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Are outcomes after fixation of distal humerus coronal shear fractures affected by surgical approach? A systematic review and meta-analysis

Open AccessPublished:September 12, 2022DOI:https://doi.org/10.1016/j.jseint.2022.08.011

      Background

      Surgical management of coronal shear fractures of the distal humerus is associated with a high rate of complications. Several surgical approaches have been described to address these fractures. The complication profiles associated with each approach have not previously been compared, and that is the aim of the present study.

      Methods

      A systematic review of the literature was performed to identify all studies addressing coronal shear fractures of the distal humerus published between 2001 and January 2022. Of the 189 articles identified, 45 met the criteria for inclusion. Summaries of continuous data were calculated using the inverse variance method for pooling with random effects models. Fixed effects model estimates were reported unless significant heterogeneity was observed between studies. A subset of 6 studies reported the surgical approach and complications associated with the operative management of capitellar shear fractures without posterior comminution. The complication profiles of the extended lateral and anterolateral approaches were compared.

      Results

      The 45 studies included yielded 899 patients. The average age was 44.9 years (95% confidence interval [CI]: 39.7 to 50.2). The fracture type was Dubberley A in 38% (n = 342), Dubberley B in 33% (n = 300), and not reported in the remainder. The reoperation rate was 13.8% (95% CI: 9.6% to 19.5%). Pooled complication rates included post-traumatic arthritis in 21.2% (95% CI: 18.0% to 24.9%), heterotopic ossification in 12.0% (95% CI: 9.2% to 15.6%), nerve injury in 7.8% (95% CI: 5.6% to 10.9%), and avascular necrosis in 7.4% (95% CI: 5.3% to 10.2%). The complication rate in noncomparative studies was 25.8% following the lateral approach and 16.7% following the anterolateral approach. Reported complications following the anterolateral approach were pain (9.5%) and nerve injury (7.1%). Reported complications following the lateral approach included arthritis (9.1%), heterotopic ossification (6.1%), avascular necrosis (4.5%), instability (3.0%), nerve injury (1.5%), and wound issues (1.5%).

      Discussion and Conclusion

      Complications are common following operative management of capitellar shear fractures. In noncomparative studies, the complication rate was higher following the extended lateral compared to the anterolateral approach for Dubberley A fractures. Additionally, the reported complications following the extended lateral approach may impact long-term outcomes. Insufficient comparative evidence currently exists to recommend one approach over the other. High-quality comparative studies are needed.

      Level of evidence

      Keywords

      Partial articular shear fractures of the distal humerus involving the capitellum and the trochlea were first described by McKee et al
      • McKee M.D.
      • Jupiter J.B.
      • Bamberger H.B.
      Coronal shear fractures of the distal end of the humerus.
      and present a rare but challenging problem to the orthopedic surgeon. Open reduction and internal fixation (ORIF) has emerged as the treatment of choice for displaced fractures of the capitellum and trochlea as conservative management has often produced unsatisfactory results.
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      ,
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      ,
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      However, a high complication rate and reoperation rate have been reported following operative management.
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      Outcome after open reduction and internal fixation of capitellar and trochlear fractures.
      ,
      • Ring D.
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      • Gulotta L.
      Articular fractures of the distal part of the humerus.
      This may be explained by the complex fracture pattern, limited bone stock available for fixation, as well as difficulties in exposure secondary to the regional anatomy.
      Numerous classification systems have been proposed for the characterization of distal humerus articular fractures. Among those commonly referenced are the Bryan and Morrey classification
      • Bryan R.S.
      • Morrey B.F.
      Fractures of the distal humerus..
      and the Dubberley classification.
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      Outcome after open reduction and internal fixation of capitellar and trochlear fractures.
      The Dubberley classification is of particular use to the surgeon as this system considers the medial extent of the articular fragment as well as the presence of posterior comminution, both of which must be recognized to determine the optimal surgical approach. While various surgical approaches have been described including lateral (EL), posterior, and anterolateral (AL), the lateral approach has classically been the most utilized. This is in part due to its familiarity, safety, and extensile nature, the latter of which affords the ability to address posterolateral comminution through the same incision. However, the lateral approach may compromise visualization of the anterior joint surface, limiting the surgeon’s ability to assess and address medial extension into the trochlea. Adequate exposure in these cases often necessitates release of the lateral collateral ligament. The AL approach has gained popularity recently for the management of fractures confined to the anterior joint surface as it offers the potential advantages of a better exposure of the anterior joint surface, a more perpendicular trajectory for screw placement, and preservation of the lateral collateral ligament.
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      To date, few studies have directly compared the complications associated with various surgical approaches to the capitellum with available data limited to retrospective case series. Therefore, the purpose of the present study was to perform a systematic review of the literature and meta-analysis to more clearly define the overall complication rate associated with the fixation of coronal shear fractures of the capitellum, with a consideration of the impact of the surgical approach on the complication profile.

      Materials and methods

      In accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a search of PubMed, Medline, EMBASE, and Cochrane Libraries was performed to identify relevant literature through January, 2022. The search terms included “capitellum AND fracture,” “capitellar AND fracture,” “capitellum AND shear,” “capitellar AND shear,” or “coronal AND shear.” The initial search yielded 187 results. This list was narrowed for the following reasons: (1) management was other than ORIF, (2) the study was cadaveric-based or purely biomechanical, (3) patient age was less than 18 years, (4) the articles were historical (greater than 20 years), (5) case series with less than 5 patients, or (6) the work was a technique article or level V evidence. After these exclusion criteria were applied, 43 studies met the eligibility criteria. These studies were carefully examined and cross-referenced, which yielded an additional two studies. A total of 45 studies were included in the final analysis (Fig. 1).
      Figure thumbnail gr1
      Figure 1PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart.
      Patient demographic data, fracture morphology, surgical approach, fixation construct, and complications were assessed. All data were transferred into an electronic spreadsheet and descriptive statistics were performed for all compiled information. A subset analysis was performed to assess the complications following the AL approach or the EL approach in the management of Dubberley A fractures (those without posterior comminution).

      Statistical analysis

      Summaries of continuous data, including patient age and length of follow-up, were calculated using the inverse variance method for pooling with random effects models. Pooled estimates of the study outcomes were calculated using the inverse variance method. Fixed effects model estimates were reported unless significant heterogeneity was observed between studies. If significant heterogeneity was observed, random effects estimates were reported. Heterogeneity was calculated with the I2 statistic. All analyses were performed using the meta package for R (R Foundation for Statistical Computing, Vienna, Austria).

      Results

      Demographics

      A total of 899 patients from the 45 studies reviewed were included in the analysis. One study had level I evidence, 2 had level III evidence, and 42 studies had level IV evidence (Table I). The average patient age was 44.9 years (95% confidence interval [CI]: 39.7 to 50.2) with 54% female. The average follow-up time was 29.7 months. (standard deviation: 23.0 to 36.5). Fracture morphology was Dubberley A in 342 cases (38%), Dubberley B in 300 cases (33%), or not reported (29%) (Table II).
      Table IStudy demographics and baseline characteristics.
      StudyLevel of evidenceNF:MAge (range, SD)Injury mechanism (mechanical fall, traffic accident, other
      other mechanisms include blunt trauma, biking, fall from a height.
      )
      Bryan-Morrey (1,2,3,4)Dubberley (total A, B)Other classificationStudy follow-up (SD)
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      Articular fractures of the distal part of the humerus.
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      SD, standard devitaion.
      other mechanisms include blunt trauma, biking, fall from a height.
      Table IIStudy summary.
      Characteristics
      No. of studies45
      No. of patients899
      Age, y, mean (95% CI)44.9 (39.7 to 50.2)
      Sex
       Female485 (54%)
       Male372 (41%)
       Not reported42 (5%)
      Fracture type (Dubberley)
       A342 (38%)
       B300 (33%)
       Not reported257 (29%)
      Follow-up, mo, mean (SD)29.7 (23.0 to 36.5)
      CI, confidence interval; SD, standard deviation.

      Complications

      Pooled complication rates were investigated for the most frequently reported complications (Table III, Table IV). Post-traumatic arthritis (PTA) was reported in 21.2% (95% CI: 18.0% to 24.9%) and reoperation was reported in 13.8% (95% CI: 9.6% to 19.5%), most commonly to address symptomatic hardware. Other frequently reported complications included heterotopic ossification (HO) in 12.0% (95% CI: 9.2% to 15.6%), nerve injury in 7.8% (95% CI: 5.6% to 10.9%), avascular necrosis (AVN) in 7.4% (95% CI: 5.3% to 10.2%), and nonunion in 6.6% (95% CI: 4.6% to 9.2%).
      Table IIIPooled estimates of study complications.
      OutcomeNo. of studiesProportion (95% CI)I2 (95% CI)
      Reoperation, n (%)3713.8% (9.6 to 19.5%)60.2% (42.9% to 72.2%)
      Nonunion, n (%)336.6% (4.6% to 9.2%)0.0% (0.0% to 33.9%)
      Arthritis, n (%)3921.2% (18.0% to 24.9%)47.6% (23.8% to 64.0%)
      Avascular necrosis, n (%)337.4% (5.3% to 10.2%)0.0% (0.0% to 17.7%)
      Heterotopic ossification, n (%)3212.0% (9.2% to 15.6%)46.2% (18.4% to 64.5%)
      Nerve injury, n (%)267.8% (5.6% to 10.9%)0% (0.0% to 14.9%)
      CI, confidence interval.
      Table IVFunctional and patients reported outcomes and complications.
      StudyNTotal arc ROMROM Ex.ROM Fl.Total sup.-pro. ROMMean MEPI score“Excellent” outcome“Good” outcomeComp. TotalAVNArthritisHONerve injuryReops.
      Ashwood et al. 2010
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      • Verma M.
      • Hamlet M.
      • Garlapati A.
      • Fogg Q.
      Transarticular shear fractures of the distal humerus.
      26114.714.1128.8NR81.3998010026
      Ballesteros-Betancourt et al. 2020
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      • Munoz-Mahamud E.
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      • Llusa-Perez M.
      • et al.
      The anterior limited approach of the elbow for the treatment of capitellum and trochlea fractures: surgical technique and clinical experience in eight cases.
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      • Sen C.
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      Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation.
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      Nonunion of operatively treated capitellum and trochlear fractures.
      3011565145NRNRNRNR2208105
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      Outcome after the surgical treatment of the Dubberley type B distal humeral capitellar and trochlear fractures with a buttress plate.
      10119.617.9137.5151.195.553311001
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      [Surgical treatment of type I capitellar-humeral fractures using the Henry ventral approach approach. Short- and medium-term results].
      7106.67113.6NRNR21202000
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      • Faber K.J.
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      • Patterson S.D.
      • King G.J.
      Outcome after open reduction and internal fixation of capitellar and trochlear fractures.
      2811919138NR91NRNR2719000
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      Distal humeral coronal plane fractures: management, complications and outcome.
      15NRNRNRNR83.3722546700
      Garg et al. 2020
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      • Sain A.
      • Sharma V.
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      • Rangaswamy N.
      Functional outcome of a coronal shear fracture of the capitellum managed by herbert screw fixation using the anterolateral surgical approach.
      10136NRNR18096NRNR100010
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      8NRNRNRNR84NRNR800022
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      Fractures of the capitellum and trochlea.
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      • Huang F.G.
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      2099.617.5117.1NRNR10715264114
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      • Zilleken C.
      • Pennig D.
      • Koslowsky T.C.
      Reconstruction of radial capitellar fractures using fine-threaded implants (FFS).
      15124NRNR17390771508000
      Hussain et al. 2018
      • Hussain S.
      • Ali A.
      • Tahir Yusuf M.
      • Irfan Siddique R.M.
      Humeral capitellar fractures fixation with herbert screws.
      151257.6135NRNR104802400
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      • Imatani J.
      • Morito Y.
      • Hashizume H.
      • Inoue H.
      Internal fixation for coronal shear fracture of the distal end of the humerus by the anterolateral approach.
      6113.814.5128.3NRNR14200000
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      • Kapil Mani K.C.
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      • Sigdel A.
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      • Dahal S.C.
      Functional outcomes of capitellum fractures treated by open reduction and internal fixation with herbert screw: a descriptive cross-sectional study.
      22138.41NRNR161.5990.22NRNRNR00000
      Lopiz et al. 2016
      • Lopiz Y.
      • Rodriguez-Gonzalez A.
      • Garcia-Fernandez C.
      • Marco F.
      Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years.
      201228122NR921441213511
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      • Xu L.P.
      • Song Z.
      • et al.
      Clinical efficacy of vertical or parallel technique of a micro-locking plate for treatment of Dubberley B-type capitellar fractures.
      241118.5122.5160.289.8185300000
      Lu et al. 2016
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      Surgical techniques and clinical efficacy of micro locking plate in the treatment of capitellar fractures.
      471126118NR87.63112000000
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      • Pehlivan O.
      • Akmaz I.
      • Rodop O.
      Treatment of fractures of the humeral capitellum using herbert screws.
      11117NRNR15193.683400000
      Marinelli et al. 2018
      • Marinelli A.
      • Cavallo M.
      • Guerra E.
      • Ritali A.
      • Bettelli G.
      • Rotini R.
      Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients.
      45NRNRNRNR7812152326467
      Mighell et al. 2010
      • Mighell M.
      • Virani N.A.
      • Shannon R.
      • Echols Jr., E.L.
      • Badman B.L.
      • Keating C.J.
      Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws.
      18128NRNR176NR1251235300
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      • Mukohara S.
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      25120.210130NR96.31851637210
      Ravishankar et al. 2017
      • Ravishankar M.R.
      • Kumar M.N.
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      Choice of surgical approach for capitellar fractures based on pathoanatomy of fractures: outcomes of surgical management.
      33133NRNR15180.91410921100
      Ring et al. 2003
      • Ring D.
      • Jupiter J.B.
      • Gulotta L.
      Articular fractures of the distal part of the humerus.
      219627123180NR41214000210
      Rotini et al. 2011
      • Rotini R.
      • Guerra E.
      • Marinelli A.
      • Cavaciocchi M.
      Resorbable Herbert screws in capitellum fractures fixation.
      10NRNRNRNR98NRNR000000
      Ruchelsman et al. 2008
      • Ruchelsman D.E.
      • Tejwani N.C.
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      • Egol K.A.
      Open reduction and internal fixation of capitellar fractures with headless screws.
      161231013318091.6961104601
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      • Rokkaku T.
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      6131.77.5139.2180NR33000000
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      4512510130170NRNRNR14001615
      Singh et al. 2010
      • Singh A.P.
      • Singh A.P.
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      • Jain A.
      • Gulati D.
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      14124.57.5132180NR104000000
      Singh et al. 2012
      • Singh A.P.
      • Dhammi I.K.
      • Garg V.
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      • Xue H.
      • et al.
      Anti-sliding plate technique for coronal shear fractures of the distal humerus.
      52133313618090.6361113032017
      Sultan et al. 2017
      • Sultan A.
      • Khursheed O.
      • Bhat M.R.
      • Kotwal H.A.
      • Manzoor Q.W.
      Management of capitellar fractures with open reduction and internal fixation using Herbert screws.
      1512010130NR91.33105201002
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      • Kural C.
      • Altun S.
      Capitellum fractures: treatment with headless screws and outcomes.
      21102NRNR16581.9961137100
      Tarallo et al. 2015
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      • Mugnai R.
      • Adani R.
      • Zambianchi F.
      • Costanzini C.A.
      • Catani F.
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      8125201251809253300101
      Tarallo et al. 2021
      • Tarallo L.
      • Novi M.
      • Porcellini G.
      • Giorgini A.
      • Micheloni G.
      • Catani F.
      Surgical tips and tricks for coronal shear fractures of the elbow.
      24113.1NRNR18092.1NRNR401003
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      • Teng L.
      • Zhong G.
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      19130.5NRNR167.485.8984031010
      Tomori et al. 2022
      • Tomori Y.
      • Nanno M.
      • Sonoki K.
      • Majima T.
      Surgical outcomes of coronal shear fracture of the distal humerus in elderly adults.
      887.5NRNRNR78.813811000
      Vaishya et al. 2016
      • Vaishya R.
      • Vijay V.
      • Jha G.K.
      • Agarwal A.K.
      Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients.
      1612210132NRNR106200010
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      • Wang P.
      • Kandemir U.
      • Zhang K.
      • Zhang B.
      • Song Z.
      • Huang H.
      • et al.
      Treatment of capitellar and trochlear fractures with posterior comminution: minimum 2-year follow-up.
      15NR11123.7NR89122411101
      Yoshida et al. 2021
      • Yoshida S.
      • Sakai K.
      • Nakama K.
      • Matsuura M.
      • Okazaki S.
      • Jimbo K.
      • et al.
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      16NRNRNRNR83.876200001
      Yu et al. 2019
      • Yu T.
      • Tao H.
      • Xu F.
      • Hu Y.
      • Zhang C.
      • Zhou G.
      Comparison of lateral approach versus anterolateral approach with Herbert screw fixation for isolated coronal shear fractures of humeral capitellum.
      26134NRNR16992NRNR100010
      Yu et al. 2018
      • Yu T.
      • Tao H.
      • Xu F.
      • Hu Y.
      • Zhang C.
      • Zhou G.
      Management of isolated coronal shear fractures of the humeral capitellum with Herbert screw fixation through anterolateral approach.
      15134NRNR17293114500010
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      • Zhang Y.
      • Hu J.
      • Li X.
      • Qin X.
      Humeral capitellum fracture combined with humeral lateral column injury: a novel classification system and treatment algorithm.
      34NRNRNRNRNRNRNR1709008
      ROM, range of motion; Ex., extension; Fl., flexion; sup-pro, supination-pronation; MEPI, Mayo Elbow Performance Index; AVN, avascular necrosis; HO, heterotopic ossification; reops., reoperations.

      Approach and complications

      Approaches used to address capitellum fractures included lateral/extended lateral, anterolateral, and posterior (Table V). Fractures confined to the anterior joint surface (Dubberley A) were most often addressed via either the EL or AL approach, while fractures with posterior comminution (Dubberley B) were addressed via the EL or a posterior approach. Six studies identified the approach to address a Dubberley type A fracture and reported postoperative complications. Studies were limited to those addressing Dubberley A fractures to minimize fracture heterogeneity. These studies included 108 patients undergoing surgery via the lateral approach (n = 66) or via the anterolateral approach (n = 42). The overall complication rate among these studies was 24.2%. The complication rate in noncomparative studies was 25.8% following the lateral approach and 16.7% following the anterolateral approach. Reported complications following the anterolateral approach included pain (9.5%) and nerve injury (7.1%). Reported complications following the lateral approach included arthritis (9.1%), HO (6.1%), AVN (4.5%), instability (3.0%), nerve injury (1.5%), and wound issues (1.5%).
      Table VApproaches and fixation methods used.
      StudyNLateral approach
      Includes Kaplan and extended lateral approaches.
      Anterolateral approachOlecranon osteotomyPosterior approach
      Posterior approaches that are not olecranon osteotomies.
      Other approachFixation with HCS only
      Includes Herbert compression screws, Acutrak, or Mitek.
      Fixation with HCS + provisional fixation
      Includes k-wire, plate, rod.
      HO prophylaxis?
      Ashwood et al. 2010
      • Ashwood N.
      • Verma M.
      • Hamlet M.
      • Garlapati A.
      • Fogg Q.
      Transarticular shear fractures of the distal humerus.
      2626000011121
      Ballesteros-Betancourt et al. 2020
      • Ballesteros-Betancourt J.R.
      • Garcia-Tarrino R.
      • Garcia-Elvira R.
      • Munoz-Mahamud E.
      • Fernandez-Valencia J.A.
      • Llusa-Perez M.
      • et al.
      The anterior limited approach of the elbow for the treatment of capitellum and trochlea fractures: surgical technique and clinical experience in eight cases.
      800000800
      Bilsel et al. 2013
      • Bilsel K.
      • Atalar A.C.
      • Erdil M.
      • Elmadag M.
      • Sen C.
      • Demirhan M.
      Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation.
      181602002130
      Brouwer et al. 2011
      • Brouwer K.M.
      • Jupiter J.B.
      • Ring D.
      Nonunion of operatively treated capitellum and trochlear fractures.
      30000000170
      Chang et al. 2020
      • Chang A.L.
      • Dieterich J.D.
      • DiPrinzio E.V.
      • Kim J.M.
      Surgical approach and internal fixation techniques for intra-articular distal humerus fracture with coronal shear capitellar fracture.
      900900000
      Demir et al. 2020
      • Demir M.T.
      • Ertan Birsel S.
      • Salih M.
      • Pirincci Y.
      • Birsel O.
      • Kesmezacar H.
      Outcome after the surgical treatment of the Dubberley type B distal humeral capitellar and trochlear fractures with a buttress plate.
      101000000101
      Dietz et al. 2005
      • Dietz S.O.
      • Muller L.P.
      • Korner J.
      • Rommens P.M.
      [Surgical treatment of type I capitellar-humeral fractures using the Henry ventral approach approach. Short- and medium-term results].
      700007701
      Dubberly et al. 2006
      • Dubberley J.H.
      • Faber K.J.
      • Macdermid J.C.
      • Patterson S.D.
      • King G.J.
      Outcome after open reduction and internal fixation of capitellar and trochlear fractures.
      285141473301
      Durakbasa et al. 2013
      • Durakbasa M.O.
      • Gumussuyu G.
      • Gungor M.
      • Ermis M.N.
      Distal humeral coronal plane fractures: management, complications and outcome.
      151102201401
      Garg et al. 2020
      • Garg S.
      • Sain A.
      • Sharma V.
      • Farooque K.
      • Rangaswamy N.
      Functional outcome of a coronal shear fracture of the capitellum managed by herbert screw fixation using the anterolateral surgical approach.
      100100001000
      Goodman et al. 2005
      • Goodman H.J.
      • Choueka J.
      Complex coronal shear fractures of the distal humerus.
      840400000
      Guitton et al. 2009
      • Guitton T.G.
      • Doornberg J.N.
      • Raaymakers E.L.
      • Ring D.
      • Kloen P.
      Fractures of the capitellum and trochlea.
      382203211500
      He et al. 2019
      • He S.K.
      • Zhao S.C.
      • Guo J.H.
      • Qin T.W.
      • Huang F.G.
      Combined use of Kirschner wires and hinged external fixator for capitellar and trochlear fractures: a minimum 24-month follow-up.
      20140600001
      Heck et al. 2012
      • Heck S.
      • Zilleken C.
      • Pennig D.
      • Koslowsky T.C.
      Reconstruction of radial capitellar fractures using fine-threaded implants (FFS).
      15150000001
      Hussain et al. 2018
      • Hussain S.
      • Ali A.
      • Tahir Yusuf M.
      • Irfan Siddique R.M.
      Humeral capitellar fractures fixation with herbert screws.
      151500001300
      Imatani et al. 2001
      • Imatani J.
      • Morito Y.
      • Hashizume H.
      • Inoue H.
      Internal fixation for coronal shear fracture of the distal end of the humerus by the anterolateral approach.
      606000600
      K.C. et al. 2020
      • Kapil Mani K.C.
      • Acharya P.
      • Marahatta S.B.
      • Sigdel A.
      • Amuda K.C.
      • Dahal S.C.
      Functional outcomes of capitellum fractures treated by open reduction and internal fixation with herbert screw: a descriptive cross-sectional study.
      222200002200
      Lopiz et al. 2016
      • Lopiz Y.
      • Rodriguez-Gonzalez A.
      • Garcia-Fernandez C.
      • Marco F.
      Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years.
      201613001100
      Lu et al. 2021
      • Lu Y.
      • Fu L.
      • Ma T.
      • Xu Y.B.
      • Xu L.P.
      • Song Z.
      • et al.
      Clinical efficacy of vertical or parallel technique of a micro-locking plate for treatment of Dubberley B-type capitellar fractures.
      24240000001
      Lu et al. 2016
      • Lu Y.
      • Wang Q.
      • Hu B.
      • Xue H.
      • Sun L.
      • Ren C.
      • et al.
      Surgical techniques and clinical efficacy of micro locking plate in the treatment of capitellar fractures.
      474700004701
      Mahirogullari et al. 2006
      • Mahirogullari M.
      • Kiral A.
      • Solakoglu C.
      • Pehlivan O.
      • Akmaz I.
      • Rodop O.
      Treatment of fractures of the humeral capitellum using herbert screws.
      111100001100
      Marinelli et al. 2018
      • Marinelli A.
      • Cavallo M.
      • Guerra E.
      • Ritali A.
      • Bettelli G.
      • Rotini R.
      Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients.
      45370800030
      Mighell et al. 2010
      • Mighell M.
      • Virani N.A.
      • Shannon R.
      • Echols Jr., E.L.
      • Badman B.L.
      • Keating C.J.
      Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws.
      181800000180
      Mukohara et al. 2021
      • Mukohara S.
      • Mifune Y.
      • Inui A.
      • Nishimoto H.
      • Kurosawa T.
      • Yamaura K.
      • et al.
      Effects of trochlear fragmentation on functional outcome in coronal shear fractures: a retrospective comparative study.
      25131012024130
      Ravishankar et al. 2017
      • Ravishankar M.R.
      • Kumar M.N.
      • Raut R.
      Choice of surgical approach for capitellar fractures based on pathoanatomy of fractures: outcomes of surgical management.
      332256002500
      Ring et al. 2003
      • Ring D.
      • Jupiter J.B.
      • Gulotta L.
      Articular fractures of the distal part of the humerus.
      2114070010110
      Rotini et al. 2011
      • Rotini R.
      • Guerra E.
      • Marinelli A.
      • Cavaciocchi M.
      Resorbable Herbert screws in capitellum fractures fixation.
      10000001000
      Ruchelsman et al. 2008
      • Ruchelsman D.E.
      • Tejwani N.C.
      • Kwon Y.W.
      • Egol K.A.
      Open reduction and internal fixation of capitellar fractures with headless screws.
      161600000160
      Sano et al. 2005
      • Sano S.
      • Rokkaku T.
      • Saito S.
      • Tokunaga S.
      • Abe Y.
      • Moriya H.
      Herbert screw fixation of capitellar fractures.
      640200600
      Shergold et al. 2022
      • Shergold S.
      • Derias M.
      • Moverley R.
      • Murphy R.J.
      • Guryel E.
      • Phadnis J.
      Coronal shear fractures of the distal humerus managed according to the Modified Dubberley Classification System.
      45250241413210
      Singh et al. 2010
      • Singh A.P.
      • Singh A.P.
      • Vaishya R.
      • Jain A.
      • Gulati D.
      Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws.
      141400001400
      Singh et al. 2012
      • Singh A.P.
      • Dhammi I.K.
      • Garg V.
      • Singh A.P.
      Outcome of surgical treatment of type IV capitellum fractures in adults.
      10100000421
      Song et al. 2020
      • Song Z.
      • Wang Q.
      • Ma T.
      • Wang C.
      • Yang N.
      • Xue H.
      • et al.
      Anti-sliding plate technique for coronal shear fractures of the distal humerus.
      52520000000
      Sultan et al. 2017
      • Sultan A.
      • Khursheed O.
      • Bhat M.R.
      • Kotwal H.A.
      • Manzoor Q.W.
      Management of capitellar fractures with open reduction and internal fixation using Herbert screws.
      151500001500
      Tanriverdi et al. 2020
      • Tanriverdi B.
      • Kural C.
      • Altun S.
      Capitellum fractures: treatment with headless screws and outcomes.
      211900202100
      Tarallo et al. 2015
      • Tarallo L.
      • Mugnai R.
      • Adani R.
      • Zambianchi F.
      • Costanzini C.A.
      • Catani F.
      Shear fractures of the distal humerus: is the use of intra-articular screws a safe treatment?.
      880000800
      Tarallo et al. 2021
      • Tarallo L.
      • Novi M.
      • Porcellini G.
      • Giorgini A.
      • Micheloni G.
      • Catani F.
      Surgical tips and tricks for coronal shear fractures of the elbow.
      242400000240
      Teng et al. 2020
      • Teng L.
      • Zhong G.
      Surgical treatment of comminuted coronal shear fracture of distal humerus.
      191102060190
      Tomori et al. 2022
      • Tomori Y.
      • Nanno M.
      • Sonoki K.
      • Majima T.
      Surgical outcomes of coronal shear fracture of the distal humerus in elderly adults.
      851020820
      Vaishya et al. 2016
      • Vaishya R.
      • Vijay V.
      • Jha G.K.
      • Agarwal A.K.
      Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients.
      160160001600
      Wang et al. 2019
      • Wang P.
      • Kandemir U.
      • Zhang K.
      • Zhang B.
      • Song Z.
      • Huang H.
      • et al.
      Treatment of capitellar and trochlear fractures with posterior comminution: minimum 2-year follow-up.
      15150000031
      Yoshida et al. 2021
      • Yoshida S.
      • Sakai K.
      • Nakama K.
      • Matsuura M.
      • Okazaki S.
      • Jimbo K.
      • et al.
      Treatment of capitellum and trochlea fractures using headless compression screws and a combination of dorsolateral locking plates.
      161220021120
      Yu et al. 2019
      • Yu T.
      • Tao H.
      • Xu F.
      • Hu Y.
      • Zhang C.
      • Zhou G.
      Comparison of lateral approach versus anterolateral approach with Herbert screw fixation for isolated coronal shear fractures of humeral capitellum.
      2614120002600
      Yu et al. 2018
      • Yu T.
      • Tao H.
      • Xu F.
      • Hu Y.
      • Zhang C.
      • Zhou G.
      Management of isolated coronal shear fractures of the humeral capitellum with Herbert screw fixation through anterolateral approach.
      150150001500
      Zhang et al 2020
      • Zhang Y.
      • Hu J.
      • Li X.
      • Qin X.
      Humeral capitellum fracture combined with humeral lateral column injury: a novel classification system and treatment algorithm.
      34280600000
      HCS, headless compression screws; HA, hemiarthroplasty; HO, heterotopic ossification.
      Includes Kaplan and extended lateral approaches.
      Posterior approaches that are not olecranon osteotomies.
      Includes Herbert compression screws, Acutrak, or Mitek.
      § Includes k-wire, plate, rod.

      Discussion

      Distal humerus coronal shear fractures of the capitellum and trochlea are a challenging injury to manage. ORIF is considered the standard of care for displaced fractures and stable fixation allows for early range of motion. However, a high complication and reoperation rate have been reported, in part because of the often-limited bone stock available for fixation as well as the difficulty in adequately exposing the fracture for surgical fixation. Recent meta-analyses have assessed functional outcomes and complications following operative management of these fractures,
      • Fram B.R.
      • Seigerman D.A.
      • Ilyas A.M.
      Coronal shear fractures of the distal humerus: a review of diagnosis, treatment, and outcomes.
      ,
      • He S.K.
      • Xu L.
      • Guo J.H.
      • Liao J.P.
      • Qin T.W.
      • Huang F.G.
      The impact of associated injuries and fracture classifications on the treatment of capitellum and trochlea fractures: a systematic review and meta-analysis.
      but the present study is the first to compare the complication profiles of different surgical approaches.
      Available literature was reviewed and the reoperation rate following ORIF of these injuries was determined to be 13.8% (95% CI: 9.6% to 19.5%); however, there was considerable heterogeneity in the literature. Post-traumatic arthritis was reported in 21.2% (95% CI: 18.0% to 24.9%) of cases and heterotopic ossification was seen in 12% (95% CI: 9.2% to 15.6%) of cases. A sub-analysis was performed to associate the surgical approach with complication profile in the management of Dubberley A fractures. In attempt to homogenize the fracture patterns, those analyzed were limited to Dubberley A fractures. The aim was to eliminate the confounding effect of Dubberly B fractures, which are known to be associated with worse outcomes.
      • Ashwood N.
      • Verma M.
      • Hamlet M.
      • Garlapati A.
      • Fogg Q.
      Transarticular shear fractures of the distal humerus.
      ,
      • Durakbasa M.O.
      • Gumussuyu G.
      • Gungor M.
      • Ermis M.N.
      Distal humeral coronal plane fractures: management, complications and outcome.
      ,
      • Marinelli A.
      • Cavallo M.
      • Guerra E.
      • Ritali A.
      • Bettelli G.
      • Rotini R.
      Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients.
      In noncomparative studies, the overall complication rate was higher following the lateral approach (25.8%) compared to the anterolateral approach (16.7%). Pain (9.5%) and incomplete posterior interosseous nerve (PIN) palsy (7.1%) were more highly associated with the anterolateral approach while post-traumatic arthritis (9.1%), HO (6.1%), and AVN (4.5%) were more likely to be reported after the extended lateral approach. Only one study included in our analysis directly compared the two approaches. The authors reported one case of temporary PIN palsy associated with the anterolateral approach, but had no cases of post-traumatic arthritis, HO, or AVN.
      • Yu T.
      • Tao H.
      • Xu F.
      • Hu Y.
      • Zhang C.
      • Zhou G.
      Comparison of lateral approach versus anterolateral approach with Herbert screw fixation for isolated coronal shear fractures of humeral capitellum.
      It is worth noting that permanent injury of the PIN was not reported in any of the articles. The increased incidence of PIN temporary palsy with the AL approach may be explained by the fact that the PIN is directly in the surgical field during the AL approach. The extensive dissection associated with the EL approach may explain the relatively high rate of HO and AVN following this approach. These complications of PTA, HO, and AVN following the lateral approach have the potential to affect long-term outcomes.
      Numerous studies have found Dubberley B fractures to be associated with worse functional outcomes and increased complication rates compared to Dubberley A fractures.
      • Ashwood N.
      • Verma M.
      • Hamlet M.
      • Garlapati A.
      • Fogg Q.
      Transarticular shear fractures of the distal humerus.
      ,
      • Brouwer K.M.
      • Jupiter J.B.
      • Ring D.
      Nonunion of operatively treated capitellum and trochlear fractures.
      ,
      • Dubberley J.H.
      • Faber K.J.
      • Macdermid J.C.
      • Patterson S.D.
      • King G.J.
      Outcome after open reduction and internal fixation of capitellar and trochlear fractures.
      ,
      • Marinelli A.
      • Cavallo M.
      • Guerra E.
      • Ritali A.
      • Bettelli G.
      • Rotini R.
      Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients.
      Marinelli et al assessed the outcomes following operative management of 45 consecutive distal humerus shear fractures (17 type A, 28 type B).
      • Marinelli A.
      • Cavallo M.
      • Guerra E.
      • Ritali A.
      • Bettelli G.
      • Rotini R.
      Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients.
      They report a complication rate of 29% (n = 5) following management of type A fractures compared to 64% (n = 18) following management of type B fractures. PTA (n = 5), ulnar nerve symptoms (n = 5), HO (n = 3), AVN (n = 2), and hardware loosening (n = 2) were all more common following management of type B fractures, while residual instability (n = 2) was more common following management of type A fractures. Brouwer et al also suggested a poor prognosis following management of type 3B fractures, reporting a 44% nonunion rate.
      • Brouwer K.M.
      • Jupiter J.B.
      • Ring D.
      Nonunion of operatively treated capitellum and trochlear fractures.
      Recently, the use of lower profile locking plates in the management of Dubberley B fractures has led to encouraging improvements in outcomes, with multiple studies now reporting excellent functional outcomes and a 100% union rate.
      • Song Z.
      • Wang Q.
      • Ma T.
      • Wang C.
      • Yang N.
      • Xue H.
      • et al.
      Anti-sliding plate technique for coronal shear fractures of the distal humerus.
      ,
      • Wang P.
      • Kandemir U.
      • Zhang K.
      • Zhang B.
      • Song Z.
      • Huang H.
      • et al.
      Treatment of capitellar and trochlear fractures with posterior comminution: minimum 2-year follow-up.
      This study is not without limitations. The majority of published data regarding capitellum shear fractures consists of retrospective case series, likely due to the rare incidence of this injury.
      • Morrey B.F.
      • Morrey B.F.
      The Elbow and its disorders.
      Hence, the studies analyzed in the present study were largely level IV evidence. The distinction of a single surgical approach and the reported complications were requisite for inclusion in the sub-analysis. This limited the sub-analysis to six articles and did not allow comparative statistics.

      Conclusions

      This meta-analysis demonstrated a high rate of complications associated with ORIF of capitellum shear fractures, including a reoperation rate of 13.8%. While the overall complication rate following ORIF of Dubberley A fractures was higher after the lateral approach compared to the anterolateral approach, matched comparisons could not be performed. Persistent pain and temporary PIN palsy were reported following the anterolateral approach, while post-traumatic arthritis, HO, and AVN were more often reported following the extended lateral approach. Those complications encountered following the extended lateral approach may have a long-term impact on outcomes; however, assessment of long-term outcomes is beyond the scope of this work. Surgeons may be able to utilize this information when counseling patients preoperatively. However, insufficient evidence currently exists to definitively recommend one approach over the other when addressing capitellar shear fractures. High-quality comparative studies are needed.

      Disclaimers

      Funding: No funding was disclosed by the authors.
      Conflicts of interest: Mohit N. Gilotra, MD: This author reports the following: Orthofix, Inc. (Research support); and Tigon (Unpaid consultant). Nathan N. O'Hara, PhD MHA: This author reports the following: Arbutus Medical Inc. (Stock or stock Options). The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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