http://emedicine.medscape.

com/article/1231557-overview Background The human's unique prehensile skill largely depends on the integrity of the bones, ligaments, and muscles around the elbow joint. The elbow not only bends the arm but also permits pronation and supination of the hand. Fractures of the olecranon are common and are usually detected easily.[1, 2, 3] Images below show repaired olecranon fractures.

Anteroposterior radiograph following reduction and internal fixation

of the fracture with a 7.3-mm cannulated screw and 1.6-mm cable. Lateral radiograph demonstrating the threads of the screw engaging the cortices of the ulna. Recent studies Buijze et al compared the stiffness and strength of locking compression plate fixation to one-third tubular plate fixation in a cadaveric comminuted olecranon fracture model with a standardized osteotomy. Five matched pairs of cadaveric elbows were randomly assigned for fixation by either a contoured locking compression plate combined with an intramedullary screw and unicortical locking screws or a one-third tubular plate combined with bicortical screws. Construct stiffness was measured by subjecting the specimens to cyclic loading while measuring gapping at the osteotomy site, and construct strength was measured by

subjecting specimens to ramp load until failure. The authors found no significant difference in fixation stiffness and strength between the 2 fixation methods, and all failures consisted of failure of the bone, not of hardware.[4] In a study by Buijze and Kloen, the authors noted that in patients managed with plate fixation for olecranon fractures, placement of an axial intramedullary screw may obstruct the placement of bicortical screws in the ulnar shaft. As a solution, they assessed the effectiveness of unicortical screws with a contoured locking compression plate. In the study, 19 patients with an acute comminuted olecranon fracture were managed with a contoured locking compression plate and intramedullary screw fixation, 16 of whom were available for follow-up at a minimum of 12 months after fixation. All 19 fractures healed, and the mean time to fracture union was 4 months. The mean Disabilities of the Arm, Shoulder and Hand score was 13. According to the Mayo Elbow Performance Index and the Broberg and Morrey grading system, 15 of the 16 patients followed had a good or excellent outcome. In 9 patients, hardware removal was necessary; after removal, the mean elbow extension deficit improved from 34 to10,andthemeanflexion improved from 118 to 138.[5] According to Iannuzzi and Dahners, in comminuted fractures of the olecranon (Mayo type IIB), it may be difficult or even impossible to preserve the olecranon's normal articulation with the trochlea of the humerus. The authors therefore describe a modified technique for reconstructing these fractures when it is not possible to achieve a stable anatomic reduction and fixation; in this technique, the comminuted fragments are excised and the proximal olecranon fragment is advanced past the resulting defect and fixed to the distal ulna. The authors present 2 cases with clinical follow-up and note that satisfactory preservation of range of motion and elbow stability were achieved in each case.[6] For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Elbow. Epidemiology Frequency Despite the fact that the olecranon is a very heavy, strong process of bone, it is fractured rather frequently in adults. This is due partly to its exposed position on the point of the elbow, where most direct injuries to the elbow occur, and partly to the tremendous cross strain put on the olecranon during falls on the flexed forearm. The olecranon process is rarely broken in children, because in early life, it is short,

thick, and relatively much stronger than the lower end of the humerus. Usually, children sustain supracondylar fractures of the humerus instead. Open fractures occur in 2-31% of cases. Neurologic injuries to median, radial, or ulnar nerves may occasionally occur. Ulnar neurapraxia has been reported in 2-5% of cases. Generally, symptoms resolve with conservative treatment, but late neurolysis or transposition may occasionally be required Etiology The most common mechanism of an olecranon fracture is a fall on the semiflexed supinated forearm. As the hand strikes the ground, muscles are tensed to break the fall, and the powerful triceps snaps the olecranon over the lower end of the humerus, which acts as a fulcrum. The next most frequent cause of this injury is direct trauma, as in falls on, or blows to, the point of the elbow. Occasionally, the olecranon may be fractured by hyperextension injuries, such as those resulting in elbow dislocation in adults or supracondylar fractures in children. Very rarely is the olecranon broken by muscular violence, as in throwing Presentation Most olecranon fractures are isolated. However, additional injuries to the same extremity are possible. Careful examination, including that of the shoulder, clavicle, humerus, wrist, hand, and forearm, is essential. Typically, the elbow incurs both soft tissue injury and joint effusion. Examine the skin, radial and ulnar pulses, and function of the ulnar, median, and posterior interosseous nerves. Carefully assess isolated injuries, as fracture of the coronoid process of the radial head and Monteggia fracture dislocations have a significant impact on elbow stability. When a supracondylar humerus fracture occurs in conjunction with an olecranon fracture, exposure of the humerus can be obtained by using the olecranon fracture site. Similarly, when an associated coronoid and/or radial head fracture exists, reduction and fixation can be achieved via a direct posterior approach through the displaced olecranon fragment. Although olecranon fractures generally are isolated injuries, a high index of suspicion for associated injuries is warranted in the evaluation of patients with multiple trauma. Twenty percent of patients with high-energy trauma have associated injuries (eg, long bone fracture, skull fracture, splenic injury, pulmonary contusion, axillary artery rupture). A transverse or slightly oblique break near the base of the olecranon is the usual fracture. In oblique fractures, the fracture line tends to slope down and back and

emerges on the posterior border of the olecranon. In other instances, a small piece of bone is pulled off of the proximal end of the olecranon Indications Fractures with significant displacement (>2 mm) or comminution may require surgical intervention Relevant Anatomy The elbow is a complex hinge joint. The major stabilizers to valgus stress (ie, bending away from the body) are the medial (ulnar) collateral ligament and the radial head. The major stabilizer to varus stress (ie, toward the body) is the lateral collateral ligament complex. The coronoid process stabilizes the humerus against the distal ulna. The olecranon also prevents anterior translation of the ulna with respect to the distal humerus. The anterior surface of the ulna is covered with articular cartilage. Therefore, all fractures (except the rare tip fractures) are intraarticular fractures. The olecranon articulates with the trochlea of the humerus. The triceps inserts into the posterior third of the olecranon and proximal ulna. The periosteum of the olecranon blends with the triceps. The ulnar nerve lies on the posterior aspect of the elbow, posterior to the medial collateral ligament. The ulnar nerve sweeps anteriorly to join the ulnar artery. The ulnar neurovascular bundle may be at risk during Kirschner wire (K-wire) fixation. Fracture displacement is largely due to the pull of the triceps muscle, which tends to pull a separated fragment upward but is resisted by the strong fibrous covering on the olecranon, as is shown in the image below. The blending of fibers in the lateral ligaments, the elbow capsule, and some triceps fibers that blend with the periosteum form this fibrous covering. If the fracture force does not tear this fibrous sheath, little or no tendency toward displacement exists, even in the presence of comminution.

Lateral radiograph of the elbow in a 78-year-old man who fell on his outstretched hand is shown. A displaced fracture of the olecranon was noted. Most olecranon fractures exhibit little or no displacement. Fragment displacement of more than 1.5 cm is uncommon, even with complete bony and soft tissue injury. Usually, wide separation of fragments indicates an old fracture with extensive tearing of the fibrous sheath in which the unopposed triceps is contracted gradually, drawing the separated fragment upward Contraindications Nonoperative treatment is often desirable in patients with significant associated medical conditions. Contused soft tissue healing is of paramount importance. Nonoperative treatment of even significantly displaced olecranon fractures in patients with severe medical illness, steroid use, or dementia is reasonable Imaging Studies

Standard anteroposterior and lateral radiographs of the elbow are sufficient for evaluation of isolated olecranon fractures. Direct supervision of the x-ray process may be necessary to ensure that true anteroposterior and lateral radiographs are obtained. The radiocapitellar view may be helpful for delineation of the radial head and capitellar fractures staging Several classification systems have been suggested.

The Arbeitsgemeinschaft fr Osteosynthesefragen (AO) - Association for the Study of Internal Fixation (ASIF) classification, used by the Orthopaedic Trauma Association, divides the fractures into 3 broad categories as follows[7] : o Type A fractures are extra-articular. o Type B fractures are intra-articular.

Type C fractures are intra-articular fractures of both the radial head and olecranon. Schatzker developed a classification with 6 types as follows (types A, B, and C are intra-articular fractures): o Type A is a simple transverse fracture. o Type B is a transverse impacted fracture. o Type C is an oblique fracture. o Type D is a comminuted fracture. o Type E is a more distal fracture, which actually is extra-articular. o Type F is a fracture dislocation Medical Therapy
o

The goals of olecranon fracture treatment must be individualized to the needs of the patient. In young active individuals, restoration of the articular surface, preservation of motor power, restoration of stability, and prevention of joint stiffness are important. In older patients, minimization of morbidity is the most important goal. An understanding of the extent of associated injuries is critical prior to initiating treatment. Additional fractures or disruptions of collateral ligaments render the elbow unstable. Nonoperative treatment As stated in Contraindications, nonoperative treatment is often desirable in patients with significant associated medical conditions. Contused soft tissue healing is of paramount importance. Nonoperative treatment of even significantly displaced olecranon fractures in patients with severe medical illness, steroid use, or dementia is reasonable. Skillful neglect is the treatment of choice for these patients. An Ace wrap with sufficient padding to protect the elbow is the only requirement. Patients with wide separation of fracture fragments lose significant, but not complete, elbow extension power. Late pain from an ununited displaced olecranon fracture generally is not a problem, but the extensor power is compromised. Approximately 70% of the extensor power is estimated to be lost when the fracture is displaced more than 1.5 cm. Nondisplaced fractures with intact extensor mechanisms may be treated nonoperatively. Three weeks of casting usually is sufficient. The elbow can be placed at any degree of flexion. Displacement generally can be reduced by placing the elbow in more extension. Patients can be comfortable with the elbow extended 135. However, it is often more convenient to immobilize the elbow at 90. Regaining both flexion and extension can be difficult. At first, patients are

cautioned to limit flexion to 90, at least until evidence of radiographic healing is satisfactory Surgical Therapy Nonoperative care for simple fractures is usually successful. However, fractures with significant displacement (>2 mm) or comminution may require surgical intervention. Excision and triceps advancement may be indicated for severely comminuted fractures or for patients with osteoporotic bone. Open reduction and internal fixation is preferred for displaced intra-articular fractures. Intramedullary screw fixation, with or without a wire or cable, is the most secure. Plate fixation is recommended for extensive comminuted or unstable oblique fractures not amenable to other types of treatment. Plate fixation also may be preferable in the face of an associated coronoid fracture. One study retrospectively reviewed the outcome of 18 patients who underwent locking-plate osteosynthesis after open reduction for comminuted olecranon fractures. The study results found that in all cases, complete union was achieved. The data conclude that while the risk of limited elbow motion is high in cases with concomitant injuries, locking plates are an additional and often successful option for olecranon fracture fixation Preoperative Details When determining the appropriate surgical approach, consider patient age, health, bone quality, fracture pattern, and ligamentous stability Preoperative Details When determining the appropriate surgical approach, consider patient age, health, bone quality, fracture pattern, and ligamentous stability Postoperative Details Operative management of olecranon fractures should provide sufficient fixation for immediate motion. Typically, patients are immobilized for only a brief time to assist wound healing and are then started on range-of-motion exercises at 10 days. However, muscle strengthening is not emphasized until bone healing is visualized radiographically. Patients may return to work involving vigorous use of the extremity at 3-4 months postoperatively Complications

Symptomatic hardware requiring removal is the most frequent complication following internal fixation. Hardware problems have occurred in up to 80% of patients with Kirschner tension band wires. Wire migration with soft tissue irritation, wire breakage, or fracture displacement may occur with tension-band wiring. Counsel patients about the possibility of symptomatic hardware when internal fixation is offered. Hardware complications generally occur less frequently with intramedullary screw fixation. Plate and screw fixation carries a moderate risk of subsequent need for hardware removal. Loss of motion is a common problem following fractures of the elbow but is usually not a significant issue for olecranon fractures. Generally, patients lose 15 of extension and, occasionally, a small amount of supination. Motion tends to improve progressively with time for up to 2 years. Heterotopic ossification occurs in 13-14% of patients. The range of reported rates of infection following operative treatment is 0-6%. Reflex sympathetic dystrophy occurs on rare occasions. Generally, nonunion occurs in fewer than 5% of patients. When nonunions are treated by internal fixation and bone grafting, good to excellent results occur in approximately two thirds of cases Outcome and Prognosis The best outcomes are observed in patients who have nondisplaced or minimally displaced fractures treated nonoperatively. Evaluation criteria are degree of pain, range of motion, and radiographic findings. In patients treated operatively, excision with triceps repair has the lowest rate of complications. In controlled studies, pain, subjective function, isometric strength, isokinetic work, range of motion, stability, and incidence of degenerative change were similar for patients treated with internal fixation and patients treated with excision. The preferred treatment appears to be excision when possible. Patients treated with internal fixation using an intramedullary screw plus wire or cable yield the fewest complications and best results when internal fixation is necessary. Occasionally, fixation removal is required. Of patients with plate fixation, 70-80% have good to excellent results, as compared with more than 90% of patients with tension band wiring. This probably is because simple fractures are usually treated with tension band wiring, whereas less favorable fracture patterns are treated with plate fixation Future and Controversies

Controversy exists regarding the amount of acceptable articular displacement for closed treatment. Certainly, several millimeters of displacement are usually well tolerated. Degenerative changes occur in fewer than 20% of these patients. The method chosen for open treatment of olecranon fractures is also controversial. Decisions regarding fragment excision versus internal fixation often are based on percentage of joint space involvement. McKeever and Buck in 1947 stated that as much as 80% of the trochlear notch can be excised without compromising elbow stability, provided that the coronoid and distal trochlea are preserved. One patient developed anterior instability following excision of 75% of the articular surface. The consensus certainly suggests that at least 50%, but likely less than 80%, of the articular surface can be excised, and a good result can still be obtained.[15] Future treatment of olecranon fractures may very well involve percutaneous fixation accompanied by arthroscopic assistance http://orthoinfo.aaos.org/topic.cfm?topic=a00503 Elbow (Olecranon) Fractures When you bend your elbow, you can easily feel its "tip," a bony prominence that extends from one of the lower arm bones (the ulna). That tip is called the olecranon (oh-lek'-rah-nun). It is positioned directly under the skin of the elbow, without much protection from muscles or other soft tissues. It can easily break if you experience a direct blow to the elbow or fall on a bent elbow.

The olecranon is the bony point of the elbow. Anatomy The elbow is a joint made up of three bones. It bends and straightens like a hinge. It is also important for rotation of the forearm; that is, the ability to turn our hands up (like accepting change from a cashier) or down (like typing or playing piano).

The humerus is the upper arm bone between the shoulder and the elbow. The radius is one of the forearm bones between the elbow and wrist. When standing with your palm facing up, the radius is on the "thumb side" of the forearm (the lateral side, "outside"). The ulna is the other forearm bone between the elbow and wrist, running next to the radius. When standing with your palm facing up, the ulna is on the "pinky side" of the forearm (the medial side, "inside").

Bones of the elbow. (Reproduced with permission from Tashjian RZ, Katarincic JA: Complex Elbow Instability. J Am Acad Orthop Surg 2006;14:278-286.) The elbow consists of portions of all three bones:

The distal humerus is the center of the elbow "hinge." The radial head moves around the distal humerus and also rotates when the wrist is turned up and down. The olecranon is the part of the ulna that "cups" the end of the humerus and rotates around the end of the humerus like a hinge. It is the bony "point" of the elbow and can easily be felt beneath the skin because it is covered by just a thin layer of tissue.

The elbow is held together by three main things:

Ligaments. Ligaments connect one bone to another. Muscles and tendons. Muscles and tendons move the bones around each other. Shape of the bone. The way the bones fit together hold the elbow together.

The elbow is held together by ligaments, muscles, tendons and the shape of the bones themselves. When the elbow structure is altered, either by breaking a bone or by tearing ligaments, muscles, or tendons, or a combination of those problems, then the elbow will not function normally. It can become very painful and stiff, and can cause a feeling of instability ("my elbow feels like it wants to pop out."). Cause

A. Anterior fracture-disclocations of the olecranon. B. Posterior fracturedislocations of the olecranon. There are many types of elbow fractures (breaks). Olcranon fractures are common. Although they usually occur in isolation (that is, there are no other injuries), they can be a part of a more complex elbow injury. Olecranon fractures can occur in a number of ways:

A direct blow. This can happen in a fall (landing directly on the elbow) or by being struck by a hard object (baseball bat, dashboard of a car during a crash). An indirect fracture. This can happen by landing on an outstretched arm. The person lands on the wrist with the elbow locked out straight. The triceps muscle on the back of the upper arm help "pull" the olecranon off of the ulna.

Symptoms

Sudden, intense pain Inability to straighten elbow Swelling over the bone site Bruising around the elbow Tenderness to the touch Numbness in one or more fingers Pain with movement of the joint

Diagnosis A patient with an olecranon fracture will typically go to the emergency room because the elbow will be very painful and unable to move. During the examination the doctor will:

Examine the skin to see if there are any lacerations (cuts). Lacerations can be caused by fragments of bone and can lead to an increased risk of infection. Palpate (feel) all around the elbow to determine if there are any other areas of tenderness. This can indicate other broken bones or injuries, such as a dislocation of the elbow. Check the pulse at the wrist to be sure that good blood flow is getting past the elbow to the hand. Check to see if the patient can move his or her fingers and wrist, and if the patient can feel things with his or her fingers. The doctor may ask the patient to straighten the elbow. Sometimes, the patient will be able to do this, and sometimes the patient will not. The doctor may examine the patient's shoulder, upper arm, forearm, wrist, and hand as well, even if the patient only complains of pain at the elbow.

X-rays will be taken of the elbow to confirm that a fracture has occurred. X-rays can also reveal other fractures or dislocations. X-rays may also be taken of the upper arm, forearm, shoulder, wrist, and/or hand, based upon the doctor's judgment and based upon the patient's complaints. These X-rays may reveal other injuries, such as other fractures or dislocations. Treatment

While in the emergency room, the doctor will treat an olecranon fracture with ice, pain medicine, a splint (like a cast), and a sling to keep the elbow in position. Whether or not the fracture requires surgery will be determined. Not all olecranon fractures require surgery. Nonsurgical Treatment Some olecranon fractures require just a splint or sling to hold the elbow in place during the healing process. The doctor will closely monitor the healing of the fracture, and have the patient return to clinic for X-rays fairly frequently. If none of the bone fragments are "out of place" after a few weeks, the doctor will allow the patient to begin gently moving the elbow. This may require visits with a physical therapist. The patient will not be allowed to lift anything with the injured arm for a few weeks. A nonsurgical approach to olecranon fracture may require long periods of splinting or casting. The elbow may become very stiff and require a longer period of therapy after the cast is removed to regain motion. If the fracture shifts in position, the patient may require surgery to put the bones back together. Surgical Treatment Surgery to treat an olecranon fracture is usually necessary when:

The fracture is out of place ("displaced"). Because the triceps muscles attach to the olecranon to help straighten the elbow, it is important for the pieces to be put together so you can straighten your elbow. The fracture is "open" (pieces of bone have cut the skin). Because the risk of infection is higher in an open fracture, the patient will receive antibiotics by vein (intravenous) in the emergency room, and may require a tetanus shot. The patient will promptly be taken to surgery so that the cuts can be thoroughly cleaned out. The bone will typically be fixed during the same surgery.

Techniques. Surgery can be done under general anesthesia (going to sleep) or under regional anesthesia (using medicines like novocaine that numb the arm), or both.

During surgery the patient may lie on his/her back, side, or stomach. If the patient lies on his/her belly, the face (lips, eyelids) may be swollen for a few hours after the operation is over. This is normal and temporary. The surgeon will typically make an incision over the back of the elbow and then put the pieces of bone back together. There are several ways to hold the pieces of bone in place. The surgeon may choose to use:

Pins/wires Screws only Plates and screws Sutures ("stitches") in the bone or tendons

An olecranon fracture may be held together with a tension band fixation (illustration and X-ray).

Plates and screws may be used to hold the A single medullary screw keeps the broken bones in place. fractured bones together. If some of the bone is missing or crushed beyond repair (pieces of bone lost through a wound during an accident), the fracture may require bone filler. Bone filler can be bone supplied by the patient (typically taken from the pelvis) or bone from a bone bank (from a donor), or an artificial calcium-containing material. The incision is typically closed with sutures or staples. Sometimes, a splint is placed on the arm, but not always.

Considerations Surgery has some risks. If surgery is recommended, the doctor feels that the possible benefits of surgery outweigh the risks.

Infection. There is a risk of infection with any surgery, whether it is for an olecranon fracture or another purpose. Pain is associated with surgery. Pain is controlled in the operating room by an anesthesia team, who can either put the patient to sleep or numb the arm, or both. The doctor will discuss the method of anesthesia with the patient prior to surgery. After surgery, pain is controlled with a combination of pain medications. Damage to nerves and blood vessels. There is a minor risk of damage to nerves and blood vessels around the elbow. This is an unusual side effect.

Surgery does not guarantee healing of the fracture. A fracture may pull apart, or the screws, plates, or wires may shift or break. This can occur for a variety of reasons, including:

The patient does not follow directions after surgery. The patient has other health issues that slow healing, like smoking or using other tobacco products, or diabetes. If the fracture was associated with a cut in the skin (an "open fracture"), healing is often slower.

If the fracture fails to heal, further surgery may be needed. Rehabilitation Goals The eventual goal of treatment for an olecranon fracture is to regain full motion of the elbow, as it was prior to the injury. Most patients will return to normal activities (except sports and heavy labor) within about 4 months, although full healing can take more than a year. Many patients report that, although their X-rays show full healing, they are not at 100% but are improving over time. Techniques After surgery, the patient's elbow may be splinted or casted for a short period of time. The patient may wear a sling if it provides comfort. Pain medications may be

provided. The surgeon usually removes stitches or staples 10 to 14 days after surgery. The patient is often restricted from lifting objects with the injured arm for at least six weeks. Motion exercises for the elbow and forearm should begin shortly after surgery, sometimes as early as the day after surgery. Especially early after surgery, some patients may not be able to straighten their injured elbow on their own. To straighten the elbow, the patient needs to use his/her uninjured arm to help out, or assistance from another person. Full recovery from an olecranon fracture requires a lot of work. It is extremely important that exercises, once started, are performed multiple times a day, every day. Physical therapy will sometimes be prescribed. If so, the patient should still do exercises at home on days he or she does not work with the therapist. The exercises only make a difference if they're done regularly. Recovering strength often takes longer than expected; sometimes, 6 months or more. Restrictions on driving are generally based on the arm that is injured (the right arm is used for shifting, for example) and on use of pain medications. Narcotics, such as morphine or codeine, impair judgment and therefore they impair the ability to drive a vehicle just like alcohol does. Considerations Even after the fracture has healed, full motion of the elbow may not be possible. In most of these cases, the patient cannot fully straighten his or her arm. Typically, loss of a few degrees of straightening will not have an impact on how well the arm will work in the future, including for sports or heavy labor. Loss of a significant amount of motion may require intensive physical therapy, special bracing, or further surgery to correct this problem. This is uncommon for olecranon fractures. Elbow arthritis causes the elbow joint to become stiff and painful. It is an unfortunate, but relatively common, long-term outcome of olecranon fractures. Elbow arthritis can occur rapidly following an olecranon fracture, or it may take years to develop. It occurs if the lining of the elbow joint (cartilage) was damaged from the fracture, or if the fracture leads to the lining wearing away over time. Keep in mind that not everyone who breaks their olecranon will develop elbow arthritis. In addition, elbow arthritis is not always painful. It does not always limit an individual's ability to use the arm, and if it is not bothersome, it does not require medical treatment

http://www.orthofracs.com/adult/trauma/elbow/fracture-olecranon.html Olecranon Fractures Definition

Minimally Displaced Fracture of the Olecranon

Fracture of the Olecranon

Incidence

Classification Types of Olecranon Fractures 1. undisplaced 2. displaced a. avulsion b. transverse + oblique c. comminuted d. fracture / dislocations Mayo classification Mayo Classification of Olecranon Fractures

Type I II Undisplaced Displaced (> 3 mm) stable

Description

Displaced (> 3 mm) unstable III

Subgroup A - Non-comminuted Subgroup B - Comminuted

Aetiology

Direct trauma

Pathology

History

Mechanism of Injury

Examination

Look
o o

Bruising Swelling It patient in minimal pain, ask to extend elbow to check extensor mechanism

Move
o

Feel Special Tests o Neurological Examination Ulnar Nerve

Investigations

Xrays

AP, Lateral Usually enough information for decision making

CT Scan

Usually unnecessary Helpful to check for associated injuries o further fractures around the elbow

Treatment According to Mayo Classification Mayo Classification of Olecranon Fractures Type Type I A & B Type II a Type II b Type IIIa Type IIIb splint symptomatically TBW or AO cancellous screw Plate fixation (can excise fragment & advance triceps in older group) Rigid plates

Treatment

Plates vs external fixateur

Undisplaced Fractures in Adults

To be considered nondisplaced & stable o must be displaced less than 2 mm o and exhibit no change in position with gentle flexion to 90 or with extension against gravity

Immobilize o long-arm cast for 3-4 weeks o elbow at 90 o full extension not recommended because stiffness is likely, & if the fracture requires full extension for reduction it should be treated operatively Followed by protected range of motion exercises o avoiding flexion past 90 until bone healing is complete radiographically usually around 6 to 8 weeks Elderly patient o stiffness is a concern o ROM may be initiated earlier than 3 weeks

Displaced Fractures in Adults

Tension Band Wire of Olecranon Fracture

TBW with double twist o strongest method of internal fixation for these fractures o dorsal plate (positioned in tension) is also effective

Excision of Olecranon Fractures

Requirements o Intact coronoid & distal semilunar notch o Intact collaterals Technique o Excision of proximal fragment

Retention of collaterals o Suture triceps tendon to remaining bone flush with articular surface Can excise up to 80% of olecranon process Indications o old ununited fractures o fractures with extensive comminution that aren't amenable to ORIF o fractures in the elderly o nonarticular fractures o open fractures in which the soft tissues are of questionable viability Good results have been reported with excision of up to 50% of the olecranon & reattachment of the triceps.
o

Complications

Stiffness o reduced ROM - up to 50% have some loss of ROM - only ~ 3% have functional loss from this Nonunion / Malunion o Nonunion - ~5% If high demand patient - ORIF/ BG If low demand patient - may not need to do anything. Can excise the olecranon fragment with very good results ( as long as the coronoid & anterior soft tissues are intact to provide stability) Ulnar nerve neuritis Post-traumatic Osteoarthritis o rare as is a non wght bearing joint

Prognosis

After treatment patients typically lose around 10 of extension & 5 of flexion Hardware is painful in around 50%, but needs to be removed in around half of these Ulnar nerve neuritis & heterotopic ossification are relatively common (up to 2-13%)