Olecranon Fracture

Olecranon Fractures assume clinical importance as they are invariably intra-articular fractures and, when displaced, result in a disruption of the triceps mechanism, leading to loss of elbow extension.

Avulsion olecranon fractures due to sudden contraction of the triceps are noted in the elderly, whereas fractures due to direct injuries are more common in younger patients. Direct injuries are often associated with open wounds as the olecranon is a subcutaneous bone. High-energy injuries causing elbow dislocation can be associated with comminuted olecranon fractures.

Direct injuries are often associated with severe swelling and open wounds.

Clinical Evaluation

Pain localized to the posterior elbow, in addition to swelling at the elbow joint.

Palpable defect indicates displaced fracture or severe comminution.

Inability to extend elbow : indicates discontinuity of triceps (extensor) mechanism.

Olecranon Fracture Radiology

Standard anteroposterior and lateral radiographs of the elbow should be obtained.

Patients with comminuted fractures and those associated with trochlear fractures may require additional investigation with a CT scan.

Classification

Many classification for olecranon fractures has been described:

Mayo classification

In Mayo classification of fractures of the olecranon, the fracture is divided into three main types as:

1. Type 1, undisplaced
2. Type 2, displaced
3. Type 3, unstable fractures.

Each type can be further subdivided into non-comminuted (A) and comminuted (B) fractures.

Colton classification

Type	Description
Type I	avulsion
Type II	oblique fractures with increasing complexity
Type III	fracture-dislocations
Type IV	atypical high-energy, multifragmented fractures

Schatzker Classification

Type	Description
Transverse	Represents an avulsion fracture from a sudden pull of the triceps muscle
Transverse impacted	A direct force sometimes leads to a transverse fracture with comminution and depression of the articular fragments
Oblique	This results from a hyperextension injury as the olecranon tip is impacted in the olecranon fossa. The fracture line begins at the midpoint of the sigmoid notch and runs distally
Comminuted	This results from direct high-energy trauma. Associated ligamentous injuries or fractures of the coronoid process can make the elbow unstable
Oblique distal	Fractures extend distal to the coronoid and compromise elbow stability
Fracture dislocation	This is usually associated with severe high-energy trauma and is often a compound injury

AO Classification

Type A	Extra-articular
Type B	Intra-articular
Type C	Intra-articular fractures of both the radial head and olecranon

Olecranon Fracture Treatment

Non-operative treatment is indicated only for undisplaced fractures and displaced fractures in elderly patients with significant comorbidities. Immobilization in a long arm cast with the elbow in about 45° of flexion is advised. In general, there is adequate fracture stability at 3 weeks to remove the cast and initiate range of motion exercises.

The standard Olecranon Fracture Treatment is an open reduction followed by internal fixation, the type of which is decided by the pattern of the fracture:

1. Tension band wiring with stainless steel cerclage wires is used in combination with two parallel Kirschner wires. The Kirschner wires help to keep the fragments in position and the tension band counteracts the tensile forces, converting them to compressive forces.
2. Intramedullary fixation with a single 6.5 mm cancellous lag screw can be used in transverse fractures. This may be used in conjunction with tension band wiring also.
3. Plates and screws are used for comminuted olecranon fractures, fractures with distal extension of the fracture line, associated coronoid fractures, Monteggia fractures and fracture dislocations.

Complications

• The fracture being intra-articular, pain and early degeneration may occur if accurate reduction is not established.
• Irritation of the skin owing to prominent hardware is common as the bone is subcutaneous. Removal of tension band wires after fracture union is sometimes necessary because of loosening and backing out of the Kirschner wires.

References & More

1. Sullivan CW, Herron T, Hayat Z. Olecranon Fracture. [Updated 2022 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537295/
2. Browner BD et al, editors: Skeletal trauma, ed 2, Philadelphia, 1998, WB Saunders, p 1469
3. Millers Review of Orthopaedics -7th Edition Book.
4. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.