Lecture about olecranon fractures

1. Fractures of the
Olecranon
Muhammad Abdelghani

2. Epidemiology
• Bimodal distribution:
–Younger individuals: High-energy trauma
–Older individuals: Simple falls

3. Anatomy
• The subcutaneous position of olecranon
makes it vulnerable to direct trauma.

4. Anatomy
• The coronoid process delineates
the distal border of greater sigmoid
notch of ulna, which articulates
with the trochlea.
• This articulation allows motion only
about the flexion-extension axis,
thus providing intrinsic stability to
the elbow joint.
• “Bare area”: Transverse ridge
interrupting the articular cartilage.

5. Anatomy
• Posteriorly, the triceps tendon envelops the
articular capsule before it inserts onto the
olecranon.
• Fracture olecranon with displacement
represents a functional disruption of triceps
mechanism, resulting in loss of active
extension of the elbow.

6. Mechanism of injury
• Direct: Fall on the point of elbow or direct trauma to
olecranon.
– Typically results in a comminuted olecranon fracture.
• Indirect: Fall onto the outstretched upper extremity
accompanied by a strong, sudden contraction of triceps.
– Typically results in a transverse or oblique fracture.
• A combination of these may produce displaced, comminuted
fractures, or, in cases of extreme violence, fracture-
dislocation with anterior displacement of the distal ulnar
fragment and radial head.

7. Clinical Presentation
• Patients typically
present with the
upper extremity
supported by the
contralateral hand
with the elbow in
relative flexion.

8. Clinical Evaluation
• Look:
– Abrasions over olecranon or hand can be indicative of the
mechanism of injury.
• Feel:
– Palpable defect at fracture site.
• Move:
– Inability to extend the elbow actively against gravity indicates
discontinuity of triceps mechanism.
• Neurosensory evaluation:
– Associated ulnar nerve injury is possible, esp. with
comminuted fractures resulting from high-energy injuries.

9. Radiographic Evaluation
• True lateral radiograph:
–Demonstrates:
• extent of the fracture
• degree of comminution
• degree of articular surface
involvement
• displacement of the radial head, if
present.

10. Radiographic Evaluation
• AP view:
–This should be evaluated to
exclude associated fractures or
dislocations.
–The distal humerus may obscure
osseous details of the olecranon
fracture.

12. Radiographic Evaluation
• Radiocapitellar view:
–This may be of help if the patient appears to have
a concomitant injury or displacement of the radial
head.
–Position the patient as for a lateral x-ray view but
angle the tube 45° toward the shoulder

13. Mayo Classification
• This distinguishes 3
factors that have a direct
influence on treatment:
(1) fracture displacement,
(2) comminution, &
(3) ulnohumeral stability.

14. Mayo Classification
• Type I: nondisplaced or minimally displaced:
– Subcategories: Noncomminuted (IA); Comminuted (IB).
– Treatment: Nonoperative.
• Type II: displaced proximal fragment without elbow
instability:
– Subcategories:
• IIA: noncomminuted, can be treated by tension band wire
fixation.
• IIB: comminuted & require plate fixation.
– Treatment: Operative.
• Type III: features instability of the ulnohumeral
joint.
– Treatment: Operative.

15. Schatzker classification
(Based on Fracture Pattern)
• Transverse: Occurs at apex of sigmoid notch. Usually
represents an avulsion fracture.
• Transverse-impacted: A direct force leads to comminution
& depression of articular surface.
• Oblique: results from hyperextension injury; it begins at
midpoint of sigmoid notch and runs distally.
• Comminuted fractures with associated injuries: result from
direct high-energy trauma; fractures of coronoid process
may lead to instability.
• Oblique-distal: Fractures extend distal to the coronoid &
compromise elbow stability.
• Fracture-dislocation: usually associated with severe
trauma.

16. Treatment

17. Treatment objectives
• Restoration of articular surface
• Restoration & preservation of elbow
extensor mechanism
• Restoration of elbow motion & prevention
of stiffness
• Prevention of complications

18. Nonoperative Treatment
• Indications:
–nondisplaced fractures
–displaced fractures in
poorly functioning older
individuals

19. Nonoperative Treatment
• Immobilization in a long arm
cast with the elbow in 45-90° of
flexion is favored by many
authors.
• In reliable patients a posterior
splint or orthosis with gradual
initiation of ROM after 5-7 days
may be used.
• Follow-up radiographs should be
obtained within 5-7 days after
treatment to rule out fracture
displacement.

20. Nonoperative Treatment
• Osseous union is usually not complete until 6-
8 weeks.
• In general, there is adequate fracture stability
at 3 weeks to remove the cast and to allow
protected ROM exercises, avoiding flexion
past 90°.

22. Operative Treatment
• Indications:
–Disruption of extensor mechanism (any
displaced fracture)
–Articular incongruity
–Open fractures

23. Principles of Surgical Treatment
• Rigid fixation is required.
a) Plate fixation:
• Often the best choice, esp. when comminution is present, to
maintain ulnar length and alignment.
• A number of plate fixation techniques have been described, most involving
a contoured posterior or lateral plate with, when possible,
interfragmentary screws.
a) In addition to internal fixation, use of an external
fixation device or distraction device can be helpful or
necessary to maintain joint congruity while allowing an
early motion program.

24. Principles of Surgical Treatment
• Primary bone grafting should be considered
to reduce the risk of nonunion, especially in a
type IIIB olecranon fracture.

25. Principles of Surgical Treatment
• Total elbow arthroplasty may be considered
based on the fracture pattern, bone quality,
and patient age.
– However, the results of elbow arthroplasty
following trauma are not as good as the results
for patients with inflammatory arthritis.

26. Principles of Surgical Treatment
• Restoration of articular congruity is a primary goal
of reduction and fixation of olecranon fractures.
1) Type IIIB olecranon fractures are not well suited to tension
band wiring because of the loss of bony stability under
compression.
2) Avoid narrowing of the olecranon to coronoid distance.
3) It is usually preferable to co-apt the cortical surfaces and leave
a gap in the articular surface in order to preserve a more
normal articular contour.

27. Surgical options
Tension band wiring
• Commonly used for noncomminuted,
transverse olecranon fractures.
• Tension band wiring in combination
with 2 parallel K-wires counteracts
the tensile forces & converts them to
compressive forces and is indicated
for avulsion-type olecranon
fractures.
• Various techniques have been
described.

29. Surgical options
Tension band wiring
Standard AO technique:
• This technique uses 2 intramedullary K-wires and a
figure-of-eight wire with a single knot.
• To avoid proximal migration and hardware prominence,
the K-wires can be directed anteriorly to engage the
ulnar cortex at the base of the coronoid.
a) This provides stronger fixation than the usual intramedullary
placement of the K-wires.
b) Some concerns have been raised over the potential for
neurovascular injury with this technique, although no reports
of such injuries could be found.

30. Intramedullary
placement of K-wires.
Transcortical
placement of
K-wires
Two different techniques of tension band wiring
of the olecranon

31. Surgical options
Intramedullary fixation
• Currently, the accessibility and ease
of cannulated screw systems have
made intramedullary screw fixation
an attractive treatment option.
• Indications for intramedullary
screw placement:
– Similar to tension band wiring.
– Include simple, noncomminuted
transverse fracture patterns.

32. Surgical options
Intramedullary fixation
• 6.5-mm cancellous lag screw
fixation.
• The screw must be of sufficient
length to engage the distal
intramedullary canal for
adequate fixation.
• This may be used in conjunction
with tension band wiring.

33. Surgical options
Intramedullary fixation
• Other forms of intramedullary
fixation have also been
introduced.
– Interlocking intramedullary nailing
devices have been created to treat
simple, transverse olecranon
fractures.
• Proponents of this device have touted
its “locking” capability which prevents
the need for intramedullary cortical
purchase necessary in traditional
screw techniques.

34. Surgical options
Plate and screws
• Plating has become an increasingly important
method of treating displaced olecranon
fractures.

35. Surgical options
Plate and screws
• Although plate fixation can be used for virtually any
type of olecranon fracture, it is ideal for the
following indications:
– comminuted olecranon fractures
– Monteggia fracture-dislocations
– olecranon fracture-dislocations
• A plate should also be for oblique fractures and for
fractures that extend distal to the coronoid.

36. Surgical options
Plate and screws
• Low-profile, locking
precontoured plates are
now available.
• Standard manually
contoured 3.5-mm limited
contact DCPs are also
available.

37. Surgical options
Plate and screws
• Plate fixation allows neutralization of forces
across the fracture site and should provide
adequate rigid internal fixation to begin early
motion.
• Interfragmentary compression screws should be
utilized when possible.
• Augmentation with an external fixation or
distraction device may be beneficial when elbow
stability is lacking despite fracture fixation.
• Articular step-off of > 2 mm has been associated
with poorer results.

38. Surgical options
Plate and screws
Plate position
– Most authors prefer posterior
placement of the plate.
– However, King found no significant
difference in strength of fixation
between posterior or lateral placement.
• Posterior plating allows a more direct
approach to the proximal ulna and
requires less soft tissue stripping and
less effort to contour the plate.
• A laterally placed plate may be less
prominent and less likely to require
hardware removal.

39. Hook plate
One end of a 3.5-mm semitubular
plate is
flattened with a mallet and bending
irons
A wire cutter is used to cut away a
portion of the distal plate hole
The two cut ends are then bent to 90°.
The plate is then contoured to the
olecranon. Two holes are placed in the
proximal olecranon to ease insertion of
the hooks into the fragment
Cut portions of the plate are bent 90
degrees

40. Surgical options
Fragment Excision with Triceps Advancement
• Recent advances in implant technology have made
reconstruction of a severely comminuted
olecranon fracture more feasible.
• However, proximal fragment excision and triceps
advancement still constitutes a viable option in the
treatment of comminuted olecranon fractures.
• Excision of as much as 50% of the olecranon is
effective in treating comminuted fractures.

41. Surgical options
Fragment Excision with Triceps Advancement
• Indications:
– Nonunited fractures
– Extensively comminuted
fractures
– Fractures in elderly individuals
with severe osteopenia and low
functional requirements
– Extraarticular fractures

42. Surgical options
Fragment Excision with Triceps Advancement
• Pearls and Pitfalls:
– Excision in patients with > 60% articular involvement
yields poorer results.
– When reattaching the triceps, care should be taken to
bring the tendon close to the articular surface, thus
improving stability by acting as a sling for the trochlea.
– Patients must have an intact MCL, interosseous
membrane, and DRUJ before excision, or instability will
likely develop.
– A major criticism of this technique is the potential for
significant loss of triceps power.

43. Surgical options
Fragment Excision with Triceps Advancement
• Contraindications:
– Fracture-dislocations of the elbow
– Fractures of the radial head
(Excision will compromise elbow stability)

44. Surgical options
Total Elbow Arthroplasty
• Indications:
–Total elbow arthroplasty may be considered in
elderly patients with significant comminution
and > 60% articular involvement.

45. Summary of Treatment by Mayo Fracture
Type
• Type I:
nondisplaced or
minimally
displaced,
subclassified as
either
noncomminuted
(IA) or comminuted
(type IB).
• Treatment:
– Casting or splinting and early
mobilization.
a. Long arm cast or posterior splint: used for
comfort and protection, preferably in a
position of mid-flexion and neutral forearm
rotation.
b. Dynamic extension splint: can also be used
for early motion with active flexion and
passive extension.
c. Motion can often begin by 7 days post-injury
with weekly radiographs during the first few
weeks to follow the fracture and confirm that
it remain nondisplaced.

46. Summary of Treatment by Mayo Fracture
Type
• Type II:
displaced
proximal
fragment
without elbow
instability.
• Treatment:
– Articular incongruity,
exacerbated by the deforming
forces of the triceps, biceps and
brachialis muscles, makes
surgery necessary to restore the
articular surface, prevent
redisplacement and allow early
motion.

47. Summary of Treatment by Mayo Fracture
Type
• Type IIA:
noncomminuted
• Treatment:
– Tension band wiring: several methods
• This allows neutralization of the deforming
forces and compression of the fracture site.
– Longitudinal intramedullary fixation: has
also been advocated for this fracture
pattern; however, higher rates of
displacement, poor rotational control, and
problems with screw purchase in the
medullary canal have been reported.
• The technique works best with a single large
fragment and minimal or no comminution.

48. Summary of Treatment by Mayo Fracture
Type
• Type IIB:
comminuted
• Treatment:
– The nature of these fractures creates
increased difficulty obtaining articular
congruity with tension band wire
techniques.
– Additional interfragmentary screw
fixation or plate fixation can improve
the results in these fractures.
– Fragment excision and triceps
advancement may be considered,
particularly for small fragments or in
elderly patients.

49. Summary of Treatment by Mayo Fracture
Type
• Type III:
Olecranon
fracture with
instability of the
ulnohumeral
joint
• Treatment:
– These fractures present the greatest challenge
and have the highest rate of complications.
• The elbow is unstable, usually with anterior
subluxation of the radius and ulna on the distal
humerus as a result of the deforming forces
created by the triceps, biceps, and brachialis.
• These fractures are usually comminuted (type IIIB).
• These fracture carry a high incidence of additional
elbow trauma.
a) Concomitant injuries include radial head fractures,
distal humerus fractures, and ligament rupture.
b) Concomitant injuries should be assessed and treated at
the same time as the olecranon fracture because they
have tremendous impact on the results achieved.

50. Postoperative management
• The patient should be placed in a posterior
elbow splint.
• With a stable repair, initiate early ROM
exercises.
• In cases with severe soft tissue injury, early
motion may need to be delayed until the soft
tissue healing is adequate to tolerate motion.

51. Complications.
• Hardware prominence requiring removal:
–The most common complication (up to 80%).
–More common with tension band wiring than
with plate fixation.

52. Complications
• Hardware failure (1%-5%).
• Infection (0%-6%).
• Pin migration (15%).
• Ulnar neuritis (2%-12%).
• Heterotopic ossification (2%-13%).
• Nonunion (5%).
• Decreased ROM (Stiffness): may complicate up to 50% of
cases. Loss of elbow extension is most common.