Right shoulder and arm, posterior view
Olecranon Fractures
Upper Limb Anatomy
Medial aspect of right forearm
Left Brachial plexus
Nerves Posterior to Elbow Joint
Posterior view of right elbow
Blood supply around the elbow joint
Blood supply and anastomosis around the right elbow. Anterior view
Elbow joint structural stability structures
Left Arm
Radial head/neck fractures
The triangular structure of distal humerus at elbow joint provides structural strength.
Anterior view right distal humerus bone
The elbow joint is a hinge joint with axis of rotation around throchlear axis
Extensor muscles
Flexor muscles
Haversion bone system
Olecranon Fractures
Olecranon fractures are fractures of the proximal Ulnar bone that forms the elbow joint. This area is superficial and can easily fracture when falling onto it or with a direct blow to the area (comminuted fracture type) or it can be fractured indirectly by falling with an outstretched arm (transverse/oblique fracture type).
Presentation:
- Pain swelling
- Deformity
- Inability to extend the arm
Clinically:
- Bone tenderness
- Loss of extensor arm mechanism
Investigations:
- X-ray will confirm the fracture and severity
Simple olecranon fracture
Complex olecranon fracture
Mayo Classification of Olecranon Fractures
Schatzker Classification
Exclude elbow dislocation/instability
Based on the fracture pattern
Transverse:
- Apex of sigmoid notch and usually represents an avulsion fracture
Transverse impacted:
- Direct force causing depression and comminution
Oblique:
- From hyper extension injury and begins at midpoint of sigmoid notch and runs distally
Oblique distal:
- Extend distal to the coronoid and compromise elbow stability
Comminuted with associated injuries:
- Direct high energy trauma with fractures of the coronoid process that may cause elbow instability
Fracture dislocation:
- Usually high energy with severe trauma
Schatzker Classification of Olecranon Fractures
AO Classification Proximal Radius/Ulnar Fractures
Olecranon Fracture Management
Non surgical:
Nondisplaced fractures can be managed nonoperatively in a splint or in a Plaster of Paris cast. There is however a risk of elbow stiffness with prolonged rehabilitation to restore elbow range of motion. Start mobilization after 1 week. Conservative management is a consideration for low demand, elderly individuals.
Surgery:
Surgical fixation include either tension band wiring for simple fractures or plate and screw fixation for complex oblique fractures. Plate and screw fixation has lower rate of revision surgery rates for removal of symptomatic metalware.
Other options include intramedullary nail and screw fixation, fragment excision with triceps advancement and elbow joint replacement.
Tension band wiring for transverse fracture with no comminution. The K-wire and 18-gauge tension band wire fixation converts the triceps force into a compressive force with elbow flexion.
Screw fixation with tension band wiring for transverse fracture with no comminution. The 6.5mm cancellous screw and 18-gauge tension band wire fixation converts the triceps force into a compressive force with elbow flexion.
Plate and screw fixation
Nail with screw fixation
Fragment Excision and Triceps Advancement
Proximal fragment excision and triceps advancement is optional for comminuted olecranon fractures. As much as 50% of the olecranon is effective in managing comminuted proximal olecranon fractures not amenable to surgical fixation. Limit olecranon excision <60% articular involvement preventing poor functional outcome. Triceps power is reduced after surgical procedure.
Elbow Joint Replacement
Total joint replacement a consideration for elderly patients with significant comminuted proximal olecranon fractures with > 60% articular involvement.
Surgery Technique
Posterior Approach to Distal Humerus/Elbow/Proximal Ulnar
Nerves Posterior to Elbow Joint
Posterior approach to right distal humerus, Radial nerve at risk
Radial nerve is responsible for motor elbow and wrist extension. Sensory distribution shown on pic.
Skin Incision Approach to Distal Humerus/Elbow/Proximal Ulnar
Distal humerus to curving around the lateral olecranon to 2-4cm along ulnar crest
Deep posterior approach to distal humerus/elbow:
Fascia release or olecranon osteotomy
Medial window: Medial fascia release
- Ulnar nerve exploration along medial intermuscular septum and followed to the cubital tunnel, isolate and retract with latex loop
- Retract triceps laterally
- Medial attachment of triceps along olecranon is partially released
Lateral window: Lateral fascia release
- Free triceps on lateral side
- Split triceps fascia & mobilize from lateral intermuscular septum &
- Partially release triceps tendon on lateral side of olecranon with 1mm sliver of cartilage
- Retract triceps medially
- Distally partially release anconeus
Midline Window: Midline fascia release
- Split triceps tendon in midline to to upper limit of olecranon fossa to proximal triceps muscle area with caution to Radial nerve for more proximal muscle splitting
- Medial incision along medial ulnar border ± cartilage/periosteum sleeve
- Retract the split triceps
Olecranon Osteotomy Principles
- Osteotomy
- Final bone incision with osteotome
- Olecranon fixation options: plate & screws/tension band wire
Proximal Olecranon fracture repair
K-wire fixation with figure of 8 tension band wiring
Indications:
- Simple, noncomminuted transverse fracture pattern
- Skin incision: Direct incision over proximal Ulnar.
- 2 K-wire inserted and engage anterior ulnar cortex but avoid overpenetration to prevent injury to the anterior interosseous nerve or limit forearm ROM
Screw fixation with figure of 8 tension band wiring
Indications:
- Simple, noncomminuted transverse fracture pattern
- Skin incision: Direct incision over proximal Ulnar.
- Screw length must engage distal intramedullary canal
Nail and Screw Fixation
Indications:
- Simple, transverse fracture pattern
- Skin incision: Direct incision over proximal Ulnar entry point.
- Nail with screw fixation proximally and distally.
Olecranon open reduction and internal fixation
with plate and screw fixation
Indications:
- Comminuted fracture
- Monteggia fracture or other fracture dislocation
- Oblique fracture configuration that extend into distal coronoid
- Skin incision: Direct incision over proximal Ulnar.
- Plate and screw fixation
Ulnar Fracture Excision and Triceps Advancement
Indications:
- Fracture nonunion
- Extensive comminuted proximal ulnar fractures
- Elderly patients with osteoporotic bone
- Note: procedure require elbow ligament stability
Surgery approach: directly over ulnar. Reattach triceps tendon close to the articular surface thereby improving stability as triceps acts as a sling for the trochlea.
Double Row Triceps Repair Suture Technique
2 Tunnels are drilled using a 2mm bit, drilling from proximal to distal:
- Dorsal superficial
- Volar deep
- Start at the volar corners of footprint & drill the deep tunnels in a crossing pattern so that the tunnels exit 1.5 to 2.5 cm distal to olecranon tip and 8 to 10mm to the side of dorsal ulnar ridge
- The superficial (dorsal) tunnels drilled similarly crossing corners of the footprint starting from dorsal ulnar ridge 10 to 12mm proximal to deep tunnels
- Triceps sutured with Krackow technique with 4 exiting strands exiting deep surface of triceps
- Unattached free sutures are passed, crossing retrograde through superficial tunnels exiting the dorsal corners of footprint. These sutures are passed through the triceps using a free needle from deep to superficial and tied across four corners after the Krakow sutures are tied
- Modified technique used with excision of proximal olecranon
Elbow Joint Replacement
Post Operative Rehabilitation
- Rigid fixation: arm sling for 7-10 days then elbow range of motion, non-weight bearing
- Suboptimal fixation may require splintage or elbow hinge brace
- Strengthening exercises after fracture union
Arm sling
Hand grip exercises with arm in splint
Forearm strength exercise
Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision
References
- A comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs. Matthew A Dorweiler, Rufus O Van Dyke, Robert C Siska, Michael A Boin and Mathew J DiPaola. The Orthopaedic Journal of Sports Medicine May 2017, 5(5): 23259671177080.
- Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
- A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Johnston GW. Ulster Med J 31: 51-56.
- Management of severely comminuted distal radius fractures. David M Brogan, Marc J Richard, David Ruch, Sanjeev Kakar. J Hand Surg Am. 2015 Sep; 40(9): 1905-14.
- Surgical management for olecranon fractures in adults: a systematic review and meta-analysis. Koziarz A, Woolnough T, Oitment C, Nath S, Johal H. Orthopedic. 2019 Mar 1;42(2): 75-82.
- Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
- Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
- Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures. Petra Grahn, Tero Hämäläinen, Yrjänä Nietosvaara, Matti Ahonen. Acta Orthop. 2021 Feb;92(1): 114-119.
- A narrative review on avulsion fractures of the upper limb and lower limbs. Christopher Vannabouathong, Olufemi R Ayeni, Mohit Bhandari. Clin Med Insights Arthritis Musculoskelet Disord. 2018;11: 1179544118809050.
- Outcome after ORIF of capitellar and trochlear fractures. JH Dubberley, KJ Faber, JC Macdermid, SD Patterson, GH King. J Bone Joint Surg Am. Vol. 88 2006: 46-54.
- Coronal plane partial articular fractures of the distal humerus: current concept in management. DE Ruchelsman, NC Tejwani, YW Kwon, KA Egol. J Am Acad Orthop Surg. Vol 16 2008: 716-728.
- Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.
