Updated: 8/25/2021

Olecranon Fractures - Pediatric

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
2
N/A
N/A
Questions
2
0
0
0%
0%
Evidence
3
0
0
0%
0%
Cases
1
Topic
Images
https://upload.orthobullets.com/topic/4010/images/figure 2_combined olecranon fracture lateral.jpg
https://upload.orthobullets.com/topic/4010/images/ossifcation of the elbow_moved.jpg
https://upload.orthobullets.com/topic/4010/images/cropped critol-2.jpg
https://upload.orthobullets.com/topic/4010/images/olecranon_transverse_fx.jpg
https://upload.orthobullets.com/topic/4010/images/secondary_ossification_center.jpg
  • 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
Flashcards (2)
Cards
1 of 2
Questions (2)

(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:
1

NSAIDs, rest, and immobilization with avoidance of elbow resistance exercises

5%

(80/1491)

2

Splint/cast immobilization

45%

(673/1491)

3

Elastic stable intrameduallary nailing (ESIN)

2%

(30/1491)

4

Open reduction internal fixation (ORIF) using a tension band construct

33%

(497/1491)

5

Open reduction internal fixation (ORIF) using a plate and screws

14%

(204/1491)

L 5 C

Select Answer to see Preferred Response

(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:
1

Osteogenesis imperfecta

71%

(3649/5122)

2

Neurofibromatosis

1%

(75/5122)

3

Osteosarcoma

0%

(20/5122)

4

Non-accidental injury

24%

(1237/5122)

5

Aneurysmal bone cyst

2%

(115/5122)

L 3 C

Select Answer to see Preferred Response

Evidence (3)
CASES (1)
EXPERT COMMENTS (11)
Private Note