Fracture of the olecranon

FRACTURE

OF THE OLECRANON* W.

M.D.

RUSSEL MACAUSLAND, BOSTON

F

ROM an observation of the end rest&s of many fractures of the oIecranon conservative treated by methods, I have come to believe that by far the greater proportion of these Iesions can be treated more satisfactoriIy by open operation. Conservative treatment often

the transverse and cornminuted types. in open fractures, in which joint sepsis may occur, operation is out of the question unIess the patient is seen very earIy. As a rule, the result in such cases is ankylosis, for which, after a period of one and onehaIf to two years, arthropIasty may be

FIG. I. J. C. Fracture of the oIecranon showing eIongation and consequent limitation of extension.

necessitates a Iong period of convaIescence which may be obviated by operative procedure. Many cases treated by the weIIknown method of retention of the arm in extension do not obtain a good functiona resuIt, particuIarIy as to extension. Surgica1 interference assures good motion and safeguards the power of extension. In deaIing with a bone so near the surface as the oIecranon there is IittIe operative risk. TYPES

OF

FRACTURES

Fractures of the oIecranon are of three different types : the transverse fracture, the cornminuted, and the open. The transverse type is the most common, and the cornminuted and open fractures are seen 0nIy 0ccasionaIIy. In discussing the advantages of open operation in the treatment of fractures of the oIecranon, we are concerned mainIy with * From the MacAusIand

398

FIG.

z.

Suture

of fractured oIecranon, Author’s technique.

right

arm.

performed with the expectation of restoring good function to the joint. The transverse type is usuaIIy due to direct vioIence. The fracture enters the eIbow joint, which becomes HIed with bIood. Both the transverse and cornminuted fractures may be closed or they may be compIicated by displacement of the fragments. The extent of the separation is determined by the severity of the Iateral Orthopedic

CIinics.

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MacAusIand-Fracture

tear of the triceps insertion overIying the seat of fracture. In severe cases the separation may amount to one-half inch or more. In cases of wide dispIacement, a suIcus frequently is found between the tip and the body of the oIecranon. ETIOLOGY

The majority of fractures of the olecranon are due to direct vioIence, a fall upon the elbow being the most frequent cause. In 70 out of 138 fractures of the

FIG. 3.

.I. C. End

result. Suture

of Olecranon

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Journnl of Surgerg

four hours of the accident. usuaIIy heId sIightIy flexed.

The

399

arm

is

DIAGNOSIS

The diagnosis is readiIy made from the history of the injury, the symptoms of pain, sweIIing, Iocal tenderness, crepitus, loss of the use of the lower arm, a faIse point of motion, and from the presence of a sulcus in the oIecranon. Roentgenographic examination will corroborate the clinica findings. In making a roentgeno-

of olecranon.

oIecranon reported by EIiason,* the cause was a faI1 upon the eIbow. In some cases the break is due to indirect vioIence, such as contraction of the triceps tendon. When caused by muscIe puI1, the fracture occurs at the tip of the oIecranon in the region of the epiphysea1 Iine; it does not extend compIeteIy through the joint but represents a smaI1 piece of cortica1 bone torn off at the triceps insertion. StiII other fractures may be due to a combination of direct and indirect vioIence. Fractures of the oIecranon are more common in aduIts than in chiIdren, and men are affected more frequentIy than women. SYMPTOMS

The common symptoms are pain in the eIbow, sweIIing, tenderness, crepitus, inabiIity to extend the forearm forcibIy, and effusion into the elbow joint. Ecchymosis aImost invariabIy is seen within twenty* ELIASON. Fractures of the Humerus, UIna. New York, 1925.

Radius and

Frc. 4. R. M. End resuIt. Suture

of olecranon.

diagnosis in young patients, Roberts and Kelly* warn against mistaking a partiaI1y ossified process of a norma epiphyseal Iine of a fracture Iine. Speedi_ beIieves that in fresh injuries there is sufficient ground for the diagnosis of fracture, if the power of active extension is diminished and if there is sweIIing and a persistent point of tenderness when the process is examined bv digita or pencil-end pressure. Fractures of the olecranon must be differentiated from fractures of the Iower graphic

* ROBERTS and

KELLY. Treatise on Fractures. PhiIa.

Ed. 2., 1921. ~SPEED. A Textbook Phila., 19x6.

of Fractures and Dislocation.

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end of the humerus tion of the elbow.

and backward

disIoca-

PROGNOSIS

The prognosis in simpIe transverse and cornminuted fractures without dispIacement treated ConservativeIy is good. In many cases, however, the power of flexion returns very sIowIy. If treated by operative methods, the majority of these simpIe

FIG. 5. L. M.

of OIecrsnon cornminuted fracture treated conservatively.

with

dispIacement

Case I. J. C. This patient feI1 and injured his eIbow, sustaining a cornminuted fracture of the olecranon with about one-half inch separation. His physician was advised to operate, but did not do so. The arm was put in pIaster at a right angle. Eight months after the accident, there was still 45 degrees Iimitation in extension. (Fig. I.)

End result.

transverse or cornminuted fractures recover motion more fulIy and in a shorter period of time. Th,e prognosis in fractures with wide dispIacement, in particuIar comminuted fractures with separation of the fragments, when treated conservativeIy, is Iess favorable. FIexion is somewhat Iimited and extension is never compIete. The fina Iimitation in extension is proportionate to the extent of the dispIacement of the fragments. The foIIowing case iIIustrates the resuIt commonIy obtained in a case of

APRIL, 1928

Suture of olecranon.

When fractures with dispIacement are treated by operation, the recovery of fuII extension and ffexion is assured. TREATMENT

In the treatment of fractures of the oIecranon, a perfect anatomica reposition of the fragments is essentia1 to success. OnIy when the fragments are properly approximated does soIid bony union take pIace. In fractures not properIy approximated, a fibrous union occurs which causes Iimitation of motion.

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MacAusIand-Fracture

WhiIe it is possibIe under conservative treatment to obtain good soIid union in simple transverse fractures and in some cornminuted types with moderate dispIacement of the fragments, the convaIescence under such treatment is so sIow that weeks or even months may eIapse before The recovery of function is compIete. normal flexion in particuIar is sIow. This proIonged convalescence is due to the fact

of OIecranon

A meric.?n Journnl of Surgery

40 1

In the treatment of fractures with wide pIacement, perfect anatomical reposition cannot be established by the conventiona method of treatment. Hence, a fibrous and not a soIid bony union is obtained in cases which have not been properIy approximated, or in which a superficia1 suppuration has existed, or in cornminuted fractures in which a fragment has become lost. The degree of solidity varies according to

FIG. 6. W. F. Fracture of oIecranon. Before operation.

thatithe oIecranon, like the pateIIa, is a bone which unites very sIowIy. Long immobilization is required to obtain perfect union. FrequentIy gentIe manipulations under an anesthetic are necessary. Inasmuch as operative interference in these cases wouId materiaIIy shorten the period of convaIescence and at the same time ensure a soIid bony union, I beIieve that the majority of such Iesions shouId be treated surgicaIIy.

the amount of separation of the fragments. The ffexion in these cases may be affected onIy sIightIy, but the extension is Iimited in proportion to the extent of the dispIacement of the fragments. Movement is further Iimited by the formation of excessive caIIus which usuaIIy deveIops around comminutions in cases of malposition, comminution, and unapproximated fragments. Fractures with wide dispIacement, partic-

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uIarIy cornminuted fractures with displacement, are treated most satisfactoriIy by open operation. Perfect anatomica reposition can be estabIished by operative interference, and a good bony union wiI1 result. The restoration of compIete function is assured. In cases in which fibrous union has occurred, the treatment depends upon the

of OIecranon

degree of soIidity of the union and upon the time at which the case is seen. When the fibrous union is weak, excision of the tissue and suture of the fragments is aIways indicated. Otherwise, the arm wiII aIways be weak. In earIy cases of fibrous union, remova of the fibrous tissues and approximation of the fragments is aIways to be considered with the view of providing the arm with function and strength for Iater Iife. In oId-standing fibrous cases, operation

1928

is indicated onIy if function wiI1 be improved by the use of this measure. Operation in such cases is not entireIy satisfactory, and if the existing function is adequate, a firm fibrous union is to be preferred to subjecting the patient to a surgical risk. The indications for operation, as set forth above, may be summarized as foIIows : SurgicaI interference is indicated in (I) simpIe fracture with wide separation, (2) comminuted fracture with separation and spread, (3) cases in which earIy function is of importance, and (4) Iate cases in which function can be improved. SweIIing is an indication rather than a contraindication for immediate operation in recent cases. AUTHOR’S

FIG. 7. W. F. End resuIt after suture of olecranon.

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TECHNIQUE

The operation is done under a tourniquet (Fig. 2). FoIIowing the usua1 twoa curved IongitudinaI day preparation, incision is made over the body of the oIecranon near the attachment of the triceps tendon. The skin and fascia are dissected IateraIIy to give proper exposure. If there is any dispIacement, the fracture cavity is carefuIIy wiped out without disturbing the fragments, and any smaI1 spicules of bone which wouId interfere with a perfect anatomica reduction and a11 bIood cIots are removed. A IateraI driI1 hoIe is then made through the body of the oIecranon, and at the point of attachment of the triceps tendon the fragments are brought into absoIute approximation and retained by chromic suture. After such a reduction, the reposition is perfect and onIy a crack is seen in the surface of the uIna. The periosteum at the Iine of fracture is sutured. Any tear in the IateraI capsuIe or triceps tendon expansion which may have been ruptured at the time of the accident, is Iikewise sutured. The arm is then aIIowed to ffex to the point of suture tension. The amount of flexion obtained, when the operation is carried out earIy and carefuIIy, is often beyond a right angIe. No effort should be made to force the arm

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into acute flexion, but the weight of the Limb itseIf should be the deciding factor in determining the amount of ffexion obtainable with the given suture in place. The skin is cIosed with continuous catgut and the arm is maintained in suture, ffexion by adhesive strapping and a SurgicaI convaIescence VeIpeau bandage. LateraI roentgenograms is uneventfu1.

FIG. 8. F. S. Before operation.

Fracture of oIecranon.

shouId be taken within a day or two. It is possibIe to start passive motion in ten days or two weeks. The motion should never be forced but should be very gentle and cause no pain. Some surgeons recommend the use of wire sutures, but in the opinion of the writer, these are to be discouraged because of the danger of infection. When meta is in contact with bone, suppuration often deveIops late, as is seen when buIIets are Iodged in bone. Absorbable sutures are as

of Olecranon

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efficient as wire and Iess dangerous. If chromic catgut sutures are used, they will Iast for three or four weeks, and at the end of that time, firm fibrous union will have taken pIace and there wiIl be the beginning of a bony union. Washing the joint, a process advocated by some surgeons, is to be discouraged, for it involves an unnecessary risk of infection.

FIG. 9. F. S. End

resuIt. Suture

of oIecranon.

The use of metallic pIates aIso is contraindicated, as the introduction of foreign material in a joint fracture deIays norma union and involves danger of sepsis. Suture of the fibroperiosteum and the triceps fascia is not sufficient. If open operation is performed, the joint should be and the fragments properIy exposed approximated. In addition the IateraI expansions of the triceps shouId be exposed and the transverse tear in these structures repaired.

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of OIecranon

In gunshot fractures with a Ioss of bone continuity, a bone graft may be considered after heahng has taken pIace. FioIIe* reported good resuIts foIIowing the remova of the oIecranon in a case of gunshot fracture. In ununited fractures of the oIecranon

process, Albee” uses an inIay graft, which is heId in pIace by kangaroo tendon, a &ding graft, or a tibia1 graft. BeIow, the writer reports a series of cases of fractures of the oIecranon treated by suture.

FRACTURES OF THE OLECRANON TREATED BY SUTURE

Case

J.C .

..____.....

i

.

Fracture of Ieft olecranon with considerable sweIIing, ecchymosis, and tenderness.

z days

3 weeks

16

Fracture of oIecranon with $5 in. separation and fracture of external condyIe.

4 days

6 weeks

In 6 weeks, extension to Flexion to go’ ~ i%Bing or tendern:: Final resuIt perfect. (See Fig. 4.)

18

Fracture cranon.

of

4 weeks

In 8 months, motion 45”;to

Fracture cranon.

of

I

R. M..

_.

L. M..

G.P .._.._.,,.__,

W. F.

~

ResuIts

Type

Age

..

16

right

In 8 months, rotations and flexion normaI. Extension to 160”. FinaI result perfect. (See Fig. 3.)

._

oIe-

.,........

180”. Final resuIt perfect. (See Fig. 5.) right

ole-

235 or 3

weeks

About z months Iater, motion within 15” of norma1. FinaI resuIt perfect.

735 weeks

In 3 months, elbow couId go within a few degrees of compIete extension. FinaI resuIt perfect. (See Figs. 6 and 7.)

5

weeks

I,4 days

1Simple.

I

BIBLIOGRAPHY Bull. et m&m. Sot. Anat. de Paris, 1924, xciii, 376. CHALIER and VERGNORY.Lyon cbir., 1920, xvii, 344. COTTON. DisIocations and Joint Fractures, PhiIa., 1924. DAVISON and %ITH. Autoplastic Bone Surgery, PhiIa., 1916. D~LORE, COMTE, and LABRY. Lyon mkd., 1924, cxxxvi, 689. GROVES. In Choyce, A System of Surgery, iii, 825, New York, 1923. GROVES. On modern Methods of Treating Fractures, London, 1921. BANZET.

*FIOLLE. Marseille mid., 1918, Iv, 241.

LECLERC. Lyon cbir., 1922, xix, 425. MOUCHET. Presse mid., 1922, xxx, 504. OLIVIER. Presse mCd., 1923, xxxi, 64; 268. PRESTON. Fractures and DisIocations, St. Louis, 1915. ROCHER. Gaz. bebd. d. SC. mkd. de Bordeaux, 1922, XIiii, 153. SCUDDER. The

Treatment

of Fractures,

Ed. IO, Phila.,

1926. STIMSON. A PracticaI Treatise on Fractures and Dislocations, PhiIa., Ed. 8, 1917. WILSON and COCHRANE. Fractures and DisIocations, Phila., 1925. *ALBEE. Bone-graft

Surgery, PhiIa., rgr5.