction and internal fixation with two screws. Seven patients were examined clinically, neurologically, and radiologically after 10–65 months. The fracture healed in all patients. None of the patients had a neurological deficit. According to the Morrey Score, five of seven patients had an excellent or good functional result. Open reduction and internal fixation with two screws via the Henry approach is a suitable option for surgical treatment for type I capitellar fractures.