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| CASE REPORTS |
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| Year : 2021 | Volume
: 29
| Issue : 2 | Page : 61-63 |
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Missed fracture of capitulum on initial radiograph: A case report
Ajay Goel1, Sanjay Keshkar2
1 Department of Orthopaedics, CMRI Hospital, Kolkata, India
2 Department of Orthopaedics, ESIC Medical College & Hospital Joka, Kolkata, West Bengal, India
| Date of Submission | 10-Jul-2021 |
| Date of Acceptance | 11-Jul-2021 |
| Date of Web Publication | 20-Dec-2021 |
Correspondence Address:
Sanjay Keshkar
Department of Orthopaedics, ESIC Medical College & Hospital Joka, Kolkata 700104, West Bengal.
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijors.ijors_19_21
Patients with isolated capitellar fractures mostly present with painful swelling of the elbow with definite local tenderness on clinical examination. These fractures become evident in the radiograph. In this paper, we report a young girl with an isolated capitellar fracture that was missed in the initial radiograph of the elbow and became evident in computed tomography (CT) and subsequent X-ray. This patient was treated successfully with open reduction and internal fixation by two headless screws (Herbert screw). Keywords: Capitulum fracture, elbow injury, Herbert screw, missed fracture
How to cite this article:
Goel A, Keshkar S. Missed fracture of capitulum on initial radiograph: A case report. Int J Orthop Surg 2021;29:61-3 |
| Introduction | |  |
Capitulum fracture, though rare but not uncommon, accounts for approximately 6% of distal humerus fractures and 1% of all elbow fractures.[1] Patients with capitulum fractures mostly present with painful swelling of the elbow with local tenderness and painful restriction of joint movements and locking. Patients with capitellar fractures mostly present with painful swelling of the elbow with local tenderness and painful restriction of joint movements and locking. Although these fractures become evident in the initial radiograph, misdiagnosis is also not uncommon.[2]
As far as treatment is concerned, various treatment options are available for this fracture but open reduction and internal fixation (ORIF) by headless compression screw/herbert screw is the preferred method.[3],[4],[5],[6] Herbert screw is used to achieve stable fixation so that early mobilization can be initiated and it is not necessary to remove the hardware later.[7] In this paper, we report a young girl with an isolated capitellar fracture that was missed in the initial radiograph of the elbow and became evident in computed tomography (CT) and subsequent X-ray. This patient was treated successfully with ORIF using two headless screws.
| Case Report | | |
A 20-year-old, right-handed, girl presented to us with a history of falling on her outstretched left hand with pain and swelling around the elbow. The findings of physical examination involve painful restriction of joint movements and locking. There was no neurovascular deficit. Plain radiographs were taken and the finding of the radiographs was negative for any bony injury [Figure 1A]. This X-ray finding was not correlated with the clinical findings. The findings of the subsequent X-ray [Figure 1B] and then CT scan [Figure 1C] revealed a Bryan and Morrey[1] type I osteochondral capitellar fracture that displaced anterosuperiorly. There was no other concomitant injury around elbow. ORIF was planned for the patient. All preoperative blood and other relevant tests were within normal limits. After taking informed consent, the patient underwent ORIF using two Herbert screws under fluoroscopy control under general anesthesia. The elbow was immobilized for 5 days on the above elbow posterior plaster of Paris (POP) slab to prevent swelling. This was followed by a progressive elbow mobilization program and followed up at monthly intervals for 3 months, bimonthly for the next 6 months, and final follow-up after 12 months of surgery. At this time, the fracture was united well as evident in the radiograph [Figure 1D]. Clinically, she had a full range of painless motion (flexion––extension and pronation––supination) of elbow. Her Mayo Elbow score was 95 and based on that the functional result was excellent. | Figure 1: A case of capitellar fracture. Initial radiographs of elbow (anteroposterior and lateral views) showing no bony injury (A). Subsequent X-ray (B) and then CT scan (C) revealed a Bryan and Morrey type I osteochondral capitellar fracture that displaced anterosuperiorly. Radiograph after 12 months of Open Reduction and Internal Fixation (ORIF) by two Herbert screws showing excellent union (D)
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| Discussion | | |
Patients with capitellar fractures often present with findings such as swelling, severe painful limitation of movement, and joint locking. Clinicoradiological evidences are enough to diagnose this fracture but it is not uncommon to miss it, as happened in our case. It is well proved that capitulum fractures can easily be misdiagnosed or missed in an elbow anteroposterior X-ray due to distal humerus and capitulum overlap.[2] Lateral elbow X-rays are more effective for determining such fractures,[2],[6] but, in rare instances, may not recognize in initial X-ray. CT scans are recommended for better diagnosis and also to define fracture configuration. [7,8] CT is also helpful for fracture classification and preoperative planning for the choice of internal fixation implants.[9]
Although various treatment options are available for these injuries, for example, conservative methods, ORIF, and fragment excision, ORIF by headless compression screw/Herbert screw is the preferred method for stable fixation.[3],[4],[5],[6] In our case also, ORIF by two Herbert screws was done and an excellent result was achieved.
Missed fracture of a humerus capitulum in the initial radiograph is reported in this case. One should not rely on a radiograph alone but must go for CT scan for early diagnosis, understanding fracture pattern, and planning of surgery. ORIF by headless compression screw/Herbert screw is found to be superior and considered as a choice of treatment in such fracture.
Acknowledgement
During the study period, the sole author(s) of this article was attached to ESIC Medical College & Hospital, Kolkata and performed the study then and there.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Authors’ contributions
AG contributed to the study design, analysis of data, preparation of manuscript, and reviewed the manuscript. SK contributed to the study design, analysis of data, surgical intervention, supervised the study, and reviewed the manuscript for final preparation.
| References | | |
| 1. | Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, editor. The Elbow and Its Disorders. Philadelphia, PA: WB Saunders; 1985. p. 302-39.  |
| 2. | Mehdian H, McKee MD. Fractures of capitellum and trochlea. Orthop Clin North Am 2000;31:115-27. |
| 3. | Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am 2008;90:1321-9. |
| 4. | Dubberley JH, Faber KJ, Macdermid JC, Patterson SD, King GJ. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am 2006;88: 46-54. |
| 5. | Schindler OS. Bilateral capitellum humeri fracture: A case report and review of the literature. J Orthop Surg (Hong Kong) 2003;11: 207-12. |
| 6. | Guitton TG, Doornberg JN, Raaymakers EL, Ring D, Kloen P. Fractures of the capitellum and trochlea. J Bone Joint Surg Am 2009;91:390-7. |
| 7. | Mahirogullari M, Kiral A, Solakoglu C, Pehlivan O, Akmaz I, Rodop O. Treatment of fractures of the humeral capitellum using Herbert screws. J Hand Surg 2006;31:320-5. |
| 8. | Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Coronal plane partial articular fractures of the distal humerus: Current concepts in management. J Am Acad Orthop Surg2008;16:716-28. |
| 9. | Polat B, Ozmanevra R, Aydin D, Sari E, Yalcinozan M. Missed capitellar fracture caused by avoidance of radiological evaluation in pregnancy. Case Rep Orthop 2018;2018:6024057. |
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