Master Techniques in Orthopaedic Surgery: Fractures
2nd Edition

8
Olecranon Fractures: Open Reduction Internal Fixation
Gregory J. Schmeling
Lawrence J. Maciolek
Indications/Contraindications
Olecranon fractures are a result of direct or indirect forces, or a combination of both (1). Direct forces drive the olecranon into the distal humerus, often producing comminuted fractures with depressed joint fragments, similar to a tibial plateau fracture. Olecranon fractures, which occur indirectly through the contraction of the triceps muscle, generally produce transverse or short oblique fracture patterns.
Minimally displaced olecranon fractures are defined as less than 2 mm of joint gap or step-off, intact, active-elbow extension, and no significant fragment motion with elbow flexion. Fractures are displaced if they do not meet these criteria (1).
The treatment objectives for olecranon fractures are reconstruction of the articular surface, restoration of the elbow extensor mechanism, preservation of elbow motion and function, and prevention or avoidance of complications (2). The indications for operative treatment include displaced fractures, injuries with elbow extensor-mechanism disruption, and open fractures. Indications for conservative treatment include nondisplaced fractures, injuries where the elbow extensor mechanism is intact, and poor overall medical condition of the patient.
Operative treatment options include open reduction and internal fixation (ORIF) and fragment excision with elbow extensor-mechanism reconstruction (2,3,4). For displaced fractures, the treatment goals are met most often with internal fixation techniques. These techniques consist primarily of tension band wiring or plate osteosynthesis.
Olecranon fractures usually occur as isolated injuries, but they are occasionally found in the polytrauma patient. With isolated fractures, a history of a fall with elbow pain is the most common presenting complaint. Physical examination reveals a painful, swollen elbow, and in displaced fractures, a palpable defect is often identified. Crepitus with elbow motion may also be present. The inability to extend the elbow against gravity suggests loss of the integrity of the elbow extensor mechanism. Neurovascular evaluation should include particular attention to the ulnar nerve. The proximity of the ulnar nerve places it at risk for injury, especially when direct forces are involved in the accident.
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Essential radiographs include an anteroposterior (AP) view and a true lateral view. When the olecranon fracture is part of an elbow fracture dislocation, traction radiographs are used to evaluate the injury as well. The lateral radiograph reveals the extent of the fracture and the presence of comminution or joint depression. The integrity of the radial head–capitulum articulation is examined, and subluxation or dislocation of the semilunar notch from the trochlea is noted. The AP radiograph is examined for sagittal fracture lines that are not well visualized on the lateral view. Comparison radiographs can be helpful in complex fracture patterns.
Preoperative Planning
To optimize outcomes, a preoperative plan is drawn and a surgical tactic developed. The preoperative plan begins with a tracing of the fracture fragments. The fragments are then reduced on paper. The need for bone graft to support depressed intra-articular fragments is determined. The proposed fixation is added. The method of fixation chosen is dependent on the fracture geometry and the experience of the surgeon. The surgical tactic is a sequential outline of the planned procedure and is added to the drawing (Fig. 8.1).
Although there are many classification schemes for olecranon fractures, we prefer that of the Orthopaedic Trauma Association (5). The location of the fracture is in the proximal segment of the radius and ulna (6). The fractures are divided into three types: extra-articular (21-A), articular and involving the surface of one bone (21-B), and articular and involving the surface of both bones (21-C). Extra-articular avulsion fractures are type 21-A
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while intra-articular fractures are type 21-B. A more detailed description of this classification is found in the Orthopaedic Trauma Association’s Fractures and Dislocation Compendium (5).
Figure 8.1. Preoperative plan. This is a tracing from the radiographs: ulna (blue); fixation (red); and humerus/radius (black).
It is easier to conceptualize olecranon fractures as transverse, oblique, comminuted, or elbow fracture dislocations (Fig. 8.2). Transverse and oblique fractures may have a depressed joint segment similar to that seen in tibial plateau fractures. Depressed segments are elevated and may require bone graft or other support to maintain elevation. Oblique fractures can be oriented proximally or distally. Lag screws are frequently used with oblique fractures. Comminuted fracture patterns usually occur in isolation, but the radiographs must be scrutinized to rule out a fracture dislocation of the elbow.
The two most common methods of fixation are either tension band wiring or plate osteosynthesis with or without a lag screw (3,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26). A tension band construct may consist of two Kirschner (K) wires with a figure-of-eight wire or cable, or it may be made of an intramedullary screw with a figure-of-eight wire. Alternatively, a lag screw and dorsal plate (3.5-mm semitubular or reconstruction) can be used (Fig. 8.3A–C). The cable is easier to place and has a low-profile crimp rather than two prominent wire knots. A figure-of-eight wire alone does not provide sufficient stability to resist physiologic loading (21). Advocates of the lag screw–dorsal plate technique cite less operative time, better reductions, fewer
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hardware symptoms, less postoperative loss of reduction, and lower incidence of infection (7,10,20,26). The lag screw–neutralization plate construct consists of a lag screw across the fracture and a radial, ulnar, or dorsal neutralization plate. Two K wires with a figure-of-eight wire will also neutralize the lag screw (Fig. 8.3D).
Figure 8.2. Olecranon fractures: (A1) transverse, (A2) transverse with joint depression, (B1) proximal oblique, (B2) distal oblique, (C) comminuted, (D) fracture-dislocation. (From
McKee MD, Jupiter JB. Trauma to the adult elbow and fractures of the distal humerus. In: Browner BD, Jupiter JB, Levine AM, et al, eds. Skeletal trauma. Philadelphia: W.B. Saunders; 1992:1455–1522
; Fig. 41-16.)
Based on the injury pattern, patient profile, and clinical experience, the surgeon must determine which fixation technique to employ for a given fracture. In the absence of complications, outcomes for each of the fixation techniques are comparable (12,21). However, biomechanical and clinical evidence suggests that certain techniques may be advantageous when applied to specific fracture patterns.
Figure 8.3. Tension-band constructs. A. Two K wires with a figure-of-eight wire (33). B. Medullary screw with a figure-of-eight wire (33). C. Dorsal plate with lag screw. D. Two K wires that engage the anterior cortex plus lag screw. (A and B from
Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg 1985;67A:1396–1401
; C and D from
Helm U. Forearm and hand/mini-implants. In: Muller ME, Allgower M, Schneider R, et al, eds. Manual of internal fixation. Berlin: Springer-Verlag; 1991:453–484
, Fig. 8.6.)
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Tension band wiring techniques are the mainstay of treatment for transverse, noncomminuted, olecranon fractures, but they may also be used in some comminuted fracture patterns. In commonly used constructs, intramedullary K wires or an intramedullary screw, combined with either braided cable or monofilament wire, are used. In terms of biomechanics, tension band techniques are thought to convert the force generated by the elbow extensor mechanism into a dynamic compressive force along the articular surface of the
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semilunar notch during active elbow motion (7). Although the validity of this biomechanical principle has been recently challenged, the clinical efficacy of tension band techniques is well documented (15,18,22).
Plate fixation is particularly effective when used to bridge areas of fracture comminution (7). A plate, often in conjunction with a lag screw, can also be used in oblique fractures. Whereas proximal oblique fractures are effectively treated with either tension band wiring or interfragmentary lag screws with a neutralization plate, the interfragmentary lag-screw fixation-neutralization plate construct has been demonstrated to possess a biomechanical advantage in treating more distal oblique fractures (14). Because of the subcutaneous location of the olecranon, mini and small fragment plates are indicated (Fig. 8.4D). Recently, olecranon-specific peri-articular plates have been developed as have standard locking plates.
Fractures with depressed osteo-articular fragments require joint elevation and bone grafting. Larger joint depressions may require adjunctive fixation with miniscrews or
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plates, K wires, and absorbable pins. A lag screw and a 3.5-mm plate or two K wires with a figure-of-eight wire are indicated for proximal and distal oblique fractures. Bone graft, lag screws, and a dorsal-neutralization 3.5-mm semitubular hook (see Fig. 8.4D), reconstruction, or compression plate all are required for comminuted fractures. Repair or reconstruction of the associated injuries in comminuted olecranon fractures is also required.
Figure 8.4. Hook plate. A. One end of a 3.5-mm semitubular plate is B. flattened with a mallet and bending irons. C. A wire cutter is used to cut away a portion of the distal plate hole. D. The two cut ends are then bent to 90 degrees. The plate is then contoured to the olecranon. Two holes are placed in the proximal olecranon to ease insertion of the hooks into the fragment. E. Cut portions of the plate are bent 90 degrees. (From
Mast JW, Jakob R, Ganz R. Planning and reduction techniques in fracture surgery. Berlin: Springer-Verlag; 1989
; Figs. 3.17 and 4.37.)
Excision and triceps advancement is indicated for a small, comminuted, olecranon fracture or in cases of severe osteopenia (27,28,30). Although some authors have demonstrated maintenance of elbow stability with excision of up to 80% of the trochlear notch, others have demonstrated a linear decline in elbow stability with increasing amounts of bone excision. Furthermore, several investigators have shown that fragment excision results in relatively elevated joint pressures in comparison to those found after internal fixation (7,18,28). Whenever possible, the amount of resected bone should be minimized.
Although discussions of transolecranon fracture dislocations of the elbow are beyond the scope of this chapter, we implore the surgeon to be vigilant in the identification of associated radial-head fractures, coronoid fractures, and Monteggia fracture-dislocations. When treating olecranon fractures, these additional injuries must be addressed because they may compromise the elbow function if left untreated.
Surgery
The patient is placed supine on the operating table and either regional (Bier or axillary block) or general anesthesia is administered. A tourniquet is applied, and the arm is placed in an arm holder across the patient’s chest (Fig. 8.5). Antibiotic prophylaxis consists of a cephalosporin for closed injuries, and for open injury, an aminoglycoside or penicillin (or both) are added to cefazolin. A c-arm image intensifier is positioned at either the head or foot of the table on the side of injury.
The arm is then prepped and draped (Fig. 8.6). A sterile Kerlex dressing (Kendall Healthcare Products, Mansfield, MA) is wrapped around the wrist, and a weighted speculum attached to the end of the Kerlex is passed off the table (Fig. 8.7). The weighted speculum provides enough traction to maintain the arm on the arm holder with the dorsal surface exposed. This eliminates the need for an assistant to hold the arm. As an alternate, the patient may be placed in a lateral decubitus position with the arm over a post. The elbow rests in flexion. The elbow is then extended to aid in the reduction. An iliac crest is also prepped and draped if the preoperative plan specifies the need for a bone graft.
The limb is exsanguinated, and the tourniquet inflated. The incision is begun distally on the subcutaneous border of the ulna (Fig. 8.8). It is continued proximally in line with the
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subcutaneous border of the ulna to the olecranon area, where it is curved radially around the tip of the olecranon and then extended proximally in the midline 3 to 5 cm.
Figure 8.5. The patient’s arm is placed across the chest on an arm holder. A tourniquet is applied.
Figure 8.6. The patient’s arm is prepped and draped for surgery and placed on the arm holder.
Figure 8.7. A sterile Kerlex is wrapped around the patient’s forearm. A weighted vaginal speculum is attached to the Kerlex. The traction holds the arm on the arm holder.
Figure 8.8. The skin incision is begun distally along the ulnar subcutaneous border and is curved radially around the tip of the olecranon and extended proximally in the midline.
The incision is developed down to the fascia. A subcutaneous flap is elevated over the tip of the olecranon from radial to ulnar. The dorsal component of the fracture line is now usually visible (Fig. 8.9). Two millimeters of periosteum is reflected from either side of the fracture lines to simplify visualization and fracture reduction. Distally, muscle origins are reflected extraperiosteally as needed. The fracture lines are cleaned of clot and debris. The joint is visualized by retracting the proximal fragment. The joint is cleaned of clot and debris.
Fracture reduction begins with elevation of any depressed articular component, if present. Bank or autogenous bone graft is used if necessary to support the depressed fragments. Small-screw fixation can be added if necessary. The fracture is then reduced and temporarily held in place with K wires or pointed reduction clamps. Additional lag screws are used if needed (Fig. 8.10). The fixation construct is determined by the preoperative plan.
With tension band wiring, two 1.6-mm K wires are placed by use of a parallel drill
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guide (Fig. 8.11). The K wires are over-inserted 1.0 to 1.5 cm and then are backed out to ease seating to the final depth. The K wires are placed down the intramedullary canal of the ulna. Alternately, the K wires can engage the anterior cortex of the ulna (see Fig. 8.3D), which may diminish pin migration. Intraoperative radiographs are obtained to verify the reduction and fixation position. We have abandoned the technique of anterior cortical engagement because precisely estimating the K wire length is technically difficult but necessary for preventing forearm rotational impingement or neurovascular injury should the K wire excessively protrude through the anterior cortex.
Figure 8.9. The incision is carried down to the fascia and periosteum. A subcutaneous flap is developed radially with the skin over the tip of the olecranon. The dorsal component of the fracture line is now visible.
Figure 8.10. The fracture is reduced and held in place with a pointed reduction clamp. In this case, one lag screw is placed across the fracture.
A 2-mm hole is drilled perpendicular to the long axis of the ulna approximately 3 to 4 cm distal to the fracture (distal anchor hole). This drill hole is approximately halfway between the volar and dorsal surfaces of the ulna. Anterior placement of this drill hole has been advocated based on a mathematical analysis (24). The anchor hole may be drilled before or after fracture reduction and K wire placement. Drilling the distal anchor hole before K wire placement avoids the potential complication of the drill hitting the K wires but does not eliminate the possibility that the K wires will prevent tension-band-wire placement in the distal anchor hole.
An 18-gauge figure-of-eight wire is passed through this distal drill hole. This wire is then crossed over the dorsal surface of the olecranon. A small loop is added to the wire proximal to the point where the wire crosses the dorsal olecranon surface on the radial side (Fig. 8.12). A 14-gauge angiocatheter is then passed from ulnar to radial side between the triceps tendon and the tip of the olecranon to help avoid injury to the ulnar nerve. The needle is removed. The radial limb of the figure-of-eight wire is inserted into the angiocatheter (see Fig. 8.12), and the angiocatheter is gently pulled back out (Fig. 8.13). The figure-of-eight wire is now located anterior to the triceps insertion, which has been shown to be the optimal position (8). This portion of the wire is twisted to the other end of itself. Two knots are now present in the wire, one knot on each side of the ulna.
The wire knots are then tightened simultaneously. This provides more uniform tension to the bone-implant construct. The knots are cut to a length of 3 to 4 mm, bent down, and buried in the soft tissues (Fig. 8.14). The K wires are bent dorsally just past 90 degrees with a metal suction tip (Fig. 8.15) and cut, leaving 3 to 4 mm of wire remaining past the bend. By using a wire pliers, the K wires are bent over to 180 degrees (Fig. 8.16) and rotated until
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the short portion of the bent wire is anterior. The K wires are then seated with a mallet and nail set (Fig. 8.17).
Figure 8.11. The preoperative plan in this case included a tension band construct with K wires and a figure-of-eight wire. Two 1.6-mm K wires are placed across the fracture site with a parallel drill guide.
Figure 8.12. The figure-of-eight anchor hole is placed in the distal fragment. A wire is passed through the hole and crossed over the dorsal cortex of the ulna. A twist with a loop is placed into the limb of the wire that is now radial. A 14-gauge angiocatheter is passed from ulnar to radial side anterior to the triceps tendon along the tip of the olecranon. The needle is removed. The radial limb of the wire is put into the angiocatheter.
Figure 8.13. With gentle pushing on the wire, the angiocatheter is removed. The figure-of-eight wire now lies anterior to the triceps tendon on the tip of the olecranon. This end of the wire is twisted to itself.
Figure 8.14. By using two needle holders, the figure-of-eight wire is tightened by twisting the loop on the radial side and the knot on the ulnar side. The twists are cut to a length of 3 to 4 mm.
We prefer to use a 1.3-mm stainless-steel cable with a small crimp instead of figure-of-eight wire. The cable sleeve is placed along the ulna so that the soft tissues can easily cover it, making it less prominent. In theory, the cable has the ability to achieve greater tension in a more symmetric fashion than the figure-of-eight wire. Care must be exercised to avoid applying too much tension on the cable, resulting in fragment crushing and loss of reduction.
The tourniquet is released. Final radiographs are obtained. The fracture is examined through a full range of elbow motion to verify stability (Fig. 8.18). The wound is irrigated and closed in layers. A drain is not used if adequate hemostasis is obtained after tourniquet release. The arm is placed into a posterior plaster splint. Antibiotics are continued for 24 hours.
Figure 8.15. The two K wires are bent dorsally to 90 degrees with a metal suction tip and a heavy needle holder.
Figure 8.16. The K wires are then cut, leaving 3 to 4 mm past the bend. A heavy needle holder is used to bend the K wires to 180 degrees.
Figure 8.17. The bent K wires are rotated 180 degrees so that the short end of the bend is now anterior. The K wires are seated with a nail set.
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Alternative Constructs
Medullary Screw with a Figure-of-Eight Wire
A medullary screw can substitute for the K wires in the previously described technique (see Fig. 8.3B). Advocates of this technique point out that static and dynamic compression are applied, that the screw is less likely to back out, and that this fixation is the strongest biomechanical construct (12,16,21). Disadvantages include prominent hardware and loss of reduction as the screw engages the distal ulnar canal, causing fragment translation.
The medullary screw is placed after fracture reduction. A 6.5-mm cancellous (32-mm thread length) or 4.5-mm malleolar screw is used. A washer is used to help anchor the figure-of-eight wire proximally. The triceps tendon is split in line with its fibers. The pilot hole is drilled, starting at the tip of the olecranon, and subsequently tapped. An alternative method is to leave the fracture displaced and to drill the pilot hole retrograde into the proximal fragment. The fracture is then reduced and held in place with clamps. The pilot hole is identified in the proximal fragment and the drill bit is inserted through it into the distal fragment.
As the screw engages the distal ulna, translation of the proximal fragment can occur. Before final seating of the screw, the figure-of-eight wire is inserted as described. The wire is passed around the screw below the triceps tendon. After the wire is tightened, the screw is
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seated. The washer is located on the bone deep to the triceps tendon. This technique avoids injury to the triceps tendon during final seating of the screw. The procedure continues as described.
Figure 8.18. The reduction and quality of fixation is evaluated as the arm is placed through a range of motion.
Lag Screw and Tension Band Plate
This technique involves placing a lag screw, usually through the plate, across the fracture, and placing a plate on the dorsal surface of the olecranon (see Fig. 8.3C). It is especially useful with oblique fractures in the sagittal plane. The lag screw is usually inclined from just distal to the tip of the olecranon to the coronoid process. The plate is bent around the tip of the olecranon, and two screws are placed proximally. The plate is tensioned by first placing a screw distal to the end of the plate. One limb of a Verbrugge clamp is then placed around the screw head, and the other hooks the last hole in the plate (Fig. 8.19). Closing the clamp applies tension to the plate. As an alternative, an articulated tensioning device can be used to tension the plate. Three to four screws are then added distally. The procedure continues as described previously. The use of a peri-articular plate with or without locking screws can be very helpful.
Comminuted Fractures
The surgical exposure described previously is used for comminuted fractures. Care is taken to avoid devascularization of bone fragments. Reduction proceeds in a step-wise fashion. Temporary fixation is achieved with K wires. The quality of the reduction, proposed final fixation, and bone is now assessed. If the fracture cannot be reduced, a spanning or bridging plate can be considered, or the fragments excised, and the triceps tendon advanced.
If adequate fixation can be achieved with an anatomic reduction, then final fixation is applied. K wires are replaced with lag screws. Bone graft is used to support osteochondral fragments. A dorsal plate is then applied to neutralize the lag screws. Several custom-designed plates are currently available. In addition, locking plates now offer other alternatives for fixation. While their role needs to be better defined biomechanically before advocating routine use, we have found locking plates very useful when the fracture is comminuted or is in osteopenic bone. A pelvic reconstruction plate can also be shaped to fit dorsally to the tip of the olecranon. In another alternative, a 3.5-mm semitubular plate is fashioned into a hook plate (see Fig. 8.4A–C) and shaped to fit dorsally to the tip of the olecranon (Fig. 8.4E). The hooks engage the olecranon at the most proximal point. This supplies additional points of fixation. The quality of fixation is assessed by moving the elbow neutral to 120 degrees. Closure continues as previously described.
Open Fractures
Patients with open fractures are taken to the operating room immediately, where irrigation and debridement of the injury are completed. The open wounds are extended as needed. Fixation proceeds as previously described. Part of the wound is left open, but the joint may be closed over a suction drain. The patient is returned to the operating room on postinjury days 2 and 4 for wound and fracture irrigation and debridement. Wound closure is completed on postinjury day 4. Wound closure is accomplished by
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delayed primary closure, skin graft, local rotational flap, or free-tissue transfer as needed. Antibiotics are used for 24 hours after each wound manipulation.
Figure 8.19. The fracture is reduced and a plate applied. A screw is placed into the ulna. A Verbrugge clamp is applied to the screw and the plate. Closing the clamp puts tension on the plate. This is unmeasured tension and care must be taken so the fracture is not displaced.
Postoperative Management
The postoperative rehabilitation is divided into three phases: initial, motion, and strengthening. Initially, the limb is splinted at 90 degrees for 3 to 5 days to promote soft-tissue healing. The second phase (motion) depends on the fixation used. Patients with fractures fixed with the tension band principle begin early active motion on day 5. A cast brace is used as needed; the decision is based on fixation quality and patient reliability. Fractures fixed with the lag screw–neutralization principle are placed in a long arm cast for a total of 2 to 3 weeks. A cast brace is used for an additional 3 to 4 weeks. Active and active-assisted motion exercises continue until the patient enters phase three. Isometric and isotonic exercises are started early as dictated by patient tolerance.
Phase three consists of strengthening. The prerequisites for entering this phase are radiographic evidence of progression to union, clinical evidence of union (no pain with physiologic stress), and an active range of motion of at least 75% of the contralateral elbow (75% of normal with bilateral injuries). The patient begins a progressive-resistance program designed to strengthen the entire upper extremity. Functional capacity evaluations are used for return to work for manual laborers.
The rehabilitation protocol is tempered by the quality of fixation and the intraoperative stability achieved. If stable fixation is achieved, even in comminuted fractures, then the protocol continues as described. If the quality of fixation will not withstand early motion, then the arm is splinted for 3 weeks. The rehabilitation protocol then continues as described and is adjusted if needed.
Complications
The most frequent complications of internal fixation of olecranon fractures are related to the hardware. Hardware symptoms are present in 22% to 80% of cases (7,10,13,26,29,31,32,33). K wire migration occurs in up to 15% of the cases. Hardware removal is required in 20% to 66% of fractures. Hardware failure occurs in 1% to 5% of cases.
When a K wire and figure-of-eight wire construct is used, several steps may help avoid symptoms related to the implants. K wires are over-inserted 1 cm and then backed up to ease deep final seating. The K wires are bent 180 degrees before final seating so that the bent portion of the wire penetrates the tip of the olecranon, making the wires less prominent. K wires that engage the anterior cortex may prevent the wires from backing out (23). The figure-of-eight wire knots should be buried in the surrounding muscle to avoid their prominence. The use of plate fixation may decrease the incidence of hardware-related complaints and the need for subsequent hardware removal (25,34). However, hardware prominence, symptoms, and removal may be unavoidable in this very superficial area. The preoperative discussion should include a description of the hardware-related symptoms and the frequent necessity for hardware removal.
Infection occurs in 0% to 6% of cases. The risk of infection is reduced with the use of perioperative antibiotics and in open fractures with attention to the soft tissues and wound closure. Acute infection is managed with irrigation and debridement as needed, antibiotics, and wound closure or soft-tissue reconstruction (tissue transfer).
Ulnar neuritis is present postoperatively in 2% to 12% of the cases. The ulnar nerve is not routinely exposed during ORIF, but the surgeon’s constant awareness of its location minimizes the possibility of injury. Observation is usually all that is required as symptoms either quickly resolve or improve with time. Late neurolysis may reduce symptoms in some patients.
Heterotopic ossification occurs in 2% to 13% of fractures. Indomethacin is recommended to help prevent heterotopic ossification in fractures at risk (associated, severe, soft-tissue
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injury, or elbow dislocation). Significant heterotopic ossification is treated with delayed resection and prophylactic irradiation.
Recommended Readings
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