Gãy xương: Lựa chọn điều trị pptx

Sev-eral methods of internal fixation are commonly utilized, including tension-band wiring, plate fixation, intramedullary screw fixation, and fragment excision with triceps ad-vancement

Olecranon fractures, which are

rela-tively common in adults, are a

di-verse group of injuries ranging from

simple nondisplaced fractures to

complex fracture-dislocations of the

elbow They are all intra-articular

injuries requiring anatomic

restora-tion of the articular surface

Sev-eral methods of internal fixation

are commonly utilized, including

tension-band wiring, plate fixation,

intramedullary screw fixation, and

fragment excision with triceps

ad-vancement Fixation must be

se-cure enough to permit early motion

in order to avoid significant

stiff-ness of the elbow joint Because of

the variability of fracture pattern and associated injuries, no single treatment method is appropriate for all fractures

Anatomy

The elbow is a complex hinge joint

in which the major stabilizers to valgus stress are the anterior band

of the ulnar collateral ligament and the radial head The major stabilizer against varus stress is the lateral col-lateral ligament complex, including the ulnohumeral ligament.1,2 The coronoid process stabilizes the

humerus against distal translation

on the proximal ulna Injury to the coronoid process may result in instability of the elbow, which greatly increases the complexity of the injury and adversely affects the prognosis The olecranon prevents anterior translation of the ulna with respect to the distal humerus.3 The articular portions of the olec-ranon and coronoid process are covered by hyaline cartilage There may be a transverse bare area de-void of cartilage midway between the olecranon and the coronoid process.4,5 Overcompression of this region during fracture reduction in

an attempt to appose the articular cartilage is a technical error that will result in narrowing of the olec-ranon fossa and an incongruous reduction The olecranon articu-lates with the trochlea of the hu-merus The triceps inserts into the posterior third of the olecranon and proximal ulna, blending through a broad expansion with the

aponeu-Dr Hak is Assistant Professor of Orthopaedic Surgery, University of California - Davis School of Medicine, Sacramento Dr Golladay

is Chief Resident, Section of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor.

Reprint requests: Dr Hak, Department of Orthopaedic Surgery, University of California -Davis, Suite 3800, 4860 Y Street, Sacramento,

CA 95817.

Copyright 2000 by the American Academy of Orthopaedic Surgeons.

Abstract

Fractures of the olecranon process of the ulna typically occur as a result of a

motor-vehicle or motorcycle accident, a fall, or assault Nondisplaced fractures

can be treated with a short period of immobilization followed by gradually

increasing range of motion Open reduction and internal fixation is the

stan-dard treatment for displaced intra-articular fractures Stable internal fixation

with figure-of-eight tension-band wire fixation for simple transverse fractures

allows early motion to minimize stiffness Use of two knots produces

symmet-ric tension at the fracture site and provides more rigid fixation than a single

knot Care should be taken to ensure that the tension-band wire and the

proxi-mal ends of the Kirschner wires are positioned deep to the triceps fibers to

pre-vent wire migration If the anterior cortex is engaged, overpenetration of the

wires into the soft tissues should be avoided Plate fixation is appropriate for

severely comminuted fractures, distal fractures involving the coronoid process,

oblique fractures distal to the midpoint of the trochlear notch, Monteggia

frac-ture-dislocations of the elbow, and nonunions For comminuted fractures and

nonunions, a dorsally applied limited-contact dynamic-compression plate with

supplemental bone graft should be utilized to support comminuted depressed

articular fragments A one-third tubular hook-plate can be used for fractures

with a small proximal fragment for which additional fixation of the olecranon

tip is desired Fragment excision and triceps advancement is appropriate in

selected cases in which open reduction seems unlikely to be successful, such as

in osteoporotic elderly patients with severely comminuted fractures.

J Am Acad Orthop Surg 2000;8:266-275

David J Hak, MD, and Gregory J Golladay, MD

rosis of the anconeus muscle and

the common extensor origin The

periosteum of the olecranon is

inti-mately associated with the triceps

tendon

The ulnar nerve lies on the

me-dial aspect of the elbow, posterior to

the ulnar collateral ligament, and

sweeps anteriorly to join the ulnar

artery The brachialis inserts broadly

on the midportion of the anterior

coronoid and the proximal ulnar

metaphysis.6 The ulnar

neurovascu-lar bundle may be at risk for anterior

cortical penetration by Kirschner

wires used during tension-band

wiring

Mechanism of Injury

Olecranon fractures may occur as a

result of direct trauma, indirect

trauma, or a combination of both.7

The subcutaneous location of the

olecranon renders it susceptible to

direct trauma, in which the

olecra-non is impacted against the distal

humerus, often resulting in

com-minuted fractures with depression

of a portion of the joint surface

Indirect trauma results from

force-ful contraction of the triceps muscle

during a fall on an outstretched

hand and usually produces a

trans-verse or short oblique fracture The

most common causes of injury

include motor vehicle and

motorcy-cle accidents, falls, and assaults.8-11

Open fractures have been reported

to occur in 2% to 31% of cases.11,12

Associated Injuries

Although olecranon fractures are

usually isolated injuries, a high

index of suspicion for associated

injuries should be present in the

evaluation of the polytrauma

pa-tient Wolfgang et al11 reported a

20% incidence of associated injuries,

including long-bone fractures, skull

fracture, splenic injury, pulmonary

contusion, and axillary artery rup-ture Ipsilateral extremity injuries should be carefully assessed, as fractures of the coronoid process or radial head and Monteggia fracture-dislocations have a significant im-pact on elbow stability Occasion-ally, articulated external fixation may be required to treat an unstable fracture, so as to provide adequate stability and allow early range-of-motion.13 When a supracondylar humerus fracture occurs in conjunc-tion with an olecranon fracture, exposure of the humerus can be obtained by utilizing the olecranon fracture site

Classification Systems

Although numerous classification systems have been described for olecranon fractures, none has been universally accepted Classifica-tions serve several purposes, in-cluding improving communication among surgeons, determining treat-ment, and predicting prognosis

Some classification systems have incorporated associated injuries to the radial head and supracondylar humerus, which may have a signifi-cant impact on prognosis.11,13 The AO classification system divides fractures of the proximal ra-dius and ulna into three broad cate-gories Type A are extra-articular fractures involving the metaphysis

of either the radius or the ulna

Type B fractures are intra-articular fractures of either the radius or the ulna, with type B1 being an intra-articular fracture of the olecranon alone Type C fractures are intra-articular fractures of both the radial head and the olecranon.14 The Or-thopaedic Trauma Association clas-sification system for olecranon frac-tures follows the AO system

Morrey13 reported the Mayo classification of olecranon fractures, which is based on degree of dis-placement, elbow joint stability,

and comminution Type I fractures are nondisplaced with minimal or

no comminution Type II fractures are displaced, but the elbow joint remains stable; sufficient anterior joint surface remains to maintain stability, and the anterior portion of the medial collateral ligament also remains intact Type III fractures render the elbow unstable and involve a large portion of the olec-ranon They are frequently com-minuted and may have an associated radial head fracture Type II and type III fractures are subclassified

as noncomminuted (subtype A) and comminuted (subtype B) In a review of 100 consecutive fractures

at the Mayo Clinic, 12 were nondis-placed (type I), 82 were disnondis-placed with a stable elbow joint (type II), and 6 were displaced with an un-stable elbow joint (type III)

Schatzker’s classification of olec-ranon fractures15 includes mechan-ical considerations related to the type of internal fixation required (Fig 1) There are six types: type A

is a simple transverse fracture; type

B, a complex transverse fracture with impaction of the central por-tion of the articular surface; type C,

a simple oblique fracture; type D, a comminuted fracture; type E, an oblique fracture distal to the mid-point of the trochlear notch (Schatz-ker states that this pattern requires one or two interfragmentary lag screws and a 3.5-mm dynamic-compression plate rather than a one-third tubular plate, which is not strong enough to resist the tor-sional forces); type F, a fracture of the olecranon with associated radial head fracture, which is frequently associated with a rupture of the medial collateral ligament

No single classification system is universally applicable, and any clas-sification is subject to interobserver variability However, a working knowledge of the existing classifica-tion systems is essential in assessing fractures radiographically and

se-lecting appropriate treatment For

these purposes, the Schatzker

classi-fication may be the most useful to

the practicing orthopaedist

Diagnostic Evaluation

Most olecranon fractures are isolated

injuries When present,

concomi-tant injury most often involves the

ipsilateral extremity A careful

ex-amination of the upper extremity,

including the clavicle, shoulder,

hu-merus, elbow, forearm, wrist, and

hand, is essential The elbow

typi-cally has both soft-tissue swelling

and an effusion The subcutaneous

location of the fracture often makes

it easily palpable, with a depression

present when the fracture is

signifi-cantly displaced The skin should

be carefully inspected for an open

fracture Function of the median,

ulnar, radial, and posterior

interos-seous nerves should be examined

The presence of radial and ulnar

pulses should be documented

Standard anteroposterior and

lateral radiographs of the elbow are

sufficient for evaluation of isolated

olecranon fractures Direct

supervi-sion of the radiographs may be

nec-essary to ensure that true

antero-posterior and lateral radiographs

are obtained A radiocapitellar

view may be helpful for delineation

of radial head or capitellar shear fractures

Treatment Options

The goals of olecranon fracture treatment include anatomic recon-struction of the articular surface, preservation of motor power, res-toration of stability, prevention of joint stiffness, and minimization of morbidity.16

Nonoperative Treatment

Nondisplaced fractures in which the elbow extensor mechanism is in-tact may be treated nonoperatively

Controversy exists about the amount

of acceptable articular displacement

Although immobilization in full extension may improve fracture reduction, it often results in dimin-ished flexion Immobilization of the elbow in 45 to 90 degrees of flexion for approximately 3 weeks has been recommended for nondisplaced fractures.7 Motion is then begun, limiting flexion to 90 degrees until there is radiographic evidence of fracture healing

Operative Treatment

The ideal construct for fixation

of olecranon fractures has been the

subject of considerable research Tension-band wiring, as recom-mended in the AO manual, is designed to convert the tensile dis-traction force of the triceps into a compressive force at the articular surface.13

Rowland and Burkhart17 recom-mended modification of the stan-dard AO technique to minimize the possibility that the articular fracture surface may not be adequately com-pressed They argued, on the basis

of free-body analysis, that the distal drill hole for the figure-of-eight wire should be placed anterior to the long axis of the ulna rather than through its subcutaneous border, to increase static compression at the articular surface Roe18challenged the math-ematical validity of this technical modification, and Paremain et al19 failed to demonstrate an increase in static resistance to gap formation at the fracture site when the proposed modification was used

Several studies have tested fixa-tion strength of olecranon fractures

in vitro Prayson et al20tested four different tension-band constructs in simulated transverse fractures They demonstrated that bicortical Kirschner-wire purchase and braided cable reduced fracture displacement more than traditional intramedul-lary Kirschner wires and monofila-ment figure-of-eight wire

Horner et al21 reported on a ca-daveric study of 10 oblique distal olecranon fractures They found that fixation with a one-third tubu-lar plate was approximately three times more rigid than tension-band wiring in resisting the deforming forces of the biceps and brachialis Fyfe et al22assessed movement at the fracture site in cadaveric elbows with transverse, oblique, and commi-nuted olecranon osteotomies tested

by slow loading with the elbow in

90 degrees of flexion Transverse osteotomies were most rigidly fixed with a tension-band wire construct with two tightening knots Oblique

Figure 1 Schatzker classification of olecranon fractures (Adapted with permission from

Browner BD, Jupiter JB, Levine AM, Trafton PG [eds]: Skeletal Trauma Philadelphia: WB

Saunders, 1992, p 1137.)

A: Transverse B: Transverse-impacted C: Oblique

D: Comminuted E: Oblique-distal F: Fracture-dislocation

osteotomies were fixed equally well

with either a tension-band plate or a

one-third tubular plate In

commi-nuted osteotomies, plate fixation was

found to be slightly more rigid than

fixation with a tension band

Fixa-tion with a cancellous screw was

found to be erratic, depending on

the match between screw diameter

and medullary canal size

Augmen-tation with a single figure-of-eight

wire improved screw fixation The

validity of this study is

compro-mised by the fact that specimens

were tested with more than one

technique, and slow loading (rather

than the more physiologic rapid

loading) was used

Murphy et al23tested the fixation

strength of transverse olecranon

osteotomy at the midpoint of the

semilunar notch in fresh cadaver

specimens by rapid loading to

fail-ure An intramedullary screw plus

a tension-band wire was found to

have the greatest energy to failure

The authors described the modes of

failure of the four methods of

fixa-tion they tested The figure-of-eight

wire failed by breakage at the

tight-ening loop The cancellous screw

pulled out or bent AO tension-band

wiring failed because of pullout or

breakage of the Steinmann pins

The screw-and-wire combination

failed by wire displacement and

screw breakage

Surgical Techniques

The patient is commonly

posi-tioned supine with the arm draped

across the chest or supported on an

arm holder placed across the chest

Alternatively, a lateral decubitus or

prone position may be used with

the arm draped over a well-padded

support Either general or regional

anesthesia (Bier block or axillary

block) may be utilized

With the tourniquet applied high

on the upper arm, the olecranon is

approached through a posterior

incision Some authors recommend

a curvilinear incision to avoid plac-ing a scar over the tip of the olecra-non On the medial side, the mus-cular origin of the flexor digitorum profundus, flexor digitorum super-ficialis, and deep head of the prona-tor teres may be elevated if neces-sary The location of the ulnar nerve can usually be identified by palpation Rarely is it necessary to isolate or transpose the ulnar nerve

The fracture site is cleared of hema-toma, and the periosteum is elevated approximately 2 mm from the edges of the fracture The fracture

is reduced and held with a tenacu-lum Placement of a small oblique drill hole in the ulnar shaft distal to the fracture will aid in anchoring the distal tine of the tenaculum

Fixation alternatives include ten-sion-band wire fixation with Kirsch-ner wires or in combination with

an intramedullary screw,

intramed-ullary screw fixation alone, or plate fixation Separate interfragmentary compression screws may be re-quired for certain fracture patterns Occasionally, excision of the frag-ments and advancement of the tri-ceps may be indicated

After internal fixation is com-pleted, the elbow should be taken through a range of motion to con-firm stability and guide postopera-tive rehabilitation Pronation and supination should be examined to confirm that there is no blockage due to malpositioned hardware

Tension-Band Wiring

Tension-band wire fixation can

be effectively utilized for most sim-ple noncomminuted transverse olec-ranon fractures The tension-band technique converts the extensor force of the triceps to a dynamic compressive force along the articu-lar surface (Fig 2).14

Figure 2 Tension-band wire fixation of a transverse olecranon fracture Static compres-sion is achieved dorsally (paired thin arrows) The extensor force of the triceps (single thick arrow) is converted into dynamic compression just below the articular surface (paired thick arrows) (Adapted with permission from Müller ME, Allgöwer M, Schneider

R, Willenegger H [eds]: Manual of Internal Fixation: Techniques Recommended by the AO-ASIF

Group, 3rd ed Berlin: Springer-Verlag, 1991, p 19.)

Several technical tips are helpful

in achieving optimal results with

the tension-band wire technique

One-point 6-mm Kirschner wires

are utilized, as their ends can be

easily bent Some surgeons prefer

to place the Kirschner wires in the

intramedullary canal; others prefer

to angle the wires volarly, engaging

the anterior cortex to provide

greater resistance to wire migration

The most important factor in

pre-venting wire migration is ensuring

that the bent proximal end of the

wire is buried beneath the fibers of

the triceps If the anterior cortex is

engaged, care should be taken to

avoid overpenetration of the wires,

as they may cause neurovascular

damage, restrict forearm rotation,

or incite heterotopic ossification or

radioulnar synostosis Full

prona-tion and supinaprona-tion should be

ensured after the wires have been

inserted The length of the wire

should be noted at the point where

it engages the second cortex Once

the wire penetrates the far cortex, it

should be partially backed out and

bent 180 degrees at the previously

measured position The excess wire

should then be cut off The fibers of

the triceps tendon should be split

sharply with a scalpel at the site of the Kirschner wires to allow the cut and bent ends to be impacted against the cortex (Fig 3, A) If the bent end of the Kirschner wire is left superficial to the triceps fibers, routine postoperative elbow exten-sion may cause the Kirschner wire

to back out (Fig 3, B)

An intravenous catheter is uti-lized to pass an 18-gauge wire beneath the fibers of the triceps The needle and plastic cannula are inserted deep to the triceps tendon, adjacent to the bone, beneath the two Kirschner wires (Fig 3, C) The insertion needle is removed, leaving the plastic cannula in place The 18-gauge wire can then be inserted into the end of the plastic cannula, and both cannula and wire are pulled back, passing the wire deep to the triceps fibers The wire is passed through a transverse drill hole placed distal to the fracture Two twisted knots are placed in the wire, one radial and one ulnar, and each is tightened to produce symmetric ten-sion at the fracture site Placing two knots results in more rigid fixation than using a single knot.22 The ends

of the twisted wires are then cut and bent down against the cortex

Following fixation, the elbow should be examined to confirm full range of motion, including prona-tion and supinaprona-tion, and to confirm fixation stability Plain radio-graphs should be obtained in the operating room It is important to confirm that the tension-band wire

is properly looped proximally around the Kirschner wires, as oc-casionally the wire may be passed dorsal to one or both of the wires and may engage only the triceps tendon

Wolfgang et al11treated 45 frac-tures with tension-band wiring with or without supplemental fixa-tion, depending on the fracture configuration Excellent or good results were reported in 98% of cases Tension-band wiring both with Kirschner wires engaging the anterior cortex and with use of a double-loop 18-gauge figure-of-eight wire is adequate for all sim-ple transverse fractures for which internal fixation is chosen Braided cable has been shown in a cadaveric model to be stronger than mono-filament wire; however, it may fray and increase the risk of sympto-matic hardware prominence.20 An interfragmentary lag screw is

use-Figure 3 Technique for tension-band wiring A, Fibers of the triceps tendon should be split to allow the bent end of the Kirschner wires

to be impacted firmly against bone B, If the ends of the Kirschner wires are left superficial to the triceps tendon, elbow extension may cause migration or fatigue failure of the Kirschner wires C, A 16-gauge or larger intravenous catheter is used to pass the tension-band

wire deep to the triceps fibers.

ful when an oblique fracture plane

is present

Intramedullary Screw Fixation

The use of a single large-diameter

intramedullary cancellous screw

has also been advocated.13 In one

study, a higher rate of fixation loss

was reported after intramedullary

screw fixation alone compared

with tension-band wiring.24 Some

authors recommend

supplementa-tion of intramedullary screw

fixa-tion with a tension-band wire

around the screw head.23,25 In the

frontal plane, there is approximately

4 degrees of valgus angulation of

the ulnar shaft with respect to the

sigmoid notch If an intramedullary

screw is used, care must be

exer-cised to properly place the screw

along the intramedullary shaft axis

and thus avoid displacement of the

fracture (Fig 4)

Johnson et al26reported good

re-sults in 24 patients treated with a

6.5-mm cancellous screw with or

without supplementary tension

banding Sixteen patients (67%)

had motion within 15 degrees of

full range by postoperative week 9

The authors reported four operative

complications: one poor reduction,

one loss of compression, one

fixa-tion failure, and one bent screw

For large displaced fractures or

osteotomy fixation, Wadsworth27

recommended use of a partially

threaded intramedullary screw with

or without a washer He reported

100% union in six patients and no

complications with this technique

and emphasized the importance of

early motion

The indications for

intramedul-lary screw placement mirror those

for tension-band wiring (e.g.,

sim-ple noncomminuted transverse

fractures) An intramedullary

screw may be best suited for

fixa-tion of an olecranon osteotomy, as

predrilling the screw prior to

osteotomy helps guide anatomic

reduction later

Plate Fixation

Plate fixation is most commonly recommended for comminuted frac-tures in which tension-band wire fixation is not feasible It is also indi-cated for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations of the elbow.15,28 Oblique fractures are best treated with one or two inter-fragmentary compression screws in conjunction with plate fixation to resist torsional forces.15

Some authors have reported use

of one-third tubular, dynamic com-pression, and pelvic reconstruction plates for fixation of comminuted olecranon fractures The proximal end of the one-third tubular plate can be modified to make a hook-plate that will provide additional fixation for small proximal fracture fragments In severely comminuted fractures, one-third tubular plates may not provide sufficient strength, leading to hardware fatigue failure.28 While the subcutaneous location

of the hardware raises concern about prominence necessitating subsequent removal, the frequency

of hardware prominence may actu-ally be higher after tension-band wiring than after plate fixation.8 In most cases, the plate is placed along the dorsal surface of the olec-ranon and contoured around the tip of the olecranon (Fig 5) The dorsal ulna is the tension side of the bone and as such is biomechan-ically best suited to plating A screw placed in the most proximal hole may either engage the coro-noid process or be inserted down the intramedullary canal If this screw is intramedullary, the other screws in the plate must be angled slightly radially or ulnarly

In a prospective, randomized study of 41 patients with displaced fractures treated with either tension-band wiring or one-third tubular plates, tension-band wiring was

more likely to result in either articu-lar incongruity greater than or equal

to 2 mm or loss of reduction The authors concluded that strong con-sideration should be given to plating

of olecranon fractures.8 Simpson et

al28 reported 73% good or excellent results in a retrospective study of the use of a dorsally applied 3.5-mm limited-contact dynamic-compression (LC-DC) plate for fixation of 13 com-plex proximal ulna fractures and 24

Figure 4 A, Proper placement of an

intramedullary screw B, Placement of an

intramedullary screw slightly off the intramedullary axis results in fracture malreduction.

Figure 5 Plate fixation of a comminuted olecranon fracture (Adapted with permis-sion from Mast JW, Jakob R, Ganz R:

Planning and Reduction Techniques in Fracture Surgery Berlin: Springer-Verlag,

1989.)

Monteggia fracture-dislocations.

Only one patient had problems with

hardware prominence They

recom-mend plate fixation if the fracture

ex-tends to the metaphyseal-diaphyseal

junction or if the coronoid process

is involved The LC-DC plate is

lower in profile and easier to contour,

and its screw holes allow greater

screw angulation than those of the

standard dynamic-compression

plate

In severely comminuted

frac-tures, care must be taken not to

narrow the olecranon-to-coronoid

distance.16 Because there is no

ar-ticular cartilage in the midportion

of the sigmoid notch, aligning the

remaining articular surfaces in

comminuted fractures will result in

narrowing of the

olecranon-to-coronoid distance.4,5 The dorsal

cortical fragments may serve as a

guide to reconstruct the correct

anatomic alignment Use of an AO

universal distractor may aid in

re-duction and provisional

stabiliza-tion.28 The congruency of the

artic-ular surface should be meticulously

restored Bone graft should be

uti-lized to support the articular

sur-face after elevation of depressed

fragments Supplemental

Kirschner-wire fixation may also be required

Plate fixation is appropriate for

severely comminuted fractures,

dis-tal fractures involving the coronoid

process, oblique fractures distal to

the midpoint of the trochlear notch,

Monteggia fracture-dislocations of

the elbow, and nonunions In

com-minuted fractures and nonunions, a

dorsally applied LC-DC plate with

supplemental bone graft should be

utilized to support comminuted

depressed articular fragments that

have been elevated A one-third

tubular hook-plate can be used to

achieve additional fixation of the

olecranon tip for fractures with a

small proximal fragment A portion

of the triceps insertion may need to

be incised to allow apposition of the

plate to the bone

Excision of Fragment and Triceps Advancement

Excision of the fracture fragment and reattachment of the triceps ten-don may be indicated in a select group of elderly patients with os-teoporotic bone in whom the olec-ranon fracture fragments involve less than 50% of the joint surface13,29 and are too small or too comminuted for successful internal fixation The integrity of the medial collateral lig-ament, the interosseous membrane, and the distal radioulnar joint must

be established before consideration

is given to excision; otherwise, instability will result.30 The triceps tendon is reattached with nonab-sorbable sutures that are passed through the drill holes in the proxi-mal ulna Cabanela and Morrey16 recommend that the triceps be re-attached adjacent to the remaining articular surface, creating a sling for the trochlea (Fig 6) Triceps reat-tachment in this manner creates a smooth, congruent transition from the triceps tendon to the articular cartilage of the olecranon but de-creases the moment arm and may result in greater extensor weakness

McKeever and Buck29stated that

as much as 80% of the trochlear notch can be excised without com-promising elbow stability, provided the coronoid and distal trochlea are preserved Gartsman et al12 re-ported one case of anterior instabil-ity in a patient in whom approxi-mately 75% of the articular surface had been excised An et al3 evalu-ated elbow stability with varying degrees of proximal ulnar resection

in vitro They found linear de-creases in elbow constraint with increasing amounts of resection and suggested that resection of more than 50% of the articular sur-face may result in instability

Inhofe and Howard31 reported good or excellent results in 11 of 12 patients with adequate follow-up after excision of as much as 70% of the articular surface Gartsman et al12

reported lower complication and reoperation rates following excision compared with internal fixation and concluded that excision is the pre-ferred treatment alternative provided the coronoid process remains intact Although weakening of the extensor apparatus has been a criticism of the technique of fragment excision and triceps advancement, Gartsman et al found no differences in isometric strength between patients treated by excision and those treated with inter-nal fixation Although that series did provide some comparison between excision and internal fixation, the treatment was not randomized, and selection bias requires cautious inter-pretation of the conclusions Other authors have recommended excision only as a last resort in cases in which open reduction and internal fixation

is not possible.10,11 Excision should be reserved for selected cases in which open reduc-tion seems unlikely to be successful Open reduction and internal fixa-tion should be attempted in most cases, as it permits early motion and allows bone-to-bone healing Excision and triceps advancement can still be performed as a salvage procedure if internal fixation fails

Figure 6 When excision and triceps advancement is performed, the triceps should be attached adjacent to the articular surface (Adapted with permission from Cabanela ME, Morrey BF: Fractures of the proximal ulna and olecranon, in Morrey BF

[ed]: The Elbow and Its Disorders, 2nd ed.

Philadelphia: WB Saunders, 1993, p 416.)

Rehabilitation

Operative management of

olecra-non fractures should provide

suffi-ciently stable fixation to allow early

motion The ideal time to start

motion has not been addressed in

any prospective study; therefore,

the surgeon must consider fixation

stability, patient compliance, and

wound healing Patients typically

are placed in a posterior splint or

sling, and active motion is instituted

as early as postoperative day 1.11

Immediate supervised

gravity-assisted range-of-motion exercises

are effective for all fractures with

stable internal fixation.28 Unless

there are wound-healing problems,

a removable posterior splint is

ap-plied, and the patient is instructed

in range-of-motion exercises on the

first postoperative day More

com-plex or comminuted fractures may

require longer periods of

immobi-lization, and more stiffness can be

anticipated Distraction devices

may be helpful in the postoperative

regimen for unstable, comminuted

fractures, followed by the use of

adjustable splints to help regain

motion.13 Muscle strengthening is

begun when bone healing is

ade-quate, generally 6 weeks from

surgery.28 Patients may return to

work involving rigorous use of the

extremity at 3 to 4 months

Complications

Hardware prominence requiring

removal is one of the most frequent

complications after internal fixation

of olecranon fractures Symptoms

due to hardware prominence have

been reported in 3% to 80% of

cases.25,28 The wide range of

symp-tomatic hardware prominence is

likely related both to technical

fac-tors and to varying definitions of

prominence Wire migration,

soft-tissue irritation, olecranon bursitis,

wire breakage, or fracture displace-ment may occur with tension-band wiring.32 Kirschner wires should

be firmly seated against the olecra-non through slits in the triceps ten-don, and the wire knots should be positioned away from the subcuta-neous border of the ulna Preopera-tive patient counseling should include the possibility of sympto-matic hardware prominence and the potential need for hardware re-moval Hume and Wiss8reported a higher incidence of painful hard-ware prominence after tension-band wiring than after compression plating No cases of symptomatic hardware prominence were reported

by Simpson et al28after LC-DC plat-ing Hardware failure or loss of fix-ation occurs more commonly in comminuted fractures and in pa-tients with poor bone stock

Loss of motion is a common problem after fractures about the elbow but is rarely significant in patients with isolated olecranon fractures.8,11 Patients with isolated injuries typically lose 10 to 15 de-grees of extension.13 However, in patients with associated fractures of the radial head, capitellum, or coro-noid or with a Monteggia fracture-dislocation, the range of motion may be more severely compro-mised.27,30 Comminuted fractures and open injuries are also more likely

to result in stiffness Some gains in motion may be achieved with ag-gressive physical therapy Patients with a functional deficit related to stiffness may be treated with pro-gressive splinting, a turnbuckle-type brace, or capsulectomy

Heterotopic ossification may oc-cur after olecranon fractures, par-ticularly in patients with significant associated soft-tissue injuries and in those with closed head injuries

Wolfgang et al11reported a 13% rate

of heterotopic ossification, mainly in patients with an associated radial head dislocation Simpson et al28 reported a 14% rate of heterotopic

ossification in 27 complex fractures

of the proximal ulna Ilahi et al33 found a 0% incidence of grade II, III, or IV heterotopic ossification about the elbow when unstable elbow fractures were operated on within 48 hours of injury, com-pared with a 33% incidence when the delay between injury and surgi-cal treatment exceeded 48 hours Nonunion of olecranon fractures

is infrequent, and patients typically present with pain, instability, or loss of motion Papagelopoulos and Morrey34reported only two nonunions in 196 fractures initially treated at the Mayo Clinic over a 10-year period Treatment options for nonunions include excision, osteosynthesis with a compression plate or lag screw, or elbow arthro-plasty in cases of severe posttrau-matic arthritis Cancellous bone graft or a corticocancellous bone plate fixed with screws may be use-ful Papagelopoulos and Morrey also reported on the treatment of 24 patients with olecranon nonunion, most of whom had been referred from other institutions After use

of one or more of the treatment options mentioned, the results were excellent in 12 patients (50%), good in 4 (17%), fair in 6 (25%), and poor in 2 (8%) In another study, Danziger and Healy35reported that union was achieved in all five cases treated by either tension-band plat-ing or wirplat-ing and bone graft Poorer results have been reported with intra-articular step-off of more than 2 mm, but few studies have sufficient follow-up to document the long-term incidence of post-traumatic arthrosis.25 Gartsman et

al12reported a 20% rate of arthrosis following olecranon fractures regardless of whether they were treated by excision or internal fixa-tion

The reported rates of infection after operative olecranon fracture treatment range from 0% to 6%.12,34 Papagelopoulos and Morrey34

re-ported two cases of transient reflex

sympathetic dystrophy in their

series of 24 olecranon nonunions

Ulnar neurapraxia has been

report-ed in 2% to 5% of cases Ulnar

neu-ritis may occasionally occur.10

Symptoms usually resolve with

conservative treatment, but late

neurolysis or transposition may

occasionally be required

Outcomes

Generally good and excellent

re-sults have been reported for all

types of olecranon fracture

treat-ment However, prospective

stud-ies in which validated outcomes

measures were used to compare

different forms of treatment have

not yet been reported

Murphy et al25performed a

ret-rospective study of patients with

simple transverse or oblique

olecra-non fractures, using a 19-point scale

to evaluate pain, function, range of

motion, and radiographic findings

Of the 33 patients, 10 were treated

with an intramedullary screw plus

wire, 13 with an intramedullary

screw alone, and 10 with tension-band wire fixation The average ratings for the three groups were similar: 17.7 for intramedullary screw plus wire treatment, 17.2 for intramedullary screw fixation, and 16.7 for tension-band wire fixation

Gartsman et al12 reported a ret-rospective review of a series of 107 isolated olecranon fractures in 53 patients treated by excision and 54 treated by internal fixation (primar-ily screw or tension-band fixation)

Pain, subjective function, isometric strength, isokinetic work, range of motion, stability, and the incidence

of degenerative changes were simi-lar between the two groups at an average follow-up of 3.6 years

Thirteen patients who underwent internal fixation had complications, compared with only 2 in the exci-sion group Thirteen patients in the internal fixation group required reoperation for hardware removal

Because of the high rates of compli-cations and reoperation after inter-nal fixation, the authors concluded that excision is the preferred treat-ment alternative provided the coro-noid process is intact

Summary

Fractures of the olecranon process may present in isolation or in combi-nation with more complex injuries about the elbow Generally good or excellent results have been reported with all forms of treatment of simple olecranon fractures Nondisplaced fractures may be treated nonopera-tively Excision and triceps advance-ment may be indicated for patients with small extra-articular fragments

or severely comminuted fractures, as well as for elderly patients with os-teoporotic bone Open reduction and internal fixation is preferred for displaced intra-articular fractures Tension-band wire fixation is com-monly utilized for simple fractures Plate fixation is recommended for comminuted or unstable oblique fractures Intramedullary screw fixa-tion has also been recommended Because of its subcutaneous location, hardware may need to be removed after union is achieved Although minor losses of motion are common, most patients can be expected to have good results provided early controlled motion can be instituted

References

1 Cohen MS, Hastings H II: Rotatory

instability of the elbow: The anatomy

and role of the lateral stabilizers J

Bone Joint Surg Am 1997;79:225-233.

2 O’Driscoll SW, Bell DF, Morrey BF:

Posterolateral rotatory instability of

the elbow J Bone Joint Surg Am 1991;

73:440-446.

3 An KN, Morrey BF, Chao EYS: The

effect of partial removal of proximal

ulna on elbow constraint Clin Orthop

1986;209:270-279.

4 Shiba R, Sorbie C, Siu DW, Bryant JT,

Cooke TDV, Wevers HW: Geometry

of the humeroulnar joint J Orthop Res

1988;6:897-906.

5 Stormont TJ, An KN, Morrey BF, Chao

EY: Elbow joint contact study:

Com-parison of techniques J Biomech 1985;

18:329-336.

6 Cage DJN, Abrams RA, Callahan JJ,

Botte MJ: Soft tissue attachments of

the ulnar coronoid process: An ana-tomical study with radiographic

corre-lation Clin Orthop 1995;320:154-158.

7 Hotchkiss RN: Fractures of the olecra-non, in Rockwood CA Jr, Green DP,

Bucholz RW, Heckman JD (eds):

Rock-wood and Green’s Fractures in Adults,

4th ed Philadelphia: JB Lippincott,

1996, pp 984-996.

8 Hume MC, Wiss DA: Olecranon frac-tures: A clinical and radiographic com-parison of tension band wiring and

plate fixation Clin Orthop 1992;285:

229-235.

9 Macko D, Szabo RM: Complications

of tension-band wiring of olecranon

fractures J Bone Joint Surg Am 1985;

67:1396-1401.

10 Rettig AC, Waugh TR, Evanski PM:

Fracture of the olecranon: A problem of

management J Trauma 1979;19:23-28.

11 Wolfgang G, Burke F, Bush D, et al:

Surgical treatment of displaced olecra-non fractures by tension band wiring

technique Clin Orthop 1987;224:192-204.

12 Gartsman GM, Sculco TP, Otis JC: Operative treatment of olecranon frac-tures: Excision or open reduction with

internal fixation J Bone Joint Surg Am

1981;63:718-721.

13 Morrey BF: Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid.

J Bone Joint Surg Am 1995;77:316-327.

14 Müller ME, Allgöwer M, Schneider R,

Willenegger H (eds): Manual of

Inter-nal Fixation: Techniques Recommended by the AO-ASIF Group, 3rd ed Berlin:

Springer-Verlag, 1991

15 Schatzker J: Fractures of the olecranon,

in Schatzker J, Tile M (eds): The

Ra-tionale of Operative Fracture Care Berlin:

Springer-Verlag, 1987, pp 89-95.

16 Cabanela ME, Morrey BF: Fractures of

the proximal ulna and olecranon, in

Morrey BF (ed): The Elbow and Its

Disorders, 2nd ed Philadelphia: WB

Saunders, 1993, pp 405-428.

17 Rowland SA, Burkhart SS: Tension

band wiring of olecranon fractures: A

modification of the AO technique.

Clin Orthop 1992;277:238-242.

18 Roe SC: Tension band wiring of

olec-ranon fractures: A modification of the

AO technique [letter] Clin Orthop

1994;308:284-286.

19 Paremain GP, Novak VP, Jinnah RH,

Belkoff SM: Biomechanical evaluation

of tension band placement for the

repair of olecranon fractures Clin

Orthop 1997;335:325-330.

20 Prayson MJ, Williams JL, Marshall

MP, Scilaris TA, Lingenfelter EJ:

Bio-mechanical comparison of fixation

methods in transverse olecranon

frac-tures: A cadaveric study J Orthop

Trauma 1997;11:565-572.

21 Horner SR, Sadasivan KK, Lipka JM,

Saha S: Analysis of mechanical factors

affecting fixation of olecranon

frac-tures Orthopedics 1989;12:1469-1472.

22 Fyfe IS, Mossad MM, Holdsworth BJ:

Methods of fixation of olecranon frac-tures: An experimental mechanical study.

J Bone Joint Surg Br 1985;67:367-372.

23 Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical

analysis of fixation methods Clin

Orthop 1987;224:210-214.

24 Helm RH, Hornby R, Miller SWM:

The complications of surgical treat-ment of displaced fractures of the

olec-ranon Injury 1987;18:48-50.

25 Murphy DF, Greene WB, Dameron TB Jr: Displaced olecranon fractures in

adults: Clinical evaluation Clin

Orthop 1987;224:215-223.

26 Johnson RP, Roetker A, Schwab JP:

Olecranon fractures treated with AO

screw and tension bands Orthopedics

1986;9:66-68.

27 Wadsworth TG: Screw fixation of the olecranon after fracture or osteotomy.

Clin Orthop 1976;119:197-201.

28 Simpson NS, Goodman LA, Jupiter JB:

Contoured LCDC plating of the

proxi-mal ulna Injury 1996;27:411-417.

29 McKeever FM, Buck RM: Fracture of the olecranon process of the ulna: Treatment by excision of fragment and

repair of triceps tendon JAMA 1947;

135:1-5.

30 Teasdall R, Savoie FH, Hughes JL: Comminuted fractures of the proximal

radius and ulna Clin Orthop 1993;292:

37-47.

31 Inhofe PD, Howard TC: The treatment

of olecranon fractures by excision of fragments and repair of the extensor mechanism: Historical review and

report of 12 fractures Orthopedics

1993;16:1313-1317.

32 Horne JG, Tanzer TL: Olecranon

frac-tures: A review of 100 cases J Trauma

1981;21:469-472.

33 Ilahi OA, Strausser DW, Gabel GT: Post-traumatic heterotopic ossification about

the elbow Orthopedics 1998;21:265-268.

34 Papagelopoulos PJ, Morrey BF: Treat-ment of nonunion of olecranon fractures.

J Bone Joint Surg Br 1994;76:627-635.

35 Danziger MB, Healy WL: Operative

treatment of olecranon nonunion J

Orthop Trauma 1992;6:290-293.