OLECRANON FRACTURES

Olecranon Fractures

Shawn W. O’Driscoll

Olecranon fractures are common, yet pose specific unresolved challenges for the surgeon. Stable and noncomminuted fractures can be treated with tension band wiring, although hardware-related complications have been reported in a high percentage of cases. Complex fractures of the proximal ulna, including comminuted fractures of the olecranon with ulnohumeral subluxation or dislocation, require rigid fixation with a plate. The coronoid must be reduced and fixed if fractured. New precontoured plates designed specifically for the olecranon are now commercially available.

Indications

1. Tension band wiring—noncomminuted fractures without elbow instability

2. Plating—comminuted fractures and those with elbow instability

Contraindications

Undisplaced fractures with elbow extension preserved can be treated non-operatively.

Mechanism of Injury

A fall onto an outstretched hand or direct blow to elbow.

Physical Examination

1. Tenderness, swelling, bruising at fracture site

2. Bony prominence beneath skin

3. Weakness or inability to extend elbow

Diagnostic Tests

1. Plain anteroposterior and lateral radiographs.

2. Tomograms or computed tomography scans may be useful to assess for associated fractures (coronoid and radial head).

Differential Diagnosis and Concomitant Injuries

1. Fractures of the coronoid and radial head

2. Monteggia variant

3. Lateral collateral ligament injury with posterolateral rotatory instability

Special Considerations

1. Treatment of these fractures should be principle-based.

2. Principles are to obtain:

a. Congruous reduction of the articular surfaces with respect to the trochlea

b. Adequate fixation in the proximal fragment (which is sometimes small)

c. Stable fixation maintaining the relationship between the proximal fragment, the coronoid, and the ulnar shaft

Preoperative Planning and Timing of Surgery

1. Avoiding delay decreases swelling and may improve recovery.

2. Prolonged delays are thought to possibly increase the risk of heterotopic ossification.

3. The arm should be kept elevated in a long-arm padded Jones bandage (to minimize edema) with an anterior plaster slab maintaining the elbow in full extension.

Special Instruments

1. Bankart awl from shoulder set

2. 14-gauge angiocatheter

3. Harris wire tier

4. AO/ASIF “bending pliers”

5. Acumed congruent elbow olecranon plates

Patient and Equipment Position

1. Supine

2. Arm across chest

3. Elbow flexed 90 degrees

Surgical Approach

Utilize a posterior, longitudinal skin incision (approximately 8 to 12 cm in length) just lateral to the tip of the olecranon. Avoid the olecranon prominence.

Tension Band Wiring

Tension band wiring is currently the most frequently used form of treatment. It is our preferred treatment for noncomminuted fractures in which the elbow demonstrates no apparent potential for instability (Figs. 44–1A,B). It is contraindicated in the presence of significant comminution or elbow instability. There are five sets of steps:

1. Tension band wire placement through the distal ulnar fragment:

a. Expose the posterior half of the ulna subperiosteally 3 cm distal to the fracture. Drill a hole from each side, angled toward each other, and connect them with a curved Bankart awl.

b. Bend an 18-gauge (or Luque) wire at the tip to the shape of the awl, and pass it through the ulna using a needle driver.

2. Fracture reduction and intramedullary pin placement:

a. With the elbow flexed 90 degrees across the chest, reduce the olecranon.

b. Pass two 0.062 smooth Steinmann pins through the triceps insertion and olecranon, into the intramedullary canal.

c. The pins can be placed through the anterior cortex, but ensure that they do not protrude when finished.

d. Back out the pins 1 cm so you are certain that they can be impacted later when they are bent over after placement of the tension band wire.

3. Tension band wire placement proximally:

a. Cut off the tip of the tension band wire at a sharp angle, bend it to a curve, and pass it under the triceps tendon immediately proximal to the Steinmann pins.

b. An alternative method is to pass a 14-gauge angiocatheter under the triceps tendon, remove the needle, and pass the wire through the cannula.

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