Introduction Epidemiology bimodal distribution high energy injuries in the young low energy falls in the elderly Pathophysiology mechanism direct blow usually results in comminuted fracture indirect blow fall onto outstretched upper extremity usually results in transverse or oblique fracture Anatomy Osteology together with coronoid process, forms the greater sigmoid (semilunar) notch greater sigmoid notch articulates with trochlea provides flexion-extension movement adds to stability of elbow joint Muscles triceps inserts onto posterior, proximal ulna blends with periosteum innervated by radial nerve (C7) anconeus inserts on lateral aspect of olecranon innervate by radial nerve (C7) Classification Mayo Classification Based on comminution, displacement, fracture-dislocation Colton Classification Nondisplaced - Displacement does not increase with elbow flexion Avulsion (displaced) Oblique and Transverse (displaced) Comminuted (displaced) Fracture dislocation Schatzker Classification Type A Simple transverse fracture Type B Transverse impacted fracture Type C Oblique fracture Type D Comminuted fracture Type E More distal fracture, extra-articular Type F Fracture-dislocation AO Classification Type A Extra-articular Type B Intra-articular Type C Intra-articular fractures of both the radial head and olecranon Presentation Symptoms pain well localized to posterior elbow Physical exam palpable defect indicates displaced fracture or severe comminution inability to extend elbow indicates discontinuity of triceps (extensor) mechanism Imaging Radiographs recommended views AP/lateral radiographs true lateral essential for determination of fracture pattern additional views radiocapitellar may be helpful for radial head fracture capitellar shear fracture CT may be useful for preoperative planning in comminuted fractures Treatment Nonoperative immobilization indications nondisplaced fractures displaced fracture is low demand, elderly individuals technique immobilization in 45-90 degrees of flexion initially begin motion at 1 week Operative tension band technique indications transverse fracture with no comminution outcomes excellent results with appropriate indications intramedullary fixation indications transverse fracture with no comminution (same as tension band technique) plate and screw fixation indications comminuted fractures Monteggia fractures fracture-dislocations oblique fractures that extend distal to coronoid excision and triceps advancement indications elderly patients with osteoporotic bone fracture must involve <50% of joint surface nonunions outcomes salvage procedure that leads to decreased extension strength may result in instability if ligamentous injury is not diagnosed before operation Surgical Techniques Tension band technique technique converts distraction force of triceps into a compressive force engaging anterior cortex of ulna with Kirschner wires may prevent wire migration avoid overpenetration of wires through anterior cortex may injury anterior interosseous nerve (AIN) may lead to decreased forearm rotation use 18-gauge wire or non-absorbable thick suture in figure-of-eight fashion through drill holes in ulna cons high % of second surgeries for hardware removal (40-80%) does not provide axial stability in comminuted fractures Intramedullary fixation technique can be combined with tension banding intramedullary screw must engage distal intramedullary canal Plate and screw fixation technique place plate on dorsal (tension) side oblique fractures benefit from lag screws in addition to plate fixation one-third tubular plates may not provide sufficient strength in comminuted fractures may advance distal triceps tendon over plate to avoid hardware prominence pros more stable than tension band technique cons 20% need second surgery for plate removal Excision and triceps advancement technique triceps tendon reattached with nonabsorbable sutures passed through drill holes in proximal ulna Complications Symptomatic hardware most frequent reported complication Stiffness occurs in ~50% of patients usually doesn't alter functional capabilities Heterotopic ossification more common with associated head injury Posttraumatic arthritis Nonunion rare Ulnar nerve symptoms Anterior interosseous nerve injury Loss of extension strength
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Olecranon Fracture ORIF with Tension Band Andrew Hsu Benjamin C. Taylor Trauma - Olecranon Fractures Technique Guide CPT Codes: 24685 Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Olecranon Fracture ORIF with Plate Fixation Orthobullets Team Trauma - Olecranon Fractures
QUESTIONS 1 of 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12TR.11) A 35-year-old patient sustains an upper extremity injury after a motor vehicle collision. Radiographs are shown in Figures A and B. Which treatment modality will optimize internal stability of the elbow? QID: 3926 FIGURES: A B Type & Select Correct Answer 1 Open reduction and internal fixation with k-wires 0% (29/6221) 2 Open reduction and internal fixation with tension band wiring 2% (128/6221) 3 Open reduction and internal fixation with plate fixation 96% (5980/6221) 4 Open reduction and internal fixation with an intramedullary screw 1% (42/6221) 5 Cast immobilization 0% (9/6221) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.114) An 82-year-old nursing home resident falls onto his elbow while rising from a seated position. He has pain and swelling at the elbow without evidence of instability. His radiographs show a comminuted displaced olecranon fracture involving 25% of the articular surface with global osteopenia. Which of the following treatment options has a low risk of complications and a high likelihood of a functional elbow outcome? QID: 3537 Type & Select Correct Answer 1 Cast immobilization in 45 degrees of flexion for 8 weeks 12% (621/5206) 2 Closed reduction and percutaneous pinning 2% (80/5206) 3 ORIF with a tension band construct 5% (253/5206) 4 ORIF with a locking plate 33% (1736/5206) 5 Cast immobilization in 90 degrees flexion 48% (2483/5206) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.141) Bridge plating of the olecranon is MOST appropriate in which of the following clinical scenarios? QID: 3564 Type & Select Correct Answer 1 Fixation of an olecranon osteotomy used for distal humerus surgery in a 24-year-old male 1% (30/3601) 2 Simple transverse olecranon fracture in 33-year-old female 1% (54/3601) 3 Comminuted olecranon fracture in 45-year-old male 85% (3054/3601) 4 Severely comminuted proximal olecranon fracture in an osteoporotic 91-year-old female 12% (421/3601) 5 Aphophyseal elbow fracture in 6-year-old male 0% (15/3601) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept (OBQ10.107) There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following? QID: 3201 Type & Select Correct Answer 1 Ipsilateral proximal humerus fracture 2% (18/1158) 2 Protrusion of Kirschner wire fixation through the volar cortex of the proximal ulna 85% (989/1158) 3 Use of ulnar intramedullary Kirschner wire fixation 2% (21/1158) 4 Olecranon fracture comminution 10% (115/1158) 5 Lack of triceps tendon repair 1% (8/1158) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (OBQ10.38) During surgical treatment of an olecranon fracture with a tension band construct as seen in Figure A, what nerve is at risk with over penetration of the proximal anterior cortex of the ulna with the Kirchner wire? QID: 3126 FIGURES: A Type & Select Correct Answer 1 Median nerve 8% (117/1482) 2 Anterior interosseous nerve 75% (1110/1482) 3 Posterior interosseous nerve 13% (186/1482) 4 Ulnar nerve 3% (45/1482) 5 Radial nerve 1% (12/1482) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (OBQ09.243) A 79-year-old woman with osteoporosis presents with a displaced, severely comminuted olecranon fracture involving the proximal 40%. Which of the following represents the most appropriate surgical treatment? QID: 3056 Type & Select Correct Answer 1 Intramedullary screw 0% (5/1040) 2 Kirschner wire tension band 3% (34/1040) 3 Total elbow arthroplasty 17% (176/1040) 4 Fragment excision and triceps advancement 61% (631/1040) 5 Dorsal bridge plating 18% (189/1040) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (OBQ09.192) A 19-year-old male sustains the isolated, closed injury seen in Figure A. He is subsequently treated as shown in Figure B. When utilizing this technique, what forces are generated at the articular surface? QID: 3005 FIGURES: A B Type & Select Correct Answer 1 Neutralization 1% (14/937) 2 Torque 1% (8/937) 3 Two-point bending 2% (17/937) 4 Shear 1% (10/937) 5 Compression 94% (878/937) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ07.204) A 24-year-old male sustains the isolated, closed injury seen in Figure A as the result of a fall. What surgical treatment is recommended for this fracture? QID: 865 FIGURES: A Type & Select Correct Answer 1 Intramedullary nailing 1% (8/1365) 2 Tension band with intramedullary screw 8% (110/1365) 3 Triceps advancement 1% (9/1365) 4 Plate and screw fixation 90% (1227/1365) 5 Total elbow arthroplasty 0% (2/1365) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (OBQ05.181) A 62-year-old man falls on his porch and sustains an elbow injury. A radiograph is provided in Figure A. Which of the following is the best treatment? QID: 1067 FIGURES: A Type & Select Correct Answer 1 Closed reduction and long arm casting 0% (4/2422) 2 Early motion with a hinged elbow brace 0% (6/2422) 3 Open reduction internal fixation with a tension band construct 15% (373/2422) 4 Open reduction internal fixation with a plate 83% (2012/2422) 5 Fragment excision and advancement of the triceps tendon 1% (20/2422) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (OBQ04.138) A 45-year-old male undergoes open reduction internal fixation for a displaced olecranon fracture as shown in Figure A. What is the most common complication for this type of fixation? QID: 1243 FIGURES: A Type & Select Correct Answer 1 anterior interosseous nerve palsy 7% (64/940) 2 osteomyelitis 1% (5/940) 3 implant failure 4% (33/940) 4 symptomatic implants 89% (832/940) 5 avascular necrosis 0% (3/940) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept
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