The anterior limited approach of the elbow for the treatment of capitellum and trochlea fractures: Surgical technique and clinical experience in eight cases

Highlights

• Coronal fractures of the distal part of the humerus involving the capitellum and the trochlea are complex injuries.

• We present an alternative to Henry's anterior approach, bypassing the major vasculo-nervous structures of the anterior surface of the elbow.

• In fractures of the distal humerus, the position of the limb in extension during surgery facilitates the reduction of the articular fragments.

• Through an anterior approach, the placement of the definitive implants is done in a plane perpendicular to the fracture from anterior to posterior.

• Associated injuries (fracture of the coronoid process and the head of the radius) may be treated through the anterior approach of the elbow.

Abstract

When a coronal fracture affects the capitellum and the trochlea, the Kocher lateral approach may be inadequate for the correct visualisation, reduction and fixation of the fracture. In such cases an associated medial elbow approach may be required, or a posterior transolecranon approach may be preferred. The anterior limited approach to the elbow (ALAE) could be a valid option when treating these types of fracture, as it does not involve the detachment of any muscle group or ligament, thereby facilitating the recovery process. We can also treat associated injuries such as fractures of the radial head or coronoid process with this approach.

We describe the surgical technique and the functional outcome of eight patients with a mean of 66 years of age (range, 53–76) who where treated with open reduction and internal fixation for capitellar and trochlear fractures through the ALAE. Patient outcomes were assessed with physical and radiological evaluation, range-of-motion measurements with a follow-up from 24 to 60 months. Two different quality of life questionnaires were carried out: the EuroQol Five Dimensions Questionnaire (EQ-5D) and the patient-answered questionnnaire of the Liverpool Elbow Score patient (PAQ-LES).

Four fractures involved the capitellum, one involved the capitellum with the lateral ridge of the trochlea, and three involved the capitellum and trochlea as separate fragments. The patients presented a favorable clinical evolution at a median of 33 months (range, 24–60), with an average of motion of 10–138°. Four patients presented a fracture of the head of the radius (Mason type 2) and 3 fractures of the coronoid (Bryan-Morrey Type 1) associated. All the patients presented radiological consolidation without signs of osteonecrosis, being the average EQ-5D 0.857 (range, 0.36–1.0) and the PAQ-LES of 35 (range 17 to 36).

Patients with isolated capitellar fractures had better results than those with trochlear involvement. The presence of associated fractures does not seem to worsen the results. We believe that the ALAE is a technical option to consider for the open surgical treatment of a capitellar fracture with or without involvement of the trochlea.

Level of Evidenceis

Therapeutic Level III

Introduction

Coronal fractures of the distal part of the humerus involving the capitellum and the trochlea are complex injuries. These fractures may be associated with others lesions like a radial head fracture or a coronoid fracture [1], [2], [3], [4]. Often the capitellar fragment has a small trochlear fragment attached (lateral trochlear ridge, classified as Dubberley type 1 fracture), and when the capitellum is reduced correctly, the affected trochlear part is also reduced. However, the trochlear involvement may be greater: in some cases the capitellar fragment is attached to a large fragment of trochlea (Dubberley type 2) while in others the fractured trochlear and capitellar fragments are separated (Dubberley type 3) [5]. In these cases, a lateral approach of the elbow (Kocher approach) may be inadequate, so some surgeons decide to either add a medial elbow approach or to use a single posterior elbow approach with an olecranon osteotomy for adequate exposure. Depending on the extent of the approach and the de-inserted structures that must be repaired after fracture has been fixed the time required for healing and functional recovery can increase [6], [7], [8], [9], [10], [11], [12].

In addition, whether an extended Kocher approach is performed or an osteotomy of the olecranon, the dissection and detachment of the periosteum of the posterior aspect of the capitellum may compromise the vascularisation of the capitellum (Fig. 1) [13], [14], [15], [16], [17], [18], [19]. On the other hand, performing a olecranon osteotomy compromises the possibility of later implanting a total elbow prosthesis in one of these cases that could eventually evolve to early post-traumatic osteoarthritis [5].

In addition, we would like to mention that although Dubberley classifies fractures according to the absence (type A) or presence of posterior condylar comminution (B) in his work, we have found in our patients that the comminution rather than posterior, is located distally. It is true that the comminution when it exists, it is in a distal and posterior plane with respect to the trochlea and the capitellum, but the posterior aspect of the humerus (the columns) are usually intact (Fig. 2A,B and C). This detail is important, because we need this area to be respected, in order to obtain a good fixation of the fragment by using cannulated screws implanted in the anteroposterior direction [20,21]. Our preferred osteosynthesis technique is to achieve fixation by cannulated headless screws. The use of cannulated screws guided by a Kirschner wire can help to confirm the correct position of the screw, and thus avoid the possibility of repeated attempts of broaching in the case of poor positioning of the drill bit when using non-cannulated screws [22], [23], [24], [25]. When we perform an anterior approach, the patient is positioned supine, with the elbow in full extension, since it aids in the reduction of the fracture. In addition, placement of the Kirschner guidewires and definitive implants is performed in the anteroposterior direction and in a plane perpendicular to the plane of the fracture, which adds biomechanical advantages to the synthesis [23].

In some cases total or partial arthroplasty is an option to take into account given the technical difficulty for the open reduction and fixation of these fractures. However, for patients with high functional demands, such as manual workers or very young patients, elbow arthroplasty, elbow arthroplasty is not a good option because we know that the components are loosened early when the limb is subjected to intense physical activity [2,5,7,9,22,26,27]. That is why osteosynthesis in this group of patients should be the first option, despite the greater technical difficulty of this option.

The purpose of this current study was to describe a limited anterior approach for open reduction and fixation of a displaced capitellar and trochlear fracture and to perform an evaluation of the clinical outcomes and complications of this technique.