Olecranon fracture
Drawing depicting a comminuted olecranon fracture

Definition

A fracture of the olecranon consists of a break of the proximal end of the ulna, which forms the tip of the elbow. This is the protruding bone easily felt when bending the forearm.

X-rays showing a healthy left, and a fractured olecranon, right

Pathology

Fractures of the olecranon are a frequent consequence of falls when striking a hard surface with the elbow. They result from high-energy trauma in young population and low-energy falls in the elderly. An indirect fracture to the olecranon may result from falling on the outstretched arm. This is often accompanied with injuries to the wrist or other bones of the elbow. Olecranon fractures display a variety of characteristics that are described in detail below in the classification.

Associated injuries

An olecranon fracture may be present as an isolated pathology, simultaneously to elbow dislocations, triceps strain or tear, a sprained wrist, and fractures to the radius, radial head, hand and wrist. Although seldom in children olecranon fractures may arise with radial head dislocation or fracture. They may be combined with soft tissue injuries to:

Ligaments (medial collateral ligament)

Nerves, more often the radial nerve causing drop hand

Vessels (brachial artery)

Top: Mayo type I undisplaced (L + R); Middle Mayo type II displaced, A non-comminuted (L), B comminuted (R); Bottom: Mayo type III, A non-comminuted (L), B comminuted (R)

Classification

Fractures of the olecranon are grouped into different types depending on the relative position of the bone fragments.

The Mayo classification is mostly utilised for the definition of olecranon fractures:

Mayo Type I - Undisplaced

Mayo Type II, A-non comminuted or B-comminuted - Displaced

Mayo Type III, A-non comminuted and B-comminuted - Displaced over 3 mm and unstable

Open fractures

Stress fractures

 

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

A fall with the elbow on a hard surface can lead to an olecranon fracture

Causes

Olecranon fractures mostly occur through direct injuries to the elbow when:

Falling on the semiflexed or outstretched arm

Blow to the olecranon with a hard object (cricket bat)

Motor vehicle accidents

Stress fractures in throwing athletes

Falls in the elderly represent a risk for fractures

Risk factors

Most recreational and professional sports represent a risk factor for olecranon fractures, as falls on the elbow are relatively common. Other factors include falls during daily activities such as walking and descending stairs and they occur mostly in the older population. These are the typical risk factors for an olecranon fracture:

Tendency to fall

Sport (snowboarding, skateboarding, ice skating, cycling, running)

Throwing sports (basketball, baseball)

Swelling, redness and tenderness are symptoms of olecranon fracture

Symptoms

Following injury, a patient feels a sudden, intense pain to the tip of the elbow.

Other symptoms include:

Bruising and swelling over the elbow

Open wound at the elbow tip

Tenderness at touch

Deformity of the elbow

Inability to straighten and rotate the elbow

Restricted movement of the elbow

Numbness in one or more fingers

Changes in sensation of the areas innervated by the radial nerve

Changes in motor function of thumbs and fingers controlled by the radial nerve

X-ray showing a fracture of the olecranon

Diagnosis

Olecranon fractures require first care at the Emergency Department. Physical examination begins with the medical history including the mechanisms of injury leading to the fracture. The examiner looks for the presence of deformities and bruises around the elbow and changes in the range of movement to establish functional limitations and pain level when the elbow is moved passively in extension and supination.

Palpation is used to identify the exact location by triggering pain, or the instability of bony parts in complicated fractures. Examination of other body parts (hand, wrist, shoulder and arm) is necessary to exclude any associated injuries

X-rays are the first radiological method to evaluate the type and severity of olecranon fracture and determine the optimal treatment management. A CT scan or MRI may provide further information on the position of the bone fragments to plan a detailed surgical approach.

 

Treatment

Temporary treatment with a sling following olecranon fracture

Nonoperative treatment

Conservative treatment is sufficient in case of simpler Type I and II olecranon fractures without bone displacement and when they do not impact on the joint function. The elbow is immobilised with a splint or sling for 7-10 days, and the fracture healing is monitored with repeated X-rays. Only gentle movements are allowed. Stiffness of the elbow has to be avoided under any circumstances by maintaining a continuous physiotherapy plan to be intensified as early as possible after fracture healing. Additional conservative care include:

Rest

Application of ice pads

Administration of NSAIDs

Pain killers

Two surgical methods to fix an olecranon fracture: plate and screws left and wires right

Surgical treatment

Surgery is required in more complicated and displaced olecranon fractures or in case of open fractures whereby the laceration/bone fragments are cleaned up to reduce the risk of infection. An incision in the back of the elbow allows the surgeon to access the fracture. Open reduction and internal fixation is achieved with various devices relative to the shape of the fracture (pin, wires, plates, sutures of the bone) in order to reconnect the bone parts. If fragments of the fractured bone are excised during surgery mostly in elderly, osteoporotic patients, the triceps tendon is reattached to the olecranon. Importantly, removal of over 50% of the olecranon causes elbow instability. Occasionally bone replacement material may be required to substitute lost bone. This procedure includes the use of autologous bone taken from the pelvic crest or artificial bone and cadaver bone transplant.

Complications

Complications arising from olecranon fractures include:

Prolonged pain

Damage to nerves and blood vessels

Infection, especially in open fractures, requiring antibiotic treatment

Incomplete fracture healing in smokers and diabetic patients possibly undergoing second surgery

Hardware intolerance and complications requiring surgical removal

Elbow stiffness

Reduced extension of the elbow (deficit of the extensor muscle)

Arthritis of the elbow joint due to cartilage damage

Massage of the elbow after an olecranon fracture

Rehabilitation

Post-surgical treatment involves the use of a splint or cast for a few days and medications given to alleviate the pain. Although gentle movements are recommended soon after surgery, weight lifting is not allowed for at least 6 weeks. Intense physiotherapy can then begin to acquire flexibility and strength of the elbow. Functional recovery is achieved in a period ranging from 6 months to a year post-surgery.

Physical therapy also relies on the following methods:

Application of ice or heat pads

Elbow taping and bracing

Use of a compression bandage

Massage

Joint mobilisation

Stretches

Electrotherapy

Ultrasound

Activity modification advice

Preventing falls reduces the risk of fractures

Prevention

Avoiding any type of fall in the young and older populations will reduce the incidence of olecranon fractures and associated injuries. In addition it is recommended to follow simple instructions especially when an elbow injury has already occurred:

Remove tripping hazards and avoid smooth/wet surfaces to prevent falls in the elderly

Use of support devices to assist ambulation in the elderly

Use of taping and bracing to protect the elbow during sport or physical activities

Physical exercise to strengthen the arm muscles and maintain elbow flexibility

Return to sport with training guided by a physiotherapist

Use seatbelt when driving

Do not hang the elbow out of the car window