Olecranon fractures

Canadian Shoulder and Elbow Society Residents course

Dr. Michael LapnerAssistant Clinical Professor

February 2017

I, Michael Lapner declare that in the past 3 years:

I have received manufacturer funding from the following companies*: No

I have done consulting work for the following companies*: No

I have done speaking engagements for the following companies*: None

I or my family hold individual shares in the following*: None

*pharmaceutical or medical/dental equipment 2

Declaration of Conflict of Interest

Olecranon Fractures - Objectives

• Principles of olecranon fractures management

Objectives – Olecranon Fractures

• Anatomy• Clinical Evaluation• Classification• Treatment options• Post-op Protocol• Evidence

Anatomy of the Olecranon

• Trochoid joint• Stability

– Osseous– Soft tissue

• Important angles– # 9 ° varus– PUDA 5.7 °b Bare spot

Athwal et al, JSES 2010

PUDA

Ozsoy, SRA, 2014

Varus angulation

• With a straight dorsal plate– plate extends radially off

the ulna, and slightly dorsal

Pichler et al., JSES 2007

Anatomy olecranon

• POH = 25 mm• MOH = 17 mm• AOH = 33 mm

Ozsoy, SRA, 2014

Epidemiology of proximal ulna fractures

• 10% of upper extremity fractures involve olecranon

• Bimodal– Younger, higher energy– Older patients

• 22% associated ipsilateral limb injuries– Ie Proximal radius

• Open fractures 6%

Duckworth 2011

History Olecranon Fractures

• Direct blow• Acute tension (overload)• Chronic overload

Physical Exam Olecranon Fractures

• Document skin condition• Nerve status

– Ulnar

• Assess extensor mechanism (if non op)

Imaging Studies Olecranon Fractures

• Radiographs• AP, Lateral, obliques

• CT if required / intra articular comminution

Biomechanics of tension band

AO

ClassificationsSchatzker

Mayo

AO

Classification of Olecranon #’s• AO

– A (extra articular)– B (intra articular)– C (intra articular both radial head/olecranon)

• Morrey (Mayo)– I (undisplaced / minimal comminution)– II (displaced / stable joint)– III (displaced / unstable)

• A | B = no comminution / comminution• Schatzker; six types

– A simple transverse– B transverse depression central– C simple oblique– D comminuted– E olibique distal to mid point of trochlea– F associated radial head

• Colton– Undisplaced and displaced

• Tension band– 18 gauge wire | braided heavy suture– K-wires or 7.3 mm screw

• Open reduction internal fixation with plate & screws

• Intramedullary nail

Surgical treatment options

Indication

• Most olecranon fractures are treated operatively• If stable

– Extensor mechanism intact, or low demand/elderly• Meticulous follow up, watch for displacement

• Principles of treatment– Obtain reduction– Maintain reduction– Mobilize– Preserve vascularity

Surgical technique Olecranon Fractures

• Position– Supine or lateral– Well padded elbow support

• Longitudinal, posterior incision– Small full thickness fasciocutaneous flaps to

expose olecranon– Slightly off midline around olecranon

Surgical Technique Continued

• Once exposure has been obtained• Obtain the reduction

– Use of reduction clamps– Dental picks– Temporary k-wires – Relax triceps

• Maintain reduction– Plate/tension band

Surgical technique

• K-wire technique• 2 small splits in triceps• Advance k-wire

– Tamp end with mallet, bury– Maintain long k-wire in medullary canal

• Pass 18 gauge tension band wire– 2 fracture length distal to primary fracture line– Keep 18 gauge wire on bone

Tension band pearls

• K – wires – if advanced past anterior cortex– Risk synostosis– Risk of nerve injury

• AIN

• Intramedullary safer• risk of backing out

– Van der Linden et al. (2012) JSES showed less migration with advance past second cortex

Surgical technique• If using screws

– 6.5 mm cannulated– Proximal ulna is bowed– Start slightly lateral to midline

• Risk displacement if medial

– Drill 3.2 mm then 4.5 mm– Split triceps, bury, tension band

Rossenwasser 2014 JHS

Surgical technique plating

• Obtain reduction• Maintain

– Apply plate, split triceps for placement– Make use of oblong hole distally

• Screw distally in hole

– Insert locking screws in proximal fragment • Compress fracture using screw in oblong hole as

– ‘push/pull’ device

– Insert remaining screws

Complex intraarticular cases• Some pearls• Recognize them• Pre-op CT if required• Freer to elevate intraarticular fragments• C-arm• Small tamps/bone graft if needed• Multiple threaded k-wires (cut within bone)• Plates & screws to secure / home run screw• Do not over compress

– Do not throw out osteoarticular fragments, fix them or use graft

Edwards, 2013 JHS Am

77 yo M

Triceps advancement

• Low demand/poor bone quality– Triceps advancement

• Greater than 50% of notch remains

• Evidence from HULC– 12.5 % removal of olecranon can have adverse

biomechanical effects

Gartsman 1981 JBJS (Am)Bell, Fereira 2010

Closure

• Close thick fasciocutaneous flaps• 2-0 vicryl• 3-0 prolene / nylon for skin

– Horizontal mattress

Rehabilitation

• Most surgeons– Extension splint 7-10 days– Begin AROM / PROM– Progress until 6 weeks, then AAT

• Is there any science behind this?– 5 plates compared, cadaver– Is pull out strength for ‘push – up’ from chair

adequate?– All failed, at 4.4 kg

• Less than 6.6 kg theoretical needed

Edwards et al., 2011 JOT

OutcomesNon-operative treatment?

• Non operative treatment of low demand, elderly patients– Displaced fractures (mayo II)– Mean age 78– Short term FU

• 72 % excellent results• 78 % non-union

– Long term FU• 91 % satisfied• 17 % weak/inability to push up from chair

– Mean 6 year FU

Duckworth 2014

Outcomes Plating

• Outcomes after plating for displaced olecranon fractures

• PeriLock S&N• 163 (19 lost)• DASH after six months

– 10• 40 % lack of full extension (at least 10°)• 67 % asymptomatic hardware• 20 % pain with leaning• 15 % hardware removal

– Prominent corner screw associated with removal

James (Injury) 2016

Outcomes Tension band wires

• n=62, age 49, FU 9 yrs• 82 % hardware removal• Pin migration not affected by anterior cortex position• MEPS

– 86% good/excellent– 10% fair– 5% poor

• Satisfaction – 9.3/10

Pournaras, JOSR, 2008

So which is better PF or TBW?

• One RCT reported outcomes.. 41 patients• 19 TBW vs 22 PF• PF longer OR time• ROM same at 6/12• Metal prominence 42% TBW vs 5% in PF

– K-wire migration only in 1 patient• Loss of reduction 53% TBW, vs PF 5%

– Articular step off• Clinical outcomes TBW 37 % good, vs 63% PF

Wiss, CORR, 1992

So which is better PF or TBW?• Similar outcomes between both• Retrospective design

– 48 patients, 23 TBW, 25 hook PF– No difference in demographics, MAYO # type, FU

• PF less terminal extension (9 vs 4 degrees)• Longer time to radiographic union with plates

– 19 vs 12 weeks• No differences in

– Hardware– MEPI– Clinical outcomes

• Reoperation 2 per group

Egol et al, 2016, EJOST

So which is better PF or TBW?• Cochrane review 2014

– Insufficient evidence to draw robust conclusions on the relative effects of the surgical interventions evaluated by the included trials.

– Further evidence, including patient-reported data, on the relative effects of plate versus tension band wiring is already pending from one recently completed RCT.

– Further RCTs, using good quality methods and reporting validated patient-reported measures of function, pain and activities of daily living at set follow-ups, are needed, including checking positive findings such as those relating to the use of an intramedullary screw and the cable pin system.

– Such trials should also include the systematic assessment of complications, further treatment including routine removal of metalwork and use of resources.

Are wires better than suture?

• Cadaveric study– Wires (18 gauge) vs fibrewire (#5)

• No difference in failure with tension band technique

• Brink et al. 2013 injury, tension band wiring vs plates– TBW - not really dynamic principle of osteosynthesis– TBW ‘negligable’ compression during active extension– Plates had much better compression

• There is variability in proximal ulnar morphology– Even tension band plates are variable, and some

‘precontoured plates need to be bend to accommodate the patient

Take home points

• Olecranon anatomy– Varus angulation, and PUDA

• Most are operative– Elderly, or intact extensor mechanism non op

• Understand AO principles– Restore the sigmoid notch

• Outcomes of plate vs wires?– TBW probably for simple fractures patterns– If more complex/comminuted, consider PF– Best evidence does support one method over another

Take home points

• Olecranon anatomy– Restore notch, varus angulation, and PUDA

• Most are operative– Elderly or intact extensor mechanism non op

• Understand AO principles• Outcomes of plate vs wires?

– TBW probably for simple fractures patterns– PF if more complex/comminuted– Best evidence does not support one method

Cases

• What about cases with small / comminuted proximal fragments?– Suggest augment repair with heavy braided suture

to repair

Intraarticular comminution

Cases - malreduction

• Olecranon step

Cases -

• Avulsion of MCL/LCL– Rare– Reduction / stabilize to plate/bone tunnels

Pearls

So which is better plate or tension band?

• Maybe both..