Olecranon Fracture

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Definition/Description

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Olecranon fractures frequently occurs with elbow disorders. These fractures are regarded as one of the simplest articular lesions and its operative and physiotherapeutic treatment are straightforward. These fractures are mostly intra-articular and are generally associated with joint effusions and hematomas. Extra-articular fractures include avulsion fractures and are most commonly seen in the elderly.

Clinical relevant anatomy

The elbow joint are made up of the following joints:

• Ulna-humeral joint:
  • Function: Stability; elbow flexion/extention
• Radio-humeral joint
  • Function: Lateral stability; forearm pronation/supination
• Proximal radio-ulnar joint
  • Function: Forearm pronation/supination

Olecranon function:

• Insertion point for triceps, thus plays important role in extensor mechanism of the elbow.
• Major articulation for elbow joint

Epidemiology/Etiology

Mechanism of injury

• Direct:
  • Fall on the forearm
    • The olecranon is forced into the distal humerus by hyper-extending the elbow on an outstretched hand
  • Penetrating injuries affecting the articular surface (e.g. panga wounds)

• Indirect: Through triceps contraction
  • The contraction of the triceps avulses the olecranon and tears the distal triceps expansion
  • Sportsmen (e,g. wrestlers and gymnasts) that generate a lot of isometric arm power (e.g. wrestlers and gymnasts) are at risk

Characteristics/Clinical presentation

Clinical presentation

Patients with a broken olecranon are unable to extend their arm.

Classification

The Mayo classification system of olecranon fractures are based on the displacement of the olecranon, comminution and elbow stability. There are 3 types of fractures, each with two subtypes.

• Type I:  Non-comminuted and minimally comminuted fractures
• Type II:  Displaced fracture with intact ulnar collateral ligaments
  • Displaced vs non-displaced
  • Stable fracture

• Type III:  Fracture with disruption between the forearm and the humerus
  • Displaced vs non-displaced
  • Unstable as a result of the disruption of the medial collateral ligament

Diagnostic procedures

Physical examination

• Subjective interview:
  • Mechanism of injury: Direct blow to the elbow
  • Complaints:
    • Pain over elbow
    • Inability to extend elbow
• Observation:
  • Deformity:
    • Obvious around elbow
    • Forearm appears shorter
    • Distortion of bony landmarks of elbow
  • Swelling
  • Bruising
• Palpation:
  • Tender over tip of olecranon and proximal ulna
  • Palpable gap at fracture site
• Range of motion: Limited elbow extension
• Neuromuscular examination of the hand to rule out concomitant

Special investigations

• X-rays: AP and lateral views
  • Rule out concominant injuries

Medical management

Management of olecranon fractures depends on displacement, comminution , and elbow stability. Primary elbow instability and fracture morphology are prognostic factors for elbow function and development of arthrosis after operative treatment. The goal of this management is to restore the extensor mechanism of the elbow, and recon

• Type I: 2 weeks immobilization and symptomatic treatment
• Type II + III: Require surgical fixation.

 

Surgical intervention

• Tension band wiring fixation:
  • Indication:  Non-comminuted transverse fractures involving less than half the articular olecranon surface
  • Complications:
    • Loss of fixation
    • Non-union
    • Skin breakdown
    • Infection
    • Olecranon bursitis
    • Radial head subluxation
    • Prominent hardware

• Plate fixation (more stable):
  • Indication:  Comminuted fractures
  • Good outcomes with regards to union and the prevalence of hardware complications

• Intramedullary screw fixation:
  • Indication:  Simple, non-comminuted transverse fractures:  Intramedullary screw fixation
  • Improved pain, function, and range of motion when compared to tension band wiring

• Olecranon exision and/or the triceps advancement-technique:
  • Indication:  Articular surface is too comminuted or osteoporotic for fixation (elderly/low-demand patients).
  • To decrease the risk of instability, the following criteria also applies -  Intact:
    • Medial collateral ligament
    • Interosseous membrane
    • Distal radioulnar joint
    • Method:  The triceps tendon is reattached to the proximal edge of the articular surface.

Surgical management

The following process can be followed post-operatively:

• Week 1: A splint or cast is applied for fixation, in 60° elbow flexion to minimize tension on the skin. The physiotherapist has to check for capillary refill, sensation ,active and passive range of motion of the digits, excessive swelling.Active range of motion of the shoulder, the hand and the digits (with splint) may begin. The digits and hand may be edematous as a result of the fracture. After 3 to 4 days, isometric exercises to the wrist are started and gentle active elbow flexion and active range of motion of the wrist can begin (without splint).
  The patient may use the uninvolved extremity for self-care activities.
• Week 2: Bone healing is now in the reparative phase. There’s none to minimal stability in the elbow. Extension to the elbow less than 90° is not permitted in a cast or splint.
  In most cases, the splint or cast is now definitive removed. The physiotherapist begins with gentle isometric exercises of the biceps and isotonic exercises to the digits.
• Week 4-6: The fracture is partially stable. Active and active-assistive range of motion to the shoulder, elbow, and wrist have to be continued. Passive range of motion at the elbow has to be avoided. Isometric exercises to the elbow and wrist in flexion and extension are now permitted. The patient uses the affected extremity for stability and light self-care.
• Week 8-12: If the fracture is clinically and radiographically healed, the patient may progressively bear weight to begin resistive exercises to elbow flexors and extensors. The physiotherapist has to continue active and active-assistive range of motion to the elbow and wrist in all planes until satisfactory range is achieved. There may be some limitations in elbow extension. Gentle passive stretching may be necessary. A dynamic splint may be used for passive elbow stretch.

Complications

Possible complications with olecranon fractures and surgery thereof, include:

• Permanent extension loss
• Heterotophic ossification

Physiotherapy management

Precise post-operative care is very important for maximum healing. The functional goal of the physiotherapist is to restore and normalize activities of daily living. Rehabilitation and bone healing will take approximately 12 weeks:

Week 1

Inflammation phase:

• A splint or cast is applied for fixation, in 60° elbow flexion to minimize tension on the skin
• Assess capillary refill, sensation, active and passive range of motion of the digits, excessive swelling
• Commence active range of motion of the shoulder, hand and digits (splint to be kept on)
• Oedema management
• After 3 to 4 days:
  • Isometric exercises of the wrist
  • Gentle active elbow flexion (without splint).
  • Active range of motion of the wrist
  • Teach patient functional adaptions, e.g. to use the uninvolved extremity for self-care activities

Week 2

Reparative phase: None to minimal stability in the elbow.

• Extension to the elbow < 90° is not permitted in a cast or splint
• Splint or cast removed in most cases
• Gentle isometric exercises of the biceps
• Isotonic exercises to the digits

Week 4-6

Fracture now partially stable:

• Active and active-assistive range of motion to the shoulder, elbow and wrist
• Avoid passive range of motion at the elbow
• Isometric exercises to the elbow and wrist in flexion and extension
• Activities of daily living: Uses the affected extremity for stability and light self-care

Week 8-12

If fracture is clinically and radiographically healed:

• Progressively weight bearing through affected limb
• Resistive exercises to elbow flexors and extensors
• Active and active-assistive range of motion to the elbow and wrist in all planes (until satisfactory range is achieved)
• There may be some limitations in elbow extension:
  • Gentle passive stretching may be necessary
  • Dynamic splint may be used for passive elbow stretch.