a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
Fractures of the capitellum and their variants extending to thetrochlea are rare and account for around 1% of the fracturesat elbow level and 6% of the fractures at the level of the distalhumerus.1,2This injury pattern results from a shearing forcetransmitted from the proximal extremity of the forearm bonesto the proximal extremity of the humerus by means of axialloading. These are intra-articular fractures that require carefultreatment and anatomical reduction in order to diminish thecomplications, such as joint stiffness.
Case report
The patient was a 16-year-old right-handed male who suf-fered a fall from a ladder in which his left hand took theforce of the impact on the ground. This resulted in axialtransmission of energy through the extended left arm. In theadmission examination at the emergency service, significantlocal pain was noted, with increased volume and limitation ofleft elbow movement. There were no skin injuries. Neurovas-cular examination of the extremity did not demonstrate anyabnormalities. The initial radiographic evaluation revealedfracturing of the distal extremity of the left humerus, withoutgood characterization of the pattern (Figs. 1 and 2). In lateralview, the "double arch sign" could be seen (Fig. 2).4To define
the fracture pattern and enable better preoperative planning,a tomographic evaluation was made. This defined the coronaloutline, extending from the capitellum to the trochlea in a sin-gle fragment (Figs. 3 and 4). In the light of the imaging study,the fracture was classified as type IV according to the classifi-cation of Bryan and Morrey,1as modified by McKee et al.,4oras type 13 B3.3 according to the AO classification.
After the initial evaluation had been made, from which pro-visional plaster-cast immobilization was performed and otherinjuries and comorbidities were ruled out, surgical treatmentwas indicated. The patient was kept in hospital for care, andto await scheduling of the operation at the same public ortho-pedic and traumatology service.
After a hospital stay of 14 days, the surgical treatmentwas performed. It was decided to use an anterior access inthe elbow, on a proximal internervous plane between the
brachioradialis muscle (innervated by the radial nerve) andthe brachialis muscle (innervated by the musculocutaneousnerve), and distally between the brachioradialis and the prona-tor teres muscle (innervated by the median nerve),6underleft brachial plexus block in association with sedation. Thepatient was positioned in dorsal decubitus with the left armabducted and supinated on a lateral support table. After per-forming rigorous antisepsis and preparation of the skin usinga chlorhexidine solution, and placement of sterile fields, thepneumatic tourniquet was inflated. After layer-by layer dis-section and identification of the fracture focus, anatomicalreduction was performed, with fixation using two Herbertscrews that were inserted from anterior to posterior.
Discussion
Since this was an intra-articular fracture pattern with signif-icant displacement, a surgical approach became necessary inorder to reestablish the anatomy and joint congruence. In thisregard, open reduction with stable internal fixation becauseimperative.8Since the usual radiographic views do not allowdetailing of the fracture pattern, tomographic assessmentplays an important role in understanding the injury andenables better surgical planning.
In most of the series,2-4,7the surgical approach was lateral,medial or posterior and the synthesis material was positionedfrom posterior to anterior. However, in the case reported here,given that the treatment was implemented 14 days after thefracture occurred, the possibility of reduction by means of ananterior access was considered to allow for the possibility ofosteoclasis ("calloclasis"), thereby explaining the choice.
After anatomical reduction with satisfactory positioningof the bone fragment in its bed had been achieved, fix-ation was performed using two Herbert screws (Zimmer,Warsaw, Indiana) inserted from anterior to posterior. This
could be observed in the postoperative radiographic evalua-tion (Figs. 5 and 6).
Although the surgical method used in this case was notthe one chosen by the majority of the surgeons who treatthis type of injury, there is backing for our approach in the
literature.1,3,4,6-8,10Its disadvantage is its technical difficulty,given the risk of neurovascular injury to the structures of thecubital fossa cubital. On the other hand, it enables extensiveviewing of the focus of the fracture, which is especially helpfulfor anatomical reduction, and this is a decisive factor for goodevolution of the case.
Conflicts of interest
The authors declare no conflicts of interest.
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