Dr. Ebraheim’s educational animated video describes olecranon fracture, and provides a simple and easy to understand review about it, the signs and symptoms, diagnostic tests, and treatment options.
Fractures of the olecranon can occur from a direct blow to the elbow or from a fall on an outstretched hand.
There is several classification systems, the classifications I use is the Colton classification:
• Nondisplaced fracture:
- Stable.
- The fracture has less than 2mm of separation
- That separation will not increase with elbow flexion
- The extensor mechanism is intact and the patient will be able to extend the elbow against gravity.
• Displaced fracture:
- Avulsion fracture
- Oblique or Transverse fracture
- Comminuted fracture
- Fracture dislocation
The olecranon fracture dislocation can be several types:
Anterior trans-olecranon fracture dislocation
Posterior Montiggia fracture dislocation.
Examination of the patient will show the patient is unable to extend the elbow with these displaced fractures.
A true lateral view in the x-ray will clearly show the olecranon fracture.
Usually this fracture is followed by stiffness of the elbow, in about 50% of the patients.
But it really doesn’t affect the function.
So when you talk about treatment of the olecranon fracture, the goal should be: restorations of the articular surface, preservation of the continuity of extensor mechanism, maintain the elbow stability, and it would be nice to avoid stiffness of the elbow.
Non-operative treatment is used for non-displaced fractures, and it could be used for some displaced fractures in the elderly patients, you treat the elbow with some flexion with a splint, I would personally use a minimally invasive technique in these patients unless the skin is very bad or the fracture is comminuted.
Surgery treatment: you want to know about 3 techniques:
1- Tension band technique: will be used for transverse fractures with no comminution, you can use the screws or the k wire, when doing this technique; you want to engage the anterior cortex of the ulna.
You want to avoid over-penetration, to avoid affecting the forearm rotation or injuring the anterior interosseous nerve.
Make sure at the end of the operation you can do pronation and supination otherwise pull them out a little bit.
This tension band mechanism takes the distractive force of the triceps and converts it to compression force at the articular surface, especially when the patient bends the elbow.
There are some technical points in this operation; one of them is the drill for the wire should be 4-5 cm from the fracture which gives enough safe distance so that the fracture will not propagate.
The second one: put the wire through the drilled holes, before application of the k wire.
Make sure that the hook of the k wire is posterior; the tension band wire is close to the bone so that there is no laxity in the fixation and instability.
Never use the cancellous screws by itself.
2- Detach Olecranon and Reattach Triceps: excision of the fracture fragment and triceps advancement is used, if the fracture is less than 50% of the joint space, to treat elderly patients, especially if the fracture is comminuted, for some nonunions when the fracture is small and it can’t be fixed.
Make sure this procedure is done when the elbow is stable, if the elbow has ligamentous instability and you excise the piece of olecranon, and then you are going to make the elbow very unstable.
And when you attach the triceps, attach it closer to the articular surface.
3- Plate and Screw fixation: we use it for everything else, such as:
- Comminuted fractures
- Monteggia fracture
- Oblique fractures extending to the coracoid
- Fracture dislocation
The plate is placed on the tension side of the olecranon (dorsal side).
Sometimes you make an opening in the triceps and place the plate against the bone then suture the triceps on top of the plate so that will avoid hardware prominence.
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