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Olecranon spur
OLECRANON
SPUR
J. M. H. PATERSON AND B. A. ROPER From the Royal London Hospital, London
Full extension of the elbow is normally made possible by accommodation of the olecranon within an appropriately shaped fossa in the distal humerus. We report three cases where disability has resulted from an abnormally shaped olecranon. Journal of Hand Surgery (British and European Volume, 1993) 18B: 9-10
Case 1 A Fit 16-year-old boy with no history of upper limb trauma started work as a mechanic, subsequently presenting with discomfort in the posterior aspect of both elbows, and difficulty in lifting weights. Examination revealed that he lacked the last 30” of extension in both elbows. Radiographs showed unusually prominent olecranon processes. At operation, it was confirmed that the tips of these processes were impinging on the base of the olezranon fossa of the humerus when the elbow was 30” short of full extension. Reduction of the spur-like processes resulted in improvement in elbow extension by 20”, and abolition of the pre-operative discomfort. Case 2 Thle 13-year-old sister of the above patient presented shortly after her brother, with limitation of extension in both elbows, and mild intermittent aching in both joints. She denied any discomfort at an earlier age, and was unable to say with any certainty for how long she had been aware of her inability to straighten her elbows. She lacked 20” of extension bilaterally, and spurs of bone at the: proximal tip of the olecranon were seen on radiographs. She also underwent excision of these bony processes, gaining a moderate improvement in range of movement of about lo” on each side. Fig
Case 3 A fit 15year-old boy presented with a one-year history of inability to extend his left elbow, associated with painful “locking” in the fully extended position. In another hospital, he had previously undergone arthrography and open exploration of the joint in an attempt to locate a presumed loose body, but this had not been found. Examination confirmed loss of 20” of extension. A lateral radiograph (Fig 1) showed a long curving olecranon process, and CT scans (Fig 2) showed clearly that this spur abutted against the floor of the fossa at less than full extension. Excision of the spur (Fig 3) resulted in only a modest improvement in movement, but completely relieved the painful locking sensation.
1
Case 3. Lateral olecranon spur.
radiograph
of left elbow,
showing
a long
entity, or that it is too commonplace to warrant specific mention. Consultation with many of our colleagues leads us to suspect the former to be the case. The proximal epiphysis of the lilna appears at about the eighth year, and fuses by the 18th year (Last, 1972). The variability in size and shape of this epiphysis is well recognized (Basmajian, 1971), and in our three cases, it was the proximal tip of the epiphysis that appears to have grown to an abnormal size. The relationship between the first two cases suggests a familial factor in the aetiology, but there is no history of similar problems in the rest of the family. Although the epiphysis has been regarded by some as a traction apophysis of triceps (Basmajian, 1971), this spur of bone was found at surgery to be well anterior to the triceps tendon, and could in no way be regarded as ossification occurring within the tendon, as might be seen following
DISCUSSION The lack of any reference to this condition in the literature indicates either that it is not recognized as a pathological 9
10
THE JOURNAL OF HAND SURGERY VOL. 18B No. 1 FEBRUARY 1993
Fig 2 Case 3. Sagittal CT scan of left elbow, in maximal extension (lacking 207, showing impingement of the olecranon spur in the fossa.
an avulsion injury. Accessory ossicles around the elbow have been described (Schwartz, 1957), but not in this particular location. The aetiology therefore remains unclear. Although by the time they reached their mid-teens, all three patients had limitation of elbow extension, it was the associated discomfort that led them to seek treatment. In at least two instances this occurred after the patient started regular manual work. The possibility of an olecranon spur should be considered in a teenager presenting with elbow discomfort and decreased extension in the absence of a history of injury. Lateral radiographs made in the position of maximum extension may suggest impingement, and the diagnosis can be confirmed by a sagittal CT scan. Our experience would suggest that surgical reduction of an olecranon spur is likely to reduce the discomfort associated with elbow movement, and should also result in some increase in movement.
Fig 3 Case 3. Lateral radiograph of left elbow two years after excision of the olecranon spur.
References BASMAJIAN, J. V. Grant’s
Method ofAnatomy. 8th Edn. Baltimore, Williams and Wilkins, 1971:172. Regional and Applied. Edinburgh and London, Churchill LAST, R. 1. Anatomy: Livingstone, 1972:184. SCHWARTZ, G. S. (1957). Bilateral antecubital ossicles (fabellae cubiti) and other rare accessory bones of the elbow: With a case report. Radiology, 69:73&734.
Accepted: 15April 1992 J. Mark H. Paterson, Whitechapel, London
FRCS, Consultant El 1BB.
0 1993 The British Society
for Surgery
Orthopaedic
of the Hand
Surgeon,
The Royal
London
Hospital,
SPUR
J. M. H. PATERSON AND B. A. ROPER From the Royal London Hospital, London
Full extension of the elbow is normally made possible by accommodation of the olecranon within an appropriately shaped fossa in the distal humerus. We report three cases where disability has resulted from an abnormally shaped olecranon. Journal of Hand Surgery (British and European Volume, 1993) 18B: 9-10
Case 1 A Fit 16-year-old boy with no history of upper limb trauma started work as a mechanic, subsequently presenting with discomfort in the posterior aspect of both elbows, and difficulty in lifting weights. Examination revealed that he lacked the last 30” of extension in both elbows. Radiographs showed unusually prominent olecranon processes. At operation, it was confirmed that the tips of these processes were impinging on the base of the olezranon fossa of the humerus when the elbow was 30” short of full extension. Reduction of the spur-like processes resulted in improvement in elbow extension by 20”, and abolition of the pre-operative discomfort. Case 2 Thle 13-year-old sister of the above patient presented shortly after her brother, with limitation of extension in both elbows, and mild intermittent aching in both joints. She denied any discomfort at an earlier age, and was unable to say with any certainty for how long she had been aware of her inability to straighten her elbows. She lacked 20” of extension bilaterally, and spurs of bone at the: proximal tip of the olecranon were seen on radiographs. She also underwent excision of these bony processes, gaining a moderate improvement in range of movement of about lo” on each side. Fig
Case 3 A fit 15year-old boy presented with a one-year history of inability to extend his left elbow, associated with painful “locking” in the fully extended position. In another hospital, he had previously undergone arthrography and open exploration of the joint in an attempt to locate a presumed loose body, but this had not been found. Examination confirmed loss of 20” of extension. A lateral radiograph (Fig 1) showed a long curving olecranon process, and CT scans (Fig 2) showed clearly that this spur abutted against the floor of the fossa at less than full extension. Excision of the spur (Fig 3) resulted in only a modest improvement in movement, but completely relieved the painful locking sensation.
1
Case 3. Lateral olecranon spur.
radiograph
of left elbow,
showing
a long
entity, or that it is too commonplace to warrant specific mention. Consultation with many of our colleagues leads us to suspect the former to be the case. The proximal epiphysis of the lilna appears at about the eighth year, and fuses by the 18th year (Last, 1972). The variability in size and shape of this epiphysis is well recognized (Basmajian, 1971), and in our three cases, it was the proximal tip of the epiphysis that appears to have grown to an abnormal size. The relationship between the first two cases suggests a familial factor in the aetiology, but there is no history of similar problems in the rest of the family. Although the epiphysis has been regarded by some as a traction apophysis of triceps (Basmajian, 1971), this spur of bone was found at surgery to be well anterior to the triceps tendon, and could in no way be regarded as ossification occurring within the tendon, as might be seen following
DISCUSSION The lack of any reference to this condition in the literature indicates either that it is not recognized as a pathological 9
10
THE JOURNAL OF HAND SURGERY VOL. 18B No. 1 FEBRUARY 1993
Fig 2 Case 3. Sagittal CT scan of left elbow, in maximal extension (lacking 207, showing impingement of the olecranon spur in the fossa.
an avulsion injury. Accessory ossicles around the elbow have been described (Schwartz, 1957), but not in this particular location. The aetiology therefore remains unclear. Although by the time they reached their mid-teens, all three patients had limitation of elbow extension, it was the associated discomfort that led them to seek treatment. In at least two instances this occurred after the patient started regular manual work. The possibility of an olecranon spur should be considered in a teenager presenting with elbow discomfort and decreased extension in the absence of a history of injury. Lateral radiographs made in the position of maximum extension may suggest impingement, and the diagnosis can be confirmed by a sagittal CT scan. Our experience would suggest that surgical reduction of an olecranon spur is likely to reduce the discomfort associated with elbow movement, and should also result in some increase in movement.
Fig 3 Case 3. Lateral radiograph of left elbow two years after excision of the olecranon spur.
References BASMAJIAN, J. V. Grant’s
Method ofAnatomy. 8th Edn. Baltimore, Williams and Wilkins, 1971:172. Regional and Applied. Edinburgh and London, Churchill LAST, R. 1. Anatomy: Livingstone, 1972:184. SCHWARTZ, G. S. (1957). Bilateral antecubital ossicles (fabellae cubiti) and other rare accessory bones of the elbow: With a case report. Radiology, 69:73&734.
Accepted: 15April 1992 J. Mark H. Paterson, Whitechapel, London
FRCS, Consultant El 1BB.
0 1993 The British Society
for Surgery
Orthopaedic
of the Hand
Surgeon,
The Royal
London
Hospital,