SICOT-J 2018, 4, 8© The Authors, published by EDP Sciences, 2018https://doi.org/10.1051/sicotj/2017063

Available online at:www.sicot-j.org

ORIGINAL ARTICLE

Retrospective analysis of open reduction and internal fixation ofcoronal plane fractures of the capitellum and trochlea using theanterolateral approachYashwant Singh Tanwar1,*, Yatinder Kharbanda1, Atin Jaiswal2, Vikas Birla1, and Ramsagar Pandit1

1 Department of Orthopedics, Apollo Hospital, Sarita Vihar, Delhi 110076, India2 Maya Hospital, Farrukhabad, Uttar Pradesh, India

Received 14 June 2017, Accepted 15 December 2017,

*Correspon

This is anO

Published online 16 March 2018

Abstract -- Introduction: Coronal plane distal humeral injuries are relatively rare. Numerous classificationsystems have been proposed as the complexity of these fractures has been realized.We in the present series of tenpatients describe the surgical technique of Open Reduction and Internal Fixation of Coronal plane fractures ofthe distal humerus with headless compression screws performed using the anterolateral approach.Material andmethod: It was a retrospective study, the data collected fromMarch 2010 to 2015 was analysed andthe final outcome was assessed using the DASH score. Out of a total of 13 patients with distal humerus coronalplane fractures, 10 patients were available for follow up. The X-rays and CT scans were reviewed and thefractures were classified according to Dubberley and Bryan and Morrey classification. Radiographic wereevaluated for presence of union or nonunion, avascular necrosis, joint line step-off (none/1-mm/>1-mm),hardware failure and instability.Results: The average age was 41 years. The average DASH score in our study was around 24. The time to unionranged between 8–12weeks with the average time being around 10 weeks. One patient had post traumaticArthritis radiologically classified as Broberg andMorrey Type 2 and one patient had Heterotrophic ossificationBrooker Grade 1.Conclusion: Open reduction and internal fixation of coronal shear fractures of capitellum and trochlea usingheadless screw compression via the antero-lateral approach is a reliable treatmentmodality and results in stablefixation with restoration of a functional arc of motion.Level of evidence: IV

Key words: Capitellum Fracture, Trochlear fracture, Herbert screw, Anterolateral approach elbow.

Introduction

Isolated coronal plane fractures of capitellum andtrochlea are rare injuries. Coronal plane fractures of theCapitellum were first described by Cooper and later a moredetailed description was given by Hahn, Steinthal andKocher after whom they have been named. Such injuriesusually result from low energy trauma; usually from fall onan outstretched hand with the elbow in extension. As thecentre of rotation of Capitellum is anterior to the humeralshaft, it leads to the transmission of a shearing forceresulting in a coronal fracture of the distal humerus.Trochlear fracturemay result from transmission of a similarforce from the coronoid. A higher female preponderance isexplained on the basis of a larger carrying angle leading to

ding author: tanwar_yashwant@yahoo.co.in

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greater transmission of contact forces to the lateral column[1]. The fracture may occur after an episode of acute elbowdislocation/instability. Capitellum and trochlea may besheared off by the radial head and coronoid following thereduction of a posterolateral subluxation or dislocation ofthe elbow. This might also explain distribution of damagefrom anterior to posterior, from lateral to medial in asequential manner as described in elbow dislocation,commonly known as Circle of Horii.

Capitellum fracturesmayalso be secondary to recurrentposterolateral instability of the elbow. Due to repeatedsubluxation and impingement of the radial head againstcapitellum, an osteochondral fracture of the posterolateralmargin of capitellum may occur. It has been termed asOsborne-Cotterill lesion as they were first to describe it [2].The lesion is similar to Hill-Sachs lesion seen in humerussecondary to recurrent shoulder dislocation.

monsAttribution License (http://creativecommons.org/licenses/by/4.0),n any medium, provided the original work is properly cited.

Figure 1. The different Dubberley fracture types. A and B � Type 1 fracture. C � Type 2 fracture. D � Type 3B fracture.

2 Y.S. Tanwar et al.: SICOT-J 2018, 4, 8

Themost commonly used classification system is that ofBryanandMorrey [3].Originally therewere three types anda fourth type was later added by Mc Kee et al. [4]. Type Ialso known as Hahn-Steinthal fracture involves a substan-tial portion ofCapitellumbone in the coronal plane.Type IIalso known asKocher-Lorenz fracture is anOsteo-chondralfracture involving a shell of the articular cartilagewith littlebone. Type III � comminuted fracture. Type IV McKeemodification� coronal plane fracture involving capitellumand part of trochlea as a single segment.

Arbeitsgemeinschaft für Osteosynthesefragen (AO)classification [5] although quite comprehensive anddetailed, is too complex for daily use. Distal Humerus isanatomically labelled as region 13 and partial articularcoronal plane fractures are sub-grouped as type B3. Theseare then further classified as follows:

– 13B3.1: isolated capitellar fracture; – 13B3.2: isolated trochlear Fracture; – 13B3.3: combined capitellum and trochlea fracture.

Dubberley et al. [6] proposed a classification systemthat was correlated to the clinical outcome. Type-1injuries involved primarily the capitellum with or withoutthe lateral trochlear ridge (Figures 1a and b); Type-2injuries involved the capitellum and trochlea as one piece(Figure 1c); Type-3 injuries consisted of fractures of boththe capitellum and trochlea as separate fragments(Figure 1d). This classification further sub classifies thefractures as A or B based on the presence or absence ofpostero lateral comminution.

Patients usually present with pain and swellingaround the elbow region. Examination of Bryan andMorrey type I fractures shows a mechanical block inelbow flexion, which is due to the anteriorly displacedfragment, whereas type II fractures usually show amechanical block in extension as a result of theposteriorly displaced osteo-chondral fragment. Pain overthe medial aspect may indicate an underlying MCLavulsion or tear. Lateral tenderness may indicate anassociated radial head fracture or LCL injury(Figure 1c). X-rays especially lateral view are helpfulin making the diagnosis. The typical semilunar fragmentis displaced anteriorly and superiorly. In case of type 4fractures in which the fragment consists of capitellumand the lateral half of trochlea, “Mckee’s double arc sign”is seen (Figure 2). The two arcs are due to thesubchondral bone of capitellum and trochlea. CT scanprovides a much more detailed view and should beperformed in the all the cases to know about thedisplacement pattern, amount of comminution, involve-ment of posterior cortex, epicondyles and radial head.The fracture pattern is usually more complex than that isevident on simple X-rays (Figure 3).

There are many treatment options described in theliterature ranging from conservative management tosurgical fixation with headless screws or K-wires. We inthe present series of ten patients describe the surgicaltechnique of ORIF of Coronal plane fractures of the distalhumerus with headless compression screws performed

Figure 2. Classical double arc sign signifying involvement oftrochlea in the coronal fracture.

Figure 3. Axial Section CT scan showing a complex coronalplane fracture of distal humerus with posterior and lateralcomminution.

Y.S. Tanwar et al.: SICOT-J 2018, 4, 8 3

using the anterolateral approach at a single centre by thesame senior surgeon (YK). It was a retrospective study,the data collected from March 2010 to 2015 was analysedand the final outcome was assessed using the DASH score.

Material and methods

Out of a total of 13 patients with distal humeruscoronal plane fractures, 10 patients were available forfollow up.Out of these 10 patients there were 3males and 7females. The average age was 41 years. Four patients

sustained the injury due to Road traffic accident whereasthe rest 6 had fall from height. Time interval betweeninjury and surgery ranged from 1 to 5 days, with most ofthe patients (6) having undergone the surgery within24 hours. Inclusion criteria were: Age between 18 to60 years; patients having coronal plane distal humerusfracture, patients who presented within 10 days of injuryhaving no distal neurovascular deficit; patients having noother bony injury in the ipsilateral upper limb. Patientshaving pre-existing deformities of ipsilateral shoulder,elbow or hand and patients in whom anterolateralapproach was not used were excluded from the study.This approachwas not universally used in all coronal planedistal humerus fractures rather the choice of surgicalapproach was guided by numerous variables as discussedlater (Table 2). All the surgeries were performed by thesame senior author (YK) at one institution only.

Surgical technique

The patient is placed supine and a tourniquet is placedon the upper arm. We in the present series used anAnterolateral approach in all the cases. The arm isexsanguinated using an Esmarch bandage and tourniquetis inflated. A curved S shaped incision is made, with thesuperior limb being along the lateral border of biceps(Figure 4). The incision is then curved medially at thelevel of elbow joint to avoid crossing a flexion crease at 90degrees and distal limb of the incision is curved along themedial border of Brachioradialis. The lateral cutaneousnerve of the forearm is identified and preserved as itbecomes superficial lateral to the biceps tendon. Proxi-mally the plane between Brachialis and Brachioradialis isdeveloped and distally the plane between medial border ofBrachioradialis and lateral border of Pronator teres isdeveloped (Figure 5). The radial nerve is identifiedproximally at the level of elbow joint between Brachialisand Brachioradialis (Figure 5). The nerve is traceddistally and its three branches namely: Superficial Radialnerve which continues distally below the Brachioradialis,Posterior Interosseous which pierces the Supinator andthe branch to extensor carpi radialis brevis (ECRB) whichenters the muscle almost immediately, are identified andpreserved throughout the procedure. Small branches ofthe recurrent radial arterial arcade are identified andligated so that the Brachioradialis can be mobilized. Theelbow joint capsule is incised longitudinally if not alreadytorn and the fracture fragments are identified. Anteriorapproach provides direct access to anterior aspect of themedial and lateral column. K wires are introduced in thefracture fragments, used as joystick to manipulate theminto anatomical reduction, and then driven across thefracture site into opposite cortex. Definitive fixation isachieved with the help of headless compression cannulated2.4mm Herbert screws, placed at right angles to thefracture site (Figure 6).While exposing the LCL avulsion,elbow should be pronated and a varus stress should beplaced, so that the lateral epicondyle can be visualizedadequately. Repair of the avulsed LCL fragment is

Figure 4. The curved S shaped skin incision.

Figure 5. The deep dissection planes and the isolation of radial nerve.

4 Y.S. Tanwar et al.: SICOT-J 2018, 4, 8

therefore done last, so as avoid supinating the forearmafter wards. Associated injury of the LCL is repaired byusing a running interlocking suture, which is fixed to itsanatomical origin from the lateral epicondyle or a SutureAnchor placed in the Lateral Epicondyle bed. It’s notnecessary to fix the avulsed fragment into exact centre ofrotation of humeral capitellum, as is done while recon-structing LCL. Rather the avulsed fragment should befixed at its anatomic position as judged intra-operatively(Figure 7).

Post-operatively arm is placed in a Soft Dressing andarm sling for two weeks. Gentle active and active assistedrange of motion exercises are started thereafter. Duringthe weeks 2–4, stress was placed on achieving adequaterange of motion: Flexion/Extension and Pronation/Supination. If concomitant LCL repair was done, thenelbowwas kept pronated for 4weeks. After 4weeksMusclestrengthening exercises were started, however arm pouchsling was continued till 6 weeks. Physical therapy sessionswere continued for 8–10weeks. A hinged Elbow Brace was

Figure 6. Intra operative image of fixation using buried Herbert screws.

Figure 7. LCL avulsion fracture and fixation of LCL with suture anchor.

Y.S. Tanwar et al.: SICOT-J 2018, 4, 8 5

used in two patients for 4weeks in whom it was felt intra-operatively that fracture fixation was not stable enoughdue to extensive comminution and an associated LCLinjury. Final assessment was done with DASH score atfollow up.

Results

The data was analysed fromMarch 2011 to 2015, out ofa total of 13 patients with distal humerus coronal planefractures, 10 patients were available for follow up. The X-rays and CT scans were reviewed and the fractures wereclassified according to Dubberley and Bryan and Morreyclassification by two authors (YK, YST). Radiographicwere evaluated for presence of union or nonunion,avascular necrosis, joint line step-off (none/1-mm/>1-mm), hardware failure and instability (Figure 8). Associ-ated LCL injury was repaired in two patients using sutureanchors. Arthrosis was evaluated subjectively using thesystem described by Broberg and Morrey [7] as: grade 0 ifthere was no signs of arthritis; grade 1 if there was slightjoint-space narrowing and minimal osteophyte formation;grade 2 if there was moderate joint-space narrowing andosteophyte formation, or grade 3 if there was severe joint-

space narrowing with gross destruction. Heterotopicossification (HO) was classified using the Brookerclassification [8] applied to the elbow: class I was definedas islands of bone within the soft tissues; class II requiredthe presence of ectopic bone from the humerus, radius, orulna, leaving at least 1 cm between opposing surfaces; classIII required ectopic bone from the humerus, radius, orulna, reducing the space between opposing bone surfacesto less than 1 cm; and, lastly, class IV HO demonstratedapparent bone ankylosis of the elbow joint. Four fractureswere sustained as a result of Road traffic accident whereasthe rest were due to falls. DASH (Disabilities of the Arm,Shoulder and Hand) score was evaluated. The DASHOutcome Measure is a 30-item, self-report questionnairedesigned to measure physical function and symptoms inpeople with any of several musculoskeletal disorders of theupper limb. The normal DASH score in the generalpopulation has been reported to be around 10 with astandard deviation of 14.68 [9]. The average DASH scorein our study was around 24. The time to union rangedbetween 8–12weeks with the average time being around10weeks (Table 1). We did not encounter any case withAVN or non-union. One patient had post traumaticArthritis radiologically classified as Broberg and Morrey

Figure 8. Post op X-rays showing union of fracture.

6 Y.S. Tanwar et al.: SICOT-J 2018, 4, 8

type 2 which was managed conservatively. One patienthad Heterotrophic ossification Brooker Grade 1, whichwas asymptomatic. The mean time between injury andsurgical intervention was 2 days (range 1–5 days).

Discussion

Isolated coronal plane articular fractures are uncommonand challenging fractures which are classically described inthe distal femur and distal humerus. Their rarity andcomplexity along with the challenges in approaching andfixing them with unfamiliar approaches, prompted us toanalyse and report our experience of surgical fixation usingthe anterolateral approach to elbow.

Coronal plane injuries can be easily missed on theradiographs, especially only if AP views have been taken.Greenspan and Norman described a modified lateral viewof the elbow in which the radiographic plate is placedunder the elbow with the arm abducted 90° at shoulderand elbow flexed to 90°. Radiographic beam is centered onthe radial head, and angled 45° dorsoventrally, eliminatingthe overlap of the humeroulnar and humeroradialarticulations thus outlining the radial head and capitellumin profile [10]. McKnee described the double arc signindicating that a segment of trochlea is involved alongwith Capitellum. We came across “Triple Arc sign” in apatient in whom the whole of trochlea along withCapitellum was fractured in Coronal plane (Figure 9).One arc represented the Capitellum and the other tworepresented medial and lateral trochlear ridges.

A high index of suspicion is required and if in doubt aCT should always be performed. CT also give additionalinformation regarding any associated occult fractures(such as radial head) and associated ligamentous injuries.Ring observed that the complexity so called “isolated”capitellar fractures was underestimated on plain X-rays.He described five different anatomic zones and classifiedthe fracture patterns according to them: capitellum and

the lateral aspect of the trochlea; lateral epicondyle;posterior aspect of the lateral column; posterior aspect ofthe trochlea; medial epicondyle. He also coined the termApparent capitellar fractures as it emphasizes the “need tolook more closely” [11].

There are numerous classification systems. We in thepresent series classified the fractures according to Bryanand Morrey and Dubberley classification systems. Animportant aspect of classification of fracture is that it givesan idea about the severity of the injury and the prognosis.All patients with posterior cortex involvement (Dubberleytype B) had high DASH scores (35.8, 29.2 and 25.8)indicating poor results. We observed that in a couple ofpatients there was a fracture of the inferior articularsurface which was separate from the anterior and posteriorsegments (Figure 10). Such a separate fracture has notbeen subclassfied separately in any of the classificationsystem.HoweverRing didmention this in his classificationof five fracture types: Type 1 – a single articular fragmentthat includes the capitellum and the lateral portion of thetrochlea. Type 2 – Type-1 fracture with an associatedfracture of the lateral epicondyle. Type 3 –Type-2 fracturewith impaction of the metaphyseal bone behind thecapitellum in the distal and posterior aspect of the lateralcolumn. Type 4 – Type-3 fracture with a fracture of theposterior aspect of the trochlea. Type 5 – Type-4 fracturewith fracture of the medial epicondyle [11].We did not feelthe need to fix this segment separately as in both the casesthe segment was well contained within the trochlear notchof ulna. We also concluded that owing to the extremelycomplex nature of these injuries, there are still manyfracture patterns which cannot be clearly classified intoone category.

Treatment options include: Closed Reduction andimmobilization in Cast [12], fragment excision, openreduction and internal fixation, arthroscopic assessmentand fixation and hemiarthroplasty [13] or Total ElbowArthroplasty.

Tab

le1.

Depicting

theva

riou

sob

servations

mad

ein

thestud

y.

Sr.No.

Dub

berley

type

Bryan

and

Morreytype

Mecha

nism

ofinjury

Interval

betw

een

injury

andsurgery

Associated

injuries

Posterior

Cortex

invo

lvem

ent

Sex

Age

ROM

DASH

Score

Tim

eto

union

inweeks

Com

plication

12A

1RTA

1LCL

–M

2815–120

27.5

10–

22A

4RTA

3–

–M

3210–130

18.3

10–

31A

1Fall

1–

–F

415–13

515

8–

43B

3Fall

5–

Present

F49

20–110

35.8

12Heterotroph

icOssification

Grade

15

2B

3Fall

1LCL

Present

F38

10–120

29.2

10Grade

1Arthritis

61A

1RTA

1–

–F

525–13

014

.28

–

72B

3Fall

4–

Present

F55

15–130

25.8

12–

82A

4Fall

1–

–F

4610–135

21.7

10–

92A

4RTA

1–

–M

395–13

016

.78

–

103A

4Fall

2–

–F

3710–125

3012

–

Y.S. Tanwar et al.: SICOT-J 2018, 4, 8 7

ORIF has been shown to provide the most reliable andpredictable return to function. The approach to ORIF andthe means of fixation have varied diversely [4,14,15]. Theapproach to fixation can be anterolateral [16], Lateral,[17,18] posterior [11,17] or rarely combined medial andlateral [15].

The lateral approach either utilizes the intervalbetween extensor digitorum communis and ECRB asdescribed by Kaplan (18) or the Kocher interval betweenAnconeus and ECU Extensor Carpi Ulnaris [19]. Forbetter exposure the origin of the wrist extensors andlateral collateral ligament (LCL) may need to be elevatedfrom the lateral epicondyle. LCL elevation can potentiallydisrupt the blood supply to Capitellum and exposure andvisualization of the medial trochlear fragment andposterior comminuted area is difficult [14].

Posterior exposure can be either via Chevron OlecranonOsteotomy approach or the Triceps reflecting Bryan andMorrey approach.Advantages of posterior approach includedirect visualization of the posterior comminuted area(Table 2), placement of screws in the non-articular surfaceand application of a stabilising plate on the posteriorcolumn. Besides the inherent shortcomings of a palpableimplant and the risk of non-union at the osteotomy site, theposterior approach has two more potential drawbacks;firstly if an intra-operative decision to perform a total elbowarthroplasty has been taken, then an olecranon osteotomyprecludes such a procedure; secondly it damages the alreadyprecarious blood supply to Capitellum.

In the present series anterolateral approach was usedin all the cases. To the best of our knowledge there has beenonly one case series describing the use of this approach [16].The main advantage of using an anterior approach is theadequate exposure of the medial column, which may berequired if there is extension of the fracture plane mediallyinto the trochlea as in Bryan and Morrey type 4 [20]. Oneof the drawbacks of Anterolateral approach is inadequateposterior exposure to address the posterior comminution.CT scans should be carefully evaluated regarding theextent of comminution and whether it is amenable tosurgical fixation. In cases with extensive posteriorcomminution, it is best to approach the fracture anteriorlywhere sufficient bone is available for fixation of largedisplaced fragments and address the posterior comminu-tion anteriorly. After removing the anterior fragments,varus stress is given along with traction to open/subluxthe joint. The posterior fragments can now be addressedby manipulating/pushing the fragments back in place.Any metaphyseal void thus crated can be filled with graft.If however the posterior comminution is deemed feasiblefor surgical fixation then a posterior approach should beconsidered either in isolation or in addition to antero-lateral approach (Table 2). Apart from this a simulta-neous posterior exposure may also be required if a decisionis taken to proceed to total Elbow Arthroplasty.

The major nutrient artery of the humerus terminatesproximal to the distal humerus so the elbow appears to berelatively dependent on local osseous perforating vesselsfor its blood supply. There are three arterial arcades

Figure 9. X-rays showing Triple Arc Sign.

Figure 10. Sagittal section CT scan and X-ray images showing fracture of the inferior articular surface in axial plane.

8 Y.S. Tanwar et al.: SICOT-J 2018, 4, 8

(lateral, medial, and posterior) around the elbow. Theradial and medial collateral arteries (branches of theprofunda brachii) anastomose with the ascending inter-osseous and radial recurrent arteries to form the lateralarcade, which supplies the capitellum from its posterioraspect. The intraosseous pathway of the vessels shows ahypovascular area in the trochlear groove, making thisarea theoretically more susceptible to nonunion oravascular necrosis [21]. Exposure via the Anterolateralapproach avoids the posterior soft tissue dissection andthus the main blood supply to the capitellum is preserved,theoretically decreasing the chance of AVN.

The fixation modalities can be Herbert screws, [16] Bio-absorbable screws/pins [22], hinged external fixator [23],Accutrac Screws [18], K wires [19], partially threadedCortical or Cancellous Screws [17], or anti-glide plate. Kwires alone or in combination can be used when thefragments are small like in Bryan and Morrey Type 2injuries. However there is risk of implant migration andloosening. Given the close proximity of neurovascularstructures, K wire placement seems to be dangerous.Elkowitz et al showed that the headless screws providedmore stable fixation of capitellum fractures in the cadavericspecimens than four-millimeter partially threaded cancel-lous lag screws and may do so in the clinical setting [24].

We in the present series used 2.4mm Herbert screwsfor all the cases. We did not encounter any fragmentationof the anterior part while inserting the screws. In most of

the cases (8 out of 10) the fixation was judged to be stableenough to allow early range of Motion exercises, withoutadditional support. Inmost of the cases accurate reductionis possible and when there are more than one fragments,careful attention should be given to the orientation andposition of each one. Sometimes however the fracturefragments don’t fit into the fracture bed which usuallyhappens when there is posterior impaction of the lateralcolumn. In such cases the fracture bed needs to dis-impacted gently and fixed with a Herbert screw. The needfor an additional posterior fixation should be judged ontable, keeping in mind the benefits offered by improvedstability versus the drawbacks of increased soft tissuedissection.We did not find the need to go for supplementalposterior fixation in any of our patients. The lateralepicondyle fragment is rarely large enough to accept ascrew or require a plating. We in present series encoun-tered two patients with concomitant LCL injuries both ofwhich were repaired using pull out suture/suture anchorinto the anatomical LCL location.

Complications after ORIF include AVN of thefragment, Elbow stiffness, heterotrophic ossification,Post-traumatic arthritis, non-union and Malunion. Wedid not encounter any case with AVN or non-union,probably owing to a decreased soft tissue dissection andiatrogenic interference with the posterior vascular supply.One patient had post traumatic Arthritis radiologicallyclassified as Broberg and Morrey Type 2 which was

Table 2. Algorithm for guiding the selection of appropriate approach in Distal Humerus Fracture.

Fracture extending to metaphyseal region and/or involving supracondylar ridges

Yes No

Involving Both Columns

Involving Single Column

Coronal plane fracture

Sagi al plane fracture

Intra – ar cular Comminu on

Medial Lateral

Minimal: AO type 13C 1

Significant- AO 13 C2, C3

FCU Split or Over the Top

Kaplan Or Kocher

Posterior Comminu on

Paratricipital/ Campbell/ von Gorder

Olecranon Osteotomy/ TRAP

Present and amenable to fixa on

Extensive and not amenable to fixa on/ Bag of Bones Absent

Present : Coronal plane fracture involving both lateral and medial column, with no posterior Comminu on

Anterolateral Approach

Absent: Isolated coronal plane fracture of Capitellum

Trochlear involvement/ Triple arc Sign

Lateral: Kocher/ Kaplan approach

Y.S. Tanwar et al.: SICOT-J 2018, 4, 8 9

managed conservatively. There are many potential draw-backs of the study namely a small sample size, retrospec-tive study design and lack of biomechanical data to assessthe strength of fixation.

Conclusion

Open reduction and internal fixation of coronal shearfractures of capitellum and trochlea using headless screwcompression via the antero-lateral approach is a reliabletreatment modality and results in stable fixation withrestoration of a functional arc of motion. Statisticalanalysis of our study population demonstrated that themajority of capitellum fractures occur in female patients

and involve the nondominant extremity. The drawbacksof this study include a small sample size and a retrospec-tive study design.

The study was approved by the Institutional ReviewBoard. All patients gave the informed consent prior beingincluded into the study. And the study was in accordancewith the 1964 Helsinki declaration and its later amend-ments.

Conflict of Interest

The authors declare that they have no conflict ofinterest.

10 Y.S. Tanwar et al.: SICOT-J 2018, 4, 8

Funding

There is no funding source.

Ethical approval

This article does not contain any studies with humanparticipants or animals performed by any of the authors.

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Cite this article as: Tanwar YS, Kharbanda Y, Jaiswal A, Birla V, Pandit R (2018) Retrospective analysis of open reduction andinternal fixation of coronal plane fractures of the capitellum and trochlea using the anterolateral approach. SICOT-J, 4, 8.