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10

Olecranon Fractures

Topic updated on 08/20/16 12:51pm
Introduction
  • Epidemiology
    • bimodal distribution
      • high energy injuries in the young
      • low energy falls in the elderly
  • Pathophysiology
    • mechanism
      • direct blow
        • usually results in comminuted fracture
      • indirect blow
        • fall onto outstretched upper extremity
        • usually results in transverse or oblique fracture
Anatomy
  • Osteology
    • together with coronoid process, forms the greater sigmoid (semilunar) notch
    • greater sigmoid notch articulates with trochlea
      • provides flexion-extension movement
      • adds to stability of elbow joint
  • Muscles
    • triceps
      • inserts onto posterior, proximal ulna
      • blends with periosteum
      • innervated by radial nerve (C7)
    • anconeus 
      • inserts on lateral aspect of olecranon
      • innervate by radial nerve (C7)
Classification
 
Mayo Classification
  • Based on comminution, displacement, fracture-dislocation

 
Colton Classification
Nondisplaced - Displacement does not increase with elbow flexion
Avulsion (displaced)

Oblique and Transverse (displaced)

Comminuted (displaced)

Fracture dislocation
 
Schatzker Classification
Type A Simple transverse fracture  
Type B Transverse impacted fracture  
Type C Oblique fracture  
Type D Comminuted fracture  
Type E More distal fracture, extra-articular  
Type F Fracture-dislocation  
 
AO Classification
Type A Extra-articular
Type B Intra-articular
Type C Intra-articular fractures of both the radial head and olecranon
 
Presentation
  • Symptoms
    • pain well localized to posterior elbow
  • Physical exam
    • palpable defect
      • indicates displaced fracture or severe comminution
    • inability to extend elbow
      • indicates discontinuity of triceps (extensor) mechanism
Imaging
  • Radiographs
    • recommended views
      • AP/lateral radiographs
        • true lateral essential for determination of fracture pattern
    • additional views
      • radiocapitellar may be helpful for
        • radial head fracture
        • capitellar shear fracture
  • CT
    • may be useful for preoperative planning in comminuted fractures
Treatment
  • Nonoperative
    • immobilization
      • indications
        • nondisplaced fractures
        • displaced fracture is low demand, elderly individuals 
      • technique
        • immobilization in 45-90 degrees of flexion initially
        • begin motion at 1 week
  • Operative
    • tension band technique 
      • indications
        • transverse fracture with no comminution
      • outcomes
        • excellent results with appropriate indications
    • intramedullary fixation   
      • indications
        • transverse fracture with no comminution (same as tension band technique)
    • plate and screw fixation 
      • indications    
        • comminuted fractures
        • Monteggia fractures
        • fracture-dislocations 
        • oblique fractures that extend distal to coronoid
    • excision and triceps advancement
      • indications
        • elderly patients with osteoporotic bone
        • fracture must involve <50% of joint surface
        • nonunions
      • outcomes
        • salvage procedure that leads to decreased extension strength
        • may result in instability if ligamentous injury is not diagnosed before operation
Surgical Techniques
  • Tension band technique  
    • technique
      • converts distraction force of triceps into a compressive force
      • engaging anterior cortex of ulna with Kirschner wires may prevent wire migration
      • avoid overpenetration of wires through anterior cortex
        • may injury anterior interosseous nerve (AIN)  
        • may lead to decreased forearm rotation 
      • use 18-gauge wire in figure-of-eight fashion through drill holes in ulna
    • cons
      • high % of second surgeries for hardware removal (40-80%) q
      • does not provide axial stability in comminuted fractures 
  • Intramedullary fixation 
    • technique
      • can be combined with tension banding
      • intramedullary screw must engage distal intramedullary canal
  • Plate and screw fixation post
    • technique
      • place plate on dorsal (tension) side
      • oblique fractures benefit from lag screws in addition to plate fixation
      • one-third tubular plates may not provide sufficient strength in comminuted fractures
      • may advance distal triceps tendon over plate to avoid hardware prominence
    • pros
      • more stable than tension band technique
    • cons
      • 20% need second surgery for plate removal
  • Excision and triceps advancement 
    • technique
      • triceps tendon reattached with nonabsorbable sutures passed through drill holes in proximal ulna
Complications
  • Symptomatic hardware
    • most frequent reported complication
  • Stiffness
    • occurs in ~50% of patients
    • usually doesn't alter functional capabilities
  • Heterotopic ossification
    • more common with associated head injury
  • Posttraumatic arthritis
  • Nonunion
    • rare
  • Ulnar nerve symptoms
  • Anterior interosseous nerve injury
  • Loss of extension strength

 

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Qbank (12 Questions)

TAG
(SBQ12.11) A 35-year-old patient sustains an upper extremity injury after a motor vehicle collision. Radiographs are shown in Figures A and B. Which treatment modality will optimize internal stability of the elbow?
Topic Review Topic
FIGURES: A   B        

1. Open reduction and internal fixation with k-wires
2. Open reduction and internal fixation with tension band wiring
3. Open reduction and internal fixation with plate fixation
4. Open reduction and internal fixation with an intramedullary screw
5. Cast immobilization

PREFERRED RESPONSE ▶
TAG
(OBQ11.114) An 82-year-old nursing home resident falls onto his elbow while rising from a seated position. He has pain and swelling at the elbow without evidence of instability. His radiographs show a comminuted displaced olecranon fracture involving 25% of the articular surface with global osteopenia. Which of the following treatment options has a low risk of complications and a high likelihood of a functional elbow outcome? Topic Review Topic

1. Cast immobilization in 45 degrees of flexion for 8 weeks
2. Closed reduction and percutaneous pinning
3. ORIF with a tension band construct
4. ORIF with a locking plate
5. Cast immobilization in 90 degrees flexion

PREFERRED RESPONSE ▶
TAG
(OBQ11.141) Bridge plating of the olecranon is MOST appropriate in which of the following clinical scenarios? Topic Review Topic

1. Fixation of an olecranon osteotomy used for distal humerus surgery in a 24-year-old male
2. Simple transverse olecranon fracture in 33-year-old female
3. Comminuted olecranon fracture in 45-year-old male
4. Severely comminuted proximal olecranon fracture in an osteoporotic 91-year-old female
5. Aphophyseal elbow fracture in 6-year-old male

PREFERRED RESPONSE ▶
TAG
(OBQ10.38) During surgical treatment of an olecranon fracture with a tension band construct as seen in Figure A, what nerve is at risk with over penetration of the proximal anterior cortex of the ulna with the Kirchner wire? Topic Review Topic
FIGURES: A          

1. Median nerve
2. Anterior interosseous nerve
3. Posterior interosseous nerve
4. Ulnar nerve
5. Radial nerve

PREFERRED RESPONSE ▶
TAG
(OBQ10.107) There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following? Topic Review Topic

1. Ipsilateral proximal humerus fracture
2. Protrusion of Kirschner wire fixation through the volar cortex of the proximal ulna
3. Use of ulnar intramedullary Kirschner wire fixation
4. Olecranon fracture comminution
5. Lack of triceps tendon repair

PREFERRED RESPONSE ▶
TAG
(OBQ09.192) A 19-year-old male sustains the isolated, closed injury seen in Figure A. He is subsequently treated as shown in Figure B. When utilizing this technique, what forces are generated at the articular surface? Topic Review Topic
FIGURES: A   B        

1. Neutralization
2. Torque
3. Two-point bending
4. Shear
5. Compression

PREFERRED RESPONSE ▶
TAG
(OBQ09.243) A 79-year-old woman with osteoporosis presents with a displaced, severely comminuted olecranon fracture involving the proximal 40%. Which of the following represents the most appropriate surgical treatment? Topic Review Topic

1. Intramedullary screw
2. Kirschner wire tension band
3. Total elbow arthroplasty
4. Fragment excision and triceps advancement
5. Dorsal bridge plating

PREFERRED RESPONSE ▶
TAG
(OBQ07.204) A 24-year-old male sustains the isolated, closed injury seen in Figure A as the result of a fall. What surgical treatment is recommended for this fracture? Topic Review Topic
FIGURES: A          

1. Intramedullary nailing
2. Tension band with intramedullary screw
3. Triceps advancement
4. Plate and screw fixation
5. Total elbow arthroplasty

PREFERRED RESPONSE ▶
TAG
(OBQ05.181) A 62-year-old man falls on his porch and sustains an elbow injury. A radiograph is provided in Figure A. Which of the following is the best treatment? Topic Review Topic
FIGURES: A          

1. Closed reduction and long arm casting
2. Early motion with a hinged elbow brace
3. Open reduction internal fixation with a tension band construct
4. Open reduction internal fixation with a plate
5. Fragment excision and advancement of the triceps tendon

PREFERRED RESPONSE ▶
TAG
(OBQ04.138) A 45-year-old male undergoes open reduction internal fixation for a displaced olecranon fracture as shown in Figure A. What is the most common complication for this type of fixation? Topic Review Topic
FIGURES: A          

1. anterior interosseous nerve palsy
2. osteomyelitis
3. implant failure
4. symptomatic implants
5. avascular necrosis

PREFERRED RESPONSE ▶
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