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. 2022 Sep 13;6(6):1054–1061. doi: 10.1016/j.jseint.2022.08.011

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

Kalin J Fisher a, Michael G Livesey a, Oliver C Sax b, Mohit N Gilotra a, Nathan N O'Hara a, R Frank Henn III a, S Ashfaq Hasan a,∗
PMCID: PMC9637809  PMID: 36353417

Abstract

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.

Keywords: Capitellum, Capitellum fracture, Shear fracture, Distal humerus fracture, Complications, Surgical approach

Partial articular shear fractures of the distal humerus involving the capitellum and the trochlea were first described by McKee et al27 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.21,31,35 However, a high complication rate and reoperation rate have been reported following operative management.9,33 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 classification5 and the Dubberley classification.9 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.3

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 1.

Figure 1

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PRISMA (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 I.

Study demographics and baseline characteristics.

Study Level of evidence N F:M Age (range, SD) Injury mechanism (mechanical fall, traffic accident, other∗) Bryan-Morrey (1,2,3,4) Dubberley (total A, B) Other classification Study follow-up (SD)
Ashwood et al. 20101 IV 26 13:13 39.4 (22-76, 13.5) 21,5,0 NR 16,10 NR 46
Ballesteros-Betancourt et al. 20202 IV 8 4:4 66 (53-76, 5.75) NR NR 4,4 NR 33
Bilsel et al. 20133 IV 18 12:6 45.3 (16-70, 13.5) 14,0,4 7,0,5,6 NR NR 43.6 (38.1)
Brouwer et al. 20114 IV 30 21:9 49 (17-75, 14.5) 25,2,3 NR 6,24 NR 34
Chang et al. 20206 IV 9 NR (26-70) NR NR NR NR 18
Demir et al. 20207 IV 10 6:4 43.8 (34-72, 11.1) 10,0,0 NR 0,10 NR 59.6 (38.79)
Dietz et al. 20058 IV 7 3:4 45 (21-85, 16) NR 7,0,0,0 NR NR 30.3
Dubberly et al. 20069 IV 28 24:4 43 (20-71, 12.75) 28,0,0 NR 13,15 NR 56 (33)
Durakbasa et al. 201310 IV 15 10:5 36 (11-76, 16.25) 9,3,3 NR 9,6 NR 50
Garg et al. 202012 IV 10 2:8 29.3 (21-42, 5.25) 4,6,0 NR NR NR 13.8
Goodman et al. 200513 IV 8 6:2 56 (18-80, 15.5) NR NR NR NR 14
Guitton et al. 200914 IV 27 NR NR NR NR 3, 24 Ring: 1 (1); 2 (1); 3 (9); 4 (15); 5 (1) NR
He et al. 201916 IV 20 12:8 48.3 (16-76, 15) 13,7,0 NR 17,3 NR 42.5
Heck et al. 201217 IV 15 11:4 35.7 (13-72, 14.75) NR 7,3,2,3 13,2 NR 58.5
Hussain et al. 201818 IV 15 0:15 27.5 8,0,0 11,1,1,2 NR NR 22.5
Imatani et al. 200119 IV 6 4:2 47 (38-66, 7) 4,2,0 NR NR NR 40.3
K.C. et al. 202020 IV 22 8:14 35.86 (20-64, 11.18) 8,9,5 NR 22,0 NR 9.36 (2.4)
Lopiz et al. 201622 IV 20 13:7 71 (66-79, 3.25) 19,0,1 NR 15,5 NR 48
Lu et al. 202123 IV 24 7:17 44.9 (19-75) 12,6,6 NR 0,24 NR 19.6 (7.7)
Lu et al. 201624 IV 47 16:31 56.4 42,0,5 NR 27,20 NR 18.1
Mahirogullari et al. 200625 IV 11 3:8 27.5 (17-43, 6.5) 11,0,0 11,0,0,0 NR NR 23.4
Marinelli et al. 201826 IV 45 13:32 52 (15-88, 18.25) NR NR 17,28 NR 39.6 (27.6)
Mighell et al. 201028 IV 18 16:2 45 (20-68, 12) NR NR 18,0 NR 25.5
Mukohara et al. 202130 III 25 22:3 57 (12-79, 20) 21,4,0 NR 12,13 NR 15 (9)
Ravishankar et al. 201732 IV 33 11:22 37.9 (12-70, 14.5) 10,22,1 17,3,2,11 5,6 NR 24.6
Ring et al. 200333 IV 21 19:2 50 (20-74, 13.5) 15,3,3 NR 12,9 Ring: 1 (3); 2 (2); 3 (5); 4 (4); 5 (7) 40
Rotini et al. 201134 IV 10 7:3 46.4 (15-65, 12.5) NR 3,1,0,6 NR NR 31.7
Ruchelsman et al. 200836 IV 16 13:3 40 (11-67, 17) NR 6,0,2,8 NR NR 27 (19)
Sano et al. 200537 IV 6 6:0 51 (12-78, 16.5) 5,0,1 NR NR Grantham: 2A (2); 2B (1); 2C (1); 3A (2) 67.2
Shergold et al. 202238 III 45 31:14 53 (19-86) NR NR 19,26 NR 28
Singh et al. 201040 IV 14 5:9 33 (16-46, 7.5) 11,0,3 10,1,3,0 NR NR 57.6
Singh et al. 201239 IV 10 3:7 32 (18-36, 4.5) 4,6,0 NR NR NR 24.4
Song et al. 202041 IV 52 17:35 40.4 (23-62, 9.75) 52,0,0 NR 40,12 NR 17.6
Sultan et al. 201742 IV 15 11:4 35 (20-48, 7) 15,0,0 9,0,0,6 NR NR 42.5
Tanriverdi et al. 202043 IV 21 8:13 39 (18-63) NR 14,0,3,4 NR NR 45
Tarallo et al. 201544 IV 8 2:6 50 (37-64, 6.75) 8,0,0 NR 3,5 NR 30
Tarallo et al. 202145 IV 24 16:8 50.2 (18-71) NR NR 10,14 NR 30
Teng et al. 202046 IV 19 11:8 44.6 (19-72) 14,5,0 NR 12,7 NR 17.1
Tomori et al. 202247 IV 8 8:0 76.3 (66-83, 5.1) 8,0,0 NR 1,7 NR 23.6 (13.9)
Vaishya et al. 201648 IV 16 6:10 32 (18-50, 8) 14,0,2 10,5,0,1 NR NR 27.6
Wang et al. 201949 IV 15 10:5 44.3 (22-71, 12.25) 4,8,3 NR 0,15 NR 32.5
Yoshida et al. 202150 IV 16 13:3 49 (11-78) 16,0,0 NR 10,1 NR 23.5
Yu et al. 201952 I 26 15:11 49 (32-59, 6.75) 19,7,0 NR 26,0 NR 20.5 (6)
Yu et al. 201851 IV 15 9:6 42 (19-64, 11.25) 10,5,0 NR 15,0 NR 29 (4)
Zhang et al. 202053 IV 34 26:8 49.6 (35-64.2, 7.3) 14,0,20 NR 0,34 NR 44.9 (34.6)
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SD, standard devitaion.

∗

other mechanisms include blunt trauma, biking, fall from a height.

Table II.

Study summary.

Characteristics
No. of studies 45
No. of patients 899
Age, y, mean (95% CI) 44.9 (39.7 to 50.2)
Sex
 Female 485 (54%)
 Male 372 (41%)
 Not reported 42 (5%)
Fracture type (Dubberley)
 A 342 (38%)
 B 300 (33%)
 Not reported 257 (29%)
Follow-up, mo, mean (SD) 29.7 (23.0 to 36.5)
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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 III.

Pooled estimates of study complications.

Outcome No. of studies Proportion (95% CI) I2 (95% CI)
Reoperation, n (%) 37 13.8% (9.6 to 19.5%) 60.2% (42.9% to 72.2%)
Nonunion, n (%) 33 6.6% (4.6% to 9.2%) 0.0% (0.0% to 33.9%)
Arthritis, n (%) 39 21.2% (18.0% to 24.9%) 47.6% (23.8% to 64.0%)
Avascular necrosis, n (%) 33 7.4% (5.3% to 10.2%) 0.0% (0.0% to 17.7%)
Heterotopic ossification, n (%) 32 12.0% (9.2% to 15.6%) 46.2% (18.4% to 64.5%)
Nerve injury, n (%) 26 7.8% (5.6% to 10.9%) 0% (0.0% to 14.9%)
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CI, confidence interval.

Table IV.

Functional and patients reported outcomes and complications.

Study N Total arc ROM ROM Ex. ROM Fl. Total sup.-pro. ROM Mean MEPI score “Excellent” outcome “Good” outcome Comp. Total AVN Arthritis HO Nerve injury Reops.
Ashwood et al. 20101 26 114.7 14.1 128.8 NR 81.3 9 9 8 0 10 0 2 6
Ballesteros-Betancourt et al. 20202 8 128 10 138 NR NR NR NR 1 0 0 0 0 0
Bilsel et al. 20133 18 123.9 8.9 132.8 180 86.7 12 2 1 0 0 1 0 1
Brouwer et al. 20114 30 115 65 145 NR NR NR NR 22 0 8 1 0 5
Chang et al. 20206 9 120 15 135 NR NR NR NR 2 0 2 0 0 0
Demir et al. 20207 10 119.6 17.9 137.5 151.1 95.5 5 3 3 1 1 0 0 1
Dietz et al. 20058 7 106.6 7 113.6 NR NR 2 1 2 0 2 0 0 0
Dubberly et al. 20069 28 119 19 138 NR 91 NR NR 27 1 9 0 0 0
Durakbasa et al. 201310 15 NR NR NR NR 83.3 7 2 25 4 6 7 0 0
Garg et al. 202012 10 136 NR NR 180 96 NR NR 1 0 0 0 1 0
Goodman et al. 200513 8 NR NR NR NR 84 NR NR 8 0 0 0 2 2
Guitton et al. 200914 27 NR NR NR NR NR NR NR 8 0 9 0 0 0
He et al. 201916 20 99.6 17.5 117.1 NR NR 10 7 15 2 6 4 1 14
Heck et al. 201217 15 124 NR NR 173 90 7 7 15 0 8 0 0 0
Hussain et al. 201818 15 125 7.6 135 NR NR 10 4 8 0 2 4 0 0
Imatani et al. 200119 6 113.8 14.5 128.3 NR NR 1 4 2 0 0 0 0 0
K.C. et al. 202020 22 138.41 NR NR 161.59 90.22 NR NR NR 0 0 0 0 0
Lopiz et al. 201622 20 122 8 122 NR 92 14 4 12 1 3 5 1 1
Lu et al. 202123 24 111 8.5 122.5 160.2 89.8 18 5 3 0 0 0 0 0
Lu et al. 201624 47 112 6 118 NR 87.6 31 12 0 0 0 0 0 0
Mahirogullari et al. 200625 11 117 NR NR 151 93.6 8 3 4 0 0 0 0 0
Marinelli et al. 201826 45 NR NR NR NR 78 12 15 23 2 6 4 6 7
Mighell et al. 201028 18 128 NR NR 176 NR 12 5 12 3 5 3 0 0
Mukohara et al. 202130 25 120.2 10 130 NR 96.3 18 5 16 3 7 2 1 0
Ravishankar et al. 201732 33 133 NR NR 151 80.9 14 10 9 2 1 1 0 0
Ring et al. 200333 21 96 27 123 180 NR 4 12 14 0 0 0 2 10
Rotini et al. 201134 10 NR NR NR NR 98 NR NR 0 0 0 0 0 0
Ruchelsman et al. 200836 16 123 10 133 180 91.6 9 6 11 0 4 6 0 1
Sano et al. 200537 6 131.7 7.5 139.2 180 NR 3 3 0 0 0 0 0 0
Shergold et al. 202238 45 125 10 130 170 NR NR NR 14 0 0 1 6 15
Singh et al. 201040 14 124.5 7.5 132 180 NR 10 4 0 0 0 0 0 0
Singh et al. 201239 10 111.5 6 117.5 NR NR 7 2 1 0 0 1 0 1
Song et al. 202041 52 133 3 136 180 90.6 36 11 13 0 3 2 0 17
Sultan et al. 201742 15 120 10 130 NR 91.33 10 5 2 0 1 0 0 2
Tanriverdi et al. 202043 21 102 NR NR 165 81.9 9 6 11 3 7 1 0 0
Tarallo et al. 201544 8 125 20 125 180 92 5 3 3 0 0 1 0 1
Tarallo et al. 202145 24 113.1 NR NR 180 92.1 NR NR 4 0 1 0 0 3
Teng et al. 202046 19 130.5 NR NR 167.4 85.8 9 8 4 0 3 1 0 10
Tomori et al. 202247 8 87.5 NR NR NR 78.8 1 3 8 1 1 0 0 0
Vaishya et al. 201648 16 122 10 132 NR NR 10 6 2 0 0 0 1 0
Wang et al. 201949 15 NR 11 123.7 NR 89 12 2 4 1 1 1 0 1
Yoshida et al. 202150 16 NR NR NR NR 83.8 7 6 2 0 0 0 0 1
Yu et al. 201952 26 134 NR NR 169 92 NR NR 1 0 0 0 1 0
Yu et al. 201851 15 134 NR NR 172 93 11 4 5 0 0 0 1 0
Zhang et al. 202053 34 NR NR NR NR NR NR NR 17 0 9 0 0 8
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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 V.

Approaches and fixation methods used.

Study N Lateral approach∗ Anterolateral approach Olecranon osteotomy Posterior approach† Other approach Fixation with HCS only‡ Fixation with HCS + provisional fixation§ HO prophylaxis?
Ashwood et al. 20101 26 26 0 0 0 0 11 12 1
Ballesteros-Betancourt et al. 20202 8 0 0 0 0 0 8 0 0
Bilsel et al. 20133 18 16 0 2 0 0 2 13 0
Brouwer et al. 20114 30 0 0 0 0 0 0 17 0
Chang et al. 20206 9 0 0 9 0 0 0 0 0
Demir et al. 20207 10 10 0 0 0 0 0 10 1
Dietz et al. 20058 7 0 0 0 0 7 7 0 1
Dubberly et al. 20069 28 5 14 14 7 3 3 0 1
Durakbasa et al. 201310 15 11 0 2 2 0 14 0 1
Garg et al. 202012 10 0 10 0 0 0 10 0 0
Goodman et al. 200513 8 4 0 4 0 0 0 0 0
Guitton et al. 200914 38 22 0 3 2 1 15 0 0
He et al. 201916 20 14 0 6 0 0 0 0 1
Heck et al. 201217 15 15 0 0 0 0 0 0 1
Hussain et al. 201818 15 15 0 0 0 0 13 0 0
Imatani et al. 200119 6 0 6 0 0 0 6 0 0
K.C. et al. 202020 22 22 0 0 0 0 22 0 0
Lopiz et al. 201622 20 16 1 3 0 0 11 0 0
Lu et al. 202123 24 24 0 0 0 0 0 0 1
Lu et al. 201624 47 47 0 0 0 0 47 0 1
Mahirogullari et al. 200625 11 11 0 0 0 0 11 0 0
Marinelli et al. 201826 45 37 0 8 0 0 0 3 0
Mighell et al. 201028 18 18 0 0 0 0 0 18 0
Mukohara et al. 202130 25 13 1 0 12 0 24 13 0
Ravishankar et al. 201732 33 22 5 6 0 0 25 0 0
Ring et al. 200333 21 14 0 7 0 0 10 11 0
Rotini et al. 201134 10 0 0 0 0 0 10 0 0
Ruchelsman et al. 200836 16 16 0 0 0 0 0 16 0
Sano et al. 200537 6 4 0 2 0 0 6 0 0
Shergold et al. 202238 45 25 0 2 4 14 13 21 0
Singh et al. 201040 14 14 0 0 0 0 14 0 0
Singh et al. 201239 10 10 0 0 0 0 4 2 1
Song et al. 202041 52 52 0 0 0 0 0 0 0
Sultan et al. 201742 15 15 0 0 0 0 15 0 0
Tanriverdi et al. 202043 21 19 0 0 2 0 21 0 0
Tarallo et al. 201544 8 8 0 0 0 0 8 0 0
Tarallo et al. 202145 24 24 0 0 0 0 0 24 0
Teng et al. 202046 19 11 0 2 0 6 0 19 0
Tomori et al. 202247 8 5 1 0 2 0 8 2 0
Vaishya et al. 201648 16 0 16 0 0 0 16 0 0
Wang et al. 201949 15 15 0 0 0 0 0 3 1
Yoshida et al. 202150 16 12 2 0 0 2 11 2 0
Yu et al. 201952 26 14 12 0 0 0 26 0 0
Yu et al. 201851 15 0 15 0 0 0 15 0 0
Zhang et al 202053 34 28 0 6 0 0 0 0 0
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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,11,15 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.1,10,26 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.52 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.1,4,9,26 Marinelli et al assessed the outcomes following operative management of 45 consecutive distal humerus shear fractures (17 type A, 28 type B).26 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.4 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.41,49

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.29 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.

Footnotes

Institutional Review Board approval was not required in this systematic review and meta-analysis of de-identified, published data.

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