Updated: 4/2/2019

Olecranon Fractures - Pediatric

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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 (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 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 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
<table style="width: 100%; background-color: #ffffff; border: 0px solid #f4f4f4;" border="0" cellspacing="0">
<tbody>
<tr>
<td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" bgcolor="#f4f4f4"><span style="font-size: medium; font-weight: bold;">Introduction</span></td>
</tr>
<tr>
<td>
<ul style="font-size: medium;">
<li>Epidemiology                                 
<ul>
<li>incidence                                 
<ul>
<li><span style="font-size: medium; color: #0000cc;">uncommon fracture</span><span style="font-size: medium;">&nbsp;in children&nbsp;</span></li>
<li>in the US, accounts for &lt;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><span style="color: #0000cc;">fall onto outstretched arm</span> with                                
<ul>
<li><span style="color: #0000cc;">elbow in flexion</span> 
<ul>
<li>will lead to triceps tensioning causing an olecranon avulsion fracture</li>
</ul>
</li>
<li><span style="color: #0000cc;">elbow in extension</span> 
<ul>
<li>&nbsp;can lead to varus/valgus bending forces through the olecranon causing oblique fracture lines</li>
</ul>
</li>
</ul>
</li>
<li>direct trauma&nbsp;(least common)</li>
</ul>
</li>
<li>location                                 
<ul style="font-size: medium;">
<li><span style="color: #0000cc;">metaphyseal (most common)</span></li>
</ul>
<ul style="font-size: medium;">
<li>physeal&nbsp;</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><span style="color: #0000cc;">osteogenesis imperfecta</span> 
<ul>
<li>olecranon avulsion fractures are highly suspicious for osteogenesis imperfecta&nbsp;<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>
<ul style="font-size: medium;">
<li>Ossification centers of elbow
<ul>
<li>age of ossification/appearance&nbsp;and&nbsp;<span style="color: #0000cc;">age of fusion</span>&nbsp;are two independent events that must be differentiated&nbsp;<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><span style="color: #333333;">&nbsp;<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>&nbsp;<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="" />&nbsp;</a></span></li>
<li><span>olecranon apophysis</span> 
<ul>
<li><span>ossifies/appears at age 9 years</span></li>
<li><span>fuses at age ~ 15 -17 years</span></li>
</ul>
</li>
</ul>
</li>
</ul>
</td>
</tr>
<tr>
<td style="text-align: center;"><table style="width: 663px;" border="1" cellspacing="0" align="center" bordercolor="#dfeafb">
  <tbody>
    <tr>
      <td style="font-size: medium;" width="34%" bgcolor="#dfeafb"><div style="font-size: small; text-align: center;"><em><strong>Ossification center</strong></em></div></td>
      <td style="font-size: medium;" width="36%" bgcolor="#dfeafb"><div style="font-size: small; text-align: center;"><em><strong>Years at ossification</strong>&nbsp;(appear on xray)</em><span style="font-size: 10px;">&nbsp;(1)</span></div></td>
      <td style="background-color: #dfeafb; text-align: center;"><em style="font-size: small;"><strong>Years at fusion</strong>&nbsp;(appear on xray)</em><span style="font-size: 10px;">&nbsp;(1)</span></td>
    </tr>
    <tr>
      <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">C</span></span>apitellum</span></td>
      <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">1</span></div></td>
      <td style="text-align: center;"><span style="font-size: small;">12-14*</span></td>
    </tr>
    <tr>
      <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">R</span></span>adius</span></td>
      <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">3</span></div></td>
      <td style="text-align: center;"><span style="font-size: small;">14-16<br />
      </span></td>
    </tr>
    <tr>
      <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">I</span><span style="color: #000000;">nternal (m</span></span>edial) epicondyle</span></td>
      <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">5</span></div></td>
      <td style="text-align: center;"><span style="font-size: small;"><span style="color: #0000cc;">16-18</span></span></td>
    </tr>
    <tr>
      <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">T</span></span>rochlea</span></td>
      <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">7</span></div></td>
      <td style="text-align: center;"><span style="font-size: small;">12-14*<br />
      </span></td>
    </tr>
    <tr>
      <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #000000;">O</span>lecranon</span></td>
      <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">9</span></div></td>
      <td style="text-align: center;"><span style="font-size: small;">15-17<br />
      </span></td>
    </tr>
    <tr>
      <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;">External (lateral) epicondyle</span></td>
      <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">11</span></div></td>
      <td style="text-align: center;"><span style="font-size: small;">12-14*</span></td>
    </tr>
    <tr>
      <td style="font-size: medium; padding-left: 30px;" colspan="3" height="22"><p style="font-size: medium;"><span style="font-size: x-small;">(1) +/- one year, varies between boys and girl.&nbsp;<br />
        <span style="color: #0000cc;"><span style="color: #000000;">C-R-I-T-O-E to remember age of&nbsp;ossification.&nbsp;<br />
        </span></span><span style="color: #000000;">CTE-R-O-I to remember age of&nbsp;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)</span></span></p></td>
    </tr>
  </tbody>
</table></td>
</tr>
<tr>
<td>&nbsp;</td>
</tr>
<tr>
<td style="background-color: #f4f4f4;"><strong>Anatomy</strong></td>
</tr>
<tr>
<td>
<table style="border: 0px solid #f4f4f4; width: 704px;" border="0" cellspacing="0">
<tbody>
<tr>
<td>
<ul style="font-size: medium;">
<li>Ossification centers of elbow                         
<ul>
<li><span style="font-size: medium;"><span style="color: #0000cc;">age of ossification/appearance</span>&nbsp;and&nbsp;<span style="color: #0000cc;">age of fusion</span>&nbsp;are two independent events that must be differentiated&nbsp;<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><span style="color: #333333;">&nbsp;<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>&nbsp;<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="" />&nbsp;</a></span> </span> 
<ul>
<li><span style="font-size: medium;">olecranon apophysis </span> 
<ul>
<li><span style="font-size: medium;">ossifies/appears at age 9 years</span></li>
<li><span style="font-size: medium;">fuses at age ~ 15 -17 years</span></li>
</ul>
</li>
</ul>
</li>
</ul>
</li>
</ul>
</td>
</tr>
<tr>
<td style="font-size: medium;" valign="top"><ul>
  <li><span style="color: #0000cc; font-size: 16px;">Olecranon ossification</span> 
<ul>
<li><span style="font-size: 16px;">fusion of the epiphysis to the metaphysis of&nbsp;the&nbsp;olecranon occurs from anterior to posterior</span></li>
<li><span style="font-size: 16px;">average age of closure is between the ages of 15-17 years old</span></li>
<li><span style="color: #0000cc;">partial closure may be mistaken for olecranon fractur</span><span style="color: #0000cc;">e&nbsp;</span></li>
</ul>
</li>
</ul>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td style="background-color: #f4f4f4;"><strong>Presentation</strong></td>
</tr>
<tr>
<td>
<ul>
<li><span style="font-size: medium;">History </span> 
<ul>
<li><span style="font-size: medium;">acute fall onto outstretched arm or direct elbow trauma</span></li>
</ul>
</li>
<li><span style="font-size: medium;">Symptoms </span> 
<ul>
<li><span style="font-size: medium;">pain</span></li>
<li><span style="font-size: medium;">swelling of posterior elbow</span></li>
<li><span style="font-size: medium;">inability to extend elbow</span></li>
</ul>
</li>
<li><span style="font-size: medium;">Physical exam </span> 
<ul>
<li><span style="font-size: medium;">inspection </span> 
<ul>
<li><span style="font-size: medium;">swelling and deformity</span></li>
<li><span style="font-size: medium;">contusion or abrasion over elbow may be suggestive of direct trauma</span></li>
</ul>
</li>
<li><span style="font-size: medium;">palpation </span> 
<ul>
<li><span style="font-size: medium;">crepitus</span></li>
<li><span style="font-size: medium;">defect detected between fracture fragments</span></li>
<li><span style="font-size: medium;">gapping may suggest a disruption in the posterior periosteum, which makes the fracture more unstable</span></li>
</ul>
</li>
<li><span style="font-size: medium;">movement </span> 
<ul>
<li><span style="font-size: medium;"><span style="color: #0000cc;">lack of active elbow extension</span>&nbsp;</span></li>
</ul>
</li>
</ul>
</li>
</ul>
</td>
</tr>
<tr>
<td style="background-color: #f4f4f4;"><strong>Imaging</strong></td>
</tr>
<tr>
<td>
<ul>
<li><span style="font-size: medium;">Radiographs </span> 
<ul>
<li><span style="font-size: medium;">recommended views </span> 
<ul>
<li><span style="font-size: medium;">AP and lateral xrays that should always be obtained on evaluation</span></li>
</ul>
</li>
</ul>
<ul style="font-size: medium;">
<li>findings                                                    
<ul>
<li><span style="font-size: medium;">fracture configuration (transverse, oblique, longitudinal)</span></li>
<li><span style="font-size: medium;">intra-articular displacement&nbsp;</span></li>
<li><span style="font-size: medium;">associated fracture (radial neck, medial/lateral condyle, distal radius, etc.)</span></li>
</ul>
</li>
</ul>
</li>
</ul>
</td>
</tr>
<tr>
<td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" bgcolor="#f4f4f4"><span style="font-size: medium; font-weight: bold;">Treatment</span></td>
</tr>
<tr>
<td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" valign="top">
<ul style="font-size: medium;">
<li style="color: #000000; font-size: medium; font-family: Arial, Helvetica, sans-serif;">Nonoperative                                                  
<ul>
<li style="color: #000000; font-size: medium;"><span style="font-size: medium;"><span style="color: #0000cc;"><strong><strong style="font-size: medium;"><span style="color: #0606bd;">NSAIDS, rest, immobilization with&nbsp;</span></strong>avoidance of elbow resistance exercises</strong></span> </span> 
<ul>
<li style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;"><span style="font-size: medium;">indications </span> 
<ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;">
<li><span style="font-size: medium;">partial stress fractures</span></li>
</ul>
</li>
<li><span style="font-size: medium;">outcomes</span> 
<ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;">
<li><span style="font-size: medium;">monitor until there is clinical improvement</span></li>
<li><span style="font-size: medium;">convert to casting if needed</span></li>
</ul>
</li>
</ul>
</li>
<li><span style="font-size: medium;"><span style="color: #0000cc;"><strong>long arm splint or casting </strong></span> </span> 
<ul style="font-family: Arial, Helvetica, sans-serif;">
<li><span style="font-size: medium;">indications </span> 
<ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;">
<li><span style="font-size: medium;">minimally displaced fractures</span></li>
<li><span style="font-size: medium;">integrity of posterior olecranon periosteum maintained&nbsp;</span></li>
</ul>
</li>
<li><span style="font-size: medium;">duration</span> 
<ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;">
<li><span style="font-size: medium;">3-4 weeks total</span></li>
<li><span style="font-size: medium;">repeat imaging at 7-10 days to ensure no significant displacement</span></li>
</ul>
</li>
</ul>
</li>
</ul>
</li>
<li style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: medium;">Operative </span> 
<ul>
<li><span style="font-size: medium;"><strong style="font-size: medium;"><span style="color: #0000cc;">ORIF</span></strong> </span> 
<ul>
<li><span style="font-size: medium;">indications </span> 
<ul>
<li><span style="font-size: medium;"><span style="color: #0000cc;">displaced fractures</span></span></li>
</ul>
</li>
<li style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: medium;">techniques </span> 
<ul>
<li><span style="font-size: medium;">tension band wiring&nbsp;</span> 
<ul style="font-family: Arial, Helvetica, sans-serif;">
<li><span style="font-size: medium;">AO technique with axial K-wires</span></li>
<li><span style="font-size: medium;">congruent articular surface</span></li>
<li>consider early range of motion post-operatively</li>
</ul>
</li>
<li style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: medium;">tension band suturing&nbsp;</span> 
<ul>
<li><span style="font-size: medium;">use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture)</span></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&nbsp;                                                 
<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;"><strong>Complications</strong></td>
</tr>
<tr>
<td>
<ul>
<li><span style="color: #0000cc;">Nonunion</span></li>
<li><span style="color: #0000cc;">Delayed Union</span></li>
<li><span style="color: #0000cc;">Compartment syndrome</span></li>
<li><span style="color: #0000cc;">Ulnar nerve neurapraxia</span> due to pseudarthrosis with inadequate fixation</li>
<li><span style="color: #0000cc;">Loss of Reduction</span></li>
<li><span style="color: #0000cc;">Elbow stiffness</span></li>
</ul>
</td>
</tr>
</tbody>
</table>
 

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Questions (3)

(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? Tested Concept

QID: 9114
FIGURES:
1

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

5%

(70/1307)

2

Splint/cast immobilization

47%

(613/1307)

3

Elastic stable intrameduallary nailing (ESIN)

2%

(27/1307)

4

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

32%

(413/1307)

5

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

14%

(178/1307)

L 5 C

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(OBQ05.10) The injury pattern seen in Figure A following minimal trauma is consider to be highly suspicious of which of the following conditions? Tested Concept

QID: 47
FIGURES:
1

Osteogenesis imperfecta

71%

(3515/4945)

2

Neurofibromatosis

1%

(73/4945)

3

Osteosarcoma

0%

(17/4945)

4

Non-accidental injury

24%

(1202/4945)

5

Aneurysmal bone cyst

2%

(112/4945)

L 3 C

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Evidence (3)
CASES (1)
Topic COMMENTS (11)
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