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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/elbow ossification and fusion_moved.jpg
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
          • will lead to triceps tensioning causing an olecranon avulsion fracture
        • elbow in extension
          •  can lead to varus/valgus bending forces through the olecranon causing oblique fracture lines
      • direct trauma (least common)
    • 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 fractur
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 xrays that should always be obtained on evaluation
    • findings
      • fracture configuration (transverse, oblique, longitudinal)
      • intra-articular displacement 
      • associated fracture (radial neck, medial/lateral condyle, distal radius, etc.)
Treatment
  • Nonoperative
    • NSAIDS, rest, immobilization with avoidance of elbow resistance exercises
      • indications
        • partial stress fractures
      • outcomes
        • monitor until there is clinical improvement
        • convert to casting if needed
    • long arm splint or casting
      • indications
        • minimally displaced fractures
        • integrity of posterior olecranon periosteum maintained 
      • duration
        • 3-4 weeks total
        • repeat imaging at 7-10 days to ensure no significant displacement
  • Operative
    • ORIF
      • indications
        • displaced fractures
      • techniques
        • tension band wiring 
          • AO technique with axial K-wires
          • congruent articular surface
          • consider early range of motion post-operatively
        • tension band suturing 
          • use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture)
          • may combine with oblique cortical lag screw with PDS with metaphyseal fractures
        • plate and screws 
          • considered with comminuted fractures with partially fused ossification centers
Complications
  • Nonunion
  • Delayed Union
  • Compartment syndrome
  • Ulnar nerve neurapraxia due to pseudarthrosis with inadequate fixation
  • Loss of Reduction
  • Elbow stiffness
 

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