I am a surgical scrub nurse so I have a little extra knowledge of orthopedic problems. I want to ask about surgery for my niece. She has a type two fracture of the elbow (capitellum and trochlea are still together but broken off from the rest of the bone. Her mother (my sister) is a physical therapist and wants her to have surgery. I always recommend people avoid surgery. What's best in a case like this?
From your description, it sounds like she may have what's known as a coronal shear fracture of the distal humerus. As you probably know, the distal humerus refers to the bottom end of the upper arm bone, which forms the top half of the elbow joint. This lower end of the humerus bone is shaped with two round knobs on either side of a spool-shaped center. The bony knob is called the capitellum. The spool-shaped center is the trochlea. A coronal shear fracture tells us that one or both of those bony knobs is broken off.
Classification of the fracture is based on severity and is important to help guide treatment. There are three basic types of fractures, depending on whether the fracture affects the medial side of the capitellum (type one), the capitellum and trochlea broken off as one piece (type two: this is what your niece has), or the trochlea broken away from each end of the capitellum as three separate pieces (type three).
The classification scheme has an additional subgrouping to describe a clean fracture or one with tiny bone fragments (called communition). The fracture may be impacted (bony ends pushed together) or displaced (bony ends separated). If the fracture is displaced, the bone may be shifted posteriorly (back away from the humerus). X-rays and CT scans are used to identify all areas of damage and determine the type of classification. This information is essential in making treatment decisions.
Treatment for any of these types of coronal shear fractures of the distal humerus requires surgery. Studies show too many problems develop when the nonsurgical approach is taken. Without surgical correction, patients end up with chronic pain, painful clicking of the elbow, and mechanical instability.
Surgery to pin the bones together with metal plates and screws or just screws alone has the best results. As a surgical scrub nurse you have probably seen quite a few of these procedures called open reduction and internal fixation (ORIF). It is estimated that good-to-excellent results are obtained in more than 90 per cent of all cases treated with ORIF. Patients end up with a stable, durable joint with smooth joint function. There can be complications (e.g., arthritis, stiffness, infection, nonunion or malunion), but these are rare.
In the end, the physician or surgeon's recommendation based on examination and findings on imaging will be the best tools used to make a treatment decision. Hopefully, the information provided here will help aid in the discussion among all concerned.
John J. Lee, MD, and Jeffrey N. Lawton, MD. Coronal Shear Fractures of the Distal Humerus. In The Journal of Hand Surgery. November 2012. Vol. 37A. No. 11. Pp. 2412-2417.
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