What is Olecranon Fracture?
The olecranon is a part of the ulna, which is one of the bones in your forearm. Along with another bit called the coronoid process, it makes up a semicircular notch. This notch interacts with the humerus (the bone of your upper arm) to allow your elbow to bend and stretch. If you ever wondered why you can flex and extend your elbow, this is why.
Olecranon fractures, or breaks in the bone, are fairly common in adults. This is because the olecranon is located just under the skin, making it prone to injury from a direct hit. The injuries can range from simple fractures that don’t shift the bone’s position, to complex ones that may involve an open broken bone and joint dislocation.
These fractures often require surgery in order to restore the shape and stability of the elbow joint. While the results of the surgery are often good, it’s not uncommon for patients to experience a decreased range of motion in their elbow or require another operation to remove surgical hardware.
What Causes Olecranon Fracture?
Olecranon fractures, or breakages in the tip of the elbow, usually happen in people who are 50 years or older after they fall from a standing position. Younger individuals, on the other hand, often get these injuries from high-energy accidents. These fractures can happen when the elbow is forced to stretch too far or takes a direct hit when the elbow is bent 90 degrees.
They can also happen when the triceps muscle suddenly tightens, causing what is known as an avulsion injury. These types of fractures usually have a horizontal or sloping fracture line and are more common in individuals with osteoporosis, a condition that weakens bones.
Risk Factors and Frequency for Olecranon Fracture
Olecranon fractures, or fractures in the curve of the inner arm, make up about 10% of all upper arm fractures. They happen most often at age 57, and men usually get these injuries at a younger age. They often occur alongside other injuries of the elbow, particularly those involving the radial head and coronoid, which are parts of the elbow. About 6.4% of these fractures are ‘open,’ meaning the bone has come through the skin.
- Olecranon fractures make up around 10% of all upper arm fractures.
- These fractures usually occur around the age of 57.
- Males normally suffer these injuries at a younger age.
- Often, these fractures occur alongside other elbow injuries, mainly to the radial head and coronoid.
- About 6.4% of these fractures are open, meaning the bone penetrates the skin.
Signs and Symptoms of Olecranon Fracture
If someone falls and hurts their elbow, they might have a type of break called an olecranon fracture. This often comes with pain and swelling around the elbow. If the bone is moved out of place, then there could be a noticeable change in the shape of the elbow, and even a gap that can be felt. The main sign of an olecranon fracture is not being able to straighten the arm without help from gravity. A health professional can check this by lifting up the person’s arm and asking them to straighten their elbow.
It’s also important to look at the whole arm that’s been hurt to check for other injuries. There might be cuts that suggest the bone has broken through the skin. Other parts of the elbow like the little bump on the inside (coronoid process), the top of the radius bone (radial head), or the joint where the radius and ulna meet might also be injured. These can be seen on x-rays.
The health professional should feel the elbow and the nearby joints. They should also check the nerves and blood flow in the injured arm. Particularly, they should check the ulnar nerve, which can be easily damaged because it’s just under the skin on the inside of the elbow. If the injury came from a serious accident, they should be careful not to miss any other injuries that the patient might not be noticing because of the pain from their elbow. It’s a good idea to ask the patient about any other pain they’re feeling, and to check all their limbs for creaking sounds, changes in shape, or pain when they’re moved.
Testing for Olecranon Fracture
The initial examination for elbow fractures often involves two types of bone scans, or radiographs. The first one scans from front to back, known as anteroposterior, and the second one takes a side-on view, known as lateral. This set is usually enough to understand the nature of the fracture.
In some cases, a specific radiocapitellar view may also be taken to check for fractures on the head of the radius (a bone in the forearm) and a part of the elbow called the capitellum. These scans should also be checked for any related injuries such as a fractured or a dislocated radius, or any issues with the connection between the elbow and the forearm.
In serious or complex situations where other injuries might be present, a Computed Tomography (CT) scan might be used to get a clearer picture before planning any surgery.
When it comes to categorizing elbow, specifically olecranon fractures (around the bony tip of your elbow), doctors generally use a system called the Mayo classification. This system was developed by a doctor named Morrey in 1993. It breaks the fractures down into three types, A and B, which refers to whether the fracture has shattered into multiple parts (comminuted) or not.
Type I fractures are minor ones where the bones haven’t moved out of place. Type II fractures are more serious where the bones have shifted at least 3mm, but the elbow joint remains in alignment, meaning the ligaments that hold it together are intact. Type III involves both bone displacement and an unstable elbow joint, often resulting in a fracture-dislocation, and the ligaments might not be holding things in place properly. The majority of olecranon fractures are Type II, making up 80-85% of cases, while Type I accounts for 5-12% and Type III is approximately 6% of cases.
Treatment Options for Olecranon Fracture
When suspecting an olecranon (the point of the elbow) fracture, it’s essential to consult with an orthopedic specialist. Once a complete medical history, physical examination, and imaging have been done, the fractured elbow should be put in a posterior splint with a slight extension. For severe injuries, the fracture may need to be realigned to link the remaining joint surface with the trochlea, an important part of the elbow.
Non-displaced olecranon fractures, where the bones haven’t moved out of place, can be treated initially by immobilizing the elbow in a long-arm splint. The elbow should be bent at an angle of 45-90 degrees. Progression to active motion exercises, avoiding forceful elbow extension, should be the next step. It’s important to regularly monitor these patients with x-rays to ensure the fracture is healing properly and hasn’t moved out of place.
Surgical treatment is typically needed for more severe fractures. However, non-operative treatment may still be an option for displaced fractures in elderly patients over 70 years. While they might lose full elbow extension, some patients might prefer this to the risks associated with surgery. A thorough conversation is needed, discussing benefits and risks of both surgical and non-surgical management, and tailoring treatment to individual patient needs.
For displaced, stable fractures without fragmentation of the bone, a technique known as tension band wiring may be used. It uses the pull of the triceps muscle to create a compressive force that maintains the joint.
For more unstable fractures with significant fragmentation, plate and screw fixation is recommended. The screws and plates used vary and depend on the specifics of the fracture. Patients should achieve a full and natural realignment of the fracture under direct visualization.
Internal rods, known as intramedullary nails, are also useful in some cases. They help avoid complications linked to the superficial position of traditional hardware used for olecranon fractures.
In elderly, low-demand individuals, when the fractured piece is too small for fixation or affects less than 50% of the joint surface, the option of removal and triceps muscle reattachment is viable. But it’s important to ensure other supporting structure of the elbow and forearm are intact to prevent instability.
What else can Olecranon Fracture be?
When checking for elbow injuries, it’s critical to rule out other issues that may change the treatment approach. Examine the skin for open bone fractures. Other commonly associated injuries may include fractures of the coronoid process (a protrusion in the upper arm bone), the radial head and neck (parts of your forearm bone near the elbow), dislocation of the radial head (when your forearm bone pops out from the elbow joint), and injuries to the collateral ligaments (ligaments that support the elbow).
What to expect with Olecranon Fracture
Generally, people tend to recover well after treatment for a fracture in the olecranon, which is found at the tip of the elbow. It’s possible that there might be a slight loss of full extension, around 10-15 degrees, although this normally doesn’t cause significant issues. In long-term follow-up studies of 15-25 years, a whopping 96% of patients were found to have good or excellent functionality.
The healing rate for these fractures is quite high, with only about 1% of fractures not healing completely, a condition known as nonunion.
Possible Complications When Diagnosed with Olecranon Fracture
The most common complication after a surgical operation to fix bone damage (like a fracture), is irritation that necessitates the removal of the surgical hardware. This is due their placement just under the skin. Different studies show a variable rate of hardware removal, however, a recent one reported a hardware removal rate of 50% when tension-band wiring (TBW) is used and 22% with plate fixation. Intramedullary devices, which are put inside the bone, are less prominent and thus have a lower risk of causing irritation which would result in a secondary operation. Another complication can be wire migration, which happens when the wire moves out of place, often accompanied by wire breakage and fracture displacement.
Wound complications or infections are another problem, as the bone surface doesn’t have much soft tissue coverage. Placing plates on the side of the bone where there’s more robust soft tissue can help reduce this risk. The Kirschner wires (k-wires) used might back out and cause wound problems or irritation of the soft tissue. Subsequent issues can be reduced by certain placement and adjustment techniques. Using pins that are too long can also cause problems by adversely affecting the muscle movement or damaging the tendon or muscles. Studies have reported a higher rate of infections in patients treated with plate fixation compared to TBW.
Post-operation, patients can commonly experience a loss of range of motion, especially in elbow extension. However, this isn’t usually serious as it doesn’t significantly affect the functional range of motion. Also, stiffness might be experienced by up to 50% of patients, but this doesn’t usually affect function substantially. After surgery, about 50% of patients may exhibit degenerative changes on their x-rays at long-term follow-up, but this does not necessarily impact their overall outcomes negatively.
The following complications may also manifest:
- Heterotopic ossification (abnormal bone growth) is seen in about 13% of patients.
- Ulnar nerve neuritis (nerve inflammation) – occurs in roughly 2-12% of cases, but can often be resolved with conservative management. Stubborn cases may require neurolysis (nerve decomposition) and ulnar nerve transposition (moving the nerve).
- Nonunion, which is when the bone doesn’t heal properly, happens in around 1% of cases. Treatment options range from conservative measures, securing with internal devices with or without bone graft, to more invasive ones like excision and triceps advancement, and elbow arthroplasty (elbow joint replacement).
- Malunion is when the bone heals in the wrong position and can be treated with an osteotomy (surgical cutting of the bone).
Recovery from Olecranon Fracture
The procedures followed after an operation can change based on the place it’s performed. Doctors usually decide how long a patient needs to keep still based on factors like how stable the fracture is, how well the wound is healing, and how well the patient can follow instructions. Usually, patients are given an above elbow back-slab, or removable splint, to wear for 7 to 10 days after the operation. During this period, the elbow is bent at ninety degrees and the wrist is kept straight. After this stage, patients typically start moving their elbow slowly with the help of gravity.
When the x-rays show that the injury has healed well, which is usually around 6 to 8 weeks after the operation, patients can start doing exercises to regain the full range of motion and strength in their elbow. Patients can expect to be able to return to sports and activities that require full movement of the elbow after about 3 to 4 months.
Preventing Olecranon Fracture
It’s vital to clearly explain to the patient the potential risks and what they can expect from both surgical and non-surgical treatments. Surgeries often come with general and specific risks, and there’s a high likelihood of needing a follow-up surgery to remove the surgical hardware if it causes discomfort. Often, the patient may experience a slight loss of full elbow extension – about 10-15 degrees. While this usually doesn’t hinder functionality, it might cause aesthetic concerns. It’s important to discuss this potential outcome with the patient before the surgery. For the best results, it’s essential for the patient to follow weight-bearing limitations, do exercises to maintain a range of motion, and build strength.
