3.5 Olecranon
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1 Introduction
Olecranon fractures account for 80% of all fractures of the proximal ulna. Similar to distal radius and vertebral fractures, olecranon fractures may serve as a “sentinel fracture” that indicates widespread poor bone quality [1].
There is a steep increase in incidence of proximal ulna fractures in the seventh decade of life with a peak in the ninth decade for both male and female patients. The incidence increases from 12 per 100,000 in the general population to 70–80 per 100,000 in the geriatric population (> 65 years). There seems to be no gender predominance and open fractures are relatively rare [1]. About 25–30% of the patients with a fracture of the proximal ulna sustain a concomitant injury to the ipsilateral limb most frequently a proximal radius fracture followed by a proximal humerus, forearm, metacarpal and classic geriatric hip and pelvic fractures ( Case 3: Fig 3.5-7 , Case 4: Fig 3.5-8 , Case 5: Fig 3.5-9 , Case 15: Fig 3.5-19 ) [1, 2].
The most common cause of this type of injury is the direct impact from a fall from standing height [1]. In such cases, the olecranon impacts on the distal humerus, potentially resulting in a comminuted fracture pattern. Indirect trauma as a result of a powerful contraction of the triceps muscle during a fall on the outstretched arm typically results in a simple transverse or oblique fracture pattern [3, 4]. Overall, the simple 2-part fracture represents the most frequent fracture type (Mayo 2A; AO/OTA 2U1B) [1]. Fracture displacement occurs as a result of triceps muscle pull in cases of a ruptured periosteum and triceps aponeurosis, which can lead to a considerable loss of function [3]. However, older patients may demonstrate satisfactory function that meets their personal needs despite gross displacement ( Case 5: Fig 3.5-9 ).
Based on a combination of case series review and traditional experience, the standard treatment for displaced olecranon fractures is open reduction and operative fixation including tension band wiring or one of a variety of plate fixation methods [5, 6]. However, due to osteoporotic bone and vulnerable soft-tissue conditions, operative complications are frequently reported at rates up to 70% [7, 8]. Due to the frailty of this group of patients, even displaced olecranon fractures are often treated nonoperatively, leading to reasonable results without the risk of anesthetic or operative complications [1, 9, 10]. This chapter provides an overview and treatment algorithm for olecranon fractures in older adults.
2 Diagnostics
Diagnostic and therapeutic recommendations should be based on the unique medical, cognitive, and social conditions as well as the functional needs of each patient. A thorough medical history examination including the patient′s general condition and health status, comorbidities as well as functional expectations are mandatory prior to the planning of the individual treatment. Patients should also be carefully reviewed for any cognitive disabilities, as those may limit adequate patient compliance with the treatment course.
2.1 Clinical evaluation
The history should ask the following questions:
How did the injury happen (ie, mechanism of injury)?
Was it a single injury or are there additional injuries and locations of pain?
What was the preinjury level of function and activity (eg, independent, walking aids, or bedridden)?
Was the dominant hand injured?
What is the level of care available at the patient′s current residence (ie, independent, family, or nursing home)?
What are the patient′s medical comorbidities and chronic treatments including anticoagulation?
What is the patient′s mental status and expected ability to comply?
The clinical examination should address the following aspects:
Fracture crepitus, soft-tissue status, open bursa, or even an open fracture?
Severe pain or pseudoparalysis?
Joint stability?
Active range of motion (ROM)?
Vascular and neurological status?
Damage to the ulnar nerve (ie, proximity to the fracture site)?
Complaints of pain at other locations (ie, concomitant injury)?
2.2 Imaging
Plain AP and lateral x-rays are usually sufficient ( Fig 3.5-1 ).
A computed tomographic scan should be obtained in cases without adequate conventional x-rays to clearly identify the fracture pattern ( Case 1: Fig 3.5-2 , Case 2: Fig 3.5-3 ). This is especially important for operative planning and for visualization of concomitant fractures of the radial head or the coronoid process.
CASE 1
Patient
An 87-year-old woman fell down the stairs.
Comorbidities
Rheumatoid arthritis
Degenerative changes of the joint
Treatment and outcome
Owing to an insufficient view of the fracture on conventional x-rays, a computed tomographic scan was obtained, which revealed a simple Mayo type IA fracture pattern. The patient was treated nonoperatively ( Fig 3.5-2a–b ).
The lateral view 4 months after the initial injury showed a nonunion and destruction of the elbow joint. The patient could reach her mouth but could not perform any overhead activities (range of motion 0–0–90°). However, the patient refused any further treatment and was referred to physical therapy ( Fig 3.5-2c ).
CASE 2
Patient
A 79-year-old man had a fall while rock climbing.
Treatment and outcome
The computed tomographic scan was essential to assess the complete fracture pattern and to accurately plan the surgery ( Fig 3.5-3a–b ).
The patient was treated with open reduction and internal fixation using a locking plate, followed by 3 weeks of cast fixation and physical therapy without cast fixation. Six months after surgery, the patient was satisfied and pain free with almost full range of motion ( Fig 3.5-3c ).
3 Classification
There are four major classification systems commonly used for olecranon fractures: Colton [11], Mayo [12], Schatzker [13], and the AO/OTA Fracture and Dislocation Classification [14]. They are based on the fracture pattern and do not consider the patient′s age or bone quality. Overall, all systems are associated with low reproducibility and none has yet been universally accepted [15, 16].
3.1 AO/OTA Fracture and Dislocation Classification
The AO/OTA classification differentiates between the following three types:
Type 2U1A—extraarticular fracture
Type 2U1B—partial articular fracture
Type 2U1C—complete articular fracture, of olecranon and coronoid (C3)
3.2 Mayo classification
The system is based on stability, displacement, and comminution ( Fig 3.5-4 ) [12, 16]:
Type I—nondisplaced noncomminuted (IA) and comminuted (IB) olecranon fractures
Type II—displaced but stable noncomminuted (IIA) and comminuted (IIB) olecranon fractures with more than 3 mm of fragment displacement but intact collateral ligaments and a stable forearm in relation to the humerus
Type III—displaced and unstable noncomminuted (IIA) and comminuted (IIB) olecranon fractures with an unstable forearm in relation to the humerus (fracture dislocation)
4 Decision making
Due to the increased risk of anesthetic and operative complications in older adults, nonoperative treatment is a reasonable treatment option in many cases. The American Society of Anesthesiologists (ASA) score is known to correlate with the rate of intraoperative complications as well as the operative outcome [17, 18, 19]. Nondisplaced Mayo type I fractures can be successfully treated nonoperatively and avoid the risk of operative or anesthetic complications. Uneventful fracture healing is frequent, and there remains no significant functional loss even in cases of nonunion.
Displaced Mayo type II fractures remain controversial regarding the treatment of choice. Recent studies demonstrate good clinical outcomes for low-demand geriatric patients with a nonoperative approach [20, 21]. However, displaced fragments may significantly reduce elbow function, leading to a decreased ROM. Furthermore, the overlying skin may be compromised, potentially resulting in severe skin irritation and ulceration. For these cases, the ASA score can predict individual patient′s risk for operative treatment. The anticipated functional benefits of surgery should be carefully balanced against the risks in this patient group, with interdisciplinary decision making involving orthopedic surgeons, geriatricians, anesthesiologists, and the patient and family.
The decision for nonoperative or operative treatment can be made depending on the fracture classification and the ASA score ( Fig 3.5-5 ). Ideally, the final decision should be made based on an orthogeriatric discussion.
In Mayo type II and III fractures, nonoperative treatment has been shown to provide reasonable clinical results in older, low-demand patients [20, 21].
These fragility fractures have the potential to heal nonoperatively with osseous union ( Case 3: Fig 3.5-7 ) or nonunion ( Case 4: Fig 3.5-8 , Case 6: Fig 3.5-10 ). Either way, the clinical outcome is usually satisfactory in older adults, resulting in nearly normal extension and, in the authors’ experience, adequate pain control, even in cases with a large displaced fragment ( Case 5: Fig 3.5-9 ) or multiple fracture fragments ( Case 4: Fig 3.5-8 ).
Displaced fragments can be addressed operatively by tension band wiring, which does have the potential to provide good fracture consolidation and satisfactory clinical outcomes as early as 3 months postinjury ( Case 9: Fig 3.5-13 ). However, in cases with poor bone quality, K-wires might loosen and fracture dislocation can occur. In older adults, revision surgery then has to be considered very carefully, as adequate fracture healing, sufficient ROM, and good clinical outcome is still possible without reoperation ( Case 8: Fig 3.5-12 ). Even with significant loss of reduction, surgical revision can be avoided in cases of satisfactory elbow function. A more specific indication for operative revision is surgical hardware causing ongoing soft-tissue compromise.
Locking plate fixation with functional aftertreatment is another preferred option in older patients. In our experience, plate fixation often leads to satisfactory results with comparable ROM to the uninjured contralateral extremity ( Case 11: Fig 3.5-15 , Case 12: Fig 3.5-16 , Case 14: Fig 3.5-18 ). There are various plating systems without evidence of one plate being superior to another [22]. In osteoporotic bone, a locking plate has been shown to be advantageous in various other fracture locations, and should be used in osteoporotic bone to decrease the risk of cut out and secondary fracture dislocation [23–26]. One exception involves Mayo type IIA fractures in which there was no benefit of plate fixation over tension band wiring [27, 28]. In a multifragmentary fracture type Mayo IIB plating offers more options for fragment fixation and provides overall a more stable construct compared to wiring.
Operative treatment of osteoporotic bones is less successful and may lead to complications, potentially resulting in salvage procedures. Because of skin irritation, wound breakdown, or pain, implant removal ( Case 11: Fig 3.5-15 ) becomes ne cessary in up to 80% of all cases following open reduction and internal fixation of olecranon fractures in older adults [29]. Salvage procedures include fragment excision, arthroplasty, or revision surgery with or without bone grafting. In the absence of adequate randomized controlled trials of operative versus nonoperative approaches, the optimal treatment of displaced olecranon fractures remains controversial [6].
5 Therapeutic options
There are various nonoperative and operative treatment options, depending on the fracture classification ( Fig 3.5-6 ).
5.1 Nonoperative treatment
Nonoperative treatment ( Case 3: Fig 3.5-7 , Case 4: Fig 3.5-8 , Case 5: Fig 3.5-9 , Case 6: Fig 3.5-10d-f ) should include initial functional passive physical therapy without limitation and elbow cast fixation for comfort for up to a maximum of 3 weeks depending on the patient′s pain level. For nonoperative treatment, suggestions for the maximally acceptable fragment displacement range from 2 mm to 5 mm in the literature [10, 30]. However, even higher degrees of displacement can have the potential for a pain-free result with satisfactory ROM ( Case 5: Fig 3.5-9 ).
CASE 3
Patient
A 67-year-old male patient fell at home and sustained a nondisplaced olecranon fracture.
Treatment and outcome
X-rays showed a nondisplaced fracture of the olecranon (Mayo type IA) ( Fig 3.5-7a ), accompanied by a distal radial fracture ( Fig 3.5-7b–c ) on the ipsilateral side. For more information on the Mayo classification, see topic 3 in this chapter.
Both fractures were treated nonoperatively ( Fig 3.5-7d–e ). After 3 weeks of elbow cast fixation and initial physical therapy, the patient was pain free. He was dismissed from the outpatient clinic 6 weeks postinjury.
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