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An unusual case of an isolated capitellar fracture of the right elbow in a child: a case report
© Gonçalves Pestana et al; licensee BioMed Central Ltd. 2012
Received: 29 April 2011
Accepted: 10 February 2012
Published: 10 February 2012
Although elbow fractures have a high incidence in the pediatric population, fractures of the capitellum are almost exclusively observed in individuals older than 12 years of age. Due to their rarity in children, reports with large numbers of cases are lacking in the literature and the surgical treatment options are poorly defined.
We present the case of an 11-year-old Portuguese girl with a displaced fracture of the capitellum of the right elbow, a typical Hahn-Steinthal or Type 1 fracture, which was followed for one year. The treatment and outcome of this fracture are described. Our patient underwent an open reduction and internal fixation with two cannulated screws. There were no complications and normal elbow function was recovered.
The authors believe that cannulated screw fixation is a reliable method of treatment for Type 1 capitellar fracture in children because it enables good interfragmentary compression, early mobilization, faster functional elbow recovery and implant removal is rarely necessary.
Isolated capitellar fractures are rare and represent only 1% of all elbow fractures and 6% of distal humeral fractures [1–3]. In children under the age of 12, these fractures are even more unusual and, to the best of our knowledge, such an injury has not been reported in a young child [3–8]. The mostly cartilaginous composition of the capitellum below that age makes it more resistant to stress. Therefore, a fall on the outstretched hand (which is the mechanism of injury in most of these cases) is more likely to produce a supracondylar or lateral condylar fracture. As the capitellum grows and ossifies in older children, it becomes more susceptible to shear injury [5, 9]. Fracture of the lateral humeral condyle is usually seen at a younger age group and may be confused with a fracture of the capitellum. A fracture of the capitellum is an osteochondral fracture and is entirely intra-articular. The epicondyle, the growth plate and the metaphysis are not involved, and the posterior part of the lateral condyle remains intact. Differentiation between a fracture of the lateral humeral condyle and a capitellar fracture is important with respect to treatment [7, 8].
In adults, a variety of treatment methods have been described. As this type of fracture became better recognized in the adult population, treatment options evolved from closed reduction and immobilization, or excision of the capitellar fragment, to open reduction and internal fixation in order to achieve a stable anatomic reduction [2, 3, 10–17].
We present the case of an 11-year-old patient with a Hahn-Steinthal fracture treated by open reduction and internal fixation with two cannulated screws.
The follow-up period was of one year with regular clinical examination and roentgenographic control. Our patient was asked about pain and daily activities. Her elbow flexion-extension and pronation-supination were evaluated and compared with the contralateral side.
Hahn-Steinthal fracture of the capitellum is rarely seen in children younger than 12 years of age [3, 5, 7]. It is important to emphasize that these fractures can be misdiagnosed simply because of bad radiologic examinations, inexperience in the interpretation of capitellar fragments and the bizarre appearance of the fracture, especially if there is considerable rotation associated with the displacement. They can, however, lead to significant disability by limiting elbow motion if undiagnosed and untreated [4, 5].
There are few references in the orthopedic literature to surgical treatment of these fractures in the pediatric population, and even less about internal fixation with cannulated screws [5–8, 13]. Closed reduction has been particularly advocated in this population, but this can be difficult to achieve . Internal fixation with Kirschner wire has been the historically preferable method of fixation, as the cartilaginous component of the fragment is often very large with a minimal amount of cancellous or subchondral bone [4, 5, 8]. However, Kirschner wires penetrate the articular surface, do not provide stable fixation and cast immobilization is mandatory for a long period. Cannulated screw fixation enables adequate interfragmentary reduction and compression. Contrary to pin or wire techniques, this type of fixation does not require further hospital admissions and the rehabilitation program starts earlier and is uninterrupted [2, 3]. Headless double-threaded screws (Herbert type) could also be used [2, 5]. However, we feel that for thin fragments this type of screw can fail to confer satisfactory fixation due to its compression mechanism. Headed screws sunk into the cartilage were chosen in the presented case due to previous experience and the implants available to the authors. Presently, the preferred method of treatment for isolated Hahn-Steinthal Type 1 capitellum fracture in adults is open reduction and internal fixation and a wide variety of techniques are described, such as Kirschner wires, compression screws, Herbert screws and biodegradable pins [2, 3, 10, 12].
In our reported case, a large capitellum fragment displaced upwards and forwards was visualized on an oblique radiograph of her elbow. The method of treatment chosen by the authors, which was internal fixation with two cannulated screws, allowed them to achieve precise reduction of the large capitellum fragment and accurate placement of the screws where desired to offer good compression and stability. The excellent fixation obtained allowed our patient to start early active motion after cast removal, which occurred three weeks after surgery. It is important to emphasize that, as with most serious elbow injuries, this joint may take many months to regain a full range of motion. At one year follow-up, our patient had full recovery, no pain and a radiographic examination showed no signs of avascular necrosis, physeal arrest or angular deformity. She was also able to fully participate in sports without symptoms.
A displaced Hahn-Steinthal type 1 capitellum fracture such as described must be anatomically reduced to restore articular congruity and to minimize potential disablement. This goal is more often achieved by open reduction and internal fixation, and cannulated screw fixation has many advantages. Being subarticular, it provides suitable interfragmentary compression and avoids incongruence, allowing early joint motion. It does not need to be removed.
The authors recommend open reduction and internal fixation with cannulated screws to best achieve these goals in the pediatric age group.
The authors recognize limits of this case report, due to a short term follow-up and the absence of an index score to classify the clinical and radiological evolution.
Written informed consent was obtained from the mother of the patient for publication of this case report (the patient's legal guardian) and any accompanying images. The written consent is available for review by the Editor-in-Chief of this journal.
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