Displaced Olecranon Fracture

 

Olecranon Fractures

 

 Olecranon fractures involve the upper end of the ulna (one of the bones in the forearm) and represent the area in which the triceps (the large muscle in the back of the arm) anchors to the forearm.  If the olecranon fracture is displaced, this disconnects the triceps muscle from the forearm and if left untreated results in profound weakness and inability to straighten the forearm. In addition, these fractures may disrupt the surface of the elbow joint (cartilage).  Typically the surface of the joint is smooth allowing the bones to glide past one another with very little friction.  If the surface is incongruent because the bones are not aligned, chronic damage to the joint occurs ultimately leading to arthritis and loss of cartilage.  It is therefore very important to ensure that the surface of the cartilage is repaired as accurately as possible.  Because of this, I recommend surgical repair in any fracture of the Olecranon in which the joint has more than 2 mm of displacement. 

 

   

Sawbones model showing olecranon and x-ray of corresponding area

 

For non displaced fractures, close observation and casting are the suggested treatment. The only downside to conservative management is that the elbow tends to stiffen quickly after immobilization.  In adults this can lead to permanent loss of motion so I try keep patients in a long arm cast no longer than 4-5 weeks. If you are going to have your cast on for more than 1-2 weeks I would advise you to check out cast protectors as shown below.  They are form fitting plastic covers with a rubber diaphram at the top, they work very well to keep moisture out of the cast when you are taking a shower.  I have included a couple websites below that sell covers online. They are relatively inexpensive and well worth the extra $$.

 

 

Cast Cover Web Sites

 

 

http://castcoversnow.com/

 

http://www.nextag.com/waterproof-cast-covers/search-html

 

http://www.brokenbeauties.com/fashion-new/castcovers-arm.php

   

Long arm Cast and long arm cast protector

 

  In displaced fractures I recommend surgery to restore the congruence of the joint and provide stability to the triceps anchorage.  The procedure typically takes approximately one hour and can be performed on an outpatient basis. The surgical incision is centered on the back of the elbow and most of the time the incision is about 6 inches long.  The method I use to repair the fracture depends on a number of factors including the amount of splintering (comminution) and the quality of the bone.  If the fracture is a fairly clean break with two large pieces, I will repair the fracture with a contruct called a tension band with several wires holding the frature.

 

 

    

Olecranon fracture repaired with tension band wiring

 

 

 

 

 

Highly comminuted olecranon fracture not amenable to tension banding

 

In cases where the patients bone is very soft or the fracture has multiple fracture lines and splintering (comminution) I use a plate to repair the fracture.  There are several manufacturers who produce custom bent plates for use in the olecranon.  Many of these plates offer (locking screws) where the screws thread into the plate and this prevents toggling and loosening.  These types of locking plates are ideal for use in patients with softer bone. I have listed links to the 3 plates I most commonly use in the olecranon.  They are all very good and I don't have a strong preference for any one plate.

 

 

Synthes LCP Olecranon Plates

 

Stryker Variax Olecranon Plates

 

Acumed Olcranon Plates

 

 

      

 

The same fracture after plating with a locked olecranon plate

 

After surgery I put patients in a splint, which is soft padding sandwhiched by a layer of plaster.  This allows your arm to swell some but still provides immobility from a rigid splint.  I have patients wear a split (soft cast) for about 2 weeks and then begin a fairly aggressive protocol with physical therapy to regain range of motion in the elbow. Recovery is generally fairly quick and most patients regain full function within 8-12 weeks after surgery. Once the fracture has healed, many patients experience irritation from the prominence of the wires. Because of this I generally recommend removal of the wires approximately 10-12 months after the initial procedure.

 

The primary long term problem that develops after surgery is stiffness of the elbow joint.  Most patients are able to bend fairly well but getting the elbow completely straight is often troublesome and I tell patients to expect to loose 5-10 degrees of extension (ability to completely straighten the arm) once they are done healing. Unfortunately, surgical release of the scar tissue around the elbow often makes the problem worse, so I discourage this approach in all but the most severe contractures.  To help combat stiffness, I will often perscribe a Dynasplint (a dynamic splint the patient uses on their own typically in the evenings) as an adjunct to physical therapy.  This can help patients regain motion more quickly.  I have included a photo of a dynasplint below and a link to their website.  In general, I have found this device to be quite useful in regaining elbow motion.

 

  

 

Pictures of Elbow Dynasplints

 

Link to Dynasplint Website

 

For more information about surgery, what to expect after surgery and some useful tips and FAQ's, I recommend looking at my post-op elbow instruction sheet (link below).  It contains a lot of information about surgery, timing, what's not and what's not.  If you're scheduled to have surgery on your elbow, you should read this

 

 

Elbow Surgery Post op Instructions