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https://upload.orthobullets.com/topic/1022/images/olecranon avulsion..jpg
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  • summary
    • Olecranon Fractures are common fractures of the elbow that lead to loss of extensor mechanism.
    • Diagnosis can be made with plain radiographs of the elbow.
    • 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
      •  12 per 100,000 per year
      •  account for approximately 10% of upper extremity fractures
    • Age
      • mean age is ~57 years
      • Bimodal distribution
        • high energy injuries in the young
        • low energy falls in the elderly
  • Etiology
    • Pathophysiology
      • mechanism
        • direct blow
          • usually results in comminuted fracture
        • indirect blow
          • fall onto outstretched upper extremity
          • usually results in transverse or oblique fracture
    • Associated conditions
      • Transolecranon fracture/dislocation
        •  severe axial load leading to potential instability of the ulnohumeral joint due to severe intra-articular comminution of the olecranon fracture
        •  considered an anterior dislocation of the elbow (distal humerus is driven through the olecranon)
        •  there is no disruption of the proximal radioulnar joint
  • 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 (Transolecranon)
      • 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 with intact extensor mechanism
          • displaced fracture in 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
  • 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
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