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Olecranon Fractures

Categories
  • Elbow
  • Joint/Tendon
Tags
  • Elbow injury
Elbow

Upper Limb Anatomy

Right shoulder and arm, posterior view
Right shoulder and arm, posterior view

Right shoulder and arm, posterior view

Normal Upper Limb Anatomy
Triceps Brachii Muscle
Upper Limb Anatomy (Arm)
Muscles of the Forearm
Muscles of the Forearm
Upper Limb Anatomy (Nerve)
Medial aspect of right forearm

Medial aspect of right forearm

Left Brachial plexus

Left Brachial plexus

Nerves Posterior to Elbow Joint

Posterior view of right elbow

Posterior view of right elbow

Blood supply around the elbow joint

Blood supply and anastomosis

Blood supply and anastomosis around the right elbow. Anterior view

Elbow Joint

Elbow joint structural stability structures

Elbow joint structural stability structures

Left Arm

Left arm
Left arm
Humerus

Radial head/neck fractures

The triangular structure of distal humerus at elbow joint provides structural strength.

Anterior view right distal humerus bone

Anterior view right distal humerus bone

Rotation around throchlear axis

The elbow joint is a hinge joint with axis of rotation around throchlear axis

Extensor muscles

Extensor muscles

Resisted finger flexion

Flexor muscles

Bone Structure
Haversion bone system

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

Simple olecranon fracture

Complex olecranon fracture

Complex olecranon fracture

Mayo Classification of Olecranon Fractures

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

Schatzker classification of olecranon fractures

AO Classification Proximal Radius/Ulnar 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.

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.

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

Plate and screw fixation

Nail with 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.

Fragment excision and triceps advancement

Elbow Joint Replacement

Total joint replacement a consideration for elderly patients with significant comminuted proximal olecranon fractures with > 60% articular involvement.

Arthroplasty of the elbow joint
Elbow joint replacement

Surgery Technique

Surgery

Posterior Approach to Distal Humerus/Elbow/Proximal Ulnar

Nerves Posterior to Elbow Joint

Posterior view of right elbow

Posterior approach to right distal humerus, Radial nerve at risk

Structure of Radial NerveStructure of Radial Nerve

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

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

Fascia release or olecranon osteotomy

Medial window: Medial fascia release

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

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

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

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
K-wire fixation with figure of 8 tension band wiring
  • 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
Screw fixation with figure of 8 tension band wiring
  • Skin incision: Direct incision over proximal Ulnar.
  • Screw length must engage distal intramedullary canal

Nail and Screw Fixation

Indications:

  • Simple, transverse fracture pattern
Nail and screw fixation
  • 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
Olecranon open reduction and internal fixation with plate and screw fixation
  • 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
Ulnar fracture excision and triceps advancement

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

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

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

Arm sling

Hand grip exercises with arm in splint

Hand grip exercises with arm in splint

Forearm strength exercise

Forearm strength exercise

Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision

apple app store  google play store

References

  1. 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.
  2. Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
  3. 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.
  4. 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.
  5. 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.
  6. Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
  7. Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.

Contributor:

Dr N J Kauta

Learn More

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