Olecranon Fractures Allan Peljovich, MD, MPH The Hand & Upper Extremity Ctr of GA; Shepherd Center; Atlanta Medical Center Orthopedic Residency Program Olecranon Fx Anatomy Olecranon Fx Considerations Soft tissue, i.e., closed vs. open Simple vs. Comminuted Associated elbow injury Patient s age Co morbidities 1
Olecranon Fx Classification Colton (displacement) Mayo (stability, displacement, comminution) Schatzker (morphology) AO (comminution, radial head) Tamaoki, et al, 2014; Benetton, et al, 2015 Olecranon Fx Nonoperative Rx No clear guidelines or data <2mm displacement and stable with flexion lateral Typically reported for elderly None with dislocation Very good to excellent outcomes are the norm Regardless of displacement Mayo type 2 case control study Avg 55 years (9/14 > 60 years old) MEPI 91F, 99M QuickDASH 6F, 18M Veras Del Monte, et al, 1999; Erturer, et al, 2011; Duckworth, et al, 2014; Galluci, et al, 2014; Putnam, et al, 2017; Marot, et al, 2018 Olecranon Fx Operative Rx Displacement (>2mm) & Instability Articular incongruity Recent study brings attention to the intermediate fragments in comminuted fractures. Associated trauma von Rüden, et al, 2011 2
Olecranon Fx ORIF Tension Band Wiring (TBW) TBW works by resisting triceps pull more than creating an anterior compressive force Gold standard? 86 96% good/excellent outcomes Non union is rare Arthrosis in approx 5 10% Hardware removal!!! 45 85% (many for personal reasons) Wound problems 0 10% Kozin, et al, 1996; Hutchinson, et al, 2003; Duckworth, et al, 2012; van der Linden, et al, 2012; Saeed, et al, 2014; Flinterman, et al, 2014; Kim, et al, 2014; Claessen, et al, 2016 Olecranon Fx TBW Specifics Short, intramedullary K wires migrate Improving K wire placement? Penetrate the anterior cortex Occasional problems with anterior prominence Run into the distal intramedullary canal Avoids complications associated with prominent wires K wires with eyelets less likely to migrate Utilize large threaded compression screw Kozin, et al, 1996; Woo, et al, 2000; Huang, et al, 2010; Hammond, et al, 2012; van der Linden, et al, 2012; Kim, et al, 2013; Kim, et al, 2014 Olecranon Fx TBW Scope Secure regardless of the level of the fracture Can be utilized for comminuted fragments Add K wires or other fixation for fragments Allows for precise positioning of the intermediate fragment Can add an extra wire for further stability Biomechanically stronger than single wire Can be applied with comminuted fragments Suresh 2009; Hammond, et al, 2012; Kim, et al, 2014 3
Olecranon Fx Pseudo TBW Designed to reduce hardware irritation Olecranon Sled MEPI 95.5 in 22 pts No hardware issues 1 case of HO Tension band plate Combination of transcortical screw and TBW Some biomechanical superiority to TBW Gruszka, et al, 2017; Lovy, et al, 2018 Olecranon Fx Plates? Comminution and extensive injuries Consistent anatomic articular alignment Excellent outcomes MEPI 90 s & DASH 10 Loss of full elbow extension 39% lacked >10degrees in one study >15% hardware removal rate Proximal screw hole especially irritating Plates on the subcutaneous border of the ulna irritate 20% with mild arthrosis at long term f/u Non union rare Erturer, et al, 2011; Flinterman, et al, 2014; De Giacomo, et al, 2016 Olecranon Fx Plates Plate design Extended proximal fixation? Locking vs. non locking plates Plate alternatives Mini plate with home run screw As strong as a 3.5mm locked plate!! No loss of reduction/fixation Nearly 50% required hardware removal Dual plating for sagittal and comminuted fragments Buizje & Kloen, 2009; Erturer, et al, 2011; Morwood, et al, 2015; Wellman, et al, 2015; Wellman, et al, 2017; Boden, et al, 2018 4
Olecranon Fx What Else? Fragment excision and triceps advancement Intermediate fragment excision and olecranon advancement Intermediate fragment size loss of motion Suture bridge fixation Triceps avulsion Poor soft tissue envelope Elderly Transcortical screw fixation biomechanics to TBW with lower profile IM nail (internal profile) Fern & Brown, 1993; Iannuzzi & Dahners 2009; Argintar, et al, 2012; Jones, et al, 2014; Cha, et al, 2014; Henseler, et al, 2014; Bateman, et al, 2015; Cha, et al, 2016; Marmor, et al, 2017 Olecranon Fx Comparative Studies Outcome Consistently TBW = plate fixation Long term results similar Mobility TBW > plate Need for re operation (hardware removal) TBW > plates, but not absolutely Costs TBW more cost effective than plates Duckworth, et al, 2012; Flinterman, et al, 2014; Schliemann, et al, 2014; Tarallo, et al, 2014; Claessen, et al, 2016; DelSole, et al, 2016; Ren, et al, 2016; Francis, et al, 2017; Liñán Padilla 2017 Olecranon Fx Conclusions ORIF is successful with reproducible outcomes Hardware removal/irritation is among the primary issues with surgery TBW is pretty much gold standard Important to be facile with alternatives like plating There is a role for excision/advancement and non operative treatment 5