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..