Fractures of the olecranon may occur due to a direct blow to
the elbow or from a fall onto an outstretched hand. Nondisplaced fractures have
less than 2mm of separation and are considered stable. Fracture separation will
not increase with elbow flexion. Extensor mechanism is intact and the patient
will be able to extend the elbow against gravity. Displaced fractures could be
an avulsion, oblique, transverse, comminuted, or dislocated.
Olecranon fracture dislocations can be anterior (transolecranon)
or posterior (similar to monteggia fracture dislocation). An examination will
show that the patient is unable to extend the elbow with these displaced
fracture types. A true lateral view x-ray will clearly show the olecranon
fracture. Usually, these fractures are followed by stiffness of the elbow in
about 50% of the patients. However, this does not affect the function.
The goal of treatment for olecranon fractures should be
restoration of the articular surface, preservation of the continuity of
extensor mechanisms, maintain elbow stability, and avoid stiffness of the
elbow. Nonoperative treatment is used for nondisplaced fractures and it may be
used for some displaced fractures in elderly patients (treat elbow in some
flexion with a splint). I would personally use minimally invasive techniques in
these patients unless the skin is very bad, or the fracture is very comminuted.
There are three techniques used for surgical treatment: the
tension band technique, detach olecranon and reattach triceps, and plate and
screw fixation. The tension band technique is only used for transverse fractures
with no comminution. K-wires and screws are used, and the surgeon may use
either a 6.5mm screw or Kwires for the tension band. When doing the tension
band technique, you want to engage the anterior cortex of the ulna. The surgeon
should avoid over penetration to avoid affecting the forearm rotation or
injuring the anterior interosseous nerve. The surgeon needs to be sure that the
pins are not fixing the radius and that after the operation, the patient can
perform pronation and supination of the forearm (pull the pins out slightly if
needed). The distractive force of the triceps is converted to compression force
at the articular surgace, especially when bending the elbow. The drill hole for
the K-wire should be positioned about 4-5cm from the fracture which gives
enough safe distance so that the fracture will not propagate. Place the tension
band wire through the drilled holes before application of the K wires. The
surgeon should be sure that the hook to the K-wire is posterior. Make sure that
the tension band wire is close to the bone so there is no laxity in the
fixation and instability. An intramedullary screw could be used. This screw
fixation may need a washer to capture the tension band wire. Intramedullary
6.5mm screw fixation is a reasonable option for fixation but it may need to be supplemented
with tension band wires. Never use cancellous screw alone. The tension band
technique are for transverse fractures of the olecranon. If fractures
comminution is present, change the plan of fixation.
When detaching the olecranon and reattaching the triceps, an
excision of the fracture fragment and triceps advancement is used:
- If the fracture is less than 50%
- To treat elderly patients (especially if fracture is comminuted)
- For some nonunions when the fracture is small and cannot be fixed
The surgeon must be sure that the procedure is done with the
elbow is stable. If the elbow has ligamentous instability and excision of the
fracture fragment is done, this will make the elbow very unstable. The triceps
should be attached closer to the articular surface.
Special olecranon plates are available when using a plate
and screw fixation technique. The bridge plate and screw fixation technique is
used in comminuted, Monteggia, oblique fractures extending to the coranoid, and
fracture dislocation. The plate is placed on the tension side of the olecranon
(dorsal side). Sometimes, an opening is made through the triceps and the plate
is placed against the bone, then suturing the triceps tendon over the plate to
avoid hardware prominence.
In summary, if the patient is elderly with a small,
comminuted fracture fragment less than 50% of the joint space, excise the
fragment, and reattach the triceps tendon to the olecranon. If the olecranon
fracture is transverse and proximal to the base of the coranoid process, then
use the tension band technique. Use plate fixation for all olecranon fracture
scenerios, such comminuted fractures, oblique fractures, unstable fractures, dislocation,
or fractures distal to the coranoid process. The typical exam question scenario
will discuss a comminuted fracture that should be treated with a plate. You
probably need to remove above 20% of the plate fixations due to hardware irritation.
Hardware irritation is worse with the tension band surgical treatment (may need
to remove in more than 50% of cases).
