Olecranon fracture

The mechanism behind these fractures is often related to a direct or indirect blow to the elbow. A direct blow, such as from an object, usually results in a comminuted fracture where the bone breaks into several fragments. An indirect blow occurs when an individual falls on his or her hand with the arm outstretched, transmitting force to the olecranon and leading to transverse or oblique fractures of the olecranon. In some cases, olecranon fractures may be associated with a transolecranon dislocation fracture. This occurs when severe axial loading is applied to the elbow joint, resulting in potential instability of the humero-ulnar joint due to the severe intra-articular comminution of the fracture. In this situation, the ulna is dislocated anteriorly to the humerus and there is no rupture of the proximal radio-ulnar joint.

Patients usually experience localized pain on the back of the elbow. This pain may worsen with movement or pressure on the affected area. On physical examination, a palpable defect may be present, indicating a displaced fracture or severe comminution of the olecranon. Another important finding is the inability to fully extend the elbow, usually due to discontinuity of the triceps extensor mechanism.

When assessing an olecranon fracture, imaging plays a crucial role. The recommended initial imaging modality is radiography, which provides essential information regarding displacement and alignment. In some cases, where there is a complex or comminuted fracture pattern, a CT scan may be recommended. This provides a detailed three-dimensional visualization of the fracture fragments, facilitating preoperative planning. It helps assess the degree of comminution, the involvement of articular surfaces and the alignment of fragments, which can guide surgical decision-making.

Treatment can be either non-operative or operative, depending on a variety of factors. Conservative treatment is generally considered for non-displaced fractures with an intact extensor mechanism, or for displaced fractures in elderly patients with low demand. Immobilization is a key element of treatment, enabling the fracture to heal without the need for surgery. The elbow is placed in a cast or splint, usually at 45-90 degrees of flexion initially. After a period of about a week, gentle movement exercises are initiated to prevent stiffness and promote functional recovery.

Surgical options are available, depending on the characteristics of the fracture and the patient. A commonly used technique is tension band wiring, which is indicated for transverse fractures without comminution. This technique involves the placement of a wire to convert tensile forces into compressive forces, promoting fracture stability and healing. The results of this technique are generally excellent when the appropriate indications are followed.

Intramedullary fixation is another option for non-comminuted transverse fractures, similar to the tension band technique. In this method, a specially designed intramedullary nail or screw is inserted into the medullary canal of the ulna to provide stability and promote healing.

Plate and screw fixation is indicated for comminuted fractures, Monteggia fractures (associated fracture of the proximal ulnar shaft and dislocation of the radial head) and fracture-luxations. It is also used for oblique fractures extending distally to the coronoid process. Plate-and-screw fixation involves the use of metal plates and screws to fix fracture fragments and restore stability.

Excision of the fractured fragment and advancement of the triceps may be considered when the fracture involves less than 50% of the articular surface, in elderly patients with osteoporotic bone, or in cases of pseudarthrosis. The procedure is designed to relieve pain and improve function, particularly in people who may not tolerate or benefit from other surgical techniques. However, it should be noted that this technique may result in reduced extension strength and potentially lead to instability if concomitant ligament damage is not diagnosed and treated prior to surgery.

Despite appropriate treatment, olecranon fractures can be associated with a variety of complications. Irritation or discomfort caused by implants is the most frequently reported complication, but this does not necessarily require removal and can often be managed conservatively. Stiffness is another frequent complication, occurring in around 50% of patients, and although it can limit range of motion, it generally has no significant impact on functional capabilities. Post-traumatic arthritis is another possible complication, and can occur as a result of damage to the articular surface and subsequent degenerative changes, leading to chronic pain and reduced joint function. Pseudarthrosis, although rare, is a potential complication where the fractured bone does not heal, which may require further intervention. Symptoms in the ulnar nerve territory may occur due to compression or traction of the nerve during surgery. These symptoms may include numbness, tingling or weakness in the hand and fingers, but often resolve spontaneously. Injury to the anterior interosseous nerve is possible, and may result in weakness or paralysis of specific muscles in the hand and forearm. Finally, loss of extension strength may be observed in cases of triceps tendon rupture or inadequate surgical repair.

To minimize the risk of complications, appropriate treatment, careful surgical technique and thorough post-operative rehabilitation are essential. Regular follow-up visits are important to monitor and promptly treat any potential complications.