lecranon fractures represent approximately 10% of all fractures around the elbow.1 These fractures can result from either direct trauma to the olecranon, forcing it into the distal humerus, or from an indirect mechanism through triceps contraction. Extensor integrity is examined by asking the patient to extend the elbow against gravity. It is also critical to check the integrity of the ulnar nerve preoperatively because its proximity to the fracture site renders it vulnerable to injury. Anteroposterior and true lateral radiographs are usually sufcient to determine fracture pattern, but traction views and computed tomography scan can help in comminuted patterns and complex instability cases, such as transolecranon fracture dislocation, concomitant radial head, or neck injury. Olecranon fractures are considered to be nondisplaced or minimally displaced if there is 2 mm gap or step-off, the extensor mechanism is intact, and there is no displacement with elbow exion. Fractures meeting all these criteria can be treated successfully nonoperatively. Surgery is preferred for open fractures, displaced fractures, and disrupted extensor mechanism. Many treatment options can be used depending on characteristics of the fracture pattern and the experience of the surgeon. Several fracture patterns have been described, each varying in their degree of stability and complexity. The primary goals in managing these intra-articular fractures is to restore articular congruity while providing a stable-enough
construct to permit early range of motion and providing an intact elbow extensor mechanism.
Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Address reprint requests to John-Erik Bell, MD, Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. E-mail: jebell527@yahoo.com
1048-6666/10/$-see front matter 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2009.09.016
18
Figure 1 (Reproduced with permission from Newman SDS, Mauffrey C, Krikler S: Olecranon fractures. Injury 40:575-581, 2009; adapted from Browner BD, Jupiter JB, Levine AM, et al: Skeletal trauma. Philadelphia, Saunders, 1992, p 1137.)
divided into 3 categories: Types A-C.4 Type A fractures represent extra-articular fractures of the metaphysis of either the radius or ulna. Type B fractures are intra-articular fractures of the radius or ulna. Olecranon fractures, specically, are subclassied in this group as type B1 fractures. Type C fractures are intra-articular fractures of both the olecranon and radial head. The Mayo classication system of olecranon fractures is divided on the basis of the fractures degree of stability, displacement, and comminution.5 This system, described by Morrey, was devised to provide a basic algorithm for treatment. According to this algorithm, type I or nondisplaced fractures should be treated with immobilization and symptomatic treatment alone. Type II fractures, which include fractures with 3-mm displacement, intact collateral ligaments, and preserved forearmhumerus relationship, would typically require operative treatment. Type III fractures include fractures with a disruption in the relationship between the forearm and the humerus, constituting a fracture dislocation. These fractures also typically require operative xation (Fig. 2). The utility of each system remains a difcult question. Rommens et al6 completed a retrospective study in 2004 evaluating which system seemed to have the most clinical applicability. This review reported that primary elbow instability and fracture morphology were more predictive of elbow function and development of arthrosis after operative fracture xation. As a result, this study recommended use of the Mayo Clinic classication system or the Schatzker Schmeling classication system.
Surgical Techniques
Plate Fixation
Plating has become an increasingly important method of treating displaced olecranon fractures. One of the rst recorded uses of plate xation for olecranon fractures was described in 1951 by Zuelzer7 who reported the successful use of a hook plate in a case report of a comminuted olecranon fracture. Although plate xation can be used for virtually any type of olecranon fracture, it is ideal for the following indications: comminuted fractures, Monteggia fracture dislocations, oblique fractures distal to the midpoint of the trochlear notch, and fractures that involve the coronoid process.2 Several studies have shown the biomechanical advantages of
Figure 2 (Reproduced with permission from Newman SDS, Mauffrey C, Krikler S: Olecranon fractures. Injury 40:575-581, 2009; adapted from Morrey BF, Adams RA: Fractures of the proximal ulna and olecranon, in The Elbow and its Disorders. Philadelphia, WB Saunders, 1993, pp 405 428. The Copyright of The Mayo Clinic Foundation Section of Publication.)
Olecranon fractures
tensor carpi ulnaris muscles. The triceps insertion is not violated. No more than 2 mm of periosteum at the fracture edges is elevated to visualize an anatomical reduction. The reduction is provisionally held by a small pointed reduction tenaculum with 1 tine through the triceps on the olecranon tip proximally and the distal tine in a small unicortical drill hole in the ulnar shaft just distal to the fracture. Two Kirschner wires (K-wires) are then drilled antegrade from the medial and lateral margins of the proximal fragment to hold the reduction without obstructing midline plate placement. Reduction of the fracture is conrmed with biplanar uoroscopic imaging. The authors prefer a low prole, precontoured locking plate of sufcient length to allow 3 or 4 screws to be placed distal to the fracture. The contoured plate is then applied to the dorsal surface of the olecranon with the proximal portion of the plate being applied supercial to the triceps tendon. We typically use a home-run screw placed from the olecranon tip into the coronoid perpendicular to the fracture line to lag the fracture fragments together. If there is extensive articular comminution, bone graft is occasionally placed beneath the subchondral bone. If there is extensive comminution in the region of the coronoid, a second small one-third tubular plate or free lag screws are sometimes placed to control these additional fragments. Figure 3 illustrates a comminuted olecranon fracture treated with plate xation and supplemental lag screw xation distally (Fig. 3). Functional and patient-rated outcomes using plate xation have proven to be very successful. A retrospective study of 25 patients who underwent plate xation for displaced olecranon fractures demonstrated excellent functional and patient rated results according to Disabilities of the Arm, Shoulder and Hand and Mayo Elbow Performance Indexes.10 Other techniques used for plating olecranon fractures include lat-
19 eral plating and dual medial-lateral plating methods. A study by King et al11 evaluated the biomechanical differences between posterior and lateral plating in comminuted olecranon fractures. This study demonstrated that no statistical difference in static and cyclic stability was present. A contemporary advancement in the treatment of olecranon fractures is the development of precontoured locking plates. A paucity of published data has been reported on the efcacy of these devices. A recent article in the Journal of Orthopaedic Trauma reported on 32 patients who underwent plate xation using a precontoured locking plate.12 These patients were assessed using radiographic, functional, and patient-rated outcomes. Radiographs demonstrated that 30 of 32 patients went on to radiographic union, and that only 3 patients had symptomatic hardware that necessitated removal. Average postoperative arc of motion at approximately 2 years was 120. Patient satisfaction was outstanding, with 92% of patients reporting good or excellent results. The authors conclusion stated that congruent elbow plating of displaced olecranon fractures is a safe, effective option, which permits early range of motion and a low rate of hardware removal.
Figure 3 (A) Preoperative and (B) postoperative radiographs demonstrating precontoured locking plate xation.
20 olecranon fracture and osteoporotic bone that would make reconstruction difcult or impossible.2,5 In addition, patients must have an intact medial collateral ligament, interosseous membrane, and distal radioulnar joint before excision, or instability will likely develop.13 Outcomes after excision of the proximal fragment and triceps advancement have been variable. Several studies have touted the benets of this technique for complex articular injuries, particularly for lowdemand patients or severely comminuted fractures involving small proportions of the olecranon. Gartsman et al14 performed a retrospective review of 107 patients who underwent either olecranon excision or open reduction and internal xation (ORIF). Their results demonstrated acceptable results for excision vs ORIF, with the added benet of lower rates of postoperative wound complications and reoperation compared with ORIF (using a predominantly tension band technique). Inhofe and Howard15 also have demonstrated the benets of this technique for comminuted olecranon fractures. Their series demonstrated 11 of 12 patients who underwent olecranon excision and triceps advancement to have self-reported excellent or good functional results. In vitro biomechanical studies have demonstrated some potential problems with this technique and argue for reconstruction of the proximal ulna. Moed et al16 used a cadaver model to compare articular stresses after ORIF and proximal fragment excision. Their results showed proximal fragment excision results in elevated joint stresses, which he concluded may contribute to the development of elbow pain and osteoarthrosis. One historical controversy regarding this technique is the amount of trochlear notch that can be excised without destabilizing the elbow. The original description of this technique, by McKeever and Buck17 in 1947, suggested that a maximum of 80% of the trochlear notch could be excised without destabilizing the elbow. An et al18 evaluated elbow stability with varying degrees of proximal ulnar resection in a cadaveric model. Their analysis showed a linear increase in instability with increasing amounts of resection, and these authors concluded that resection of 50% of the articular surface may result in elbow instability. A major criticism of this technique is the potential for signicant loss of triceps power. There has been considerable debate over the technique for reattachment of the triceps. Some authors advocate placement of the triceps immediately adjacent to the articular surface to create a smooth ulnohumeral articulation.19 Alternatively, Didonna et al20 demonstrated that reattachment of the triceps tendon in a more posterior position increases the mechanical advantage of the triceps and increases extension power.
Intramedullary Fixation
Intramedullary screw xation is another technique commonly used in the treatment of olecranon fractures. One of the rst forms of intramedullary treatment involved placement of intramedullary rods as described by Rush and Rush in 1937. This technique was expanded by MacAusland (1942) and Harmon (1945) to include placement of an in-
Olecranon fractures
21
Figure 4 (A) Preoperative and (B) postoperative radiographs demonstrating intramedullary screw xation.
73 patients were followed up to 15 months, with 68 of 73 patients reporting excellent or good results.28
the compressive forces at the articular surface.34 A 14-gauge angiocatheter is placed from ulnar to radial between the triceps and the tip of the olecranon, and an 18-gauge wire is then passed in a gure-of-8 manner through the distal anchor hole and the angiocatheter. Two wire loops are then created, one at the junction of the 2 limbs, and the other just proximal to the point where the wire crosses the ulna on the radial side. These loops are then tightened simultaneously and subsequently cut at a length of 3-4 mm and bent anteriorly on either side of the ulna. The K-wires are then bent to approximately 180, cut to 3-4 mm, and then seated with a mallet. This represents a critical step to prevent K-wire migration and secondary soft tissue irritation. Several studies have reported that symptomatic K-wire prominence is the most common complication of tension band wiring.35 In 1 study, 46% of patients required hardware removal with most of these cases because of symptomatic hardware.36 Figure 5 shows xation with a tension band technique (Fig. 5). A variety of modications on this technique have been described. More recent modications have included using different materials in place of the 18-gauge wire. Most reports of soft-tissue complications associated with tension band wiring include a discussion of the parallel K-wires causing irritation; however, some reports have recognized that the steel wire has the potential to cause signicant soft-tissue irritation necessitating hardware removal.37 As a result, researchers have attempted to nd lower prole tension band materials with equivalent strength. One in vitro study compared standard 18-gauge wire to braided polyethylene cable and tested the constructs ability to maintain the reduction.38 No signicant difference was found regarding fracture displacement under signicant tensile loads. A similar study demonstrated equivalent results using a high strength polyester and polyethylene suture.39 Despite the complications associated with tension band wiring, this technique continues to produce excellent results
22
Figure 5 (A, B, and C) Preoperative and postoperative radiographs demonstrating tension band xation.
in the treatment of noncomminuted, transverse olecranon fractures. Villaneuva et al36 retrospectively reviewed 37 olecranon fractures repaired using a tension band technique. These patients were reviewed at 4 years postoperatively and 89% of patients had no pain or mild pain, Mayo elbow performance scores were rated as good or excellent in 86% of patients, and average arc of motion was 124. Wolfgang et al21 treated 45 olecranon fractures with tension band wiring, using supplemental xation in complex fractures (associated radial head or neck fractures), and reported 98% excellent or good outcomes at an average follow-up of 16 months.
References
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Conclusions
Fractures of the olecranon represent a common injury treated by orthopaedic surgeons. Several surgical options for this injury are available today, with each option being based on the fracture pattern present, surgeon preference, and the functional demands of the patient. If treatment decisions are
Olecranon fractures
8. Hume MC, Wiss DA: Olecranon fractures. A clinical and radiographic comparison of tension band wiring and plate xation. Clin Orthop Relat Res 285:229-235, 1992 9. Tejwani NC, Garnham IR, Wolinsky PR, et al: Posterior olecranon plating: Biomechanical and clinical evaluation of a new operative technique. Bull Hosp Jt Dis 61:27-31, 2002 10. Bailey CS, MacDermid J, Patterson SD, et al: Outcome of plate xation of olecranon fractures. J Orthop Trauma 15:542-548, 2001 11. King GJ, Lammens PN, Milne AD, et al: Plate xation of comminuted olecranon fractures: An in vitro biomechanical study. J Shoulder Elbow Surg 5:437-441, 1996 12. Anderson ML, Larson AN, Merten SM, et al: Congruent elbow plate xation of olecranon fractures. J Orthop Trauma 21:386-393, 2007 13. Teasdall R, Savoie FH, Hughes JL: Comminuted fractures of the proximal radius and ulna. Clin Orthop Relat Res 292:37-47, 1993 14. Gartsman GM, Sculco TP, Otis JC: Operative treatment of olecranon fractures. Excision or open reduction with internal xation. J Bone Joint Surg Am 63:718-721, 1981 15. Inhofe PD, Howard TC: The treatment of olecranon fractures by excision or fragments and repair of the extensor mechanism: Historical review and report of 12 fractures. Orthopedics 16:1313-1317, 1993 16. Moed BR, Ede DE, Brown TD: Fractures of the olecranon: An in vitro study of elbow joint stresses after tension-band wire xation versus proximal fracture fragment excision. J Trauma 53:1088-1093, 2002 17. McKeever F, Buck RM: Fracture of the olecranon process of the ulna treatment by excision of fragment and repair of triceps. J Am Med Assoc 135:1-5, 1947 18. An KN, Morrey BF, Chao EY: The effect of partial removal of proximal ulna on elbow constraint. Clin Orthop Relat Res 209:270-279, 1986 19. Cabanela ME, Morrey BF: Fractures of the proximal ulna and olecranon, in Morrey BF (ed): The Elbow and its Disorders (ed 2). Philadelphia, PA, WB Saunders, 1993, pp 405-428 20. Didonna ML, Fernandez JJ, Lim TH, et al: Partial olecranon excision: The relationship between triceps insertion site and extension strength of the elbow. J Hand Surg Am 28:117-122, 2003 21. Wolfgang G, Burke F, Bush D, et al: Surgical treatment of displaced olecranon fractures by tension band wiring technique. Clin Orthop Relat Res 224:192-204, 1987 22. Hutchinson DT, Horwitz DS, Ha G, et al: Cyclic loading of olecranon fracture xation constructs. J Bone Joint Surg Am 85-A:831-837, 2003 23. Wadsworth TG: Screw xation of the olecranon after fracture or osteotomy. Clin Orthop Relat Res 119:197-201, 1976 24. Murphy DF, Greene WB, Dameron TB Jr: Displaced olecranon fractures in adults. Clinical evaluation. Clin Orthop Relat Res 224:215223, 1987
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