summary Olecranon Fractures are rare fractures in the pediatric population and most commonly occur as a result of fall onto an outstretched hand with the elbow in flexion. Diagnosis is made with plain radiographs. Treatment may be nonoperative for nondisplaced fractures with an intact extensor mechanism. Surgical management is indicated for displaced fractures or fractures associated with loss of extensor mechanism. Epidemiology Incidence uncommon fracture in children in the US, accounts for <5% of all pediatric fractures peak age between 5-10 year old Etiology Pathophysiology mechanism fall onto outstretched arm with elbow in flexion (most common) triceps and brachialis tensioning causes a transverse olecranon fracture elbow in extension varus/valgus bending forces through the olecranon causes longitudinal fracture lines varus may lead to associated radial head dislocation valgus may lead to an associated fracture of the radial neck direct trauma (least common) shear force creates anterior tension failure with anterior displacement of the distal fracture and intact posterior periosteum location metaphyseal (most common) physeal epiphyseal (apophyseal) intra-articular extra-articular Associated conditions osteogenesis imperfecta olecranon avulsion fractures are highly suspicious for osteogenesis imperfecta Anatomy Ossification centers of elbow age of ossification/appearance and age of fusion are two independent events that must be differentiated olecranon apophysis ossifies/appears at age 9 years fuses at age ~ 15 -17 years Olecranon ossification fusion of the epiphysis to the metaphysis of the olecranon occurs from anterior to posterior average age of closure is between the ages of 15-17 years old partial closure may be mistaken for olecranon fracture Ossification center of the Elbow Years at ossification (appear on xray) Years at fusion (appear on xray) Capitellum 1 12-14 Radial head 3 14-16 Internal (medial) epicondyle 5 16-18 Trochlea 7 12-14 Olecranon 9 15-17 External (lateral) epicondyle 11 12-14 Presentation History acute fall onto outstretched arm or direct elbow trauma Symptoms pain swelling of posterior elbow inability to extend elbow Physical exam inspection swelling and deformity contusion or abrasion over elbow may be suggestive of direct trauma palpation crepitus defect detected between fracture fragments gapping may suggest a disruption in the posterior periosteum, which makes the fracture more unstable movement lack of active elbow extension Imaging Radiographs recommended views AP and lateral elbow xrays findings fracture configuration (transverse, oblique, longitudinal) intra-articular displacement high suspicion for associated fracture (radial neck, lateral condyle, distal radius, etc.) proximal physis is oblique (green line) which differentiates it from a fracture (red line) secondary ossification center (patella cubiti) does not represent a fracture Treatment Nonoperative NSAIDS, rest, immobilization with avoidance of elbow resistance exercises indications stress fractures in repetitive motion athletes apophysitis outcomes monitor until there is clinical improvement convert to casting if needed long arm splint or casting indications minimally displaced fractures duration 3-4 weeks total repeat imaging at 7 days to ensure no significant displacement Operative ORIF indications displaced fractures unstable fractures with loss of posterior periosteum comminution techniques tension band wiring AO technique with axial K-wires congruent articular surface consider early range of motion post-operatively high rate of removal of hardware tension band suturing use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture or fiberwire) may combine with oblique cortical lag screw with PDS with metaphyseal fractures plate and screws considered with comminuted fractures with partially fused ossification centers axial screw +/- tension wiring Complications Nonunion Delayed Union Compartment syndrome Ulnar nerve neurapraxia due to pseudarthrosis with inadequate fixation Loss of Reduction Elbow stiffness
QUESTIONS 1 of 2 1 2 Previous Next (SBQ10PE.88.1) A 5-year-old girl presents to the emergency room after a fall off a playground with right elbow pain. She refuses to move her arm due to the pain but is neurovascularly intact distally. Radiographs are shown in Figures A and B. What is the best next step in treatment? QID: 9114 FIGURES: A B Type & Select Correct Answer 1 NSAIDs, rest, and immobilization with avoidance of elbow resistance exercises 6% (78/1398) 2 Splint/cast immobilization 46% (641/1398) 3 Elastic stable intrameduallary nailing (ESIN) 2% (29/1398) 4 Open reduction internal fixation (ORIF) using a tension band construct 33% (455/1398) 5 Open reduction internal fixation (ORIF) using a plate and screws 14% (189/1398) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.10) The injury pattern seen in Figure A following minimal trauma is consider to be highly suspicious of which of the following conditions? QID: 47 FIGURES: A Type & Select Correct Answer 1 Osteogenesis imperfecta 71% (3621/5082) 2 Neurofibromatosis 1% (75/5082) 3 Osteosarcoma 0% (20/5082) 4 Non-accidental injury 24% (1227/5082) 5 Aneurysmal bone cyst 2% (113/5082) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic