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Fracture, Olecranon

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Fracture, Olecranon
Greg Nakamoto
Basics
  • Issue of fundamental concern when evaluating fractures of the olecranon is determining whether the fracture is displaced or nondisplaced.
  • Nondisplaced fractures can be managed with immobilization.
  • Displaced fractures should be referred to an orthopedic surgeon for fixation.
Description
  • The olecranon is the curved process extending from the posterior proximal surface of the ulna. It forms a large portion of the articulating surface between the ulna and the trochlea of the humerus. The triceps inserts into the posterior third of the olecranon.
  • For a fracture of the olecranon to be considered nondisplaced and stable, it must be displaced <2 mm, must not change in position with gentle flexion to 90 degrees, and must not change in position with extension against gravity (1).
Epidemiology
  • Account for ∼10% of fractures of the adult elbow (1)
  • Olecranon fractures can range from simple nondisplaced fractures to complex fracture dislocations of the elbow (1).
  • Olecranon fractures are uncommon in children because early in life the olecranon process is short, thick, and relatively stronger than the distal humerus (2).
Risk Factors
  • Direct trauma, such as a fall onto the tip of the elbow, may cause a fracture directly and is most often associated with isolated injuries (1).
  • Indirect trauma, such as a fall onto the hand with the elbow partially flexed, may cause an avulsion owing to eccentric contraction of the triceps (1).
  • Fracture dislocation also is possible with a high-energy mechanism of injury. The olecranon fragment usually displaces posteriorly (1).
Commonly Associated Conditions
  • Ulnar nerve injury: Occurs in 2–5% of cases (2)
  • Discontinuity of the triceps mechanism
  • Fracture dislocation of the elbow
  • Open fracture
  • Can lead to chronic pain and arthritis
Diagnosis
History
Mechanism of injury (1):
  • A fall or blunt trauma to the posterior elbow may cause the fracture directly.
  • A fall onto an outstretched hand may cause a fracture indirectly, often through avulsion by the triceps.
  • A high-energy mechanism of injury increases the likelihood of fracture dislocation.
Physical Exam
  • Pain and swelling over the posterior elbow
  • Elbow effusion owing to the intraarticular component of the fracture
  • Painful and limited motion at the elbow
  • Determine if patient can extend the elbow against gravity. Inability to extend suggests either discontinuity of the triceps mechanism or a mechanical block. Either problem merits surgical consultation (1)[C].
  • Perform distal neurovascular examination. The ulnar nerve may be injured; more common in comminuted fractures (1).
  • Excessive soft tissue injury, swelling, or ecchymosis may influence the timing of surgery (1).
Diagnostic Tests & Interpretation
Imaging
  • Standard radiographs: Anteroposterior (AP), lateral, and oblique views (1)[C]
  • A true lateral view is necessary to evaluate for fracture displacement and articular disruption; slightly obliqued views are inadequate substitutes for a true lateral.
  • Fat pad signs: Collection of intraarticular fluid (eg, caused by intraarticular fracture) causes displacement and hence visualization of the fat pads around the elbow. The anterior fat pad sometimes may be visible in the normal elbow; the posterior fat pad usually is not visible on a normal lateral radiograph and may be the only radiographic evidence of occult fracture.
  • Children: Often helpful to obtain radiographs of the contralateral elbow for comparison
  • Good-quality standard radiographs as just listed are essential for accurate diagnosis, classification, and operative planning. In cases of isolated olecranon fracture, they also should be sufficient, and CT scan in such cases rarely provides additional information that alters decision making. CT scan generally is reserved for more complex fracture combinations (1,2)[C].
Differential Diagnosis
  • Radial head fracture
  • Coronoid process fracture
  • Olecranon bursitis
Treatment
  • There are several systems used for classification of olecranon fractures, including the AO classification, the Schatzker classification, and the Mayo classification. No single classification is used universally.
  • The Mayo classification is useful in determining whether an olecranon fracture should be treated surgically (1,2)[C].
    • Mayo type I fractures (undisplaced [<2 mm] ± communition) can be treated nonoperatively.
    • Mayo type II (stable fractures with >3 mm displacement) and type III fractures (unstable, displaced fracture dislocations) should be treated surgically.
  • In the specific case of avulsion fractures, treatment is generally operative (1,3)[C].
  • Reduction techniques:
    • Nondisplaced fractures: Unnecessary
    • Displaced fractures: Surgical reduction and fixation
    • Fracture dislocation: See “Elbow Dislocation.”
    • Immobilization of nondisplaced fractures: While it is generally agreed that stable nondisplaced fractures of the olecranon can be managed nonoperatively, there are varying protocols for the duration of strict immobilization.

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  • Traditionally, a more conservative approach treated all nondisplaced olecranon fractures in a long-arm cast with the elbow in 90 degrees of flexion for 3–4 wks, followed by protected range-of-motion exercises (1,2)[C].
    • Follow-up x-rays are obtained 5–7 days after cast application to ensure that displacement has not occurred.
    • Flexion past 90 degrees is avoided until complete radiographic bony healing at 6–8 wks.
    • To avoid excessive stiffness, elderly patients are allowed to start range of motion before 3 wks if pain allows.
    • Other authors advocate even earlier motion (3)[C].
    • Patient is immobilized at 90 degrees in a splint or cast for 7–10 days.
    • After 7–10 days, the patient starts gentle motion, beginning with pronation and supination.
    • At 2–3 wks, limited flexion and extension exercises can begin.
    • Flexion past 90 degrees can occur when radiographs show complete bone healing.
    • Repeat standard x-rays weekly until evidence of healing to ensure that there is no displacement requiring surgical referral.
Additional Treatment
  • Splinting: If there is a delay until definitive treatment can be accomplished, then temporary splinting may be done for patient comfort and protection.
    • Undisplaced fractures should be splinted with the elbow flexed at 90 degrees and hand in neutral position.
    • Displaced fractures should be splinted in a comfortable position with the elbow between 45 and 90 degrees and hand in neutral position; prompt orthopedic consultation should be obtained.
  • Elderly patients with undisplaced fractures: Because of their propensity to develop stiffness at the elbow, elderly patients should spend much less time immobilized. In patients most prone to stiffness, joint immobilization can be achieved with a sling initially, and careful range of motion can begin once the patient is comfortable as soon as a few days later.
  • Ice and oral analgesics are useful in the prehospital setting. Oral analgesics may be required for several days after casting.
  • Nondisplaced fractures: Protected range of motion advanced as described earlier. If the patient still has stiffness, then dynamic splinting and physical therapy referral for elbow range of motion may be of benefit.
  • Displaced fractures: Range of motion to be initiated as determined by the operating surgeon.
Surgery/Other Procedures
Referral is required for all displaced fractures, including avulsion fractures, unstable fractures, and fracture dislocations (1,2)[C].
Ongoing Care
Follow-Up Recommendations
  • Nondisplaced fractures (Mayo type I): Can be released to home in a splint or cast with follow-up x-rays in 1 wk
  • Displaced fractures: Disposition determined in consultation with an orthopedic surgeon
Complications
  • Loss of motion:
    • Typically 10–15 degrees of extension in isolated olecranon fractures (1)
    • Motion may improve somewhat for up to 2 yrs after injury (2).
  • Nonunion is reported in 1–5% of patients (1,2).
  • Heterotopic calcification occurs in 13–14% of patients (2).
  • Painful hardware requiring subsequent removal is one of the most common complications after internal fixation; reported in up to 80% of patients (1,2).
References
1. Veillette CJ, Steinmann SP. Olecranon fractures. Orthop Clin North Am. 2008;39:229–236, vii.
2. Pritchett J, Porembski M. (2006) Olecranon fractures. eMedicine. Retrieved Aug 11, 2009, from http://emedicine.medscape.com/article/1231557-overview.
3. Sanchez-Sotelo J, Barwood S, Blaine T. Current concepts in elbow fracture care. Curr Opin Orthop. 2004;15:300–310.
Additional Reading
Bartlett III C. Elbow fractures. Curr Opin Orthop. 2000;11:290–304.
Karlsson MK, Hasserius R, Karlsson C, et al. Fractures of the olecranon: a 15- to 25-year followup of 73 patients. Clin Orthop Relat Res. 2002;403:205–212.
Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr Course Lect. 1995;44:175–185.
Nork SE, Jones CB, Henley MB. Surgical treatment of olecranon fractures. Am J Orthop. 2001;30:577–586.
Rockwood C, Green D, Bucholz R, et al., eds. Rockwood and Green's fractures in adults, 4th ed. Philadelphia: Lippincott-Raven Publishers, 1996.
Schippinger G, Seibert FJ, et al. Management of single elbow dislocations. Arch Surg. 1999;384(3):294–297.
Codes
ICD9
  • 813.01 Fracture of olecranon process of ulna, closed
  • 813.11 Fracture of olecranon process of ulna, open
Clinical Pearls
  • The goal when evaluating fractures of the olecranon is determining whether the fracture is nondisplaced and stable versus displaced and/or unstable.
  • For a fracture of the olecranon to be considered nondisplaced and stable, it must be displaced <2 mm, must not change in position with gentle flexion to 90 degrees, and must not change in position with extension against gravity.
  • The assessment of stability and displacement usually can be made with standard radiographs and clinical examination. CT scan is rarely necessary for isolated olecranon fractures.
  • Stable, nondisplaced fractures (Mayo type I) can be treated nonoperatively. Other fractures merit orthopedic consultation for consideration of surgical treatment.
  • Physician response to common patient question:
    • How long do I need to wear this cast/sling?
      • Nondisplaced fractures: In the case of a stable fracture in a reliable patient, immobilization is for comfort and can be discontinued after initial pain and swelling have resolved in 7–10 days (even less in the elderly patient prone to stiffness). If the patient is at particular risk for displacing an otherwise stable fracture, immobilization in a long-arm cast for up to 3 wks may be required.
      • Displaced fractures: Depends on the extent of injury and type of repair required


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