Full text of DOI:10.1016/S0020-1383(99)00254-5

Injury, Int. J. Care Injured 31 (2000) 204±206
www.elsevier.com/locate/injury
Case report
Cannulated screw ®xation of fractured capitellum: surgical
technique through a limited approach
A.A. Malki*, F.M. Salloom, J. Wong-Chung, A.I. Ekri
The Department of Orthopaedic Surgery, Salmaniya Medical Center, P.O. Box 12, Adliya, Bahrain
Accepted 28 September 1999
1. Introduction
ition of the screw is checked using image intensi®ca-
tion. The 1.25-mm guide wire is removed and the
wound closed in layers with a small size drain in the
joint. The arm is placed in a removable splint with the
elbow at 908. The drain is removed after 24 h and
gentle active mobilization of the elbow started. Sutures
are removed, the splint discarded within two weeks
and active exercises continued.
We describe a limited anterolateral approach for
open reduction of a displaced capitellar fracture. Fix-
ation is achieved by percutaneous insertion of an ante-
grade cannulated screw guided by a wire passed from
posterior to anterior aspects to avoid damage to the
articular surface. No soft tissue dissection is performed
posteriorly or laterally.
2.1. Case 1
2. Surgical technique and case reports
A 37-year old lady injured her right elbow from a
fall on the outstretched hand. Radiographs demon-
strated a displaced fracture of the capitellum (Fig. 1a).
Open reduction and cannulated screw ®xation were
performed. Follow-up radiographs showed union of
the fracture (Fig. 1b). The elbow remained stable with
a painless full range of movement. The screw was
removed after one and a half years through the small
posterior incision.
An eight-cm lateral skin incision is centred over the
lateral humeral epicondyle. The elbow joint is opened
longitudinally anterior to the lateral condyle. The frac-
ture surfaces are inspected, irrigated and reduced. A
1.25 mm threaded guide wire is placed on the radial
aspect of the elbow joint perpendicular to the fracture
line. Through a small stab wound over the posterolat-
eral aspect of the elbow, a similar wire is inserted par-
allel to the outside wire until it is about to elevate the
articular cartilage of the reduced fragment. The pos-
ition of the wire is checked and the required screw is
measured. The posterior cortex is perforated by a 3.5-
mm cannulated drill bit and a 3.5-mm cannulated tap.
The guide wire, drill bit and tap are used within their
appropriate sleeves. A short threaded 3.5-mm cannu-
lated screw is inserted over the wire from the posterior
aspect. The stability of the fracture is tested. The pos-
2.2. Case 2
A 32-year old manual worker fell and sustained a
fracture of the left capitellum (Fig. 2a). The fracture
surfaces being ¯at providing no interlocking at the
fracture interface, one screw was not enough to hold
the fracture ®rmly. Two screws were therefore used
(Fig. 2b). Follow-up at 3 and 6 months revealed a full
range of movement, normal power and a stable elbow.
2.3. Case 3
* Corresponding author. P.O. Box 15805, Adliya, Bahrain. Tel./
fax: +973-692-660 (H); tel.: +973-279-740 (S); fax: +973-275-612
(O).
A 24-year old lady sustained a fracture of the left
capitellum from a fall on the outstretched left hand.
E-mail address: ram81@batelco.com.bh (A.A. Malki).
0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.
PII: S0020-1383(99)00254-5

Fig. 2. Case 2. (a) Fractured capitellum with ¯atter fracture surfaces.
(b) Follow-up radiographs showing ®xation with two cannulated
screws.
Fig. 1. Case 1. (a) The large fractured capitellar fragment appears as
a displaced half-moon on the lateral radiograph of the elbow. (b)
Follow-up radiograph with screw ®xation. The fracture has united
with no signs of avascular necrosis.
Fig. 3. Case 3. Post-operative radiographs with one cannulated screw ®xation.

206
A.A. Malki et al. / Injury, Int. J. Care Injured 31 (2000) 204±206
Fixation with one cannulated screw was performed
(Fig. 3). At 3 and 6 months postoperatively, she lacked
the last 108 of elbow extension.
out of the ®ve elbows were re-explored because of pro-
blems with screw position and length [4].
In this report, we use a limited exposure as the
guide wire and cannulated screws are inserted from the
posterior to the anterior aspects. This technique limits
soft tissue dissection. Passing the wire and screw in an
antegrade manner requires a smaller space and avoids
damage to the articular cartilage. The use of one or
two cannulated screws guided by wires will con®rm
accurate positioning before screw insertion and reduces
the chances of multiple trials.
3. Discussion
The relatively common Hahn±Steinthal fracture
with a large capitellar fragment was described as type
1 by some authors [1] and type 2 by others [2]. Open
reduction and internal ®xation of this fracture is tech-
nically demanding [3]. The lateral Kocher approach
with detachment of the common extensor origin is the
standard exposure used by many surgeons [1,4]. Provi-
sional ®xation is performed with transarticular wires
passed through the joint surface. De®nitive ®xation is
achieved by screws, which are inserted either from the
anterior or the posterior surfaces. In some reports it
was also necessary to re¯ect the lateral collateral liga-
ment [1] to gain enough access for reduction and ®x-
ation by noncannulated 4-mm cancellous or Herbert
screws [5]. In a modi®ed technique on ®ve elbows, two
parallel wires were inserted from the lateral cortex into
the reduced fragment and small fragment 4.0-mm
screws were inserted from the posterior aspect. Two
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