Fractures of the olecranon in children

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Fractures of the olecranon in children J. G. Matthews King Edward VII Orthopaedic Hospital, Sheffield Summary

Forty-nine fractures of the olecranon in children have been followed for up to 3 years after the injury. A notably large number (22) sustained associated injuries or complications which delayed or prevented a satisfactory outcome. Just over half of the whole series (27) achieved a satisfactory return to normal use within 12 weeks. Methods of treatment and a number of important complications are discussed. FRACTURE of the olecranon in childhood is said to be a common injury, but has received little attention in the literature and most text books of

paediatric fractures. A review of unselected cases seen over the past five years in Sheffield Children’s Hospital suggests that this fracture is commonly subject to a number of hazards and complications not previously emphasized. PATIENTS

AND

METHODS

Forty-nine out of 56 consecutive recorded cases of fracture of the olecranon have been traced between January 1973 and December 1977.

These 49 patients have either been followed up personally by the author or the relevant information has been extracted from the clinical notes. Three cases defaulted during follow-up. There were 22 girls and 26 boys (one boy fractured both olecranons at different times) aged between 1 year 10 months and 13 years 9 months. Seventeen fractures occurred on the right and 32 on the left. The sole criterion for inclusion in the series was radiological evidence of a fracture of the olecranon irrespective of associated injury. When possible the patients were followed up in fracture clinics up to the time of discharge, and all available radiographs were scrutinized. A record of initial clinical and radiological assessment was made, together with a note of treatment instituted and progress to discharge, where applicable. Recovery was assessed in terms of extension lag, the triceps’ power, residual deformity, neurovascular deficit and a note was made of the time of return to normal

I. Undisplaced olecranon fracture of the left ulna in a child of 2 years which was treated in a full-arm plaster cast for one week.

Fig.

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Fig. 2. Fracture of the right olecranon involving the coronoid process and radial head in a child of 7 years which was treated in a collar and cuff for three weeks.

The fractures fell into four categories: group I: simple undisplaced fracture with no associated injury; group II: simple undisplaced (or angulated) fracture associated with fracture (or fracture-dislocation) of the radial head or neck or the distal end of the humerus; group III: simple undisplaced fracture with closed soft tissue injury; group IV: displaced fracture (with more than 4 mm step or separation of fragments). There were no open fractures recorded in the series. Treatment

Fig. 3. Displaced fracture of the right olecranon associated with a supracondylar fracture of the humerus in a child of 5 years. This was treated by open reduction and suture with collar and cuff immobilization for one month. in all cases. Anteroposterior and lateral radiography was carried out on all patients at the initial visit (Fig. l), and follow-up films obtained where necessary. use

RESULTS

Fractures of the olecranon represented approximately 4 per cent of fractures and dislocations at the elbow joint seen during the relevant period.

Eighteen of the 26 cases in group I were treated by means of a collar and cuff sling with the elbow held at a right angle for 2 weeks, occasionally longer (mean 2.5 weeks). The remaining 8 cases were treated in a full-arm plaster cast or backslab for the same mean period for no clear indication other than the preference ofthe clinician. Four of the 11 cases in group II were treated in plaster, including 2 cases treated by closed reduction (Fig. 2). The remaining 7 were treated in collars and cuffs. The mean period of immobilization for both methods was three weeks. Group III includes cases sustaining neurovascular damage or showing prolonged or excessive local swelling or bruising, indicative of capsular or ligamentous injury. One of the 5 cases was treated in plaster (for one week), the other 4 being treated in collars and cuffs for a mean of three weeks. In the 7 cases of displaced fracture in group IV (Figs, 3 and 4) a separation of the fragments producing a gap or a step at the joint surface of

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Fig. 4. Displaced fracture of the let? olecranon associated with fracture of the radial neck in a child of 10 years. This was treated by open reduction and suture with plaster immobilization for three weeks, and collar and cuff for a further three weeks. Table I. Results of cases treated by closed methods Plaster-o f-Paris

Collar and cuff Fracture

type I II III Total

(2-3 weeks) No. of No. satis. cases

No.(Zfm3 weeks)

cases

No. satis.

16 7 4 27

16 3

Three defaulters were required operation.

1 20 lost

8 3

4

1

:,

12

5

to follow-up;

7 cases

tion at the elbow was I2 weeks, after which the patient was normally discharged from followup. Only just over half (27) of the cases fell into this category and were considered satisfactory. All the others (22) followed to discharge, except one, took at least twice this time to recover; the remaining cases are still under supervision and 3 of these have been followed up for over 3 years. These are considered unsatisfactory. The results of those cases treated by closed methods are shown in Table I. Complications Dislocation

of the head of the radius

Two cases sustained this associated injury.

4 mm or more was considered

Case 1 A boy aged 5 years 8 months fell about six feet from a

Recovery The usual period needed to regain a full and painless range of movement and normal func-

climbing frame, injuring the right elbow. The mechanism of injury was not clear. He was seen in the casualty department the same day when radiography (Fig. 5) confirmed a longitudinal comminuted fracture of the olecranon with lateral dislocation of the radial head. The dislocation went unnoticed and the injury was treated in a collar and cuff without reduction of the dislocation. Diagnosis was not made until five weeks later despite regular outpatient attendance. The patient was by then rapidly regaining pain-free function, and operation at this stage was felt to be contraindicated. Three years after injury he has a full range of movement at the elbow, but the radial head remains unstable. Case 2 A boy aged 5 years IO months fell about three feet

an indication for operation, especially if the triceps was ruptured or closed reduction had proved impossible. The fragments were reduced under direct vision and immobilized by suture: cat-gut (4 cases), wire tension banding (2 cases) or nonabsorbable atraumatic sutures (I case) were used on the preference of the surgeon. Five cases were immobilized after operation in plaster, the other 2 in collars and cuffs. When cat-gut was used, a mean period of 5 weeks immobilization followed, compared with 2.5 weeks for the others.

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Fig. 5. Fracture of the right olecranon in a child of 6 years with associated lateral dislocation of the radial head which was treated without reduction in collar and cuff for five weeks. Missed diagnosis.

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Fig. 6. Fracture of the left olecranon in a child of 6 years with associated anterior dislocation of the radial head. Reduction in flexion/supination and treated in a full-arm plaster cast for three weeks.

flexion and full supination for 3 weeks. When movement was begun the radial head appeared stable and at five weeks he lacked only 30 ’ extension with almost full stable pronation. This patient has defaulted from follow-up and is not included in Table I.

Peripheral nerve injury One patient had clinical evidence of neurapraxia of the ulnar nerve on first examination. Although he recovered a full range of movement at the elbow and full power of the small muscles by 12 weeks, he still had an ulnar distribution of paraesthesia when last seen 3.5 months after injury.

Fig. 7. Volkmann’s ischaemic contracture in a child of 2 years following treatment in a full-arm plaster cast for an undisplaced crack fracture. Radiograph shown in Fig. I. from a chest of drawers, injuring the left elbow. The IeR arm was apparently extended behind him as he fell. He was seen in the casualty department the same day when he had extreme pain on attempted pronation and supination. Radiography (Fig. 6) confirmed a greenstick fracture of the olecranon with lateral angulation of the proximal fragment, together with anterior dislocation of the radial head. He was treated by closed manipulation and a full arm cast at 90’

Volkmann’s ischaemic contracture One patient developed Volkmann’s ischaemic contracture of the forearm (Fig. 7) following treatment of an undisplaced closed fracture of the olecranon (Fig. I) by a full-arm plaster cast. Despite admission for overnight elevation and subsequent operative decompression with evacuation of blood clot from the volar aspect of the forearm, the patient had developed the full clinical picture of ischaemic contracture by 8 weeks after the injury. Non-union One patient sustained a displaced closed fracture and was treated by open reduction, cat-gut suture and plaster immobilization for one month. The fracture failed to unite and a radiograph taken several weeks later (Fig. 8), following further trauma, showed clear evidence of non-union with separation of the fragments. This patient had power 4 extension with IO Dlag 12 months after injury.

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plaster had an associated injury, as did 36 per cent of the cases treated in collars and cuffs. The mean length of time spent immobilized by either method was the same, and it appears that neither duration of treatment nor the presence of associated injury is responsible for the slower return to normal in the plaster-treated cases. This, together with its association with one ischaemic catastrophe, would seem to contraindicate the routine use of plaster immobilization. Open reduction

Rang (1974) suggests that tension banding with early mobilization is the treatment of choice, although our series is too small to confirm or refute this conclusion. Associated

Fig. 8. Non-union in a displaced fracture of the left olecranon in a child of 7 years following open reduction and repair with cat-gut. Radiograph months after injury.

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DISCUSSION Incidence

Although fracture of the olecranon is said to be common, a figure of 4 per cent of fractures and dislocations at the elbow represents only one case per month at Sheffield Children’s Hospital. Associated fractures and dislocations occur in about 20 per cent of cases and should therefore be sought in all cases. Mechanism of injury In most cases it is impossible

to determine the mode of injury. However, undisplaced crack fractures and separated fractures are usually the result of a direct blow on the flexed elbow, while longitudinal splits and angulated fractures appear to be produced by hyperextension-rotation injuries, especially when associated with fractures or dislocations of the radial head (Figs. 2, 3 and 6) (Hume, 1957; Theodorou, 1969). Immobilization

In the 42 cases initially treated by closed methods, the presence of associated injury did not influence the choice between a sling and plaster; 40 per cent of elbows immobilized in

injury

The presence of associated bony or soft tissue injury in a case which can be treated conservatively is not only common but is predictably prejudicial to early recovery (66 per cent of affected cases were delayed). Soft tissue injury appears to carry a somewhat worse prognosis than bony injury. Only 15 cases (all male) with associated dislocation of the head of the radius have been reported in the literature (Theodorou, 1969) and the two cases in this series suggest that this injury may not be so rare as has been thought (Beddow and Corkery, 1960; Wright, 1963).

CONCLUSION

Fracture of the olecranon in a child is often only part of a complex injury to the bone and soft tissues around the elbow. Uncomplicated recovery within 12 weeks using the simplest treatment occurred in only just over half of this series; evidence of more extensive damage should always be sought. When associated injury is diagnosed from the onset, some delay in regaining normal function can be anticipated, although closed soft tissue damage, undisplaced fractures of the radial head and neck and closed peripheral nerve injury can be treated expectantly in most cases without detriment. Collar and cuff immobilization for 2-3 weeks is the best conservative regimen, plaster fixation being reserved for special cases. Open reduction is indicated in displaced fractures and the use of non-absorbable material with early mobilization is the treatment of choice.

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Acknowledgements My thanks are due to Mr R. H. Baker, Mr D. K.

Hume A. C. (1957)Anterior dislocation of the head of the radius associated with undisplaced fracture of the olecranon in children. J. Bone Joint Surg. 39B, 508. Rang M. (1974) Children’s Fractures. Philadelphia, Lippincott. Theodorou S. D. (1969) Dislocation of the head of the radius associated with fracture of the upper end of the ulna in children. J. Bone Joint Surg. 51B, 700. Wright P. R. (1963) Greenstick fracture of the upper end of the ulna with dislocation of the radiohumeral joint or displacement of the superior radial epiphysis. J. Bone Joint Surg. 45B, 727.

Evans, Mr W. J. W. Sharrard and Mr F. W. Taylor for permission to review their patients, to Mr W. J. W. Sharrard and Professor T. Duckworth for their suggestions and encouragement and to Mrs M. Price, Mrs S. E. Allwood and Mrs M. E. Chapman for secretarial assistance. REFERENCES

Beddow F. H. and Corkery P. H. (1960) Lateral dislocation of the radio-humeral joint with greenstick fracture of the upper end of ulna. J. Bone Joint Surg. 42B, 782. Requesfsforreprinlsshouldbe addressedla: Mr

J. G. Matthews, Senior Orthopaedic Registrar, King Edward VII Orthopaedic

Hospital, SheIkId.

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