Right shoulder and arm, posterior view
Right shoulder and arm, posterior view
Medial aspect of right forearm
Left Brachial plexus
Posterior view of right elbow
Blood supply and anastomosis around the right elbow. Anterior view
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 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).
Simple olecranon fracture
Complex olecranon fracture
Exclude elbow dislocation/instability
Based on the fracture pattern
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.
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
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.
Total joint replacement a consideration for elderly patients with significant comminuted proximal olecranon fractures with > 60% articular involvement.
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.
Distal humerus to curving around the lateral olecranon to 2-4cm along ulnar crest
Indications:
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.
2 Tunnels are drilled using a 2mm bit, drilling from proximal to distal:
Arm sling
Hand grip exercises with arm in splint
Forearm strength exercise