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.
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)
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
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
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)
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
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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
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
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
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
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