Olecranon fracture. Lonnie Froberg, MD, Ph.D Rigshospitalet, Copenhagen University Hospital

Transcription

1 Olecranon fracture Lonnie Froberg, MD, Ph.D Rigshospitalet, Copenhagen University Hospital

2 20% of forearm fracture 12 per persons per year Low-energy fall Increased risk >50 years 90% AO 21.B1.1 Dickworth et al. Injury 2012;43:

3 Why operate? Methods of fixation K-wire, cerklage Plating Outcome Summary

4 Why operate? Restore articular surface Achieve absolute stability Commence early active movement Preservation of range of motion and power Avoidance of complications

5 Methods of fixation?

6 Methods of fixation? Cadaveric elbow joint Standard osteotomies Five different fixation techniques Loads applied comparable to clinical situations Displacements measured Fyfe et al. Jour Bone Joint Surg (Br) B;3:

7 Methods of fixation? Fracture type Transverse Oblique Comminuted Fixation technique Tension band 1.0 mm, 1 knot, K-wire K 2.0 mm Tension band 1.0 mm, 2 knots, K-wire K 2.0 mm Tubular plate Fyfe et al. Jour Bone Joint Surg (Br) B;3: Cancellous screw, washer Cancellous screw, washer, tension band

8 Methods of fixation? Fracture type Fixation technique Transverse Tension band, 2 knots Oblique Comminuted Tension band, 2 knots or tubular plate Tubular plate Fyfe et al. Jour Bone Joint Surg (Br) B;3:

9 K-wire and cerklage

10 How to place the K-wires? K Proximal ulnar canal? Anterior cortex? Distal ulnar canal? Huang et al. J Trauma ;1:

11 How to place the K-wires? K Proximal ulnar (n=24) Anterior cortex (n=28) Distal ulnar (n=26) Average follow- up/months 34.5 s.d s.d s.d 7.2 Symptomatic implant removal 8 (33%) *p= (11%) 2 (8%) Proximal migration of K-K wire/mm Satisfactory functionel outcome 4.08 s.d *p= s.d s.d (88%) 26 (93%) 26 (100%)

12 How to place the K-wires? K Inserted as close as possible to the articular surface Back 1 cm from final position, cut obliquely, bent Incisions with lines in triceps K-wires are impacted into ulna Newman et al Injury; 40(6):

13 How to place the K-wires? K K-wire penetration more than 10 mm beyond the anterior cortex increases risk for penetration of median nerve and ulnar artery Prayson et al. Shoulder Elbow Surg ;1:

14 Which kind of tension band? Failure (> 2 mm movement across osteotomy) Compression Stainless steel wire 0% 71% Ethibond No % 66% Ethibond No. 5 40% 40% Fiber wire 0% 43% Lalliss et al. Jour Bone Joint Surg (Br) B;2:

15 Plating

16 Plating When to plate? Tension band is not appropriate Oblique fractures distal to the midpoint of the troclear notch Co-existing coronoid fracture Associated with Monteggia fracture dislocation Newman et al Injury; 40(6):

17 Which kind of plate? Cadaveric study Comminute fracture No difference in failure rate (>2 mm gap of fracture) Buijze et al. Arch Orthop Trauma Surg.2010;130:

18 Which kind of plate? Advantage of locking compression plate to conventionel plate: Angular and axial stability Preserves periosteal blood supply No toggling of unlocked screws (improves fixation in osteoporotic fractures and comminution)

19 Which kind of plate? Stainless steel or titanium? More screw in proximal fragment better than fewer screws? Larger screws better than small screws?

20 Which kind of plate? Accumed stainless stell Synthes stainless stell Synthes titanium US Implants Zimmer

21 Which kind of plate? No statistical difference between maximum load and cycles survived Edwards et al. J Orthop Trauma 2011;25(5):

22 Outcome Cochrane review Short term (2-3 3 years) *only plate fixation Pain 1 (VAS score) Motion compared to non-affected arm Radiographic evaluation Decreased supination Long-term (15-25 years) 6% severe daily symptoms Decreased flexion and extension (5 degrees) 8% OA 5% OA 1% non-union Patient-rated outcome 9.7 (VAS score) 96% excellent or good Veillette et al. Orthop Clin N Am. 2008;39:

23 Summary Tension band fixation Fracture: Transverse or oblique K-wire: Anterior cortex or distal ulnar canal K-wire penetration: <10 mm beyond the anterior cortex Tension band: 1.0 mm stainless steel wire, 2 knots

24 Summary - Plating Fractures: Distal to the midpoint of the troclear notch, co-existing coronoid fracture, Monteggia Locking compression plate theoretically superior to conventionel plate

25 Thank you

26 Technique

27 Technique

28 Technique