Olecranon fractures

Classification

There is no universally accepted classification system.

Colton apparently was the first author to classify these fractures, the AO Group offer the comprehensive classification of all fractures.

Mayo Classification

The Mayo system describes fractures based on stability, displacement, and comminution.

Type I fractures are undisplaced, type II are displaced and stable, and type III are displaced and unstable. Each is divided into subtype A (noncomminuted) or B (comminuted).

Type I:

Undisplaced fractures: In an undisplaced fracture, it matters little whether a single fragment or several fragments are present; thus, non-comminuted (Type-IA) and comminuted (Type-IB) fractures may be considered to be essentially the same lesion.
Type II:

Displaced, stable fractures: In this pattern, the fracture fragments are displaced more than 3 mm, but the collateral ligaments are intact and the forearm is stable in relation to the humerus. The fracture may be either non-comminuted (Type IIA) or comminuted (Type IIB).
Type III:

Displaced, unstable fractures: The Type-III fracture is one in which the fracture fragments are displaced and the forearm is unstable in relation to the humerus. This injury is really a fracture-dislocation. It also may be either non-comminuted (Type IIIA) or comminuted (Type IIIB).

Treatment

Undisplaced stable fractures are treated non operatively.

Displaced fractures require surgery to restore articular congruity, re-establish the elbow extensor mechanism, and prevent nonunion. However, conservative treatment can be considered in the frail elderly patients with displaced fractures. (Parker)

Several surgical treatment options exist for displaced fractures:

Tension-band wiring
Screw fixation
Plate fixation
Resection and re-attachment of the triceps

Type I: Undisplaced Fractures

Treat symptomatically, immobilize for 7 to 10 days, followed by motion as tolerated.
Under the very uncommon circumstance in which the patient cannot chance a non-union or displacement, open reduction and internal fixation might be considered. This method of treatment provides absolute stability to a fracture fragment that is displaced 2 to 3 mm, and thus it allows immediate motion with confidence. Typically, however, such treatment is not necessary.

Type II: Displaced, Stable Fractures

Type IIA (displaced non comminuted is the most common injury pattern.)

Treatment is with tension band wiring. Several biomechanical studies have been done on variations of tension band wiring.
Type-IIB (dislaced stable comminuted fracture)

Treatment depends on the age of the patient.

For physiologically elderly patients (>60 yrs of age) fragment excision and re-attachment of triceps is advocated. Care should be taken to reattach the triceps tendon as closely as possible to the articular surface of the ulna. Use of this technique virtually ensures that a second operation will not be necessary, and the functional result of this method is comparable with that of fixation.
In younger patients a contoured compression plate is advocated. Mild comminution may be treated with a tension-band wire.

Type III: Unstable, Displaced Fractures

Type-III fractures are extremely difficult to treat.

Type IIIA (unstable, displaced, no comminution)

Rigid fixation is essential using screws and a contoured neutralization plate. Special precontoured plates have been designed for this purpose. A distraction device to neutralize the force on the fracture may be added. (Hinged external fixator)

Type IIIB (unstable, displaced with comminution)
This is the most difficult type to treat. Plate fixation alone may not be enough. In this setting a distraction device is particularly helpful, if not essential. The distraction device helps neutralize forces across the fracture, provide added stability and allow some controlled elbow motion.

Approach to olecranon

Tension band wiring (click here)

Outcome

The results of the treatment of an uncomplicated olecranon fracture are quite good, with a union rate > 95%

Complications include

Metalwork removal
Ulnar nerve parasthesia
Non-union
Typically patients lose 10 to 15° of extension.
Loss of more than 10° of flexion is uncommon.
Ectopic ossification is occasionally seen, usually associated with a severe soft tissue injury, head injury or multiple operative procedures.

Long term follow up following olecranon fracture shows degenerative change in more than 50% of cases.

References

Morrey, B. F. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Current Concepts in the Treatment of Fractures of the Radial Head, the Olecranon, and the Coronoid. Journal of Bone & Joint Surgery - American Volume. 77-A(2):316-327, February 1995.

Wu, Chi-Chuan MD; Tai, Ching-Lung MS; Shih, Chun-Hsiung MD Biomechanical Comparison for Different Configurations of Tension Band Wiring Techniques in Treating an Olecranon Fracture. Journal of Trauma-Injury Infection & Critical Care. 48(6):1063-1067, June 2000

Moed, Berton R; Ede, David E; Brown, Thomas D. Fractures of the Olecranon An In Vitro Study of Elbow Joint Stresses after Tension-Band Wire Fixation versus Proximal Fracture Fragment Excision. Journal of Trauma-Injury Infection & Critical Care. 53(6):1088-1093, December 2002.

Karlsson, Magnus K; Hasserius, Ralph; Karlsson, Caroline MD; Besjakov, Jack; Josefsson, Per-Olof. Fractures of the Olecranon: A 15- to 25-Year Follow up of 73 Patients. Clinical Orthopaedics & Related Research. 1(403):205-212, October 2002.

Bartlett, Craig S. Elbow fractures. Current Opinion in Orthopedics. 11(4):290-304, August 2000.

Karlsson, Magnus K; Hasserius, Ralph; Besjakov, Jack; Karlsson, Caroline; Josefsson, Per Olof. A Comparison of tension-band and figure-of-eight wiring techniques for treatment of olecranon fractures. Journal of Shoulder & Elbow Surgery. 11(4):377-382, July/August 2002.

Parker MJ, Richmond PW, Andrew TA, Bewes PC. A review of displaced olecranon fractures treated conservatively. J R Coll Surg Edinb. 1990 Dec;35(6):392-4.