11: Open Reduction and Internal Fixation of Olecranon Fractures

PROCEDURE 11 Open Reduction and Internal Fixation of Olecranon Fractures



Greg K. Berry



image


Introduction



image Fractures of the olecranon are common injuries and vary in scope from simple transverse fractures to complex fractures associated with injury to other structures at the elbow and forearm.

image The diagnosis of the fracture can be reliably made with history, physical examination, and plain radiographs. Computed tomography (CT) scanning can aid in the preoperative planning of complex injuries.

image The aim of surgery is the anatomic restoration of the olecranon anatomy (especially the joint surface) and sufficient stability to allow early unhindered range-of-motion (ROM) exercises.


Indications




PITFALLS



• Operative care is made simple by the subcutaneous nature of the olecranon; this advantage, however, makes complaints from prominent hardware more likely.


image Undisplaced fractures typically have an intact soft tissue sleeve and are unlikely to displace.

image More typically, the pull of the triceps upon the proximal fragment generates displacement in nearly all olecranon fractures, most of which involve the articular surface, thereby providing the indications for open reduction and internal fixation (ORIF).


Examination/Imaging




Treatment Options



• If nonoperative care is chosen:
image Weekly follow-up radiographs for 2–3 weeks to ensure there is no secondary displacement

image A short period of immobilization (7–10 days) followed by progressive active and active-assisted ROM exercises but no passive ROM

image Strengthening after healing is confirmed clinically and radiographically (6–8 weeks)


image A detailed physical examination and close inspection of plain radiographs are necessary to rule out concomitant injuries. This includes assessment of:
• Bone, joint and ligament status—the coronoid process, radial head, elbow collateral ligaments, and proximal and distal radioulnar joints

• Neurologic status—median, ulnar, and radial nerve sensorimotor function

• Vascular status—radial and ulnar artery perfusion

• Skin condition—open fracture, swelling, contusion, abrasion

image Imaging includes plain radiographs (anteroposterior, true lateral, and oblique views).
• Figure 1A shows a preoperative lateral radiograph of a transverse fracture of the olecranon, the typical fracture amenable to tension band fixation (Fig. 1B).

image CT scanning may be required for complex fractures involving joint depression, severe comminution, radial head fracture, intra-articular fragment, or associated distal humerus fracture.

image

FIGURE 1



Surgical Anatomy



image Bones, muscles, and tendons of the elbow joint (Fig. 2A and 2B)

image Neurovascular anatomy of the elbow (Fig. 3A and 3B)
• Median, ulnar, and radial nerves

• Radial and ulnar arteries

image

FIGURE 2


image

FIGURE 3



CLASSIFICATION AND CHOICE OF FIXATION TECHNIQUE



image The Schatzker classification (Fig. 4) is a simple and comprehensive scheme to describe these fractures and aids in the choice of fixation technique.

image Optimal fixation technique is dependent on fracture type.
• Type A—the classic pattern for tension band fixation (Weber and Vasey, 1963); plate and screws have also been shown to be effective.

• Type B—the joint surface impaction must be recognized, reduced, and stabilized with bone graft and/or an implant; fracture fixation as per type A.

• Type C—compression across the fracture is generated by a lag screw(s), which is protected (“neutralized”) with either plate or tension band fixation.

• Type D—reduction and fixation of the intermediate fragments with transcortical or intraosseous screws is followed by either tension band fixation (if a stable fracture configuration permitting compression is achieved) or plate and screw fixation (if the fracture configuration either does or does not permit compression).

• Type E—not mechanically amenable to tension band wiring; use plate and screws with lag technique across the fracture.

• Type F—complex fracture with significant instability requiring that all osseous and soft tissue components of the injury be addressed.

image

FIGURE 4



Positioning




PEARLS



• A tourniquet is used at the discretion of the surgeon.


image Typically the patient is placed supine.

image One can consider lateral decubitus positioning (Fig. 5A

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 11: Open Reduction and Internal Fixation of Olecranon Fractures

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