Olecranon fracture
Lonnie Froberg, MD, Ph.D
Odense University Hospital
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20% of forearm fracture
12 per 100.000 persons per year
Low-energy fall
Increased risk >50 years
90% AO 21.B1.1
Duckworth et al. Injury 2012;43:343-346
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Why operate?
Methods of fixation
– K-wire, cerklage
– Plating
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Outcome
Summary
Why operate?
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Restore articular surface
Achieve absolute stability
Commence early active movement
Preservation of range of motion and
power
Avoidance of complications
Methods of fixation?
Methods of fixation?
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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).1985. 67B;3:367-372
Methods of fixation?
Fracture type
Fixation technique
Transverse
Tension band 1.0 mm, 1
knot, K-wire 2.0 mm
Oblique
Tension band 1.0 mm, 2
knots, K-wire 2.0 mm
Comminuted
Tubular plate
Cancellous screw, washer
Cancellous screw, washer,
tension band
Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372
Methods of fixation?
Fracture type Fixation technique
Transverse
Tension band, 2 knots
Oblique
Tension band, 2 knots
or tubular plate
Tubular plate
Comminuted
Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372
K-wire and cerklage
K-wire with or without eyelets?
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No significant
difference in
postoperative pain or
in rate of hard ware
removal
Kim et al. J Hand Surg Am. 2013.Jul 9
How to place the K-wires?
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Proximal ulnar canal?
Anterior cortex?
Distal ulnar canal?
Huang et al. J Trauma. 2010.68;1:173-176
How to place the K-wires?
Proximal ulnar
(n=24)
Anterior cortex
(n=28)
Average followup/months
34.5 s.d 7.2
34.0 s.d 5.9
29.6 s.d 7.2
Symptomatic
implant removal
8 (33%)
*p=0.03
3 (11%)
2 (8%)
Proximal
migration of Kwire/mm
4.08 s.d. 1.89
*p=0.001
1.53 s.d 0.56
1.31 s.d 0.54
21 (88%)
26 (93%)
26 (100%)
Satisfactory
functionel
outcome
Distal ulnar
(n=26)
How to place the K-wires?
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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. 2009. Injury; 40(6): 575-581
How to place the K-wires?
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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.
2008.17;1:121-125
Which kind of tension band?
Failure
(> 2 mm movement
across osteotomy)
Compression
0%
71%
Ethibond No. 2
100%
66%
Ethibond No. 5
40%
40%
Fiber wire
0%
43%
Stainless steel wire
Lalliss et al. Jour Bone Joint Surg (Br).2010.92B;2:315-319
Plating
Plating
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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. 2009. Injury; 40(6): 575-581
Which kind of plate?
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Cadaveric study
Comminute fracture
No difference in
failure rate (>2 mm
gap of fracture)
Buijze et al. Arch Orthop Trauma
Surg.2010;130:459-464
Which kind of plate?
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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)
Which kind of plate?
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Stainless steel or titanium?
More screw in proximal fragment
better than fewer screws?
Larger screws better than small
screws?
Which kind of plate?
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Accumed stainless stell
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Synthes stainless stell
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Synthes titanium
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US Implants
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Zimmer
Which kind of plate?
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No statistical difference between
maximum load and cycles survived
Edwards et al. J Orthop Trauma 2011;25(5):306-311
Outcome – Cochrane review
Short term
(2-3 years)
*only plate fixation
Long-term
(15-25 years)
Pain
1
(VAS score)
6% severe daily
symptoms
Motion compared to
non-affected arm
Decreased supination
Decreased flexion and
extension
(5 degrees)
Radiographic
evaluation
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;39:229-236
Summary – Tension band
fixation
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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
Summary - Plating
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Fractures: Distal to the
midpoint of the troclear
notch, co-existing coronoid
fracture, Monteggia
Locking compression plate
theoretically superior to
conventionel plate
Thank you
Technique
Technique
Technique