Olecranon#
- 1. Fractures of the Olecranon Moderator: Dr. Amrit Shrestha Presenter: Dr. Suman Subedi
- 2. • Bimodal distribution: Younger individuals: High-energy trauma Older individuals: Simple falls PDCT0RSE@£TS.COM Epidemiology
- 3. Anatomy • The subcutaneous position of olecranon makes it vulnerable to direct trauma.
- 4. Anatomy • The coronoid process delineates the distal border of greater sigmoid notch of ulna, which articulates with the trochlea. • This articulation allows motion only about the flexion-extension axis, thus providing intrinsic stability to the elbow joint. • “Bare area“: Transverse ridge interrupting the articular cartilage.
- 5. • Posteriorly,thetricepstendonenvelops the articular capsulebefore it inserts to the olecranon. • Fracture olecranon with displacement representsa functional disruptionof triceps mechanism, resulting in Ioss of active extension of the elbow.
- 6. Mechanismof injury • Direct: Fall on the point of elbow or direct trauma to olecranon. —Typically results in a comminuted olecranon fracture. • Indirect: Fall onto the outstretched upper extremity accompanied by a strong, sudden contraction of triceps. —Typically results in a transverse or oblique fracture. • A combination of these may produce displaced, comminuted fractures, or, in cases of extreme violence, fracture- dislocation with anterior displacement of the distal ulnar fragment and radial head.
- 7. Clinical Presentation • Patients typical present with the upper extremity supported by the contralateral hand with the elbow in relative flexion.
- 8. ° Look: —Abrasions over olecranon or hand can be indicative of the mechanism of injury. • Feel: —Palpable defect at fracture site. Move: —Inability to extend the elbow actively against gravity indicates discontinuity of triceps mechanism. ° Neurosensory evaluation: —Associated ulnar nerve injury is possible, esp. with comminuted fractures resulting from high-energy injuries. ClinicalEvaluation
- 9. Associated Injuries • Given the subcutaneous location of the olecranon, open fractures are not uncommon and have a reported rate of 2% to 30% of fractures. • Transolecranon fracture-dislocations may be associated with injuries to the coronoid process or segmental fractures of the ulna. • Posterior Monteggia lesions may be associated with coronoid process fractures (26%), radial head fractures (68%), ipsilateral upper extremity injuries (24%), and injuries to the collateral ligaments.
- 10. Radiographic Evaluation • True lateral radiograph Demonstrates: • extent of the fracture • degree of comminution • degree of articular surface involvement • displacement of the radial head, if present.
- 11. • AP view: This shouid be evaluated to exclude associated fractures or dislocations. The distal humerus may obscure osseous details of the olecranon fracture. Radiographic Evaluation
- 13. • Radiocapitellar view: This may be of help if the patient appears to have a concomitant injury or displacement of the radial head. Position the patient as for a lateral x-ray view but angle the tube 45° toward the shoulder Radiographic Evaluation
- 15. Mayo Classification • This distinguishes factorsthat have a direct influence on treatment: (1) fracture displacement, (2) comminution, & (3) ulnohumeral stability.
- 16. Schatzker classification (Based on Fracture Pattern • Transverse: Occurs at apex of sigmoid notch. Usually represents an avulsion fracture. • Transverse-impacted: A direct force leads to comminution & depression of articular surface. • Oblique: results from hyperextension injury; it begins at midpoint of sigmoid notch and runs distally. • Comminuted fractures with associated injuries: result from direct high-energy trauma; fractures of coronoid process may lead to instability. • Oblique-distal: Fractures extend distal to the coronoid & compromise elbow stability. • Fracture-dislocation: usually associated with severe trauma.
- 17. Treatment
- 18. Treatment Objectives Restoration of articular surface Restoration & preservation of elbow extensor mechanism Restoration of elbow motion and prevention of stiffness Prevention of complications
- 19. Nonoperative Treatment ° Indications: • nondisplaced fractures • displaced fractures in poorly functioning elder individuals
- 20. Nonoperative Treatment Immobilization in along arm cast with the elbow in 45-90° of flexion is favored by many authors. in reliable patients a posterior splint or orthosis with gradual initiation of ROM after 5-7 daysmay be used. Follow-up radiographs should be obtained within 5-7 days after treatment to rule out fracture displacement.
- 21. Nonoperative Treatment • Osseousunion isusually not complete until6-8weeks. • Typically, the elbow is splinted for 2 to 3 weeks and then gentle active- assisted flexion is started avoiding active extension against gravity or resistance for the first 6 weeks after injury. • At 6 weeks, the patient can begin active motion against gravity • resistive exercises started at 3 months
- 23. Operative Treatment Indications • Disruption of extensor mechanism (any displaced fracture) • Articular incongruity • Open fractures
- 24. Principles of Surgical Treatment • Rigid fixation is required. a) Plate fixation: Often the best choice, esp. when comminution is present, to maintain ulnar Iength and alignment. • A number of plate fixation techniques have been described, most involving a contoured posterior or lateral plate with, when possible, interfragmentary screws. a) In addition to internal fixation, use of an external fixation device or distraction device can be helpful or necessary to maintain joint congruity while allowing an early motion program.
- 25. Primary bonegrafting should be considered to reduce the risk of nonunion , especially in type IIIB olecranon fractures Principles of Surgical Treatment
- 26. Principles of Surgical Treatment • Total elbow arthroplasty may be considered based on the fracture pattern, bone quality, and patient age. However, the results of elbow arthroplasty following trauma are not as good as the results for patients with inflammatory arthritis.
- 27. • Restoration of articular congruity is a primary goal of reduction and fixation of olecranon fractures. 1) Type IIIB olecranon fractures are not well suited to tension band wiring because of the loss of bony stability under compression. 2) Avoid narrowing of the olecranon to coronoid distance. 3) It is usually preferable to co-apt the cortical surfaces and leave a gap in the articular surface in order to preserve a more normal articular contour. Principles of Surgical Treatment
- 28. Surgical Options Tension band wiring • Commonly used for noncomminuted, transverse olecranon fractures. • Tension band wiring in combination with 2 parallel K- wires counteracts the tensile forces & converts them to compressive forces and is indicated for avulsion-type olecranon fractures. • Various techniques have been described.
- 30. Tension band wiring Standard AO technique: • This technique uses 2 intramedullary K-wires and a figure-of-eight wire with a single knot. • To avoid proximal migration and hardware prominence, the K-wires can be directed anteriorly to engage the ulnar cortex at the base of the coronoid. a) This provides stronger fixation than the usual intramedullary placement of the K-wires. b) Some concerns have been raised over the potential for neurovascular injury with this technique, although no reports of such injuries could be found.
- 32. Surgical options Intramedullary fixation • Currently, the accessibility and ease of cannulated screw systems have made intramedullary screw fixation an attractive treatment option. • Indications for intramedullary screw placement: —Similar to tension band wiring. —Include simple, noncomminuted transverse fracture patterns.
- 33. Surgical options Intramedullary fixation • 6.5-mm cancellouslag screw fixation. • The screw must be of sufficient length to engage the distal intramedullary canal for adequate fixation. • This may be used in conjunction with tension band wiring. * * * , «g%•- "*
- 34. Surgical options Intramedullary fixation • Other forms of intrameduliary fixation have also been introduced. —Interlocking intramedullary nailing devices have been created to treat simple, transverse olecranon fractures. ° Proponents of this device have touted its “locking” capability which prevents the need for intramedullary cortical purchase necessary in traditional screw techniques.
- 35. Surgicaloptions Plate and screws • Plating has becomean increasingly important method of treating displaced olecranon fractures.
- 36. Surgical options Plate and screws • Although plate fixation can be used for virtually any type of olecranon fracture, it is ideal for the following indications: —comminuted olecranon fractures —Monteggia fracture-dislocations —olecranon fracture-dislocations • A plate should also be for oblique fractures and for fractures that extend distal to the coronoid.
- 37. Surgical options • Low-profile, locking precontoured plates are now available. • Standard manually contoured 3.5-mm limited contact DCPs are also available.
- 38. Surgical options Plate and screws • Plate fixation allows neutralization of forces across the fracture site and shouldprovide adequate rigid internal fixation to begin early motion. • Interfragmentary compression screws should be utilized when possible. • Augmentation with an external fixation or distraction device may be beneficial when elbow stability is lacking despite fracture fixation. • Articular step-off of > 2 mm hasbeen associated with poorer results.
- 39. Plate position —Most authors prefer posterior placement of the plate. —However, King etalfound no significant difference in strength of fixation between posterior or lateral placement. • Posterior plating allows a more direct approach to the proximal ulna and requires less soft tissue stripping and less effort to contour the plate. ° A laterally placed plate may be less prominent and less likely to require hardware removal. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fixation of olecranon fractures. Journal of orthopaedic trauma. 2001 Nov 1;15(8):542-8. Surgical Options Plate and screws
- 40. Hook plate One end of a 3.5-mm semitubular Plate flattened with a mallet and bendïng irons A wire cutter is used to cut away a portion of the distal plate hole The two cut ends are then bent to 90’“. The plate is then contoured to the olecranon. Two holes are placed in the proximal olecranon to ease insertion of the hooks into the fragments Cut portions of the plate are bent to 90 degrees
- 41. Surgicaloptions Fragment Excision with Triceps Advancement Recent advances in implant technology have made reconstruction of a severely comminuted olecranon fracture more feasible. • However, proximal fragment excision and triceps advancement still constitutes a viabie option in the treatment of comminuted olecranon fractures. • Excision of as much as 50% of the olecranon is effective in treating comminuted fractures.
- 42. Surgical Options Fragment Excision with Triceps Advancement • Indications: —Nonunited fractures —Extensively comminuted fractures —Fractures in elderly individuals with severe osteopenia and low functional requirements
- 43. Fragment Excision with Triceps Advancement • Pearls and Pitfalls: —Excision in patients with > 60% articular involvement yields poorer results. —When reattaching the triceps, care should be taken to bring the tendon close to the articular surface, thus improving stability by acting as a sling for the trochlea. —Patients must have an intact MCL, interosseous membrane, and DRUJ before excision, or instability will likely develop. —A major criticism of this technique is the potential for significant loss of triceps power.
- 44. Surgical options Fragment Excision with Triceps Advancement • Contraindications: —Fracture-dislocations of the elbow —Fractures of the radial head (Excision will compromise elbow stability)
- 45. TotalElbowArthroplasty • Indications: —Total elbow arthroplasty may be considered in elderly patients with significant comminution and > 60% articular involvement. Surgical Options
- 47. Postoperative management • The patient shouldbe placed in a posterior elbow splint. • With a stable repair, initiateearly ROM exercises. • In cases with severesoft tissue injury, early motion may need to be delayed until the soft tissue healing is adequate to tolerate motion.
- 48. Complications • Hardware prominence requiring removal: —The most common complication (up to 80%). —More common with tension band wiring than with plate fixation.
- 49. Complications • Hardware failure (1%—5%). • Infection (0%-6%). • Pin migration (15%). ° Ulnar neuritis (2%-12%). • Heterotopic ossification (2%-13%). ° Nonunion (5%). • Decreased ROM (Stiffness): may complicate up to 50% of cases. Loss of elbow extension is most common.
- 52. References Campbell’s operative orthopaedics 14 th edition Apley and Solomon’s System of Orthopaedics and Trauma: 10th edition Rockwood and Green Fractures in Adults -8th edition Handbook of fractures 6th edition Ota.org