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 triceps tendon is associated intimately with the periosteum overlying the olecranon.

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. 

• 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

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

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

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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.

Physiotherapy management

Management of olecranon fractures depends on displacement, comminution , and elbow stability. According to ‘the Mayo classification system of olecranon fractures’, also based on the displacement of the olecranon,comminution and elbow stability, there are 3 types of fractures, each with two subtypes.
The nondisplaced fractures (type I) should be cured with immobilization and symptomatic treatment. Type I fractures are classified in noncomminuted and minimally comminuted fractures. Immobilization is discontinued within 2 weeks and active motion without resistance is initiated. Type II- and III-fractures include a displacement with intact ulnar collateral ligaments (II) and respectively with a disruption in the relationship between the forearm and the humerus (III).
Type II and III fractures can both be subdivided in comminuted and noncomminuted fractures. The key difference between type II and type III is that type III is an unstable fracture in contrast with the stable type II fractures.This elbow instability is caused by the disruption of the medial collateral ligament which occurs with type III fractures. Types II and III require surgical fixation. There are several options for fixation:

• Tension band wiring for fixation of noncomminuted transverse fractures involving less than half the articular olecranon surface. A study has shown that after four months of following post-operative care, the evolution in mean range of motion was splendid: 15° flexion, 135° extension, 70° pronation and 79° supination. Complications of tension band wiring include loss of fixation, nonunion, skin breakdown, infection, olecranon bursitis, radial head subluxation, and prominent hardware.
• Comminuted fractures need plate fixation because it’s a more stable fixation. Studies demonstrate that after a year excellent results can be reached: perfect union rate and no hardware complication by using this technique.
• Intramedullary screw fixation is similar to tension band wiring, and include simple, noncomminuted transverse fracture patterns. Studies demonstrated superior results to tension band wiring for pain, function, and range of motion. Biomechanical studies have been less optimistic because there can be loss of fixation. This loss could be the result of wrong proportions of the screw.
• When the articular surface is too comminuted or too osteoporotic for fixation (p.e. with elderly or low- demand patients), then it’ s better to use the ‘olecranon exision’- and/or the ‘triceps advancement’-technique . Otherwise bonereconstruction would be impossible. But the patient must fulfill certain conditions, particularly an intact medial collateral ligament, interosseous membrane and distal radioulnar joint before excision. Otherwise there will be a development of instability.The triceps tendon is reattached to the proximal edge of the articular surface. Outcomes of this technique are variable: e.g. a biomechanical study showed that there’s an increase of triceps strength

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Primary elbow instability and fracture morphology are prognostic factors for elbow function and development of arthrosis after operative treatment. ^, , , ,

Postoperative care

Precise postoperative care is very important for maximum healing. The functional goal of the physiotherapist is to restore and normalize activities of daily living. Even then there may be some permanent loss of extension. Rehabilitation and bone healing will take approximately 12 weeks:

• Week 1: Bone healing is in the inflammatory phase. The stability depends on the bone quality. A splint or cast is applied, for fixation, in 60° 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.

All physiotherapeutic exercises have to build up progressively. Patients who have undergone fracture excision with triceps advancement should start at the 12th week with resistive exercises. These exercises are very important to recount the biomechanical function in the elbow area.

Long-term considerations and problems

Self-care activities rely more on elbow flexion than extension, so lack of terminal extension is usually not problematic. Heterotopic bone formation may significantly reduce elbow range of motion. Additional surgery to excise this bone may be necessary once it is mature.