Dear Dr. Yadav:

Your comments illustrate exactly why our article was accepted for publication in one of the premier orthopaedic journals.

1. Apparent capitellar fractures are often more extensive than they appear. If one fails to recognize this and excises the lateral lip of the trochlea along with the capitellum, irreversible harm the elbow may follow.. The articulation between the trochlea and the trochlear notch of the ulna is the keystone of the elbow. Elbows without a lateral trochlear lip can function adequately with intact radiocapitellar contact, but would be unstable in its absence. Failure to recognize these more complex articular fractures can also lead to nonunion, malunion, and arthrosis and Unfortunately,we have treated several such patients. I would recommend that you not be not be misled by the fact that you have “gotten away” with excising the capitellum in the past. If you have a more complex fracture as described in this series, excising too many of the fragments is very likely to cause problems.

Regarding classification systems--surgeons seem to expect too much from these systems. Our “system” was intended conceptualize and illustrate the points being made—nothing more. It is very true that some of these more complex patterns will only be recognized upon operative exposure—that probably is the reason that these fractures have not been more readily recognized in the past.

We recommend a high index of suspicion, computed tomography with 3D reconstructions and subtraction of the radius and ulna pre-operatively, and a low threshold to perform an extensile exposure.

If you routinely use a posterior exposure to the distal humerus such as the Campbell exposure, you will not see these fragments, let alone be able to manipulate and repair them. We recommend that surgeons be familiar with how to gain adequate anterior exposure to the elbow. This can very easily be done through a lateral exposure, but you must take down the origins of the LCL and common extensors (easily done in the presence of a fracture), elevate the origins of the radial wrist extensors and brachailis from the front of the humerus and the triceps and anconeus from the back and hinge the elbow open on the MCL. If there is involvement of the posterior trochlea or medial epicondyle we use an olecranon osteotomy, but a triceps elevating exposure also can be used, because taking the LCL down allows you to rotate the elbow out of the way of the olecranon. We would not recommend a triceps splitting exposure such as the Campbell exposure for these fractures although the anterior fragments can sometimes be attached to condyles prior to rotating them into place.

Again, thank you for your comments.

We read with interest the article " Articular fractures of the distal part of the humerus".The authors have presented a detailed and comprehensive account of a complex fracture. however the classification system of injury patterns put forth by them , though exhaustive , seems to have no implications on the clinical management of these fractures, particularly as Types III & IV are detected only operatively. Since the system does not take into account the mechanism of trauma or aid the surgeon in planning the operation , it seems to us to be of academic interest onle. In our experience with fractures involving the capitellum and the lateral trochlear flange, although the fragments appeared to be large on radiographs, they were found to be much smaller intra-operatively.

We have obtained excellent functional results with excision of such fragments. We believe that any classification of this injury pattern should include a CT based assessment of the thickness of the fragments to facilitate preoperative planning.Also, in our experience the Campbell posterior approach allows for both ease of visualisation of the articular surfaces and fixation of fragments. WE have experienced difficulty in inserting implants through the extensile lateral approach , even in the presence of lateral condylar fractures.