capitellar fractures in children and adolescents · capitellar physis. fractures involving the...

Capitellar Fractures in Children and AdolescentsClassification and Early Results of Treatment

Praveen G. Murthy, MD, Carley Vuillermin, MBBS, FRACS, Manahil N. Naqvi, BS, Peter M. Waters, MD, and Donald S. Bae, MD

Investigation performed at Boston Children’s Hospital, Boston, Massachusetts

Background: There has been limited published information regarding capitellar fractures in the pediatric population. Thepurpose of this investigation was to characterize capitellar fracture patterns in children and adolescents and to assessearly clinical and radiographic treatment outcomes.

Methods: A retrospective analysis of 37 children and adolescents with capitellar fractures presenting to a tertiarypediatric hospital from 2004 to 2014 was performed. The mean patient age at the time of injury was 11.8 years. Medicalrecords and radiographs were evaluated for fracture pattern, treatment, healing, and complications. Fractures werecategorized on the basis of prevailing patterns of injury, and a classification system is proposed that aids in treatmentdecision-making. Thirty-two patients had follow-up of at least 6 weeks and were included for assessment of treatmentoutcomes. The mean follow-up was 12.3 months.

Results: Three predominant capitellar fracture patterns were identified. Type-I fractures (n = 25) were anterior shearinjuries. Nondisplaced anterior shear fractures were successfully treated with cast immobilization. Displaced anteriorshear fractures were treated with open reduction and internal fixation, with good results in a majority of patients. Of the 21patients with Type-Ib fractures eligible for analysis, 6 (29%) required a secondary surgical procedure for loss of motionrelated to soft-tissue contracture, osteonecrosis, implant prominence, and/or intra-articular loose bodies. Type-II frac-tures (n = 9) were posterolateral shear injuries, typically associated with ulnohumeral dislocations. Among 5 patients withdisplaced fractures and adequate follow-up, 3 patients were treated nonoperatively and had poor results, with loss ofelbow motion or mechanical symptoms, and 2 patients were treated surgically and achieved good functional restoration.Type-III fractures (n = 3) were acute chondral shear injuries, which achieved full restoration of motion after surgicaltreatment.

Conclusions: A classification of pediatric capitellar fractures is proposed, guiding treatment and prognosis. Non-displaced fractures heal successfully with cast immobilization. Good results may be expected with surgical fixation ofdisplaced Type-I fractures (anterior shear). Type-II fractures (posterolateral shear) and Type-III fractures (chondral shear)are more subtle; advanced imaging and timely surgical management for displaced injuries are recommended to optimizeclinical results.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Capitellar fractures are uncommon in children andadolescents, representing <1% of pediatric elbowfractures1,2. Prior studies in adults have proposed

fracture classification and treatment algorithms dependenton injury pattern1,3-5. However, there has been little publishedinformation regarding injury patterns and anticipated resultsof treatment in the pediatric population. Delays in diagnosisor failure to restore articular congruity may lead to subop-timal outcomes. The purpose of this investigation was tocharacterize capitellar fracture patterns in children and ad-

olescents and to assess early clinical and radiographic resultsof treatment.

Materials and Methods

This retrospective case series was initiated following institutional reviewboard approval. A text query of the medical records was performed, using

the search terms “capitellar” or “capitellum” and “fracture.” From 2004 to 2014,62 children and adolescents presenting to our tertiary pediatric hospital werediagnosed with a capitellar fracture. Preoperative and postoperative radio-graphs, along with cross-sectional imaging when available, were reviewed by3 authors and consensus was obtained.

Disclosure: There was no external funding for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version ofthe article (http://links.lww.com/JBJS/E278).

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J Bone Joint Surg Am. 2017;99:1282-90 d http://dx.doi.org/10.2106/JBJS.16.01393

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Radiographic exclusion criteria included unavailable imaging, inade-quate evidence of fracture, or extension of the fracture line proximal to thecapitellar physis. Fractures involving the capitellum with extension into thelateral condyle or distal humeral metaphysis were more consistent with eitherlateral condylar fracture, supracondylar fracture, or comminuted intra-articulardistal humeral fracture, and these patients were excluded. In addition, medicalrecords and radiographs of patients with chondral shear injuries were scrutinizedto ensure acuity of the injury to distinguish traumatic chondral fracture fromsubacute or chronic presentation of an osteochondritis dissecans lesion. Patientswithout history of acute trauma were excluded.

After radiographic exclusion, 37 acute capitellar fractures remained andwere included for descriptive radiographic classification. Of these, 5 patientswere lost to follow-up prior to 6 weeks. The remaining 32 capitellar fractureshad adequate clinical and radiographic follow-up and were evaluated for resultsof treatment.

Clinical records were reviewed to determine demographic data, mech-anism of injury, treatment modality, surgical technique if applicable, elbowrange of motion throughout follow-up, and any persistent symptoms. A fullulnohumeral motion arc was defined as 0� to 135�. By convention, in this study,positive values for elbow extension denote the number of degrees lacking fromfull extension, and negative values refer to hyperextension. Complications suchas loss of motion, mechanical symptoms, or symptomatic implants were notedand were correlated with radiographic findings as described below.

On radiographic review, fractures were initially characterized usingfree-text descriptive language. Skeletal maturity was measured using elbow

ossification centers according to the Sauvegrain method6, and associated in-

juries were also noted. Predominant fracture patterns were noted, and allfractures were then classified using a novel system presented here. Follow-upradiographs were evaluated for alignment, osseous union, osteonecrosis, im-plant prominence, heterotopic ossification, loose bodies, and outcomes aftera secondary surgical procedure, when applicable.

In our final series, the mean patient age at the time of injury was 11.8years (range, 6 to 16 years). Twenty-two patients (59%) were male. Among the32 patients included for analysis of treatment outcomes, the mean follow-upwas 12.3 months (range, 1.6 to 63.0 months). The minimum follow-up was7 weeks. Twenty-six patients (81%) had follow-up of >3 months. Of the 6patients with follow-up of <3 months, all were followed to a clinical end pointof painless functional motion arc and demonstrated fracture-healing onradiographs.

Surgical Indications and TechniqueTreatment was based on the discretion of the treating pediatric orthopaedicsurgeon. Nonoperative treatment consisted of long arm casting for 3 to 6 weeks.A surgical procedure was typically recommended in patients with displacedfractures and incongruity of the radiocapitellar articulation. Overall, 27 patients(73%) in this series underwent initial surgical management.

An open posterolateral Kocher approach to the elbow was performed in26 (96%) of 27 patients undergoing surgical treatment. The remaining patientwas definitively treated with arthroscopy alone. In the Kocher approach, theanconeus-extensor carpi ulnaris interval was developed, and radiocapitellar

Fig. 1

Illustration showing the classification of pediatric capitellar fractures.

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VOLUME 99-A d NUMBER 15 d AUGUST 2, 2017CAP ITELLAR FRACTURES IN CHILDREN AND ADOLESCENTS

arthrotomy was performed. In some situations, a more extensile approach wasneeded for adequate visualization; this was performed via elevation of thelateral collateral ligament complex and wrist extensors off the lateral columnof the distal part of the humerus as a periosteal and soft-tissue sleeve.

The capitellar fracture fragment was identified and was reduced underdirect visualization. Fixation was then achieved by headless variable-pitchcompression screws (n = 14), posterior-to-anterior cannulated lag screws (n =

3), countersunk cortical screws (n = 2), smooth Kirschner wires (n = 5), orbioabsorbable fixation devices (n = 1). Two patients were treated with a loosefragment excision alone.

Statistical AnalysisData were analyzed using unpaired t tests. Significance was set at 2-tailedp values of <0.05. Statistical analyses were performed using Microsoft Excel.

ResultsClassification

All patients demonstrated 1 of 3 predominant capitellarfracture patterns, as depicted in Figure 1. Frequency, mean

age, and mean skeletal maturity, as measured using theSauvegrain method6, are summarized in Table I.

Type-I fractures (n = 25 [68%]) were anterior shear in-juries. Among these, 3 fractures were nondisplaced (Type Ia),and 22 fractures were displaced (Type Ib). Computed tomog-raphy (CT) imaging was helpful to assess the extent of trochlearinvolvement and the degree of articular incongruity. Thirteenfractures involved the capitellum only or the capitellum and thelateral aspect of the trochlea, similar to the adult Bryan-Morreytype-I (Hahn-Steinthal) fracture1,7. Nine patients had fracturelines extending beyond the trochlear groove.

Type-II fractures (n = 9 [24%]) were posterolateral shearinjuries. These fractures were poorly visualized on radiographsand were best demonstrated on sagittal CT imaging. Amongthese, 1 fracture was nondisplaced (Type IIa) and 8 fractureswere displaced (Type IIb). Displaced fractures were associatedwith known ulnohumeral dislocation in 6 of 8 cases.

Type-III fractures (n = 3 [8%]) were acute chondralshear injuries, radiographically occult and best diagnosed withmagnetic resonance imaging (MRI). All patients had a clearhistory of acute trauma without antecedent symptoms.

Results of TreatmentNondisplaced fractures, comprising Types Ia (n = 3) and IIa(n = 1), were all treated nonoperatively with long arm cast im-mobilization (Fig. 2). All went on to osseous union and restora-tion of motion, with a mean ulnohumeral arc of 1.6� to 130.0�.

Type-Ib displaced anterior shear fractures were all treatedwith open reduction and internal fixation (Fig. 3). One patientwas lost to follow-up prior to 6 weeks, leaving 21 patientseligible for analysis of outcomes. The mean postoperative ulno-humeral arc among all Type-Ib fractures was 11.4� extension to124.7� flexion. Fractures involving the capitellum only or thecapitellum and the lateral aspect of the trochlea demonstrateda mean postoperative ulnohumeral arc of 5.4� extension to131.3� flexion, significantly better than postoperative motionin fractures extending into the medial aspect of the trochlea,which demonstrated less mean extension at 16.7� (p = 0.019)and flexion at 120.0� (p = 0.007).

TABLE I Distribution of Capitellar Fracture Types

Type andSubtype No. of Cases* Age† (yr)

SauvegrainScore† (points)

Type I 25 (68%) 12.0 23.7

Type Ia 3 (8%) 10.7 20.3

Type Ib 22 (59%) 12.2 24.1

Type II 9 (24%) 11.6 21.6

Type IIa 1 (3%) 10.0 17.0

Type IIb 8 (22%) 11.8 22.2

Type III 3 (8%) 11.0 17.3

Total 37 11.8 22.7

*The values are given as the number of cases, with the percentagein parentheses. †The values are given as the mean.

Fig. 2

Figs. 2-A and 2-B Imaging of a Type-Ia nondisplaced fracture. Fig. 2-A Initial CT scan. Fig. 2-B Final radiograph after long arm casting for 6 weeks.

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Seven patients with displaced anterior shear fracturesunderwent an unplanned second procedure. One patient hadremoval of posterior-to-anterior headless compression screws

because of painful prominence of the screw heads posteriorly,but no loss of motion or mechanical symptoms. Six patients(29%) underwent a secondary surgical procedure for loss

Fig. 3

Figs. 3-A and 3-B Radiographs of a Type-Ib displaced anterior shear fracture. Fig. 3-A Initial radiograph. Fig. 3-B Follow-up radiograph 7 months after

open reduction and internal fixation with headless compression screws.

Fig. 4

Figs. 4-A, 4-B, and 4-C Imaging of a Type-Ib displaced anterior shear fracture complicated by osteonecrosis. Fig. 4-A Initial radiograph. Fig. 4-B

Postoperative radiograph after open reduction and internal fixation. Fig. 4-C Interval CT scan showing osteonecrosis and implant prominence.

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of motion related to the complications of osteonecrosis andsoft-tissue contracture (n = 1), osteonecrosis with implantprominence (n = 2), intra-articular loose fragments (n = 2), orsoft-tissue contracture alone (n = 1). Osteonecrosis was notedpostoperatively in 5 (24%) of 21 patients, 3 of whom under-went a secondary surgical procedure (Fig. 4). The mean timeto diagnosis of symptomatic osteonecrosis was 6.2 monthsafter injury.

In total, 8 (38%) of 21 patients with Type-Ib fractureshad substantial motion loss with flexion contractures exceeding20�. Among patients undergoing a secondary surgical proce-dure for motion loss, the mean motion improved after revisionfrom 33� to 14� of extension (p = 0.019) and from 110� to 123�of flexion (p = 0.123). After both initial and secondary pro-cedures, elbow motion to within 20� of full extension wasachieved in 18 (86%) of 21 patients.

Among Type-IIb displaced posterolateral shear fractures(Fig. 5), 5 of 8 patients had adequate follow-up beyond 6 weeks.Three fractures were initially missed on radiographs and weretreated nonoperatively. One of these 3 fractures was diagnosedonMRI due to persistent mechanical symptoms after 6 weeks of

brace treatment for a presumed simple elbow dislocation. In theother 2 patients, posterolateral fractures were diagnosed on CTscanning at a 1-week follow-up after cortical irregularity wasnoted on radiographs, but these fractures were believed to be in-nocuous avulsion injuries and both were treated nonoperativelywith continued long arm cast immobilization.

The mean ulnohumeral arc after nonoperative care inthese patients was 31.7� extension to 118.1� flexion. Motion losswas attributed to nonunion of the posterolateral shear fragment,which acted as an intra-articular loose body and/or mechanicalblock to elbow extension. One patient in the nonoperative groupultimately underwent a secondary surgical procedure for exci-sion of a loose capitellar fragment and heterotopic ossification,with improvement in elbow extension from 75� to 10�.

Two patients underwent early surgical fixation of theposterior shear fragment, and both went on to achieve osse-ous union and painless motion with a mean ulnohumeral arcfrom 10.0� extension to 135.0� flexion. Follow-up radiographsshowed no evidence of loose bodies or heterotopic ossificationin either case. At the time of the latest follow-up, the meanulnohumeral arc for all Type-IIb fractures was 13.3� to 117.0�.

Fig. 5

Figs. 5-A through 5-D Imaging of a Type-IIb displaced posterolateral shear fracture. Fig. 5-A Initial radiograph. Fig. 5-B Initial CT scan. Fig. 5-C Interval MRI

(sagittal short TI inversion recovery [STIR] sequence) after nonoperativemanagement, showingheterotopic ossification.Fig. 5-D Final radiograph after excision

of a loose body and heterotopic ossification of a capitellar microfracture.

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Fig. 7

Figs. 7-A through 7-D Images of a missed Type-III acute chondral shear fracture. Fig. 7-A Initial radiograph of a presumed isolated radial

neck fracture treated nonoperatively. Fig. 7-B Sagittal STIR image from follow-up MRI made because of persistent motion deficits after

appropriate rehabilitation. Fig. 7-C Radiograph made prior to a secondary surgical procedure. Fig. 7-D Final radiograph made at 3.5 years

postoperatively.

Fig. 6

Figs. 6-A and 6-B Imaging of a Type-III acute chondral shear fracture. Fig. 6-A Initial MRI (sagittal proton density sequence) showing cartilage loss from the

anterior capitellum. Fig. 6-B Adjacent image from the same sequence demonstrating a cartilaginous loose body. The patient underwent acute operative

intervention and achieved full functional restoration. No follow-up images were obtained.

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Among the 3 patients with Type-III acute chondral shearfractures, 2 patients underwent initial surgical treatment, con-sisting of arthroscopy followed by arthroscopic or open fragmentexcision with or without microfracture. Both patients attained afull painless ulnohumeral arc of 0� to 135� postoperatively (Fig. 6).

The third patient with a Type-III chondral shear injury wasinitially diagnosed with only a radial neck fracture and was treatednonoperatively in a sling for 4 weeks. He was noted to have limitedmotion on subsequent follow-up, and MRI showed nonunion ofan osteochondral fragment (Fig. 7). This was confirmed intra-operatively when the patient ultimately underwent surgical man-agement, consisting of chondral loose-body excision and capitellarfragment fixation. At the time of the latest follow-up, the patienthad persistent radiographic deformity but full painless motion.

DiscussionClassification Systems

The prevailing classification system for capitellar fracturesin adults is generally attributed to Bryan andMorrey, although

it draws upon prior eponymous descriptions of characteristicfracture patterns. Type-I fractures (Hahn-Steinthal7) are describedas displaced anterior shear injuries. Type-II fractures (Kocher-Lorenz8) are osteochondral injuries. Type-III fractures (Broberg-Morrey variants) are comminuted capitellar fractures. Type-IVfractures (McKee) are anterior shear fractures involving most ofthe trochlea.

Other classification systems in the adult literature focuson the amount of trochlear involvement and comminutionbetween the capitellum and the trochlea3 or on the number ofsequential articular segments involved4. However, in general,these systems do not adequately describe or prognosticate pe-diatric capitellar fractures.

In the current investigation, we identified 3 prevailingfracture patterns in children and adolescents. In addition to theadult-like Type-I anterior shear injuries, posterolateral shearinjuries and chondral shear fractures were seen, particularlyin younger, more skeletally immature patients. The potentialreasons for these characteristic injury patterns may include thedifferent mechanical properties of the osteocartilaginous distalhumeral epiphysis and the ligamentous laxity seen in childrenand adolescents.

Treatment OutcomesTo our knowledge, there have been only 9 published case reportsor case series regarding capitellar fractures in the pediatricpopulation, ranging in size from 1 to 9 patients2,9-16. Overall,these small studies noted good results with surgical fixationof displaced anterior shear fractures, but provided limited in-formation on the acute management of other common pedi-atric fracture patterns or on relevant complications such asosteonecrosis.

Nondisplaced capitellar fractures have been previouslydescribed in 2 patients, both of whom did well with nonop-erative management2,14. We also found excellent results withcast immobilization of Type-Ia and Type-IIa nondisplacedfractures. It should be noted that the small number of patients

with nondisplaced fractures in our series is likely to be anunderrepresentation of the true incidence, given that many ofthese fractures are not clearly visualized on radiographs and areaccordingly diagnosed as occult elbow injuries. These patientsmost often do not undergo advanced imaging and do well withnonsurgical treatment.

Type-Ib displaced anterior shear fractures are the mostwidely reported. Various modalities of fixation have been de-scribed in adults, including percutaneous probe reduction,suture repair, bioabsorbable pin fixation, Kirschner wire fixa-tion, and fixation with cortical, cannulated, or variable-pitchheadless compression screws9,17-21. In our series, headless com-pression screws were most commonly used, followed by headedcannulated screws. A posterolateral approach through the Kocherinterval was utilized by the treating surgeons in our study. Ananterior approach has also been described, which offers ex-cellent visualization for fracture reduction9.

Overall, surgical reduction and fixation of displaced an-terior shear fractures yielded acceptable results. All patients hadpain-free motion without mechanical symptoms, and a rangeof motion of at least 20� to 120� was restored after the initialprocedure in amajority of patients. Approximately one-third ofpatients underwent a secondary surgical procedure for motionloss, and after initial and secondary procedures, an ulno-humeral motion arc of at least 20� to 120� was restored in 86%of patients.

Patients with fracture lines extending into the medialaspect of the trochlea achieved less overall motion after a sur-gical procedure. This may be attributable to difficulty inachieving anatomic reduction across the entirety of the artic-ular surface using a lateral surgical approach, or, more likely,because of the greater articular disruption and subsequentcapsular contracture from the inciting injury.

The most common complication encountered in dis-placed anterior shear fractures was osteonecrosis. This has beendescribed previously in 1 study13, although the rate of osteo-necrosis and prognostic factors remain unclear. In our study,24% of patients went on to develop symptomatic osteonecro-sis. There was no statistical correlation between age, skeletalmaturity, radiographic appearance, surgical technique, or im-plant choice and development of osteonecrosis. However, thesample size was small and may be insufficiently powered todetect predictors of osteonecrosis. Given the tenuous vascu-larity of the capitellar chrondroepiphysis as well as the intra-capsular location of these injuries, osteonecrosis may beunavoidable in certain displaced fractures.

To our knowledge, Type-II posterolateral shear fractureshave not been described in the literature to date. These wereassociated with elbow dislocation in 6 of 8 patients in ourseries, suggesting that heightened suspicion for posterior shearfractures is warranted with this mechanism of injury. We foundgenerally poor results with nonoperative management, as mal-union or nonunion of the posterior shear fragment led to anextension block and/or mechanical symptoms. As such, dis-placed posterolateral fractures should not be considered asinnocuous avulsion injuries. CTor MRI is helpful for accurate

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diagnosis of these fractures, and surgical management may leadto more favorable results.

To our knowledge, Type-III acute chondral shear injurieshave been reported in only 3 patients in the literature, althoughtechniques for acute management have been wide-ranging andinclude fragment excision, suture repair, and Kirschner wirefixation11-13. Frank et al. recently described 3 adolescents withmissed osteochondral shear injuries who presented with mo-tion loss and radiocapitellar arthrosis. All 3 patients weretreated with radial head excision and joint capsule release,yielding good subjective improvement but persistent motionloss and advanced degenerative changes on follow-up radio-graphs16. In our series of 3 patients, 2 underwent acute surgicalmanagement, consisting of arthroscopic or open loose-bodyexcision with or without microfracture. These patients bothachieved excellent restoration of motion. One Type-III injurywas initially missed and was treated nonoperatively, leading tononunion of the osteochondral fragment and requiring a sec-ondary surgical procedure. In cases of symptomatic elbowtrauma without visible fracture on radiographs, early MRIscans may be indicated to allow for accurate diagnosis andprompt surgical management of chondral shear injuries.

LimitationsThis study had a number of limitations. First, the duration ofclinical and radiographic follow-up was limited. In general,long-term follow-up is difficult to achieve in pediatric fracturecare given favorable short-term results. The majority of pa-tients with <6 months of follow-up in our study demonstratedosseous healing and full restoration of motion, and these pa-tients were no longer required to return for follow-up. Furtherinvestigation with longer-term follow-up is needed. In addi-tion, given the rarity of capitellar fractures in the pediatricpopulation, the sample size among each fracture type wasrelatively small and yielded limited power for robust statisticalanalysis. We also did not evaluate the reliability of the proposedfracture classification. Finally, no patient-derived outcomemeasures were utilized to assess the results of treatment. Giventhat the most common complication in treating capitellarfractures appears to be loss of motion, objective clinical dataare of primary importance in assessing results of treatment.However, future studies would benefit from patient-derived

outcome measures to assess the qualitative impact of motionloss.

RecommendationsThe key elements of managing pediatric capitellar fracturesinclude timely and accurate diagnosis of capitellar fracturepatterns that may be unique to children and adolescents, andselection of a treatment modality that ensures restorationof articular congruity and joint stability without free intra-articular fragments. Advanced cross-sectional imaging ishelpful to elucidate the fracture pattern and to guide decision-making.

Specifically, displaced Type-II posterior shear fracturesand Type-III acute chondral injuries are easily missed on ra-diographs and have a high potential for complications becauseof nonunion of displaced shear fragments resulting in intra-articular loose bodies, impingement, and motion loss. A highindex of suspicion and low threshold for advanced imagingshould be maintained in patients with a high-risk injury pat-tern, mechanical block to motion, lateral swelling out of pro-portion to radiographic appearance, or failure to progress asclinically expected with nonoperative management. In all 3displaced fracture patterns, we found that accurate diag-nosis and adequate initial surgical treatment yielded favorableresults. n

Praveen G. Murthy, MD1

Carley Vuillermin, MBBS, FRACS2

Manahil N. Naqvi, BS2

Peter M. Waters, MD2

Donald S. Bae, MD2

1Department of Orthopaedic Surgery, Massachusetts General Hospital,Boston, Massachusetts

2Department of Orthopaedic Surgery, Boston Children’s Hospital,Boston, Massachusetts

E-mail address for D.S. Bae: [email protected]

ORCID iD for D.S. Bae: 0000-0003-4965-2395

References

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http://orcid.org/0000-0003-4965-2395

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17. Fowles JV, KassabMT. Fracture of the capitulum humeri. Treatment by excision.J Bone Joint Surg Am. 1974 Jun;56(4):794-8.18. Ma YZ, Zheng CB, Zhou TL, Yeh YC. Percutaneous probe reduction of frontalfractures of the humeral capitellum. Clin Orthop Relat Res. 1984 Mar;183:17-21.19. Hirvensalo E, Bostman O, Partio E, Tormala P, Rokkanen P. Fracture of thehumeral capitellum fixed with absorbable polyglycolide pins. 1-year follow-up of 8adults. Acta Orthop Scand. 1993 Feb;64(1):85-6.20. Liberman N, Katz T, Howard CB, Nyska M. Fixation of capitellar fractures withthe Herbert screw. Arch Orthop Trauma Surg. 1991;110(3):155-7.21. Trinh TQ, Harris JD, Kolovich GP, Griesser MJ, Schickendantz MS, Jones GL.Operative management of capitellar fractures: a systematic review. J Shoulder ElbowSurg. 2012 Nov;21(11):1613-22. Epub 2012 Jun 11.

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