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Fractures of the olecranon
FRACTURES
OF THE
OLECRANON
BY GREGORY LAVIGNE, MD, AND MARK BARATZ, MD
Fractures of the olecranon process are common in adults and reflect a spectrum of injuries to the elbow. This article provides an overview of the management for olecranon fractures, including a historic perspective, relevant anatomy, mechanism of injury, classification, evaluation, treatment, and reported outcome. Copyright © 2004 by the American Society for Surgery of the Hand arly literature on the treatment of olecranon fractures described splinting the elbow in extension for 4 to 6 weeks. This resulted in a stiff elbow in a nonfunctional position.1 Subsequent articles described splinting the elbow in midflexion. This, however, allowed the fracture fragments to separate and often led to nonunion. As early as 1884, Shelton and Lister described the benefits of fracture reduction, reduction with a loop of iron wire and early motion.1 Since that time, many methods for treating olecranon fractures have been described, including excision of the fragment, intramedullary fixation with rods (19392) or longitudinal screws (19423,4), and stabilization of the fracture with plates. Over the past 45 years, internal fixation of olecranon fractures has improved dramatically. The complex nature of the injury, however, has not permitted a single treatment method to become the gold standard.
E
RELEVANT ANATOMY he hand can be placed in an infinite array of positions under a wide range of loads by virtue of the motion and stability provided by the elbow joint.
T
From the Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA. Address reprint requests to Mark Baratz, MD, Department of Orthopaedic Surgery, Allegheny General Hospital, 1307 Federal St, Pittsburgh, PA 15212. E-mail: [email protected] Copyright © 2004 by the American Society for Surgery of the Hand 1531-0914/04/0402-0006$30.00/0 doi:10.1016/j.jassh.2004.02.004
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An arc of approximately 150° of flexion and extension is possible at the ulnohumeral joint. The proximal ulna or olecranon helps to stabilize the elbow joint against translational loads by virtue of the anterior coronoid process and the posterior olecranon process. Resistance to valgus stress at the elbow is provided by the anterior band of the ulnar collateral ligament,5 passing from the medial epicondyle of the humerus to the base of the coronoid process. Resistance to posterolateral instability of the elbow is provided by the lateral ulnar collateral ligament. The articular portion of the olecranon is covered with hyaline cartilage.5 There is typically a transverse bare area at the junction of the anterior third and the posterior two thirds5,6 (Fig 1). The triceps brachii inserts onto the posterior apex of the olecranon, blending with the aponeurosis overlying the anconeus muscle and the common extensor origin. The triceps tendon is associated intimately with the periosteum overlying the olecranon.5,6 The brachialis muscle inserts onto the midportion of the anterior coronoid and the proximal ulnar metaphysis.5,6 Both the triceps and brachialis provide a compressive force across the ulnohumeral joint during contraction.6
MECHANISM lecranon fractures occur as a result of direct or indirect trauma.5-7 Direct injuries are typically the result of a fall with impact on the dorsal aspect
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JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND 䡠 VOL. 4, NO. 2, MAY 2004
OLECRANON FRACTURES 䡠 LAVIGNE & BARATZ
FIGURE 1. Ulnohumeral articular bare area.
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FIGURE 3. Suture anchors were used to repair the ligament to its insertion on the ulna.
of the proximal forearm.5-7 Laboratory studies have shown that the position of the elbow is usually between 60° and 110° of flexion.7 The distal humeral articular surface acts as a wedge to fracture the proximal ulna, often producing comminution with joint line depression7 (Figs 2-5). If the point of impact is moved proximal to the coronoid process, a comminuted fracture is created with an associated anterior dislocation of the elbow.7 With the elbow flexed 110° to 135°, an assortment of olecranon, intracondylar, and transcondylar fractures occurred in the cadaver specimens.7
FIGURE 2. Transolecranon fracture dislocation after a fall. Intraoperative evaluation of stability revealed deficient medial collateral ligamentous complex. Surgical inspection of the medial collateral ligament revealed that it had been stripped completely from the ulna.
FIGURE 4. Postoperative radiographs after open reduction and internal fixation with a precontoured plate and banked bone (A). Again, the suture anchors mark the sight of ligamentous repair. Follow-up radiographs at 8 weeks (B).
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OLECRANON FRACTURES 䡠 LAVIGNE & BARATZ
Hyperextension of the elbow creates a bending moment across the olecranon when the olecranon is locked into the olecranon fossa of the distal humerus.6 During a fall on an outstretched hand, the distal aspect of the olecranon may be impacted into the trochlea, producing fracture by indirect trauma.6 Fracture displacement occurs by virtue of the pull of the triceps and disruption of the triceps aponeurosis or periosteum.
CLASSIFICATION o single classification system for olecranon fractures has gained universal acceptance. The Mayo classification system is based on displacement, stability, and comminution.1,5 There are 3 fracture types, each with 2 subgroups. Type I fractures are minimally comminuted with less than 2 mm of displacement and account for approximately 5% of olecranon fractures.1 Type II fractures are either noncomminuted or comminuted, and account for 85% of proximal ulna fractures.1 In this fracture the anterior band of the ulnar collateral ligament is intact, preserving the stability of the ulnohumeral joint.1 Type III fractures account for 5% of proximal ulna fractures.1 These fractures may be comminuted and often are associated with fractures of the radial head.1 The medial collateral ligament is disrupted, creating elbow instability. The associated instability may be occult if the ulnohumeral joint has reduced spontaneously.1
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EVALUATION he radiohumeral, proximal radioulnar, and distal radioulnar joints are examined in all patients.6 The soft tissues are examined carefully for skin breaks and bruising. A complete neurovascular examination is performed and documented. Radiographs of the elbow are obtained in all cases. The lateral view is particularly helpful to assess joint reduction, fracture comminution, and articular incongruity. Oblique views off the anteroposterior projection help assess medial and lateral wall reduction and comminution. Computed tomography scans help evaluate comminution of the articular surface, the size and location of
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Š FIGURE 5. Range of motion at 8-week follow-up evaluation in extension (A) and flexion (B).
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articular fragments, and the percentage of the articular surface fractured.
TREATMENT anagement of olecranon fractures depends on displacement, comminution, and elbow stability. Stable internal fixation in the setting of a displaced comminuted fracture is only part of the answer. Restoration of the articular surface without addressing joint stability may result in pain and joint degeneration. Nondisplaced fractures can be immobilized in a long arm cast or splinted in 45° to 90° of flexion.5 Repeat radiographs are obtained within 1 week to evaluate fracture displacement.5 Immobilization is discontinued within 2 weeks and active motion without resistance is initiated.5,6 Displaced fractures are treated according to the fracture pattern. Options for treatment include tension band wiring, longitudinal screws, plate fixation, or primary excision. Whatever the treatment method, the construct must be stable enough to allow for early motion. Open fractures occur in 2% to 31% of cases and should be treated urgently.1
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SURGICAL APPROACH he patient is positioned in the lateral decubitus position with the brachium supported by a padded post, such as a tibial leg holder. A longitudinal posterior incision is used to expose the posterior surface of the olecranon. The fracture site is irrigated and cleaned of debris.
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OPTIONS
FOR
FIXATION
ension band wiring is effective for noncomminuted transverse fractures involving less than 50% of the articular surface of the olecranon. A large tenaculum is used to help reduce and compress the fracture fragments (Fig 6). One tine is placed on the tip of the olecranon; the second tine is placed in a drill hole in the posterior cortex drilled several centimeters distal to the fracture. Two 0.062-in wires are inserted into the tip of the olecranon and advanced across the fracture and into the anterior cortex of the ulna. An 18-gauge wire is passed anterior to the triceps tendon,
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FIGURE 6. Reduction of olecranon fracture with large tenaculum.
using an intravenous catheter so that the wire rests firmly against the proximal ulna. A 2.0-mm drill hole is created in the posterior cortex approximately 2 cm distal to the fracture site.8 The wire is passed through the tunnel to create a figure-of-eight. The wire is pulled taught and twisted 3 full twists. The ends of the wire are cut and bent to lie against the bone. The triceps tendon is split in line with its fibers, allowing the wires to be bent 180°, cut, and impacted into the olecranon tip. The elbow is ranged to ensure that full motion has been preserved (Fig 7). Plate fixation is indicated in comminuted fractures, fractures distal to the coronoid process, oblique fractures distal to the midpoint of the trochlear notch, and those fractures associated with Monteggia fracturedislocations of the elbow.5,6 Available plates include 3.5-mm dynamic compression, 3.5-mm reconstruction, one-third tubular and precontoured plates. The one-third tubular and 3.5-mm reconstruction plates can be bent to match the posterior cortex of the olecranon. By making 2 oblique cuts at the proximal screw hole, 2 tines can be fashioned on the proximal end of the plate to create a hook plate. The one-third tubular and 3.5-mm reconstruction plates have sufficient strength to stabilize olecranon fractures without comminution. Comminuted fractures require a more stable construct. Adequate stability usually can be achieved
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OLECRANON FRACTURES 䡠 LAVIGNE & BARATZ
FIGURE 7. Preoperative films of an olecranon fracture from high-energy mechanism with extensive soft-tissue damage (A). Note the large proximal fragment amenable to tension band wiring. Postoperative lateral radiograph after tension band wiring. Wires are angled to capture the anterior cortex (B). They are then cut, bent, and impacted, burying the ends beneath the triceps tendon. Flexion (C) and extension (D) at 3-year follow-up evaluation.
OLECRANON FRACTURES 䡠 LAVIGNE & BARATZ
with a dynamic compression plate placed on the medial or posterior cortex. Plates placed on the posterior cortex minimize the possibility of malreducing the fracture in the sagittal plane. Precontoured plates with a C-shaped design seem to have adequate strength for moderately comminuted fractures. Fractures with extensive comminution may require dual plating to achieve adequate stability. A plate contoured to fit the posterior cortex can be stabilized by placing a screw in the most proximal hole. This screw can be angled to cross the fracture and engage the anterior cortex of the ulna or pass down the intramedullary canal.5 The remaining screws must be angled radially or ulnarly to avoid the centrally placed screw.5 Resection of the proximal fragments and advancing the triceps is an option for managing comminuted fractures. Resection with triceps advancement should be considered in patients in whom the fracture fragments constitute less than 70% of the articular surface and are too comminuted for fixation. The extent of resection is dictated by the insertion of the medial collateral ligament. Before resecting the fracture fragments the elbow should be stressed to assess the integrity of the medial collateral ligament. Fracture fragments are excised with care to preserve the fibers of the triceps. The triceps tendon is reattached by using nonabsorbable sutures passed through drill holes to the proximal edge of the articular surface as described by Cabenella and Morrey1 (Fig 8). This method creates a sling for the distal humerus as well as a smooth surface for articulation. This technique, however, may decrease extensor strength secondary to a shortened moment arm.1 A recent biomechanical study by DiDonna et al9 showed an increase in triceps strength by repairing the disrupted triceps mechanism in a more posterior position, but they did not evaluate the long-term effects of this position on the articular surface.
POSTOPERATIVE CARE he elbow is splinted in approximately 60° of flexion to minimize tension on the skin. The patient is re-evaluated in 5 to 7 days. If the skin has sealed, active-assisted motion is initiated. Between exercise sessions the elbow is protected in a posterior splint. The splint is discontinued after 2 weeks when
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the staples are removed. Active motion begins at 2 weeks. Passive begins when healing appears imminent. Exercise against resistance begins when the fracture has healed. In a patient who has undergone fracture excision with triceps advancement, resistive exercises do not begin until the 12th week.
RESULTS esults with tension band wiring have been excellent. Wolfgang et al10 (displaced olecranon fractures) and Ikeda et al11 (comminuted fractures with iliac craft bone grafts) reported 98% and 100% good to excellent results, respectively. Ikeda et al11 showed that union occurred typically at 4 months with a mean range of motion between 15° and 135° in flexion and extension with 70° of pronation and 79° of supination.11 Mullett et al12 examined tension band wiring with 2 different techniques for pin placement in a biomechanical model and a clinical series. In one group pins were passed down the intramedullary canal; in the second group pins were placed in the apex of the olecranon and passed across the fracture and into the anterior cortex of the ulna.12 In the cadaveric model, the pullout strength of transcortically placed pins was significantly higher (P ⬍ .0001) compared with those placed down the intramedullary canal.12 Hutchinson et al,13 however, showed no significant difference in the pullout strength of transcortical versus intramedullary pins. In 80 patients, 35 had fractures fixed with transcortical pins and 45 had fractures fixed with intramedullary pins.13 Nine patients with transcortical pin fixation had problems with pin prominence, with 4 requiring pin removal, compared with 19 patients with intramedullary pins who had to undergo removal of their hardware.13 A recent study noted no difference between traditional tension band wiring and the figure-of-8 wiring technique described earlier at a mean follow-up of 18 years after injury.14 The re-operation rate was significantly lower (43% to 81%) in the group treated with the figure-of-8 technique.14 Complications of tension band wiring include loss of fixation, nonunion, skin breakdown, infection, olecranon bursitis, radial head subluxation, and prominent hardware. Intramedullary screw and tension band constructs have been evaluated recently in the literature. Hutchinson et al13 showed a 5-fold improvement in fracture stability over tension band and pin constructs
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FIGURE 8. Preoperative radiograph showing severe comminution of the proximal ulna after jumping 50 feet from a bridge (A). Postoperative radiograph after excision of the olecranon fragment and reinsertion of the triceps as described by Cabenella and Morrey,1 creating an articular sling (B). Six-week flexion (C) and extension (D).
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FIGURE 9. The funnel shaped intramedullary canal of the proximal ulna.15
with a 7.3-mm cancellous screw passed down the medullary canal with or without the addition of a tension band. Addition of a tension band did improve stabilization of the screw construct slightly.13 Stability, however, may be gained at the cost of malreduction if screw fixation is performed improperly. A report by Baratz and Shanahan15 in 1995 identified the funnel shape of the proximal ulna. If the screw is not long enough to reach the mouth of the funnel, the screw may toggle and allow the fracture to shift. If the screw diameter chosen is too large, the screw may not pass the isthmus (Fig 9). Teasdall et al16 reported good to excellent results in 69% of patients after plate fixation of comminuted olecranon fractures with a mean flexion of 20° to 118°. Ring et al17 obtained 88% good to excellent results after olecranon fracture and ulnohumeral dislocation with a mean arc of 14° to 127° (3 simple oblique and 14 complex fractures). Complications of plate fixation include metal prominence, loss of reduction, and malreduction. With lateral plating it can be difficult to see the posterior cortex on a lateral radiograph, confounding the surgeon’s ability to assess the quality of reduction. Nonunion has been reported in less than 10% of cases. Excision of the fractured olecranon has been met with similarly good results. McKeever and Buck8 reported that as much as 80% of the trochlear notch may be excised without compromising stability if the coronoid and distal trochlea are preserved. Other studies have shown that progressive instability occurs
when the articular surface defect exceeds 50%. Gartsman et al18 compared open reduction and internal fixation with primary excision and found no statistical difference between the 2 with regard to isometric or isokinetic strength loss. Both groups lost between 24% and 29% of extensor strength when compared with the uninjured extremity.18 Overall, the reported complication rate with excision is less than that of open reduction and internal fixation. Only 4% of patients with fragment excision had complications related to the procedure, as compared with 23% of patients who underwent open reduction. In addition, 23% of patients undergoing open reduction needed removal of their hardware. Gartsman et al18 found no relationship between the size of the excised fragment and functional outcome despite 6 of 15 patients in their series having greater than 50% of the articular surface excised.
SUMMARY ractures of the olecranon represent a spectrum of injuries with no one treatment representing the gold standard. Treatment instead is dictated by the fracture pattern and the skill of the operating surgeon. No matter the treatment, the premise of olecranon fracture fixation remains the same: anatomic reconstruction of the articular surface and restoration of the stability inherent in the pre-injury ulnohumeral joint.
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REFERENCES 1. Cabanela M, Morrey B. The elbow and its disorders. Philadelphia: WB Saunders, 2000 365-379. 2. Rush LV, Rush HL. A technique for longitudinal pin fixation of certain fractures of the ulna and of the femur. J Bone Joint Surg 1939;21:619. 3. MacAusland WR. The treatment of fractures of the olecranon by longitudinal screw or nail fixation. Ann Surg 1942;116: 293. 4. MacAusland WR Jr, Wyman ET. Fractures of the adult elbow; American Academy of Orthopedic Surgeons: instructional course lectures. St. Louis: Mosby, 1975: 169. 5. Hak DJ, Golladay GJ. Olecranon fractures: treatment options. J Am Acad Orthop Surg 2000;8:266-275. 6. Papagelopoulos PJ, Morrey BF. Treatment of nonunion of olecranon fractures. J Bone Joint Surg 1994;76B:627-635. 7. Amis AA, Miller JH. The mechanisms of elbow fractures: an investigation using impact tests in vitro. Injury 1995;26: 163-168. 8. McKeever FM, Buck RM. Fracture of the olecranon process of the ulna: treatment by excision of fragment and repair of triceps tendon. JAMA 1947;135:1. 9. DiDonna M, Fernandez J, Lim T, Hastings H, Cohen M. Partial olecranon excision: the relationship between triceps insertion site and extension strength of the elbow. J Hand Surg 2003;28A:117-122. 10. Wolfgang G, Burke F, Bush D, et al. Surgical treatment of
11.
12.
13.
14.
15. 16. 17.
18.
displaced olecranon fractures by tension band wiring technique. Clin Orthop 1987;224:192-204. Ikeda M, Fukushima Y, Kobayashi Y, et al. Comminuted fractures of the olecranon: management by bone graft from the iliac crest and multiple tension-band wiring. J Bone Joint Surg 2001;83B:805-808. Mullett JH, Shannon F, Noel J, et al. K-wire position in tension band wiring of the olecranon—a comparison of two techniques. Injury 2000;31:427-431. Hutchinson D, Horwitz D, Ha G, et al. Cyclic loading of olecranon fracture fixation constructs. J Bone Joint Surg 2003;85A:831-837. Murphy DF, Greene WB, Dameron TB Jr. Displaced olecranon fractures in adults: clinical evaluation. Clin Orthop 1987; 224:215-223. Baratz ME, Shanahan JF. Fractures of the olecranon. J South Orthop Assoc 1995;4:283-289. Teasdall R, Savoie FH, Hughes JL. Comminuted fractures of the proximal radius and ulna. Clin Orthop 1993;292:37-47. Ring D, Jupiter J, Sanders RW, Mast J, Simpson NS. Transolecranon fracture-dislocation of the elbow. J Orthop Trauma 1997;11:545-550. Gartsman GM, Sculco TP, Otis JC. Operative treatment of olecranon fractures: excision or open reduction with internal fixation. J Bone Joint Surg 1981;63A:718-721.
OF THE
OLECRANON
BY GREGORY LAVIGNE, MD, AND MARK BARATZ, MD
Fractures of the olecranon process are common in adults and reflect a spectrum of injuries to the elbow. This article provides an overview of the management for olecranon fractures, including a historic perspective, relevant anatomy, mechanism of injury, classification, evaluation, treatment, and reported outcome. Copyright © 2004 by the American Society for Surgery of the Hand arly literature on the treatment of olecranon fractures described splinting the elbow in extension for 4 to 6 weeks. This resulted in a stiff elbow in a nonfunctional position.1 Subsequent articles described splinting the elbow in midflexion. This, however, allowed the fracture fragments to separate and often led to nonunion. As early as 1884, Shelton and Lister described the benefits of fracture reduction, reduction with a loop of iron wire and early motion.1 Since that time, many methods for treating olecranon fractures have been described, including excision of the fragment, intramedullary fixation with rods (19392) or longitudinal screws (19423,4), and stabilization of the fracture with plates. Over the past 45 years, internal fixation of olecranon fractures has improved dramatically. The complex nature of the injury, however, has not permitted a single treatment method to become the gold standard.
E
RELEVANT ANATOMY he hand can be placed in an infinite array of positions under a wide range of loads by virtue of the motion and stability provided by the elbow joint.
T
From the Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA. Address reprint requests to Mark Baratz, MD, Department of Orthopaedic Surgery, Allegheny General Hospital, 1307 Federal St, Pittsburgh, PA 15212. E-mail: [email protected] Copyright © 2004 by the American Society for Surgery of the Hand 1531-0914/04/0402-0006$30.00/0 doi:10.1016/j.jassh.2004.02.004
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An arc of approximately 150° of flexion and extension is possible at the ulnohumeral joint. The proximal ulna or olecranon helps to stabilize the elbow joint against translational loads by virtue of the anterior coronoid process and the posterior olecranon process. Resistance to valgus stress at the elbow is provided by the anterior band of the ulnar collateral ligament,5 passing from the medial epicondyle of the humerus to the base of the coronoid process. Resistance to posterolateral instability of the elbow is provided by the lateral ulnar collateral ligament. The articular portion of the olecranon is covered with hyaline cartilage.5 There is typically a transverse bare area at the junction of the anterior third and the posterior two thirds5,6 (Fig 1). The triceps brachii inserts onto the posterior apex of the olecranon, blending with the aponeurosis overlying the anconeus muscle and the common extensor origin. The triceps tendon is associated intimately with the periosteum overlying the olecranon.5,6 The brachialis muscle inserts onto the midportion of the anterior coronoid and the proximal ulnar metaphysis.5,6 Both the triceps and brachialis provide a compressive force across the ulnohumeral joint during contraction.6
MECHANISM lecranon fractures occur as a result of direct or indirect trauma.5-7 Direct injuries are typically the result of a fall with impact on the dorsal aspect
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JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND 䡠 VOL. 4, NO. 2, MAY 2004
OLECRANON FRACTURES 䡠 LAVIGNE & BARATZ
FIGURE 1. Ulnohumeral articular bare area.
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FIGURE 3. Suture anchors were used to repair the ligament to its insertion on the ulna.
of the proximal forearm.5-7 Laboratory studies have shown that the position of the elbow is usually between 60° and 110° of flexion.7 The distal humeral articular surface acts as a wedge to fracture the proximal ulna, often producing comminution with joint line depression7 (Figs 2-5). If the point of impact is moved proximal to the coronoid process, a comminuted fracture is created with an associated anterior dislocation of the elbow.7 With the elbow flexed 110° to 135°, an assortment of olecranon, intracondylar, and transcondylar fractures occurred in the cadaver specimens.7
FIGURE 2. Transolecranon fracture dislocation after a fall. Intraoperative evaluation of stability revealed deficient medial collateral ligamentous complex. Surgical inspection of the medial collateral ligament revealed that it had been stripped completely from the ulna.
FIGURE 4. Postoperative radiographs after open reduction and internal fixation with a precontoured plate and banked bone (A). Again, the suture anchors mark the sight of ligamentous repair. Follow-up radiographs at 8 weeks (B).
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Hyperextension of the elbow creates a bending moment across the olecranon when the olecranon is locked into the olecranon fossa of the distal humerus.6 During a fall on an outstretched hand, the distal aspect of the olecranon may be impacted into the trochlea, producing fracture by indirect trauma.6 Fracture displacement occurs by virtue of the pull of the triceps and disruption of the triceps aponeurosis or periosteum.
CLASSIFICATION o single classification system for olecranon fractures has gained universal acceptance. The Mayo classification system is based on displacement, stability, and comminution.1,5 There are 3 fracture types, each with 2 subgroups. Type I fractures are minimally comminuted with less than 2 mm of displacement and account for approximately 5% of olecranon fractures.1 Type II fractures are either noncomminuted or comminuted, and account for 85% of proximal ulna fractures.1 In this fracture the anterior band of the ulnar collateral ligament is intact, preserving the stability of the ulnohumeral joint.1 Type III fractures account for 5% of proximal ulna fractures.1 These fractures may be comminuted and often are associated with fractures of the radial head.1 The medial collateral ligament is disrupted, creating elbow instability. The associated instability may be occult if the ulnohumeral joint has reduced spontaneously.1
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EVALUATION he radiohumeral, proximal radioulnar, and distal radioulnar joints are examined in all patients.6 The soft tissues are examined carefully for skin breaks and bruising. A complete neurovascular examination is performed and documented. Radiographs of the elbow are obtained in all cases. The lateral view is particularly helpful to assess joint reduction, fracture comminution, and articular incongruity. Oblique views off the anteroposterior projection help assess medial and lateral wall reduction and comminution. Computed tomography scans help evaluate comminution of the articular surface, the size and location of
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Š FIGURE 5. Range of motion at 8-week follow-up evaluation in extension (A) and flexion (B).
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articular fragments, and the percentage of the articular surface fractured.
TREATMENT anagement of olecranon fractures depends on displacement, comminution, and elbow stability. Stable internal fixation in the setting of a displaced comminuted fracture is only part of the answer. Restoration of the articular surface without addressing joint stability may result in pain and joint degeneration. Nondisplaced fractures can be immobilized in a long arm cast or splinted in 45° to 90° of flexion.5 Repeat radiographs are obtained within 1 week to evaluate fracture displacement.5 Immobilization is discontinued within 2 weeks and active motion without resistance is initiated.5,6 Displaced fractures are treated according to the fracture pattern. Options for treatment include tension band wiring, longitudinal screws, plate fixation, or primary excision. Whatever the treatment method, the construct must be stable enough to allow for early motion. Open fractures occur in 2% to 31% of cases and should be treated urgently.1
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SURGICAL APPROACH he patient is positioned in the lateral decubitus position with the brachium supported by a padded post, such as a tibial leg holder. A longitudinal posterior incision is used to expose the posterior surface of the olecranon. The fracture site is irrigated and cleaned of debris.
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OPTIONS
FOR
FIXATION
ension band wiring is effective for noncomminuted transverse fractures involving less than 50% of the articular surface of the olecranon. A large tenaculum is used to help reduce and compress the fracture fragments (Fig 6). One tine is placed on the tip of the olecranon; the second tine is placed in a drill hole in the posterior cortex drilled several centimeters distal to the fracture. Two 0.062-in wires are inserted into the tip of the olecranon and advanced across the fracture and into the anterior cortex of the ulna. An 18-gauge wire is passed anterior to the triceps tendon,
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FIGURE 6. Reduction of olecranon fracture with large tenaculum.
using an intravenous catheter so that the wire rests firmly against the proximal ulna. A 2.0-mm drill hole is created in the posterior cortex approximately 2 cm distal to the fracture site.8 The wire is passed through the tunnel to create a figure-of-eight. The wire is pulled taught and twisted 3 full twists. The ends of the wire are cut and bent to lie against the bone. The triceps tendon is split in line with its fibers, allowing the wires to be bent 180°, cut, and impacted into the olecranon tip. The elbow is ranged to ensure that full motion has been preserved (Fig 7). Plate fixation is indicated in comminuted fractures, fractures distal to the coronoid process, oblique fractures distal to the midpoint of the trochlear notch, and those fractures associated with Monteggia fracturedislocations of the elbow.5,6 Available plates include 3.5-mm dynamic compression, 3.5-mm reconstruction, one-third tubular and precontoured plates. The one-third tubular and 3.5-mm reconstruction plates can be bent to match the posterior cortex of the olecranon. By making 2 oblique cuts at the proximal screw hole, 2 tines can be fashioned on the proximal end of the plate to create a hook plate. The one-third tubular and 3.5-mm reconstruction plates have sufficient strength to stabilize olecranon fractures without comminution. Comminuted fractures require a more stable construct. Adequate stability usually can be achieved
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FIGURE 7. Preoperative films of an olecranon fracture from high-energy mechanism with extensive soft-tissue damage (A). Note the large proximal fragment amenable to tension band wiring. Postoperative lateral radiograph after tension band wiring. Wires are angled to capture the anterior cortex (B). They are then cut, bent, and impacted, burying the ends beneath the triceps tendon. Flexion (C) and extension (D) at 3-year follow-up evaluation.
OLECRANON FRACTURES 䡠 LAVIGNE & BARATZ
with a dynamic compression plate placed on the medial or posterior cortex. Plates placed on the posterior cortex minimize the possibility of malreducing the fracture in the sagittal plane. Precontoured plates with a C-shaped design seem to have adequate strength for moderately comminuted fractures. Fractures with extensive comminution may require dual plating to achieve adequate stability. A plate contoured to fit the posterior cortex can be stabilized by placing a screw in the most proximal hole. This screw can be angled to cross the fracture and engage the anterior cortex of the ulna or pass down the intramedullary canal.5 The remaining screws must be angled radially or ulnarly to avoid the centrally placed screw.5 Resection of the proximal fragments and advancing the triceps is an option for managing comminuted fractures. Resection with triceps advancement should be considered in patients in whom the fracture fragments constitute less than 70% of the articular surface and are too comminuted for fixation. The extent of resection is dictated by the insertion of the medial collateral ligament. Before resecting the fracture fragments the elbow should be stressed to assess the integrity of the medial collateral ligament. Fracture fragments are excised with care to preserve the fibers of the triceps. The triceps tendon is reattached by using nonabsorbable sutures passed through drill holes to the proximal edge of the articular surface as described by Cabenella and Morrey1 (Fig 8). This method creates a sling for the distal humerus as well as a smooth surface for articulation. This technique, however, may decrease extensor strength secondary to a shortened moment arm.1 A recent biomechanical study by DiDonna et al9 showed an increase in triceps strength by repairing the disrupted triceps mechanism in a more posterior position, but they did not evaluate the long-term effects of this position on the articular surface.
POSTOPERATIVE CARE he elbow is splinted in approximately 60° of flexion to minimize tension on the skin. The patient is re-evaluated in 5 to 7 days. If the skin has sealed, active-assisted motion is initiated. Between exercise sessions the elbow is protected in a posterior splint. The splint is discontinued after 2 weeks when
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the staples are removed. Active motion begins at 2 weeks. Passive begins when healing appears imminent. Exercise against resistance begins when the fracture has healed. In a patient who has undergone fracture excision with triceps advancement, resistive exercises do not begin until the 12th week.
RESULTS esults with tension band wiring have been excellent. Wolfgang et al10 (displaced olecranon fractures) and Ikeda et al11 (comminuted fractures with iliac craft bone grafts) reported 98% and 100% good to excellent results, respectively. Ikeda et al11 showed that union occurred typically at 4 months with a mean range of motion between 15° and 135° in flexion and extension with 70° of pronation and 79° of supination.11 Mullett et al12 examined tension band wiring with 2 different techniques for pin placement in a biomechanical model and a clinical series. In one group pins were passed down the intramedullary canal; in the second group pins were placed in the apex of the olecranon and passed across the fracture and into the anterior cortex of the ulna.12 In the cadaveric model, the pullout strength of transcortically placed pins was significantly higher (P ⬍ .0001) compared with those placed down the intramedullary canal.12 Hutchinson et al,13 however, showed no significant difference in the pullout strength of transcortical versus intramedullary pins. In 80 patients, 35 had fractures fixed with transcortical pins and 45 had fractures fixed with intramedullary pins.13 Nine patients with transcortical pin fixation had problems with pin prominence, with 4 requiring pin removal, compared with 19 patients with intramedullary pins who had to undergo removal of their hardware.13 A recent study noted no difference between traditional tension band wiring and the figure-of-8 wiring technique described earlier at a mean follow-up of 18 years after injury.14 The re-operation rate was significantly lower (43% to 81%) in the group treated with the figure-of-8 technique.14 Complications of tension band wiring include loss of fixation, nonunion, skin breakdown, infection, olecranon bursitis, radial head subluxation, and prominent hardware. Intramedullary screw and tension band constructs have been evaluated recently in the literature. Hutchinson et al13 showed a 5-fold improvement in fracture stability over tension band and pin constructs
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FIGURE 8. Preoperative radiograph showing severe comminution of the proximal ulna after jumping 50 feet from a bridge (A). Postoperative radiograph after excision of the olecranon fragment and reinsertion of the triceps as described by Cabenella and Morrey,1 creating an articular sling (B). Six-week flexion (C) and extension (D).
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FIGURE 9. The funnel shaped intramedullary canal of the proximal ulna.15
with a 7.3-mm cancellous screw passed down the medullary canal with or without the addition of a tension band. Addition of a tension band did improve stabilization of the screw construct slightly.13 Stability, however, may be gained at the cost of malreduction if screw fixation is performed improperly. A report by Baratz and Shanahan15 in 1995 identified the funnel shape of the proximal ulna. If the screw is not long enough to reach the mouth of the funnel, the screw may toggle and allow the fracture to shift. If the screw diameter chosen is too large, the screw may not pass the isthmus (Fig 9). Teasdall et al16 reported good to excellent results in 69% of patients after plate fixation of comminuted olecranon fractures with a mean flexion of 20° to 118°. Ring et al17 obtained 88% good to excellent results after olecranon fracture and ulnohumeral dislocation with a mean arc of 14° to 127° (3 simple oblique and 14 complex fractures). Complications of plate fixation include metal prominence, loss of reduction, and malreduction. With lateral plating it can be difficult to see the posterior cortex on a lateral radiograph, confounding the surgeon’s ability to assess the quality of reduction. Nonunion has been reported in less than 10% of cases. Excision of the fractured olecranon has been met with similarly good results. McKeever and Buck8 reported that as much as 80% of the trochlear notch may be excised without compromising stability if the coronoid and distal trochlea are preserved. Other studies have shown that progressive instability occurs
when the articular surface defect exceeds 50%. Gartsman et al18 compared open reduction and internal fixation with primary excision and found no statistical difference between the 2 with regard to isometric or isokinetic strength loss. Both groups lost between 24% and 29% of extensor strength when compared with the uninjured extremity.18 Overall, the reported complication rate with excision is less than that of open reduction and internal fixation. Only 4% of patients with fragment excision had complications related to the procedure, as compared with 23% of patients who underwent open reduction. In addition, 23% of patients undergoing open reduction needed removal of their hardware. Gartsman et al18 found no relationship between the size of the excised fragment and functional outcome despite 6 of 15 patients in their series having greater than 50% of the articular surface excised.
SUMMARY ractures of the olecranon represent a spectrum of injuries with no one treatment representing the gold standard. Treatment instead is dictated by the fracture pattern and the skill of the operating surgeon. No matter the treatment, the premise of olecranon fracture fixation remains the same: anatomic reconstruction of the articular surface and restoration of the stability inherent in the pre-injury ulnohumeral joint.
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REFERENCES 1. Cabanela M, Morrey B. The elbow and its disorders. Philadelphia: WB Saunders, 2000 365-379. 2. Rush LV, Rush HL. A technique for longitudinal pin fixation of certain fractures of the ulna and of the femur. J Bone Joint Surg 1939;21:619. 3. MacAusland WR. The treatment of fractures of the olecranon by longitudinal screw or nail fixation. Ann Surg 1942;116: 293. 4. MacAusland WR Jr, Wyman ET. Fractures of the adult elbow; American Academy of Orthopedic Surgeons: instructional course lectures. St. Louis: Mosby, 1975: 169. 5. Hak DJ, Golladay GJ. Olecranon fractures: treatment options. J Am Acad Orthop Surg 2000;8:266-275. 6. Papagelopoulos PJ, Morrey BF. Treatment of nonunion of olecranon fractures. J Bone Joint Surg 1994;76B:627-635. 7. Amis AA, Miller JH. The mechanisms of elbow fractures: an investigation using impact tests in vitro. Injury 1995;26: 163-168. 8. McKeever FM, Buck RM. Fracture of the olecranon process of the ulna: treatment by excision of fragment and repair of triceps tendon. JAMA 1947;135:1. 9. DiDonna M, Fernandez J, Lim T, Hastings H, Cohen M. Partial olecranon excision: the relationship between triceps insertion site and extension strength of the elbow. J Hand Surg 2003;28A:117-122. 10. Wolfgang G, Burke F, Bush D, et al. Surgical treatment of
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