Fracture, Olecranon

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Olecranon
Greg Nakamoto
  • 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.
  • 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).
  • 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
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
  • 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
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
  • 813.01 Fracture of olecranon process of ulna, closed
  • 813.11 Fracture of olecranon process of ulna, open

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