BROKEN ELBOW

(OLECRANON FRACTURE)


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related talks: children's broken elbow; radial head fracture (type of broken elbow); elbow dislocation; elbow stiffness; broken forearm; broken arm; swollen elbow
 

What is a Broken Elbow (Olecranon Fracture)?

What is an olecranon and why does it have such a crazy name?

The olecranon is the pointy part of your elbow, which its part of the ulna bone. The ulna is one of two bones in your forearm (the other is the radius). The ulna and humerus (arm bone) form the major hinge joint of the elbow (the radius is part of the elbow joint too, but most just sits there looking pretty).

As you can imagine, this pointy part of bone can be broken when someone falls into it.   

There are a few issues that complicate things with this type of break. One problem is that the powerful triceps muscle attaches to the olecranon and when a piece breaks off, the muscle pulls it away from the rest of the bone, making it near impossible for the bone to heal on its own.  Oftentimes, this type of fall causes the elbow to break into many pieces.  Also, when the olecranon breaks the elbow is unstable and its at increased risk for dislocating.  These issues are important when treatment options are considered.

How is a Broken Elbow (Olecranon Fracture) diagnosed?

The diagnosis of an olecranon fracture is made by first listening to the history of a person's injury and their symptoms.  People report elbow pain, swelling and inability to straighten their elbow.  

Doctors will get X-rays of the elbow and forearm to diagnose the injury. It is important to not only identify the fracture, but also look for bone fragments that may have entered into the joint, and also to look at the entire elbow joint for additional breaks. 

How is a Broken Elbow (Olecranon Fracture) treated?

Treatment depends on the severity of the break.

If there is a hairline crack, but the bone fragment doesnt move out of position, then the elbow should be immobilized in a splint for about 2 weeks before starting to move it.  The splint prevents re-injury, and decreases the chance that the tricep muscle will pull on the fracture making matters worse.  

Other broken bones are protected for more than 2 weeks, usually about 4 weeks, however the risk of elbow stiffness is so concerning that most doctors will accept the small risk of a repeat injury compared to the much more common risk of significant stiffness developing.  

If there is a clean break in the olecranon and the bone fragment has separated more than 2 mm, then surgery is required because without putting the bone back together with surgery, most fractures will not heal on their own.

The common treatment for this surgery is a “tension band” which is a clever technique that uses small pins and a wire to convert the triceps into a helper (instead of pulling the bone fragments apart, it will compression them together).  If the olecranon has been broken into many pieces then a screw and plate is needed to hold the bone in the correct position as it heals. 

What is the long term outcome?  

The bone typically heals well after surgery however elbow stiffness is a big concern.  About 50% of people with this fracture develop a stiff elbow.  With proper physical therapy and early range of motion, that stiffness can be minimal, and not enough to interfere with daily activities. 

Another common complication with the surgery is discomfort from the wire or screws that are used to fix the bone. There is very little skin, muscle and other soft tissue sitting over the bone, and a lot of people can feel the screws through their skin. Oftentimes it irritates the elbow enough that it needs to be removed with a second surgery after the bone has completely healed.

Reference

1) Veillette CJ, Steinmann SP. Olecranon fractures. Ortho Clin North Am 2008; 39: 229-36. full article. review.

2)  Hak DJ, Golladay GJ. Olecranon fractures: treatment options. JAAOS. 2000 Jul-Aug;8:266-75. full article. review. 

Treatment

3) Fyfe IS et al. Methods of fixation of olecranon fractures. An experimental mechanical study. JBJS 1985; 67: 3667-72. full article. original paper on tension band wire.

4) Duckworth AD et al. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. JBJS 2014; 96: 67-72. full article. elderly do well nonop. avg. 76 yo., 72% good-exellent at 6 mo, 90% satisfaction at 6 yrs.

5) Wolfgang G et al. Surgical treatment of displaced olecranon fractures by tension band wiring technique. CORR 1987; 224: 192-204. full article.  tension band works well.

6) Hume MC, Wiss DA. Olecranon fractures a clinical and radiographic comparison of tension band wiring and plate fixation. CORR 1992; 285: 229-35. full article. plate gives better joint congruity (47% vs. 86% on xray), better clinical outcome (37% vs. 63% good result).

7) Bailey CS et al. Outcome of plate fixation of olecranon fractures. JOT 2001; 15: 542-8. full article. excellent-good outcome in 25 pt at 1-3 yrs. 20% hardware removal.

8) van der Liden SC et al. K-wire position in tension-band wiring technique affects stability of wires and long-term outcome in surgical treatment of olecranon fractures. J Shoulder Elbow Surg 2012; 21: 405-11. full article. surgical technique: transcortical k-wires prevents loosening (33% vs. 78% in those with unicortical kwires).

9) Prayson MJ et al. Biomechanical comparison of fixation methods in transverse olecranon fractures: a cadaveric study. JOT 1997; 11: 565-72. full article. transcortical k-wire wtih braided cerclage wire is most rigid (but it may fray causing sx). 

4) Parker JR et al. Anterior interosseus nerve injury following tension band wiring of the olecranon. Injury 2005; 36: 1252-3. full article. k-wires go too anterior risk AIN, or can block ROM by impinging on radial head. heres a review of other elbow nerve injuries.

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