American Shoulder and Elbow Surgeons
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Average 4.3 of 69 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 35-year-old patient sustains an upper extremity injury after a motor vehicle collision. Radiographs are shown in Figures A and B. Which treatment modality will optimize internal stability of the elbow?
Open reduction and internal fixation with k-wires
Open reduction and internal fixation with tension band wiring
Open reduction and internal fixation with plate fixation
Open reduction and internal fixation with an intramedullary screw
Select Answer to see Preferred Response
Based on the radiographs shown, the patient has a comminuted trans-olecranon fracture dislocation of the elbow. Stability will be optimized with internal fixation in the form of a plating construct.
Trans-olecranon fracture dislocations often occur in the young secondary to high energy mechanisms. Direct blows often lead to high levels of comminution; the distal humerus is driven into the proximal ulna and olecranon, thereby leading to a concomitant dislocation. In this setting, the optimal treatment is use of a plate and screw fixation construct to provide mechanical stability.
Veillette et al. review the epidemiology, pathophysiology and treatment options for olecranon fractures. They highlight that because olecranon injuries involve the articular surface, fixation constructs should allow anatomic restoration of the joint surface. Additionally, fixation constructs should allow for early mobilization in order to prevent stiffness of the elbow.
Mortazavi et al. retrospectively reviewed eight patients who sustained anterior trans-olecranon fracture dislocations of the elbow. Based on their experience, they recommend use of plate fixation to optimize stability of the elbow. Additionally, they indicate that satisfactory results can be obtained if the greater sigmoid notch is appropriately reduced.
Figures A and B show the AP and lateral radiographs of a trans-olecranon fracture dislocation of the elbow. Severe comminution of the olecranon can be seen on the lateral radiograph in Figure B.
Answers 1, 2, 4: K-wires alone would not provide optimal stability and allow for early motion. A tension-band construct or IM screw fixation is contraindicated with this degree of comminution.
Answer 5: Use of cast immobilization would lead to high levels of stiffness and is not indicated for this patient.
Veillette CJ, Steinmann SP.
Orthop Clin North Am. 2008 Apr;39(2):229-36, vii. PMID: 18374813 (Link to Abstract)
Mortazavi SM, Asadollahi S, Tahririan MA.
Injury. 2006 Mar;37(3):284-8. Epub 2006 Jan 25. PMID: 16442109 (Link to Abstract)
Mortazavi, INJURY 2006
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Average 4.0 of 9 Ratings
An 82-year-old nursing home resident falls onto his elbow while rising from a seated position. He has pain and swelling at the elbow without evidence of instability. His radiographs show a comminuted displaced olecranon fracture involving 25% of the articular surface with global osteopenia. Which of the following treatment options has a low risk of complications and a high likelihood of a functional elbow outcome?
Cast immobilization in 45 degrees of flexion for 8 weeks
Closed reduction and percutaneous pinning
ORIF with a tension band construct
ORIF with a locking plate
Cast immobilization in 90 degrees flexion
The patient in the scenario is a low-demand, elderly patient with a comminuted olecranon fracture. Recent studies have demonstrated good outcomes with non-operative treatment of olecranon fractures in this patient population.
Hak (jaos'00) reviewed the treatment of olecranon fractures, recommending ORIF for displaced intra-articular fractures, either via tension band wiring or plate osteosynthesis based on fracture pattern and associated ligamentous disruption. For elderly, low-demand, osteoporotic patients, triceps advancement and fragment excision is an option in the case of severely comminuted, osteoporotic patients with a fracture involving <50% of the joint surface.
Duckworth (jbjs'14) performed a single center retrospective review of low-demand patients with displaced olecranon fractures managed non-operatively with a short duration of immobilization followed by range of motion to tolerance. The authors found good short and long-term results with this treatment with patients experiencing minimal discomfort or loss of motion at long-term follow up.
Answer 1: Cast immobilization in 45-90 degrees of flexion is advocated for non-displaced fractures. Furthermore, casting for 8 weeks is not indicated in nonoperative care of olecranon fractures secondary to the development of stiffness.
Answers 2-4: Not the treatment in low demand patients with severe comminution and osteoporosis.
Hak DJ, Golladay GJ.
J Am Acad Orthop Surg. 2000 Jul-Aug;8(4):266-75. PMID: 10951115 (Link to Abstract)
Hak, JAAOS 2000
Duckworth AD, Bugler KE, Clement ND, Court-Brown CM, McQueen MM
J Bone Joint Surg Am. 2014 Jan;96(1):67-72. PMID: 24382727 (Link to Abstract)
Duckworth, JBJS 2014
Title: Olecranon Plating Presenter: Mark Baratz, MDColumbia University Orthopedi...
Average 2.0 of 41 Ratings
Bridge plating of the olecranon is MOST appropriate in which of the following clinical scenarios?
Fixation of an olecranon osteotomy used for distal humerus surgery in a 24-year-old male
Simple transverse olecranon fracture in 33-year-old female
Comminuted olecranon fracture in 45-year-old male
Severely comminuted proximal olecranon fracture in an osteoporotic 91-year-old female
Aphophyseal elbow fracture in 6-year-old male
Bridge plating is most appropriately used for fixation of comminuted fractures which are not able to be fixed anatomically. Of the choices listed above, this would be most appropriate in a comminuted fracture in a 45-year-old male. In contrast, literature shows that severely comminuted, osteoporotic low-demand elderly are best treated with olecranon fracture excision and triceps advancement when possible.
Bailey et al looked at the outcome of plate fixation of olecranon fractures. They concluded that plate fixation is effective for displaced olecranon fractures and leads to good functional outcome. There were low incidence of complications, although 20% did have removal of hardware due to irritation.
Hak et al reviewed the fixation options for olecranon fractures. In their review, they state that comminuted olecranon fractures can be treated by limited-contact dynamic-compression plates. They also supported the use of supplemental bone graft to support comminuted depressed articular fragments. Fragment excision and triceps advancement is appropriate in selected cases in which open reduction seems unlikely to be successful, such as in osteoporotic elderly patients with severely comminuted fractures.
Bailey CS, MacDermid J, Patterson SD, King GJ
J Orthop Trauma. 2001 Nov;15(8):542-8. PMID: 11733669 (Link to Abstract)
Bailey, JOT 2001
Average 4.0 of 17 Ratings
During surgical treatment of an olecranon fracture with a tension band construct as seen in Figure A, what nerve is at risk with over penetration of the proximal anterior cortex of the ulna with the Kirchner wire?
Anterior interosseous nerve
Posterior interosseous nerve
An inability to flex the thumb interphalangeal joint or the index finger distal interphalangeal joint is indicative of an anterior interosseous nerve palsy/injury.
This has been reported with tension band fixation of olecranon fractures, especially with overpenetration of the anterior cortex of the proximal ulna by the Kirschner wire. Anterior interosseous nerve palsy can also be possible by overpenetration of drill bits or screws through the anterior cortex. Initial treatment of this nerve injury is observation.
The referenced article by Parker et al reports a case of anterior interosseous nerve palsy after such tension band fixation. They note that this was a direct injury from the Kirchner wires.
The referenced article by Adams et al reviews nerve injuries about the elbow. They note that an appreciation of the complex anatomy of the region and an understanding of treatment options are necessary for surgeons who treat elbow injuries.
Figure A is a lateral radiograph of a olecranon fracture fixed with a tension band construct.
Incorrect Answers: The other nerves are not associated with overpenetration of the far cortex in an olecranon tension band fixation.
Parker JR, Conroy J, Campbell DA.
Injury. 2005 Oct;36(10):1252-3. Epub 2005 Mar 19. PMID: 16214467 (Link to Abstract)
Parker, INJURY 2005
Adams JE, Steinmann SP.
J Hand Surg Am. 2006 Feb;31(2):303-13. PMID: 16473695 (Link to Abstract)
Adams, JHS 2006
Average 3.0 of 28 Ratings
There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following?
Ipsilateral proximal humerus fracture
Protrusion of Kirschner wire fixation through the volar cortex of the proximal ulna
Use of ulnar intramedullary Kirschner wire fixation
Olecranon fracture comminution
Lack of triceps tendon repair
Impaired pronation/supination can be seen if the K-wire is advanced either too radial or too far through the volar (anterior) cortex of the proximal ulna. The anterior interosseous nerve is also at risk with overpenetration. Conversely, migration and loosening of the K-wire is reduced with involvement of the anterior cortex.
The referenced study by Candal-Couto et al is a cadaveric study that found that K-wire insertion in less than 30 degrees in an ulnar direction led to impingement of the K-wire on the radial head/neck, biceps or supinator. They recommend placing these wires away from this danger zone in order to minimize rotation blocks.
The referenced study by Matthews et al is a case series of two patients who had limited forearm rotation after K-wire fixation. The etiology of limited rotation was found to be from direct overpenetration of the K-wire, which led to a mechanical block.
Candal-Couto JJ, Williams JR, Sanderson PL
J Orthop Trauma. 2005 Aug;19(7):480-2. PMID: 16056081 (Link to Abstract)
Candal-Couto, JOT 2005
Matthews F, Trentz O, Jacob AL, Kikinis R, Jupiter JB, Messmer P.
J Bone Joint Surg Am. 2007 Mar;89(3):638-42. PMID: 17332114 (Link to Abstract)
Matthews, JBJS 2007
Average 3.0 of 34 Ratings
A 19-year-old male sustains the isolated, closed injury seen in Figure A. He is subsequently treated as shown in Figure B. When utilizing this technique, what forces are generated at the articular surface?
Figure A and B show a simple transverse olecranon fracture appropriately treated with a tension-band construct. This construct converts distraction forces at the joint generated by the pull of the triceps into compression forces. The change of force into compression requires active motion of the elbow extensor mechanism.
Average 4.0 of 23 Ratings
A 79-year-old woman with osteoporosis presents with a displaced, severely comminuted olecranon fracture involving the proximal 40%. Which of the following represents the most appropriate surgical treatment?
Kirschner wire tension band
Total elbow arthroplasty
Fragment excision and triceps advancement
Dorsal bridge plating
Multiple treatments exist for olecranon fractures. Tension band construct (Illustration A) and intramedullary screw or k-wire placement are typically reserved for non-comminuted olecranon fractures, whereas plate and screw fixation (Illustration B) is used for comminuted fractures.
Hak et al review olecranon fracture treatment and state that fragment excision and triceps advancement is most appropriate in elderly, osteoporotic patients with severely comminuted fractures involving the proximal 30-40% of the olecranon.
Veillette et al state that when performing a triceps advancement for treatment of an olecranon fracture, between 50% and 70% of the olecranon articular surface can be excised without compromising elbow stability provided the coronoid and distal trochlea are preserved.
When excision and triceps advancement is performed, the triceps should be attached adjacent to the articular surface.
Average 4.0 of 16 Ratings
A 24-year-old male sustains the isolated, closed injury seen in Figure A as the result of a fall. What surgical treatment is recommended for this fracture?
Tension band with intramedullary screw
Plate and screw fixation
The radiograph shows a comminuted olecranon fracture with extension distally past the coronoid. Plate fixation is recommended for olecranon fractures with significant comminution and those that extend distal to the midpoint of the trochlear notch, which is present in this instance.
The referenced article is an excellent review of olecranon fracture treatment options, including nonoperative treatment, tension band wiring, dorsal plating, and excision with triceps advancement.
Average 4.0 of 18 Ratings
A 62-year-old man falls on his porch and sustains an elbow injury. A radiograph is provided in Figure A. Which of the following is the best treatment?
Closed reduction and long arm casting
Early motion with a hinged elbow brace
Open reduction internal fixation with a tension band construct
Open reduction internal fixation with a plate
Fragment excision and advancement of the triceps tendon
The radiograph shows an olecranon fracture with articular comminution and depression of a large intra-articular fragment. This pattern is best treated with plate fixation to support the articular reduction.
Bailey et al reviewed 25 cases of olecranon fractures (simple and comminuted fracture patterns) treated with plate fixation. All 25 went on to union. There were no major complications reported. Twenty percent of patients underwent hardware removal at a later date for prominence.
Hak et al review the treatment options available for olecranon fractures. Simple intra-articular fractures without comminution are suitable for tension band fixation. Comminution of the articular surface is an indication for plate fixation and may benefit from bone graft to support depressed articular segments. Osteoporotic patients or fractures with severe comminution may do better with fragment excision and advancement of the triceps.
Average 4.0 of 21 Ratings
A 45-year-old male undergoes open reduction internal fixation for a displaced olecranon fracture as shown in Figure A. What is the most common complication for this type of fixation?
anterior interosseous nerve palsy
The most common complication of an olecranon fracture treated with tension band wiring is symptomatic implants. This is largely related to the subcutaneous nature of the olecranon.
Macko and Szabo encountered a high incidence of complications related to the technique of tension-band wire fixation of displaced fractures of the olecranon in a five-year retrospective study of twenty patients. They reported that the most frequent complication of this construct is symptomatic prominence of the hardware which is usually due to improper seating at the time of surgery. Other complications reported include loss of fixation, skin breakdown, and infection.
Hume and Wiss reported on 41 patients randomized to tension band wiring and plate fixation. They note that there was no difference in regards to elbow motion postoperatively, but plating required more operative time. Plating of these fractures resulted in a significantly increased rate of good clinical and radiographic results.
Figure A shows an AP and lateral radiograph of an olecranon fracture treated with tension-band wiring.
Answer 1: This is a possibility with overpenetration of the wires through the anterior ulnar cortex, but not a common finding.
Answer 2: This is not a common finding with this treatment method.
Answer 3: Although implant failure is a possibility with this technique, this is not the most common complication.
Answer 5: Avascular necrosis of the proximal ulna is not a common complication of this injury or treatment method.
Macko D, Szabo RM.
J Bone Joint Surg Am. 1985 Dec;67(9):1396-401. PMID: 3908460 (Link to Abstract)
Macko, JBJS 1985
Hume MC, Wiss DA.
Clin Orthop Relat Res. 1992 Dec;(285):229-35. PMID: 1446443 (Link to Abstract)
Hume, CORR 1992
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