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Olecranon Fracture

  • The olecranon:
    • Is the proximal bony projection of the ulna at the elbow
    • Articulates with the trochlea of the distal humerus to form the ulnohumeral portion of the elbow joint:
      • This articulation is responsible for flexion and extension of the elbow joint.
    • Is the insertion site of the triceps tendon
  • Contraction of the triceps pulling on the olecranon produces extension of the elbow.
  • Fracture of the olecranon disrupts the extensor mechanism of the elbow, which is critical to arm function.
  • If these intra-articular fractures are not repaired anatomically, posttraumatic arthritis will develop.
  • Classification:
    • By characteristic
      • Nondisplaced or displaced
      • Transverse or oblique
      • Simple or comminuted
    • By the amount of involvement of the articular surface in the olecranon notch
      • Type 1: Proximal 1/3 of the notch
      • Type 2: Middle 1/3
      • Type 3: Distal 1/3
General Prevention
Elbow pads should be used for contact sports and skating.
  • Olecranon fracture may occur after a fall, sports injury, or motor vehicle accident.
  • Elderly or osteoporotic patients may sustain an olecranon fracture after a low-energy fall.
  • Olecranon fractures occur less frequently in children than in adults because in children, this type of force is more likely to produce a fracture of the distal humerus (supracondylar).
Risk Factors
Activities with high fall rates, such as inline skating, have a high risk of elbow fractures.
  • The most common mechanisms of injury are:
    • Fall on the outstretched hand with the elbow in flexion
    • Direct blow to the tip of the elbow
Associated Conditions
  • Elbow dislocation
  • Radial head fracture
  • Triceps avulsion
  • Elbow instability
  • Neurologic damage (ulnar, median, and radial nerves)
Signs and Symptoms
  • Pain, swelling, ecchymosis, and deformity of the elbow
  • Inability to extend the elbow
  • These injuries often are associated with radial head fractures and elbow dislocations.
History should be obtained to determine the mechanism of injury.
Physical Exam
  • Initial evaluation should include particular attention to the function of the triceps muscle, the function of the radial and ulnar nerves, and the vascular status of the upper extremity.
  • Palpable defect often detected on posterior elbow
  • Test for triceps mechanism integrity by asking the patient to actively extend the elbow against gravity.
  • Examine the degree of soft-tissue injury and determine whether the fracture is open or closed.
Before surgery, routine preoperative laboratory tests are performed, depending on the age and medical condition of the patient.
  • Radiography:
    • Obtain AP and lateral radiographs of the elbow.
    • A radiocapitellar view may be helpful if there appears to be an associated radial head injury.
  • Obtain a CT scan of the elbow to evaluate complex fracture dislocations of the elbow.
Differential Diagnosis
  • Distal humerus fracture
  • Elbow dislocation
  • Radial head fracture
General Measures
  • Nondisplaced fractures are treated with immobilization in an above-the-elbow splint or cast with the elbow in 90° of flexion for 4 weeks.
  • Follow-up radiography is necessary 7-10 days after injury to ensure that the fracture has not displaced.
  • Displaced fractures usually require surgical fixation to restore extensor mechanism function.
  • After fracture, the arm should be splinted comfortably at 90° of flexion, and a sling should be offered.
  • Patients should be encouraged to move the hand and shoulder to prevent stiffness.
  • Patients in a sling should be helped with personal hygiene in the armpit area.
  • Care should be taken that the splint is comfortable and does not rub.
Special Therapy
Physical Therapy
  • Initially, strengthening and gentle passive ROM exercises to address the common sequelae (decreased ROM and muscle strength) of elbow immobilization after olecranon fractures
  • Gradually progress to active ROM exercises when radiographic evidence shows callus formation and fracture healing.
  • Motion of the ipsilateral shoulder and hand should be encouraged.
First Line
Narcotic medicines may be necessary for pain relief after fracture.
  • Most olecranon fractures are treated surgically because they disrupt the extensor mechanism.
  • Fractures must be repaired anatomically to restore the joint surface.
  • Choice of repair technique depends on the size of the fragment, the direction of the fracture line, and the amount of fracture comminution.
    • Stable, nondisplaced fractures may be treated nonoperatively.
    • Displaced fractures require open reduction and fixation.
    • Open fractures should be treated with surgical débridement and fixation.
    • Small avulsion fractures are treated with excision and repair.
      • The triceps tendon is sutured back to the olecranon.
      • Bone removal does increase joint pressures and, if possible, bony fixation should be attempted.
    • Transverse fractures are repaired using 2 Kirschner wires and a tension band wire to resist the pull of the triceps muscle.
    • Oblique fractures may be repaired using interfragmentary screw fixation and an accompanying tension band wire.
      • Fixation with screws has been shown to be stronger than that with tension band wires.
    • Severely comminuted fractures are not amenable to tension wiring and require fixation with plating.
      • A 3.5-mm reconstruction plate can be bent to fit the olecranon, or a precontoured plate can be used.
    • Fractures with bone loss may require bone grafting to repair defects.
After surgery, the arm is splinted until skin healing occurs, and then early ROM exercises are started.
  • The prognosis is good for >90% of patients.
  • Fractures with more articular involvement and more severity have been shown to have worse outcomes.
  • Painful hardware requiring removal occurs in 20-80% of patients.
  • Radial neuropathy
  • Ulnar neuropathy
  • Flexion contracture
  • Elbow arthritis
  • Malunion
  • Nonunion
Patient Monitoring
  • Patients should be monitored until fracture healing is observed radiographically.
  • ROM of the elbow and strength of the arm should be monitored.
  • 813.01 Closed olecranon fracture
  • 813.11 Open olecranon fracture
Patient Teaching
  • Even with a perfect reduction, patients may still have decreased ROM.
  • Patients often lose 5-10° of extension.
Until fracture healing, patients should limit lifting with the arm.
Individuals involved in sports with high risks of falls, such as skating or rollerblading, should use elbow pads.
Q: How long do olecranon fractures take to heal?
A: Fracture healing usually occurs in 2-3 months. Additional therapy is required to strengthen the arm over the next 3 months.

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