ReviewOlecranon fractures
Introduction
Olecranon fractures comprise approximately 10% of all fractures around the elbow36 and a diverse array of treatment options have continued to evolve for the management of this common trauma presentation. Olecranon fractures vary in their complexity from relatively straightforward transverse fractures to comminuted and unstable configurations. The spectrum of management options available is a consequence of the fact that no particular mode of treatment can be universally applied to the diverse array of fracture patterns encountered. To appropriately manage these fractures, the surgeon needs to have a good understanding of the anatomy, available treatment options and potential complications.
Section snippets
Anatomy
The elbow is a complex hinge joint capable of a flexion arc of 0–150°. The joint is stabilised by a number of factors including the anterior coronoid process and posterior olecranon process which resist the translational forces of the humerus on the ulna. Resistance to valgus stress is provided by the anterior band of the ulnar collateral ligament and the radial head. Varus stress is countered by the lateral collateral ligament complex.
The articular surfaces are lined with hyaline cartilage.
Mechanism of injury
Olecranon fractures can occur as a result of either direct or indirect trauma. The subcutaneous location of the olecranon makes it susceptible to injury by direct trauma. Laboratory studies have shown that the degree of elbow flexion at the time of direct trauma affects the subsequent likely fracture pattern. Radial head and coronoid fractures occur at flexion of less than 80°, olecranon fractures at 90° of flexion and distal humeral fractures at greater than 110°1. Direct trauma often produces
Classification
Multiple classification systems have been devised for olecranon fractures, although none have gained widespread acceptance. Colton et al.8 were the first, developing a system based on the displacement and character of the fracture. Type I fractures are undisplaced and stable. Type II fractures are unstable and subdivided according to fracture pattern: type IIA avulsion fractures, type IIB transverse or oblique fractures, type IIC isolated comminuted fractures and type IID are fracture
Patient assessment
The assessment of patients with a suspected olecranon fracture should begin with a careful examination of the skin for evidence of an open fracture. The olecranon is subcutaneous and it is often possible to carefully palpate the fracture. A full neurovascular assessment of the upper limb should be documented. Antero-posterior and lateral radiographs should be obtained of the elbow. Although olecranon fractures are usually isolated injuries, careful assessment of the radiographs should be made
Management
Olecranon fractures are all intra-articular injuries. The aims of treatment, as defined by the AO group, are to restore the articular surface, achieve absolute stability of the fracture, and commence early active motion29. However, the method of treatment must also consider the configuration of the fracture, the patient's co-morbidities and functional demands. Internal fixation or excision of the fragment with triceps advancement is necessary in most cases, but non-operative management can be
Non-operative management
Patients with undisplaced olecranon fractures can be treated non-operatively with immobilisation at 45–90° of flexion for approximately 3 weeks before commencing limited flexion (90°) exercises until radiographic evidence of union is achieved17. Some controversy exists over the degree of displacement that is deemed acceptable; 2 mm is often quoted as the maximum displacement allowable for conservative management38. However, elderly patients can have good functional outcomes despite significant
Operative management
Four principle methods of operative management of olecranon fractures are in use: tension band fixation, intramedullary fixation, plate fixation and excision of the proximal fragment with triceps advancement.
Rehabilitation
The exact post-operative regimen will be determined by the stability of fixation, wound healing and patient compliance. However, in our experience patients should be splinted in 45–90° of flexion to help manage post-operative pain. The splint should be discontinued after 5–7 days, passive and gentle active movements are commenced at this point. Active movements against resistance should be avoided until there is evidence of callous formation at approximately 6–8 weeks. In the case of fragment
Outcomes
The functional outcome following olecranon fracture fixation is generally good or excellent whatever method of fixation is used. A review of 73 cases by Karlsson et al.22 comprised olecranon fractures treated principally by internal fixation (84%) showed that 96% of patients had a good or excellent outcome at 15–25 years follow up. In this study, degenerative change was found to be more likely following olecranon fracture, with changes noted in 50% of the formerly fractured elbows compared to
Summary
Fractures of the olecranon are a common trauma presentation and multiple options exist for the management of these injuries. In general, internal fixation by tension band wiring is preferred in the majority of patients with simple fractures and good or excellent results can be expected as long as the surgeon ensures a good anatomical reduction of the articular surface. Intramedullary fixations with screws or nails are less commonly employed but are acceptable alternatives in experienced hands.
Conflict of interest
The authors declare that there is no conflict of interest.
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