Olecranon Fractures

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).

Isolated Fibular Fractures

Fibular fractures are usually associated with a complex injury, however they can be an isolated fracture. Complex injuries where a fibula fracture can occur include: fracture of the fibula and tibia, ankle fracture, pilon fracture, and Maisonneuve fractures.

Maisonneuve fractures involve a fracture of the proximal fibula associated with an occult injury of the ankle. Isolated fibular fractures are rare and usually the result of direct trauma. The fibula carries about 15% of the axial load and is the site of muscle attachment for the peroneus muscles and the flexor hallucis longus muscle. Check the patient who has a fibular fracture and no other fracture involving the tibia to rule out a possible Maisonneuve fracture, especially if there is no history of direct trauma to the leg. A high index of suspicion is necessary to diagnose and treat this injury. For high fibular fractures, the physician should look for signs of syndesmotic injury. Syndesmotic injury may include an unexplained increase in the medial clear space or the tibiofibular clear space is widened (should be less than 5mm). The x-ray will show the fracture to be rotational or oblique. Maisonneuve fractures require surgery to fix the syndesmosis.

Treatment will consist of reduction and fixation. It is important to determine if the injury is a Maisonneuve fracture or an isolated fibular fracture. An isolated fibular fracture will not need surgery.

Tibial Spine Fractures in Children

Tibial Spine fractures are similar to ACL injuries in adults. It occurs due to hyperextension of the knee and is commonly seen during falls from a bicycle. An injured child with a swollen knee and who has fallen from a bicycle should alert the clinician to the possibility of a tibial spine fracture. A meniscal injury may also occur, especially with the medial meniscus. The interposition of the meniscus or rotation of the fracture may prevent a closed reduction.

Tibial spine fractures are classified using the Meyers and McKeever Classification and are separated into three types. Type I classifications are nondisplaced, Type II fractures are identified as being minimally displaced with an intact posterior hinge, and Type III fractures are classified as being completely displaced.

The presentation and examination is similar to an ACL tear with immediate swelling as well as a positive Lachman’s Test or Anterior Drawer Test. An x-ray will show the fracture and a CT scan will help in planning for surgery. An MRI may be required to show a trapped or a meniscal injury.

Treatment

Treatment will consist of an aspiration of the large hematoma. Nonoperative treatment is used for Type I fractures and reducible Type II fractures; a closed reduction and immobilization in 0-20 of flexion. Surgery is performed in Type II fractures and unreducible Type II fractures. An ORIF or arthroscopic reduction and fixation will be performed. During surgery, the trapped meniscus will be moved out of the way and the surgeon will use sutures or screws for fixation. It is important for the surgeon to remember to avoid the physis.

Complication

ACL laxity is common but not clinically significant. Stiffness or arthrofibrosis occurs with surgical fixation. Growth arrest is rare.

Clay Shoveler’s Fracture

A clay shoveler’s fracture is a stable fracture through the spinous process of the vertebra C6-T1 and typically occurs at the level of C6 or C7. Clay shoveler’s fracture gets its name from the common injury suffered by men diffing deep ditches in Australia during the 1930s.

Powerful hyperflexion of the neck combined with contraction of the paraspinous muscles during shoveling is the typical mechanism of injury. The tremendous force pulls on the spinous process, producing an avulsion fracture.

The fracture is best seen on a lateral view x-ray. There will be a ghost sign on AP view x-rays—double spinal process of C6 or C7, resulting from a displaced fractured spinous process.

Stable fractures can be treated nonoperatively, utilizing a collar and physical therapy.

Jefferson Fractures

Fifty percent of patients with Jefferson fractures will have associated spine injuries. The canal is wide with a low risk of spinal cord injuries unless the transverse ligament is disrupted. It is difficult to view Jefferson Fractures on an x-ray (usually seen on the lateral side”. This fracture is considered a “Junctional Fracture” and could be missed. The classic Jefferson fracture is a burst fracture that results from an axial load. It could be a four part fracture with bilateral fractures of the anterior and posterior arch. There are variations which include two and three part fractures and incomplete formations of the posterior arch can be mistaken as a fracture.

When speaking of Jefferson fractures, it is important to be familiar with the structures that may be involved. These bony structures include: The Atlas (C1), Axis (C2), and the odontoid process. C1 and C2 are stabilized together by the transverse ligament and C1 and C2 provide a 50% of rotation of the neck. The C1 is a ring. At the upper cervical region, the spinal canal is 2.5 times larger than the cord size. The stability and treatment of Jefferson fractures depends on the integrity of the transverse ligament and the displacement of the fracture. You need to know about the important ligaments related to the Jefferson fracture. These ligaments include: the transverse ligament, the apical ligament, and the Alar ligament.

Diagnosing ligamentous injury

In order to determine a ligamentous injury, the physician will want to check the Atlanto-dens interval (A.D.I). Normally, this interval should be less than 3mm in adults and less than 5mm in children. If the ADI is between 3-5mm, this indicates an injury to the transverse ligament; the transverse ligament holds the odontoid and C1 together, alar and apical ligaments will be intact. If the A.D.I measures greater than 5mm, then there is an injury to the transverse, alar, and apical ligaments.

Fracture Types

A bony injury with the intact transverse ligament and a lateral mass displacement less than 7mm and the A.D.I is less than 3mm is considered a stable fracture. Nondisplaced fractures of this nature should be treated with a rigid orthosis. If the fracture is displaced, a halo will need to be used.

Another type of fracture can occur at C1 with a transverse ligament tear. The Atlanto-dens interval will be more than 3 mm in adults. The treatment will depend on the type of injury to the transverse ligament. With bony avulsions of the transverse ligament, the halo will need to be used cautiously. However, some surgeons prefer to do a fusion of C1 and C2. If there is an intrasubstance tear of the transverse ligament, the surgeon will perform a fusion at C1-C2. The surgeon will need to do early surgery as this is a significant injury with a risk of spinal cord compression.

In regards to “Open Mouth Views”, the normal overhang is visible during an “Open Mouth View”. If it is just a bony injury Jefferson fracture, the combined overhang will be less than 7mm and the transverse ligament is intact and it is a stable fracture. If a Jefferson fracture has a combined overhang of more than 7mm, then the transverse ligament is probably torn and there is an unstable fracture present.

Radiological Studies

A CT scan is probably the best study in diagnosing the characteristics of the bony injury. An MRI is the best study in diagnosing any associated transverse ligament injuries.

Bone Growth in Children

A Special Thanks to Miranda Ebraheim for assisting with this article

There are growth plates within the long bones which contributes to the development of the bones in children.

The growth distribution in the humerus is about 80% in the proximal and 20% in the distal area. Displaced fractures of the proximal humerus in children are usually treated without surgery.

In regards to the ulna, the growth distribution is about 80% proximal and 20% distal. Growth arrest is common in fractures involving the distal ulna and occur approximately 50% of the time. Within the radius, it is about 25% proximal and 75% distal. Fractures at the distal radius usually heals and corrects its angulation after a closed reduction. Surgery is rarely necessary. Fractures involving the growth plate of the distal radius rarely involves growth arrest.

Within the femur, the growth rate distribution is about 30% proximal and 70% distal. Fractures involving the growth plate of the distal femur may cause major growth disturbances. It is expected that a child grows 1 cm per year from the distal femur growth plate. Boys will continue to grow up until 16 years old, while girls stop growing at the age of 14.

Finally, there are the bones of the tibia and fibula. The growth distribution in the tibia is about 55% proximal and 45% distal. Within the fibula, it is about 60% proximal and 40% distal.

A growth spur occurs at the time of puberty. Puberty typically occurs in females around 8-13 years of age, and at 10-15 years of age in males. Fractures near the growth plate remodel well.