Olecranon Fractures Treatment & Management

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.

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.^{[4, 6, 8, 9, 10, 11, 12]}

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.^[13]

When determining the appropriate surgical approach, consider patient age, health, bone quality, fracture pattern, and ligamentous stability.

Excision of fragment and triceps advancement

Excision of the fracture fragment and reattachment of the triceps tendon may be indicated in a select group of elderly patients with osteoporotic bone in whom the olecranon fracture involves less than 50% of the joint surface or when the fragment is too small or comminuted for successful internal fixation.^{[8, 12, 14, 15]}

Integrity of the collateral ligaments, intraosseous membrane, and distal radioulnar joint must be established before considering excision; otherwise, instability can result. The triceps is reattached with nonabsorbable sutures that are passed through drill holes in the proximal ulna. The drill holes are placed such that the triceps will insert just off the articular margin of the olecranon articular surface, in essence extending the articular margin.

Weakening of the extensor mechanism is a drawback of excision and triceps advancement. However, comparison of the isometric strength of patients treated by excision with those who had internal fixation showed no differences. Excision and triceps advancement may be followed by immediate motion if the suture repair of the triceps is secure.

Tension band wiring

A tension band wire is the most common fixation technique for simple fractures. The goal is to convert the extensor force of the triceps to a dynamic compression force along the articular surface. In this technique, a direct straight posterior incision is used with the patient supine with the arm across the chest or, occasionally, in the prone position.^{[12, 16, 17]}

Two smooth K-wires are placed through the triceps tendon into the olecranon with great care made to bury the wires beneath the tendon and firmly impact them into the bone. Otherwise, the wires certainly will migrate posteriorly and can become an irritant or possibly a source of infection. The key is to place the tension band wire as dorsally as possible on the surface of the olecranon, as shown in the image below.

K-wires help to hold the tension band wire in place as it loops around the tip of the olecranon. A drill hole through the ulna at 1-2 cm distal to the articular surface provides the distal fixation point. Placing 2 knots in the 18-gauge wire results in more rigid fixation than a single knot and provides symmetrical tension at the fracture site.

Plate fixation

Plate fixation is most commonly recommended for comminuted fractures for which tension band wire fixation is not feasible. It also is indicated for fractures that involve the coronoid process and for those associated with Monteggia fracture dislocations of the elbow. Some authors have used one-third tubular, dynamic compression, or pelvic reconstruction plates for comminuted fractures. The proximal end of the one-third tubular plate can be modified to make a hook-plate that provides additional fixation for small fragments. The subcutaneous location of the hardware raises concerns about prominence necessitating subsequent removal of fixation.^{[18, 5]}

Do not narrow the olecranon-to-coronoid distance. Restore it to within a few millimeters of the correct anatomic distance. Bone grafting sometimes is necessary. The last hole in the plate where it has been bent to make a hook provides a good location for an intramedullary screw.

Intramedullary screw fixation

Use of a single large-diameter cancellous screw for repair of olecranon fractures has been advocated for a long time. The Rush brothers wrote that intramedullary insertion of a Steinmann pin was the beginning of the Rush pin technique of fracture fixation in 1936. They claimed this to be the first American case of intramedullary pinning. They found that Steinmann pins were difficult to use and designed their own pins. When 6.5-mm AO-ASIF screws became available, they were used more commonly.^[11]

In the frontal plane, 4° of valgus angulation exists between the ulnar shaft with respect to the sigmoid notch, as is shown in the image below. When intramedullary screws are used, take care to properly place the screw along the intramedullary shaft axis to avoid displacement of the fracture. With the advent of cannulated screws, it is much easier to correctly place the screw in the medullary canal of the ulna simultaneously, accommodating for the bow in the ulna and achieving anatomic reduction. The 7.3-mm cannulated AO screws are the most secure. Also, screw fixation is probably the easiest technique.

Biomechanically, screw fixation does not provide as secure a fixation as tension-band wiring. However, by adding a tension band around the screw, excellent fixation can be obtained. The most secure technique is placement of a large-diameter cannulated screw with a braided cable, as shown in the images below. A 1.6-mm cable is adequate and much stronger than an 18-gauge wire.

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.

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.

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.

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.