Minimum four-year clinical outcomes after on-table reconstruction technique for Dubberley type III in coronal shear fractures of the capitellum and trochlea: a report of 10 patients.

PURPOSE: Comminuted coronal shear fractures of the distal humerus represent rare injuries and are difficult to treat, especially comminuted capitellum and trochlear fractures (Dubberley Type III). The on-table reconstruction technique of comminuted articular fractures may be an option, although it has not been reported in the coronal shear fracture of the distal humerus. The aim of the present case series is to determine the functional and radiological outcomes of on-table reconstructed Dubberley III fractures. METHODS: A retrospective review was conducted of 10 patients with Dubberley type III fractures in coronal shear fractures of the capitellum and trochlea who underwent an 'on-table' reconstruction technique between January 2009 and October 2019. All patients were evaluated using the disabilities of the arm, shoulder, and hand (DASH) score, American Shoulder and Elbow Surgeons(ASES) score, Mayo Elbow Score Performance Index (MEPI) score and at least 4 years later. RESULTS: All cases achieved union. At the final follow-up, the mean range of elbow motion was 11.5°of flexion contracture and 131.9° of further flexion. The mean DASH score was 21.2 (5.7) points (range 13.3-32.5). The mean ASES score was 88.6 ± 7.4 (range, 77 to 100). The mean MEPI score was 87 (10) points (range 70-100). In complication, partial osteonecrosis of capitellum is developed in one patient. One patient had heterotopic ossification without functional impairment. CONCLUSION: The on-table reconstruction technique can be a reliable option in the surgical treatment of complex distal humerus fractures. This technique allows anatomical reduction of comminuted capitellum and trochlea, with a low risk of avascular necrosis over 4 years of follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Clinical Outcomes and Management Strategies for Capitellum and Trochlea Fractures: A Systematic Review.

Purpose: Capitellum and trochlea fractures, also referred to as coronal shear fractures of the distal humerus, are infrequent yet challenging intra-articular fractures of the elbow. There are a variety of surgical approaches and fixation methods with often variable outcomes. This systematic review investigates interventions, outcomes and complications of capitellum and trochlea fractures. Methods: A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the clinical outcomes of capitellum and trochlea fractures managed surgically. Data on patient demographics, surgical approach, implant usage, postoperative outcomes and complications were compiled. Results: Forty-one studies met the inclusion criteria with a total of 700 patients. Surgical interventions primarily utilized either the lateral (79%) or antero-lateral (15%) approaches with headless compression screws as the most common fixation method (68%). Clinical outcomes were measured using the Mayo Elbow Performance Index (MEPI) with a mean score of 89.9 (±2.6) and the DASH score with a mean of 16.9 (±7.3). Elbow range of motion showed a mean flexion of 126.3° (±19.4), extension of 5.71° (±11.8), pronation of 75.23° (±12.2), and supination of 76.6° (±9.8). The mean flexion-extension arc was 113.7° (±16.9), and the mean pronation-supination arc was 165.31° (±9.41). Complications occurred in 19.8% of cases, with re-interventions required in 8.3% of cases, mainly due to symptomatic implants and elbow stiffness requiring surgical release. Other complications included implant removal (10.4%), overall reported stiff elbows (6%), nerve palsies (2%), non-union (1.5%), and infection (1.2%). Conclusion: The treatment of capitellum and trochlea fractures yields satisfactory outcomes but has a considerable rate of complications and reoperations primarily due to symptomatic implants and elbow stiffness. There is noteworthy variability in the achieved range of motion, suggesting unpredictable outcomes. Deficits in functionality and range of motion are common after surgery, especially with more complex injury patterns.

A novel variant of type-II Monteggia equivalent in an adult: A case report with a 6-year follow-up.

Case: An 18-year-old right-handed male student presented after a road-traffic-accident; he had type-II Monteggia fracture dislocation associated with ipsilateral type-I capitellum fracture and comminuted lateral condyle avulsion fracture. He underwent open reduction and fixation of ulna with 3.5 DCP with autologous olecranon bone grafting and fixation of capitellum using Herbert screw along with lateral collateral ligament (LCL) repair using fiber wire. At 6-years follow-up good outcome was seen without functional restrictions despite 15 degrees of restriction in pronation. Conclusion: Monteggia type-II variant with type-I capitellum fracture and LCL avulsion is a unique combination that represents a novel variant of type-II Monteggia equivalent, which adds to the existing classification of Monteggia equivalents.

Optimal Screw Orientation for Fixation of Coronal Shear Fractures: A Biomechanical Comparison.

OBJECTIVE: Coronal shear fractures of the capitellum are rare injuries which can be challenging to treat. The aim of this study was to compare the biomechanical properties of different internal screw fixation techniques for Dubberley type IA fractures of the capitellum. METHODS: In this biomechanical study, Dubberley type IA fractures of the capitellum were created in 30 human fresh-frozen humeri. The specimens were then divided into three groups: fixation was either performed with 3 x 3.0 mm headless cannulated compression screws (HCCSs) in anteroposterior (AP) orientation (AP group), 3 x 3.0 mm HCCSs in posteroanterior (PA) orientation (PA group) or with 2 x 3.0 mm HCCSs in PA orientation and 1 x 3.0 mm HCCS in lateral orientation (LAT group). Displacement under cyclic loading and ultimate load-to-failure were evaluated in all specimens. RESULTS: There was no significant difference in fragment displacement after 2000 cycles between AP and PA groups (0.8 ± 0.5 mm vs. 0.8 ± 0.6 mm; p = 0.987) or PA and LAT groups (0.8 ± 0.6 mm vs. 0.8 ± 0.3 mm; p = 0.966). LAT group showed the highest load-to-failure (548 ± 250 N) without reaching statistically significant difference to AP group (388 ± 173 N; p = 0.101). There was also no significant difference between AP and PA groups (388 ± 173 N vs. 422 ± 114 N; p = 0.649). CONCLUSIONS: Variations in screw placement had no statistically significant influence on cyclic displacement or load-to-failure in Dubberley Type IA fractures. However, fracture fixation in two planes - both the coronal and the sagittal plane - by adding a screw in a lateral to medial direction may be beneficial to increase primary stability.

Surgical Management of a Three-Month-Old Mal-United Dubberley Type 2A Distal Humerus Fracture: A Case Report.

Fractures of the capitellum and trochlea are not common in orthopedic trauma and pose certain difficulties to address and manage. On primary x-rays, these fractures are commonly missed, and patients may be treated inadequately resulting in a restricted range of motion. The current case report presents the surgical outcome and challenges faced while managing a 30-year-old male patient with a mal-united capitellum, trochlea, and lateral condyle of humerus fracture. The patient had come with complaints of a restricted range of motion in his dominant hand which affected his livelihood. After undergoing adequate investigations, the patient was posted for an open reduction and internal fixation. The approach used for the procedure and the challenges faced during the surgery have been elaborated in the case report. The patient had shown an increase in the range of motion which was maintained at six- and nine-month follow-ups. Thus, it states that patients with trochlea and capitellum fractures presenting late and having a restricted range of motion can be managed adequately with good outcomes after proper planning.

The Operative Management of Capitellum Fractures.

Capitellum fractures represent fewer than 1% of elbow fractures. Most commonly, these fractures occur secondary to either axial loading with the elbow fully extended or direct impact to the lateral aspect of the elbow. Numerous classification systems exist, with many types and subtypes. Since capitellum fractures are uncommon and fracture type varies widely, there is a lack of consensus with regard to treatment recommendations. We present a case series of seven patients with capitellum fractures, who presented between January 2016 and August 2020 to Addenbrooke's Hospital (Cambridge, the United Kingdom). All patients were female, with an average age of 33 years. In each case, the affected elbow joint was immobilised using a backslab before open reduction and internal fixation (ORIF) was performed. Joint mobility was recorded both on the day of the injury and at clinic review postoperatively (first at two weeks and then at between four and eight weeks). The Oxford Elbow Score (OES) was measured retrospectively, relating to (1) before the injury and (2) six months after fracture reduction. ORIF was associated with a near-full return of pronation and supination by eight weeks, with flexion-extension also improving significantly. The Oxford Elbow Score at six months reached 82.0% of pre-injury scores. Overall, our results suggest that ORIF is a well-tolerated and effective treatment strategy for capitellum fractures. Future studies with a greater sample size are required to assess the outcomes across a longer period, to determine whether outcomes are maintained and continue to improve.

Rehabilitation and return to sport criteria following surgical treatment of osteochondritis dissecans of the capitellum: a systematic review.

Background: Osteochondritis dissecans (OCD) of the capitellum is a well-described condition that most commonly affects adolescent throwing athletes and gymnasts. There is no gold standard rehabilitation protocol or timing for return to sport (RTS) after surgical management of OCD of the capitellum. Hypothesis/Purpose: The purpose of the study was to identify in the existing literature any criteria used for RTS following surgical treatment of OCD of the capitellum. The hypothesis was that surgeons would utilize length of time rather than functional criteria or performance benchmarks for RTS. Methods: Level 1 to 4 studies evaluating athletes who underwent surgery for OCD of the capitellum with a minimum follow-up of 1-year were included. Studies not describing RTS criteria, including less than 1-year follow-up, non-operative management only, and revision procedures were excluded. Each study was analyzed for RTS criteria, RTS rate, RTS timeline, sport played, level of competition, graft source (if utilized), and postoperative rehabilitation parameters. Assessment of bias and methodological quality was performed using the Coleman methodology score and RTS value assessment. Results: All studies reported a rehabilitation protocol with immobilization followed by bracing with progressive range of motion. RTS rate was 80.9% (233/288). The majority of studies reported using time-based criteria for RTS (11/15). The most commonly reported timeline was 6 months (range: 3-12 months). Conclusion: The overall RTS rate after surgical treatment of capitellar OCD is high with no consensus on RTS criteria. The two most consistent RTS criteria reported in the literature are return of elbow range of motion and healing demonstrated on postoperative imaging. There is a wide range of time to RTS in the literature, which may be sport dependent. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.

Update in diagnosis, treatment, and prevention of osteochondritis dissecans of the capitellum.

Osteochondritis dissecans of the capitellum is debilitating and is a potentially sports career-ending injury in a young and athletic population. Osteochondritis dissecans typically occurs in patients between the ages of 10 and 24 years, and boys are more commonly affected than girls. Conventional radiographs have low diagnostic accuracy, and magnetic resonance imaging (with or without contrast) or computed tomography may aid in accurate diagnosis. The primary indication for non-operative treatment is the presence of an intact cartilage cap on magnetic resonance imaging, indicating a "stable lesion." However, if operative treatment is necessary, various surgical procedures are available when operative treatment for an osteochondritis dissecans of the capitellum is considered, including open or arthroscopic removal of loose bodies, with or without microfracturing, fragment fixation, osteochondral autograft transplantation, and osteochondral allograft transplantation. The decision-making process for selecting the appropriate treatment considers factors such as the patient's characteristics, functional limitations, and lesion morphology.

Deep learning-based osteochondritis dissecans detection in ultrasound images with humeral capitellum localization.

PURPOSE: Osteochondritis dissecans (OCD) of the humeral capitellum is a common cause of elbow disorders, particularly among young throwing athletes. Conservative treatment is the preferred treatment for managing OCD, and early intervention significantly influences the possibility of complete disease resolution. The purpose of this study is to develop a deep learning-based classification model in ultrasound images for computer-aided diagnosis. METHODS: This paper proposes a deep learning-based OCD classification method in ultrasound images. The proposed method first detects the humeral capitellum detection using YOLO and then estimates the OCD probability of the detected region probability using VGG16. We hypothesis that the performance will be improved by eliminating unnecessary regions. To validate the performance of the proposed method, it was applied to 158 subjects (OCD: 67, Normal: 91) using five-fold-cross-validation. RESULTS: The study demonstrated that the humeral capitellum detection achieved a mean average precision (mAP) of over 0.95, while OCD probability estimation achieved an average accuracy of 0.890, precision of 0.888, recall of 0.927, F1 score of 0.894, and an area under the curve (AUC) of 0.962. On the other hand, when the classification model was constructed for the entire image, accuracy, precision, recall, F1 score, and AUC were 0.806, 0.806, 0.932, 0.843, and 0.928, respectively. The findings suggest the high-performance potential of the proposed model for OCD classification in ultrasonic images. CONCLUSION: This paper introduces a deep learning-based OCD classification method. The experimental results emphasize the effectiveness of focusing on the humeral capitellum for OCD classification in ultrasound images. Future work should involve evaluating the effectiveness of employing the proposed method by physicians during medical check-ups for OCD.

"Transcranial Direct Current Stimulation (tDCS) in managing pain and recovery: A clinical case of radial capitellum fracture".

INTRODUCTION: The management of pain and functional recovery following a radial capitellum fracture poses a significant clinical challenge, especially in individuals whose professions, such as physiotherapy, demand optimal joint functionality. Transcranial Direct Current Stimulation (tDCS) emerges as a potential non-pharmacological intervention for pain management, necessitating exploration in the context of orthopedic injuries. CASE PRESENTATION: A 41-year-old male physiotherapist presented with a MASON 2 radial capitellum fracture following a fall, experiencing notable pain (NPRS 6/7) and functional impairment (DASH 45/100, PRTEE 43/100). Conservative management, involving immobilization and potential surgical consideration, was employed, followed by tDCS for pain management. Post-tDCS, significant improvements were observed in pain and functional scores (NPRS to 0, DASH to 14.2, PRTEE to 7), alongside enhancements in range of motion and muscle strength. CLINICAL DISCUSSION: The application of tDCS showcased notable efficacy in pain reduction and functional improvement, highlighting its potential in augmenting pain management strategies post-fracture. However, the variability in responses and lack of standardized application protocols necessitate further research to optimize its clinical utility. The balance between immobilization for fracture healing and mobilization for preventing stiffness and facilitating recovery was pivotal in managing the fracture and ensuring functional improvement. CONCLUSIONS: This case underscores the potential of tDCS in managing pain and facilitating functional recovery in radial capitellum fractures, warranting further exploration and standardization of its application in clinical practice. The integrated, patient-centric approach, involving interdisciplinary collaboration and personalized care, was crucial in ensuring positive outcomes and provides a framework for managing similar orthopedic cases.

Current concepts: pathology in the overhead athlete's lateral elbow.

The lateral elbow is subjected to increasing compressive force in response to repetitive valgus stress. Alterations or deficiencies in overhead mechanics and the kinetic chain may predispose an athlete to injury. Evaluation includes a focused elbow physical examination and imaging, supplemented by a robust screening of core strength, balance, and mechanics of the kinetic chain. Treatment of osteochondritis dissecans, a common lateral elbow pathology, varies based on stability of the lesion, with variable, but often positive outcomes. Proper pitching mechanics, kinetic chain integrity, and workload management provide potential opportunities for prevention.

Surgical approaches to the capitellum: a comparative anatomic study.

BACKGROUND: Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach). METHODS: The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach. RESULTS: The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface. CONCLUSION: Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.

A Comparison of Treatment of OCD Lesions of the Capitellum With Osteochondral Autograft and Allograft Transplantation.

Osteochondritis dissecans (OCD) of the capitellum occurs relatively infrequently but can be found in young overhead-throwing athletes, most commonly in baseball players and gymnasts. Although non-operative management can effectively treat stable lesions, unstable lesions can lead to debilitating symptoms of the elbow and diminished quality of life without surgical intervention. This article reviews methods of treating OCD of the capitellum categorized by stability, size, and patient characteristics, and seeks to familiarize the reader with the appropriate selection of osteochondral allograft versus autograft in treating large, unstable lesions. We complement this review with 3 case examples, each using either an osteochondral autograft or allograft, and discuss the decision-making methodology used in each case.

Detection of Factors Related to the Development of Osteochondritis Dissecans in Youth Baseball Players Screening.

On-field screening for 'elbow injury in baseball', a condition commonly seen in youth baseball players, was conducted over two years on 160 elementary school students in Ibaraki Prefecture, Japan. This on-field screening was conducted in collaboration with the Ibaraki Prefecture High School Baseball Federation. Pitchers, catchers, symptomatic players, and players who had previously experienced elbow pain were given a comprehensive evaluation that included a physical exam and ultrasound. Out of the 135 students who were successfully screened, 10 were diagnosed with osteochondritis dissecans of the humeral capitellum (OCD). Notably, seven among these were asymptomatic. This assessment identified limited range of motion and pain when extending their elbow as significant risk factors for OCD. An attempt at on-field screening for baseball elbow injuries in collaboration with the local baseball federation was introduced. The risk factors for OCD were identified. Considering these factors, more efficient screening will be possible in the next attempt.

Surgical treatment of Hahn-Steinthal fracture using Herbert screws.

Hahn-Steinthal fractures are rare and often neglected. Their initial management should be early, given the relatively high complication rate. We report eight cases of type I capitellum fractures treated by Herbert screw fixation. Between 2019 and 2022, we selected eight patients (six men and two women) with a mean age of 25 years (18-40 years). The mean follow-up was 2 years (1-3 years). Clinical results were assessed using the Mayo Clinic Elbow Performance Score (MEPS). The mean arc of mobilitý was 135° (105°-150°) for flexion/extension and 161° (150°-175°) for pronosupination. The mean MEPS was 90.6 points, with seven excellent results and one good result. The aim of this study was to highlight the good results of Herbert screw fixation technique in the management of Hahn-Steinthal fractures.

Rate of Complications After Capitellum Fracture Fixation: A Systematic Review and Meta-Analysis.

PURPOSE: This systematic review aimed to determine the incidence of complications following surgical fixation of an acute capitellum fracture. We secondarily aimed to compare the complication rate between anterior-to-posterior (A-P) versus posterior-to-anterior (P-A) screw insertion. METHODS: PubMed, EMBASE, and Scopus were searched to identify studies on surgical fixation of capitellum fractures in skeletally mature patients. The main outcome was the rate of complication after fracture fixation. Subgroup analysis was performed to assess the impact of the fixation technique on the outcomes after surgery. An inverse variance method using random or fixed effects models was used to perform a meta-analysis based on the degree of heterogeneity between studies. Study heterogeneity was evaluated using Q statistics to calculate the I2 index. RESULTS: We included 42 studies in the final analysis. The most reported complications after surgical fixation of capitellum fractures included elbow pain (21%), radiocapitellar arthritis (19%), hardware removal (17%), and heterotopic ossification (13%). When groups were stratified based on the direction of screw insertion, the mean rate of avascular necrosis was higher in the P-A direction (29% vs 11%). In comparison, the rate of revision fixation (2.9% vs 6.7%) and heterotopic ossification (7.3% vs 22%) were higher in the A-P direction. Transient posterior interosseous nerve palsy was reported in four patients in four studies, of whom three patients had A-P screw fixation. CONCLUSION: Fixation of a displaced capitellum fracture is recommended when possible. However, patients should be counseled about the potential risk of complications and chances of undergoing an unplanned surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Fractura de capitellum en el adulto

Introducción: La fractura del extremo distal del húmero afecta la superficie articular y puede provocar incapacidad biomecánica de la articulación si no se trata adecuadamente. Objetivo: Presentar una paciente con fractura del capitellum, tratada mediante osteosíntesis. Presentación del caso: Paciente femenina de 49 años que se cayó sobre su mano en extensión. Presentó dolor intenso en el codo izquierdo y se le diagnosticó una fractura del capitellum desplazada. Se trató con osteosíntesis. Conclusiones: El tratamiento mediante osteosíntesis de la fractura del capitellum constituye la mejor opción para la rápida rehabilitación del paciente.

Introduction: The fracture of the distal end of the humerus affects the articular surface and it can cause biomechanical disability of the joint if it is not treated properly. Objective: To report the case of a patient with capitellum fracture, treated by osteosynthesis. Case report: This is the case of a 49-year-old female patient who fell on her outstretched hand. She complained of severe pain in her left elbow and she was diagnosed with a displaced capitellum fracture. The pateinmet was treated with osteosynthesis. Conclusions: The treatment by osteosynthesis of the capitellum fracture is the best option for the rapid rehabilitation of the patient.