Olecranon Fractures - Pediatric - Pediatrics

Introduction

Epidemiology
- incidence
 - uncommon fracture in children
 - in the US, accounts for <5% of all pediatric fractures
 - peak age between 5-10 year old
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

Ossification center	Years at ossification (appear on xray) (1)	Years at fusion (appear on xray) (1)
Capitellum	1	12-14*
Radius	3	14-16
Internal (medial) epicondyle	5	16-18
Trochlea	7	12-14*
Olecranon	9	15-17
External (lateral) epicondyle	11	12-14*
(1) +/- one year, varies between boys and girl. C-R-I-T-O-E to remember age of ossification. CTE-R-O-I to remember age of fusion (capitellum, trochlea and external (lateral) epicondyle fuse together at puberty. Together they fuse to the distal humerus between the ages of 14-16 years old)

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

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

<tbody>

<tr>

<td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" bgcolor="#f4f4f4">Introduction</td>

</tr>

<tr>

<td>

<li>Epidemiology

<ul>

<li>incidence

<ul>

<li>uncommon fracture in children </li>

<li>in the US, accounts for <5% of all pediatric fractures</li>

<li>peak age between 5-10 year old</li>

</ul>

</li>

</ul>

</li>

<li>Pathophysiology

<ul>

<li>mechanism

<ul>

<li>fall onto outstretched arm with

<ul>

<li>elbow in flexion

<ul>

<li>will lead to triceps tensioning causing an olecranon avulsion fracture</li>

</ul>

</li>

<li>elbow in extension

<ul>

<li> can lead to varus/valgus bending forces through the olecranon causing oblique fracture lines</li>

</ul>

</li>

</ul>

</li>

<li>direct trauma (least common)</li>

</ul>

</li>

<li>location

<li>metaphyseal (most common)</li>

</ul>

<li>physeal </li>

</ul>

<ul>

<li>epiphyseal (apophyseal)

<ul>

<li>intra-articular</li>

<li>extra-articular</li>

</ul>

</li>

</ul>

</li>

</ul>

</li>

<li>Associated conditions

<ul>

<li>osteogenesis imperfecta

<ul>

<li>olecranon avulsion fractures are highly suspicious for osteogenesis imperfecta <a title="question" href="#47"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333; font-size: 12px;" src="/images/question.png" alt="" /></a></li>

</ul>

</li>

</ul>

</li>

</ul>

</td>

</tr>

<tr>

<td style="background-color: #f4f4f4;">Anatomy</td>

</tr>

<tr>

<td>

<li>Ossification centers of elbow

<ul>

<li>age of ossification/appearance and age of fusion are two independent events that must be differentiated <a href="https://upload.orthobullets.com/question/3490/images/ossifcation%20of%20the%20elbow.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333; font-size: 12px;" src="/images/pencil.jpg" alt="" /></a> <a href="https://upload.orthobullets.com/question/3490/images/elbow%20ossification%20and%20fusion.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333;" src="/images/pencil.jpg" alt="" /></a> <a style="text-decoration-line: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="AP left elbow showing ossification centers " href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /></a><a style="text-decoration-line: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="Olecranon ossification center" href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol-2.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /> </a></li>

<li>olecranon apophysis

<ul>

<li>ossifies/appears at age 9 years</li>

<li>fuses at age ~ 15 -17 years</li>

</ul>

</li>

</ul>

</li>

</ul>

</td>

</tr>

<tr>

<tbody>

<tr>

<td style="font-size: medium;" width="34%" bgcolor="#dfeafb"><div style="font-size: small; text-align: center;">Ossification center</div></td>

<td style="font-size: medium;" width="36%" bgcolor="#dfeafb"><div style="font-size: small; text-align: center;">Years at ossification (appear on xray) (1)</div></td>

<td style="background-color: #dfeafb; text-align: center;">Years at fusion (appear on xray) (1)</td>

</tr>

<tr>

<td style="font-size: medium; padding-left: 30px;">Capitellum</td>

</tr>

<tr>

<td style="font-size: medium; padding-left: 30px;">Radius</td>

<td style="text-align: center;">14-16

</td>

</tr>

<tr>

<td style="font-size: medium; padding-left: 30px;">Internal (medial) epicondyle</td>

</tr>

<tr>

<td style="font-size: medium; padding-left: 30px;">Trochlea</td>

<td style="text-align: center;">12-14*

</td>

</tr>

<tr>

<td style="font-size: medium; padding-left: 30px;">Olecranon</td>

<td style="text-align: center;">15-17

</td>

</tr>

<tr>

<td style="font-size: medium; padding-left: 30px;">External (lateral) epicondyle</td>

</tr>

<tr>

<td style="font-size: medium; padding-left: 30px;" colspan="3" height="22">(1) +/- one year, varies between boys and girl.

C-R-I-T-O-E to remember age of ossification.

CTE-R-O-I to remember age of fusion (capitellum, trochlea and external (lateral) epicondyle fuse together at puberty. Together they fuse to the distal humerus between the ages of 14-16 years old)</td>

</tr>

</tbody>

</table></td>

</tr>

<tr>

</tr>

<tr>

<td style="background-color: #f4f4f4;">Anatomy</td>

</tr>

<tr>

<td>

<tbody>

<tr>

<td>

<li>Ossification centers of elbow

<ul>

<li>age of ossification/appearance and age of fusion are two independent events that must be differentiated <a href="https://upload.orthobullets.com/question/3490/images/ossifcation%20of%20the%20elbow.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333; font-size: 12px;" src="/images/pencil.jpg" alt="" /></a> <a href="https://upload.orthobullets.com/question/3490/images/elbow%20ossification%20and%20fusion.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333;" src="/images/pencil.jpg" alt="" /></a> <a style="text-decoration: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="AP left elbow showing ossification centers " href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /></a><a style="text-decoration: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="Olecranon ossification center" href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol-2.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /> </a>

<ul>

<li>olecranon apophysis

<ul>

<li>ossifies/appears at age 9 years</li>

<li>fuses at age ~ 15 -17 years</li>

</ul>

</li>

</ul>

</li>

</ul>

</li>

</ul>

</td>

</tr>

<tr>

<li>Olecranon ossification

<ul>

<li>fusion of the epiphysis to the metaphysis of the olecranon occurs from anterior to posterior</li>

<li>average age of closure is between the ages of 15-17 years old</li>

<li>partial closure may be mistaken for olecranon fracture </li>

</ul>

</li>

</ul>

</td>

</tr>

</tbody>

</table>

</td>

</tr>

<tr>

<td style="background-color: #f4f4f4;">Presentation</td>

</tr>

<tr>

<td>

<ul>

<li>History

<ul>

<li>acute fall onto outstretched arm or direct elbow trauma</li>

</ul>

</li>

<li>Symptoms

<ul>

<li>swelling of posterior elbow</li>

<li>inability to extend elbow</li>

</ul>

</li>

<li>Physical exam

<ul>

<li>inspection

<ul>

<li>swelling and deformity</li>

<li>contusion or abrasion over elbow may be suggestive of direct trauma</li>

</ul>

</li>

<li>palpation

<ul>

<li>crepitus</li>

<li>defect detected between fracture fragments</li>

<li>gapping may suggest a disruption in the posterior periosteum, which makes the fracture more unstable</li>

</ul>

</li>

<li>movement

<ul>

<li>lack of active elbow extension </li>

</ul>

</li>

</ul>

</li>

</ul>

</td>

</tr>

<tr>

<td style="background-color: #f4f4f4;">Imaging</td>

</tr>

<tr>

<td>

<ul>

<li>Radiographs

<ul>

<li>recommended views

<ul>

<li>AP and lateral xrays that should always be obtained on evaluation</li>

</ul>

</li>

</ul>

<li>findings

<ul>

<li>fracture configuration (transverse, oblique, longitudinal)</li>

<li>intra-articular displacement </li>

<li>associated fracture (radial neck, medial/lateral condyle, distal radius, etc.)</li>

</ul>

</li>

</ul>

</li>

</ul>

</td>

</tr>

<tr>

<td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" bgcolor="#f4f4f4">Treatment</td>

</tr>

<tr>

<li style="color: #000000; font-size: medium; font-family: Arial, Helvetica, sans-serif;">Nonoperative

<ul>

<li style="color: #000000; font-size: medium;">NSAIDS, rest, immobilization with avoidance of elbow resistance exercises

<ul>

<li style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;">indications

<li>partial stress fractures</li>

</ul>

</li>

<li>outcomes

<li>monitor until there is clinical improvement</li>

<li>convert to casting if needed</li>

</ul>

</li>

</ul>

</li>

<li>long arm splint or casting

<li>indications

<li>minimally displaced fractures</li>

<li>integrity of posterior olecranon periosteum maintained </li>

</ul>

</li>

<li>duration

<li>3-4 weeks total</li>

<li>repeat imaging at 7-10 days to ensure no significant displacement</li>

</ul>

</li>

</ul>

</li>

</ul>

</li>

<li style="font-family: Arial, Helvetica, sans-serif;">Operative

<ul>

<li>ORIF

<ul>

<li>indications

<ul>

<li>displaced fractures</li>

</ul>

</li>

<li style="font-family: Arial, Helvetica, sans-serif;">techniques

<ul>

<li>tension band wiring

<li>AO technique with axial K-wires</li>

<li>congruent articular surface</li>

<li>consider early range of motion post-operatively</li>

</ul>

</li>

<li style="font-family: Arial, Helvetica, sans-serif;">tension band suturing

<ul>

<li>use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture)</li>

<li>may combine with oblique cortical lag screw with PDS with metaphyseal fractures</li>

</ul>

</li>

<li style="font-family: Arial, Helvetica, sans-serif;">plate and screws

<ul>

<li>considered with comminuted fractures with partially fused ossification centers</li>

</ul>

</li>

</ul>

</li>

</ul>

</li>

</ul>

</li>

</ul>

</td>

</tr>

<tr>

<td style="background-color: #f4f4f4;">Complications</td>

</tr>

<tr>

<td>

<ul>

<li>Nonunion</li>

<li>Delayed Union</li>

<li>Compartment syndrome</li>

<li>Ulnar nerve neurapraxia due to pseudarthrosis with inadequate fixation</li>

<li>Loss of Reduction</li>

<li>Elbow stiffness</li>

</ul>

</td>

</tr>

</tbody>

</table>