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Olecranon Fractures

Definition

Minimally Displaced Fracture of the Olecranon
Minimally Displaced Fracture of the Olecranon
  • Fracture of the Olecranon

Incidence

Classification

Types of Olecranon Fractures

  1. undisplaced
  2. displaced
    1. avulsion
    2. transverse + oblique
    3. comminuted
    4. fracture / dislocations

Mayo classification

Mayo Classification of Olecranon Fractures
Type Description
I Undisplaced
II Displaced (> 3 mm) stable
III

Displaced (> 3 mm) unstable

  • Subgroup A - Non-comminuted
  • Subgroup B - Comminuted

Aetiology

  • Direct trauma

Pathology

History

  • Mechanism of Injury

Examination

  • Look
    • Bruising
    • Swelling
  • Move
    • It patient in minimal pain, ask to extend elbow to check extensor mechanism
  • Feel
  • Special Tests
    • Neurological Examination
      • Ulnar Nerve

Investigations

Xrays

  • AP, Lateral
  • Usually enough information for decision making

CT Scan

  • Usually unnecessary
  • Helpful to check for associated injuries
    • further fractures around the elbow

Treatment

According to Mayo Classification

Mayo Classification of Olecranon Fractures
Type Treatment
Type I A & B splint symptomatically
Type II a TBW or AO cancellous screw
Type II b Plate fixation (can excise fragment & advance triceps in older group)
Type IIIa Rigid plates
Type IIIb
  • Plates vs external fixateur

Undisplaced Fractures in Adults

  • To be considered nondisplaced & stable
    • must be displaced less than 2 mm
    • and exhibit no change in position with gentle flexion to 90° or with extension against gravity
  • Immobilize
    • long-arm cast for 3-4 weeks
    • elbow at 90°
    • full extension not recommended because stiffness is likely, & if the fracture requires full extension for reduction it should be treated operatively
  • Followed by protected range of motion exercises
    • avoiding flexion past 90° until bone healing is complete radiographically usually around 6 to 8 weeks
  • Elderly patient
    • stiffness is a concern
    • ROM may be initiated earlier than 3 weeks

Displaced Fractures in Adults

Tension Band Wire of Olecranon Fracture
Tension Band Wire of Olecranon Fracture
  • TBW with double twist
    • strongest method of internal fixation for these fractures
    • dorsal plate (positioned in tension) is also effective

Excision of Olecranon Fractures

  • Requirements
    • Intact coronoid & distal semilunar notch
    • Intact collaterals
  • Technique
    • Excision of proximal fragment
    • Retention of collaterals
    • Suture triceps tendon to remaining bone flush with articular surface
  • Can excise up to 80% of olecranon process
  • Indications
    • old ununited fractures
    • fractures with extensive comminution that aren't amenable to ORIF
    • fractures in the elderly
    • nonarticular fractures
    • open fractures in which the soft tissues are of questionable viability
  • Good results have been reported with excision of up to 50% of the olecranon & reattachment of the triceps.

Complications

  • Stiffness
    • reduced ROM - up to 50% have some loss of ROM - only ~ 3% have functional loss from this
  • Nonunion / Malunion
    • Nonunion - ~5%
      • If high demand patient - ORIF/ BG
      • If low demand patient - may not need to do anything. Can excise the olecranon fragment with very good results ( as long as the coronoid & anterior soft tissues are intact to provide stability)
  • Ulnar nerve neuritis
  • Post-traumatic Osteoarthritis
    • rare as is a non wght bearing joint

Prognosis

  • After treatment patients typically lose around 10° of extension & 5° of flexion
  • Hardware is painful in around 50%, but needs to be removed in around half of these
  • Ulnar nerve neuritis & heterotopic ossification are relatively common (up to 2-13%)