Olecranon Fracture

Definition/Description

Olecranon fractures are often associated with elbow disease. These fractures are considered one of the easiest joint injuries, and surgery and physical therapy are straightforward. Most of these fractures are intra-articular and are usually associated with joint effusion and hematoma. Extraarticular fractures, including avulsion fractures, are most common in older adults. [1][2][3]

Clinical relevant anatomy

The elbow joint is made up of the following joints:[3]

• Ulna-humeral joint:
  • Function: Stability; Elbow flexion/extension
• Radio-humeral joint
  • Function: lateral stability; forearm pronation/supination
• Proximal radio-ulnar joint
  • Function: Forearm pronation/supination

Olecranon function:[3]

• Therefore, the insertion point of the triceps plays an important role in the elbow extensor mechanism. [4]
• Major articulation for elbow joint

Epidemiology/Etiology

Mechanism of injury

• Direct:
  • Fall on the forearm
    • Press the olecranon into the distal humerus by hyperextending the elbow on the outstretched hand
  • Penetrating injuries affecting articular surfaces (eg, panga injuries)
• Indirect: Through triceps contraction
  • Contraction of the triceps tears the olecranon and tears the distal triceps expansion
  • Athletes (such as wrestlers and gymnasts) who generate a lot of isometric force (such as wrestlers and gymnasts) are at risk

[1][3][5]

Characteristics/Clinical presentation

Clinical presentation

Patients with an olecranon fracture cannot extend their arms. [1][5]

Classification

The Mayo classification system for olecranon fractures is based on the displacement of the olecranon comminution and the stability of the elbow joint. There are 3 types of fractures, each with 2 subtypes. [6][7][8]

• Type I: Non-comminuted and slightly comminuted fractures
• Type II: displaced fracture with intact ulnar collateral ligament
  • Displaced vs non-displaced
  • Stable fracture
• Type III: Fracture between the forearm and humerus
  • Displaced vs non-displaced
  • Instable due to medial collateral ligament rupture

Diagnostic procedures

Physical examination

• Subjective interview:
  • Mechanism of injury: Direct hit to the elbow
  • Complaints:
    • Pain over elbow
    • Inability to extend elbow
• Observation:
  • Deformity:
    • Obvious around elbow
    • Forearm appears shorter
    • Distortion of bony landmarks of elbow
  • Swelling
  • Bruising
• Palpation:
  • Olecranon tip and proximal ulna tenderness
  • Palpable gap at fracture site
• Range of motion: Limited elbow extension
• Neuromuscular examination of the hand to rule out concomitant

[3]

Special investigations

• X-rays: AP and lateral views[3]

Outcome measures

• Disability of Arm, Shoulder and Hand (DASH)

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 the development of arthropathy after surgical treatment. The goal of this management is to restore the extensor Mechanisms and reconstructive articular surfaces of the elbow.

• Type I: 2 weeks of fixation and symptomatic treatment
  • Risk of displacement due to triceps tension
• Type II + III: Surgical fixation is required.

[1][2][6][7][8][9] 

Surgical intervention

• Tension band wiring fixation:
  • Indications: Non-comminuted transverse fractures involving less than half of the olecranon surface of the joint
  • Complications:
    • Loss of fixation
    • Non-union
    • Skin breakdown
    • Infection
    • Olecranon bursitis
    • Radial head subluxation
    • Prominent hardware

• Plate fixation (more stable):
  • Indication:  Comminuted fractures
  • Good results on prevalence of unions and hardware complications
• Intramedullary screw fixation:
  • Indications: Simple non-comminuted transverse fractures: intramedullary screw fixation
  • Improved pain function and range of motion compared to tension band routing
• Olecranonectomy and/or Triceps Progression Technique:
  • Indications: Articular surfaces too comminuted or osteoporotic to fix (elderly/low demand patients).
  • To reduce the risk of instability, the following criteria also apply – complete:
    • Medial collateral ligament
    • Interosseous membrane
    • Distal radioulnar joint
    • Approach: Reattach the triceps tendon at the proximal edge of the articular surface.

[1][2][6][7][8][9]

Complications

Possible complications of olecranon fractures and their surgery include:

• Permanent extension loss
• Heterotophic ossification[2]
• Non-union
• Malunion

Physiotherapy management

Precise postoperative care is important for maximum healing. The functional goal of the physical therapist is to restore and normalize activities of daily living. Rehabilitation and bone healing takes about 12 weeks:

Week 1

Inflammation phase:

• Splint or cast with elbow flexed to 60° to minimize tension on skin
• Active and passive range of motion to assess excessive finger swelling for capillary refill
• Start shoulder hand and finger range of motion (splint to be maintained)
• Oedema management
• After 3 to 4 days:
  • Isometric exercises of the wrist
  • Gentle active elbow flexion (no splint).
  • Active range of motion of the wrist
  • Teach patients functional adaptations, such as using the healthy limb for self-care activities

[2][4]

Week 2

Restorative phase: no or minimal stability at the elbow.

• Do not allow extension of elbow < 90° with cast or splint
• Splint or cast removed in most cases
• Gentle isometric exercises of the biceps
• Isotonic exercises to the digits

[2][4]

Week 4-6

Fracture now partially stable:

• Active and Active Assisted Range of Motion for Shoulder Elbow and Wrist
• Avoid passive range of motion at the elbow
• Isometric exercises for elbow and wrist joints
• Activities of Daily Living: Use of affected limb for stabilization and light self-care

[2][4]

Week 8-12

If the fracture heals clinically and radiologically:

• Gradual weight bearing through the affected limb
• Resistance training for elbow flexors and extensors
• Active and active assisted range of motion of the elbow and wrist in all planes (until a satisfactory range is achieved)
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