Clinical Study of Surgical Management of Olecranon Fractures

BACKGROUND AND OBJECTIVE: Olecranon fractures are one of the most commonly seen orthopaedic injuries in the emergency room. Fractures of the Olecranon process of the Ulna typically occurs as a result of a motor-vehicle or motorcycle accident, a fall, or assault. The accepted management for Olecranon fractures is for Non displaced fractures short immobilization followed by gradually increasing range of motion. When displaced ,Open reduction and internal xation with k-wires and gure of eight tension band wiring for simple transverse fractures and olecranon hook plate for comminuted fractures The present study is undertaken to evaluate the results of surgical management, the merits and demerits and to asses elbow joint motion and stability after the procedure. MATERIALS AND METHODS: It study J.J.M In this study period of 25 cases of fracture olecranon treated by Tension band wiring with Kirshner wire for Simple transverse fractures and Olecranon hook plate for Communited fractures In our series, majority of the patients were males, middle aged, with road trac accident being the commonest mode of injury, Most of the cases were Type II B fractures i.e., oblique and transverse fractures according to Colton’s classication Surgery was performed with in 3.48 average days, Union was noted clinically and radiologically and functional evaluation was done by Mayo elbow performance score. Excellent results was present in 18 patients (72%), 4(16%) good and 3(12%) fair with no poor results. From the present study it is concluded that the technique of open reduction and internal xation with Kirschner wires and tension band wiring for simple transverse and oblique fractures and olecranon plate xation for comminuted fractures are effective means and gold standard technique of treating fractures of olecranon and is based on sound biomechanical principle. of 25 cases of fracture olecranon treated by Tension band wiring with wire for Simple transverse fractures and Olecranon plate for Study was conducted with due emphasis for clinical observation and analysis of results after surgical management of fractures of olecranon by Krishner wires with Tension band wiring and Olecranon hook plate. comminuted this method of


Introduction
Olecranon fractures are one of the most commonly seen orthopaedic injuries in the emergency room.Fractures of the Olecranon process of the Ulna typically occurs as a result of a motor-vehicle or motorcycle accident, a fall, or assault.
Non displaced fractures can be treated with a short period of immobilization followed by gradually increasing range of motion.
When displaced, open reduction and internal xation are usually required to obtain anatomical realignment of the articular surface and restore normal elbow function.The xation should be stable, allow active elbow exion and extension and promote union of the fracture. 1 the past, closed reduction and plaster cast application was the treatment for fracture of olecranon.But, prolonged immobilization with its own complications increased the morbidity and mortality of patients. 2 keeping this in consideration, it has become important to intervene surgically.The active mobilisation after surgery will restore the patient to normal function as early as possible.The early and active movement not only prevents the tissue from fracture disease but greatly in uences the quality and rapidity of fracture union.
Stable internal xation with gure-of-eight tension-band wire xation for simple transverse fractures allows early motion to minimize stiffness.The K-wire used in AO tension -band technique resist shearing force better than the gure of eight wire alone.So this gives a good result by converting tensile force to compressive at the fracture site. 1,3,4r comminuted fractures, distal fractures involving coronoid process, oblique fractures, Plate xation is most appropriate mode of treatment.For comminuted fractures and non unions, a dorsally applied Olecranon hook plate is used. 1,4,5is dissertation is directed towards the clinical evaluation of Surgical management of Olecranon fractures by tension band wiring for simple transverse fractures and plate xation for communited fractures.3 Major classi cation systems, 1,4 1.The AO classi cation system 2. The Mayo Classi cation System, and 3.The Schatzker-Schmeling Classi cation System, have dominated the published data, with each system having both advantages and disadvantages.

OSSIFICATION CENTRE AROUND THE ELBOW:
1The Schatzker-Schmeling classi cation system for olecranon fractures focuses speci cally on fracture morphology and the biomechanical concerns related to each type of internal xation.

II. MECHANISM OF INJURY :
Fractures of the olecranon are usually caused by three main types of injuries :-Direct violence, such as falling on the tip of the elbow.
Indirect violence, such as falling on a partially exed elbow with indirect forces generated by the strong contraction of the triceps muscle.
Combination of direct and indirect violence.
Classi cation of olecranon fractures taken for study 54 ,

I) Un displaced and stable fractures:
To be considered un displaced and stable, the fractures must be displaced less than 2 mm, exhibit no change in position with gentle exion to 90 0 with extension against gravity.

II) Displaced fractures:
A. Avulsion fractures: A transverse fracture line separates a small proximal fragment of the olecranon process from the rest of the ulna.

B. Oblique and transverse fractures
The fracture line runs obliquely, starting near the deepest part of the semilunar notch and running dorsally and distally to emerge on the subcutaneous crest of the proximal part of the ulna.This fracture may be a single oblique line, or it may have an element of comminution caused by a fracture in the sagittal plane or a central area of depression in the articular surface.

C. Comminuted Fractures:
This group includes all the severely comminuted fractures of the olecranon, which usually result from direct trauma to the posterior aspect of the elbow.There are multiple fracture planes, often with severe crushing of many fragments.There may be associated fractures of the distal end of the humerus, the shafts of the forearm bones, or the head of the radius.

D. Fracture-Dislocations:
The olecranon fracture is at or near the level of the tip of the coronoid process, so that a plane of instability is located through the fracture site and the radiohumeral joint as well, resulting in an anterior dislocation of the ulna and radius.

TREATMENT
The treatment of fractures of the olecranon has seen the gamut from early range of motion of the elbow without regard for the fracture to precise and open anatomic reduction of the fracture site.
Before the era of aseptic surgery and the discovery of roentgenography, olecranon fractures were treated by splinting the elbow in full extension for 4 to 6 weeks 2 .This usually resulted in a stiff elbow with loss of exion.Later the practitioners slowly began to use the position of mid-exion but, this frequently led to nonunion because of wide separation of fracture fragments, resulting in decreased power of the triceps mechanism 13 .
The dilemma for nonunion and stiffness led Lister to choose the fracture of olecranon to be the rst fracture treated by open reduction and internal xation using his method of asepsis with a wire loop2.Modi cations of this technique, which was the forerunner of the tension band technique advocated by the AO group are now in use.
Multiple methods of internal xation have been proposed for olecranon fractures and the commonly used are-1.Open reduction and xation with a gure-of-eight wire loop.
3. A combination of medullary pin or screw and tension bands.

Ao plate xation.
The choice of the method of internal xation depends on the nature and location of the fracture, the amount of comminution and the age of the patient.
The advantages of open reduction and internal xation include-1.This method provides an anatomical reduction of the fracture and a congruous articular surface.
2. Rigid xation allows for an early range of motion.
4. The extensor power of the triceps muscle is maintained.

Methodology
The present study consists of 25 cases of fracture olecranon treated by Tension band wiring with Kirshner wire for Simple transverse fractures and Olecranon hook plate for Communited fractures at the Chigateri General Hospital and Bapuji Hospital, Davangere between September 2010 to September 2012.
Study was conducted with due emphasis for clinical observation and analysis of results after surgical management of fractures of olecranon by Krishner wires with Tension band wiring and Olecranon hook plate.

IMMEDIATE MANAGEMENT :
Immediately on arrival of the patient, if he/she was in shock, the level of shock was noted and managed accordingly.X-ray of the part was taken and the elbow was immobilized in whatever the position patients presence in a A/E POP posterior slab.The affected limb was kept elevated.Analgesics and antibiotics were given if necessary.Patient was then prepared for surgery and anaesthesia after the pre-anaesthetic checkup.

HISTORY :
A detailed history was elicited from the patients.The duration of injury and mechanism of injury, whether due to direct or indirect violence was noted.Whether trauma was due to tra c accidents, assault, fall from a height, industrial injury or domestic accident were speci cally asked and also other associated injuries were noted.Enquiry was made to note the severity of pain and swelling and also about the active movements of the affected joint and external wound.

SELECTION OF CASES FOR KRISHNER WIRES WITH TENSION BAND WIRING AND OLERANON HOOK PLATE
Following points were considereda) Age of the patient b) Extent of damage to the articular surface c) Degree of comminution.
The patients of extremes of age and the patients in whom operative risk was great were not taken up for surgery.

METHODS :
1) SURGICAL PROCEDURE : a) Anaesthesia -The operation was performed under general anaesthesia or brachial block.
b) Position and Tourniquet -Mid arm tourniquet was applied with patient in supine or lateral position.Site of the surgery was thoroughly painted with iodine and spirit and draped.c) Exposure -Exposure of the olecranon was done by Campbell's posterolateral approach.A vertical incision was taken over the posterior aspect of the elbow about 2.5cms proximal to olecranon, curving distally along the lateral aspect of olecranon reaching the subcutaneous border of the ulna and extending distally for about 7.5 cms distal to olecranon.Fascia was incised along the line of skin incision and fracture site was exposed.Fracture haematoma was cleared off and the fracture site was gently curettage.Accurate anatomical hairline reduction was achieved and held with either reduction clamp or long towel clip.
2 K-wires is introduced parallel from the tip of the olecranon i.e., the proximal fragment across the fracture site to the distal fragment.Periosteum was stripped from the shaft of ulna distal to fracture site and a transverse hole was drilled approximately 3 to 5cms distal to fracture site.A No.18 stainless steel malleable wire was passed through this transverse hole and crossed over the posterior surface of olecranon in a gure-of-eight manner and then passed around the protruding Kirschner wires and tightened using AO tensioner and then secured with a twist.Bend the proximal ends of the Krishner wires 180 0 and tap the cut ends back into the proximal fragment.Accuracy of reduction was checked and stability was tested by moving the joint.Wound closed in layers and sterile dressing and compression bandage given.
For communited olecranon fracture, Exposure of the olecranon was done by Campbell's posterolateral approach.A vertical incision was taken over the posterior aspect of the elbow about 2.5cms proximal to olecranon, curving distally along the lateral aspect of olecranon reaching the subcutaneous border of the ulna and extending distally for about 7.5 cms distal to olecranon.Fascia was incised along the line of skin incision and fracture site was exposed.Fracture haematoma was cleared off and the fracture site was gently curettage.Accurate anatomical hairline reduction was achieved and held with either reduction clamp olecranon hook plate was applied on the posterior surface with cortical screws after drilling and tapping, through wash was given, wound closed in layers and sterile dressing was applied.
2) POSTOPERATIVE MANAGEMENT : a) All the patients were treated with Inj.Cefotaxime 1gm twice daily for 5 days followed by Tab Ce xime 200mg daily for 5 days.Some cases were treated with Inj.Amikacin 500mg daily for 3 days.b) Anti in ammatory analgesics, Inj.Diciofenac for 3 days followed by Tab Diclofenac 50mg twice daily.c) Affected limb was elevated and patient was asked to perform nger movements on day 1.Elbow movements was adviced from 3rd postoperative day.d) For comminuted fractures and unstable xations, the limb was immobilized in A/E POP posterior slab with elbow in 90 0 exion for 2 weeks.For other fractures the limb was mobilized by about 3rd postoperative day.

3) FOLLOW UP :
This part of the study should be done very carefully and meticulously.In our study the patients on discharge were advised to report for follow up after 6 weeks and 12 weeks and thereafter every 3 months.The result is assessed 3 months after the procedure.At follow up a detailed clinical examination was done and patient was assessed subjectively for the symptoms like pain, swelling, restriction of joint motion.On clinical examination, swelling of the joint, tenderness, movements of the elbow joint, prominence of head of cancellous screw, nutrition and power of the muscles acting on the joint were noted.
Patients were instructed to carry out physiotherapy in the form of, active exion-extension and pronation-supination without loading.
Patients were instructed to carry out physiotherapy in the form of active exion extension and pronation supination without loading.
Check x-ray were taken and when nal x-ray showed union, implant was removed.In all patients duration after which they returned to job was noted.

EVALUATION OF RESULTS :
Although there are many methods of evaluation of results given by many authors, the treated olecranon fractures by Tension band wiring and olecranon hook plate were evaluated in our study withMayo Elbow Performance score (MEPS) (According to Morrey BF, An KN.Functional evaluation of the elbow.) 58for functional outcome and Standard radiographs for radiological out come.

Results
Study consists of 25 cases of fractures of the olecranon treated by Tension band wiring with Kirshner wire for Simple transverse fractures and Olecranon hook plate for communited fractures in Chigateri General Hospital and Bapuji Hospital between September 2010 to September 2012.All cases were followed up periodically during the period 2010-2012.The following are the observations made and the available data are analysed as follows.Female 8 32%

1) AGE INCIDENCE:
In the present series, males were 17 (68%) and females were 8 (32%) with M:F ratio of 2.2:1.In this series, fracture of olecranon on right side of the patient in 16 (64%) cases and left side of patients in 9 (36%) cases.

4) MODE OF INJURY : TABLE -IV :MODE OF INJURY Mechanism of injury No.of cases Percentage
Road tra c accidents 13  52   Fall from height 11 44

Assault 1 4
In this series 13 cases (52%) were due to road tra c accidents, 11 cases (44%) were due to fall and 1( %) patient due to assault.No case was operated as a surgical emergency.All the cases were operated on our regular operation theatre days, at the earliest possible time.The patients were operated upon with an average period of 3.48 days after the injury.In the present series ,two patients had radial head fracture ,one patient underwent radial head excision and one patient underwent k-wire xation.

8) INCISION :
All the cases were operated upon by Campbell's posterolateral approach.

9) IMMOBILIZATION :
Two cases of oblique fractures of the olecranon where in it was di cult to obtain rigid xation and comminuted fractures were immobilized with A/E posterior P.O.P. slab for a period of two weeks.
All the other cases were encouraged active elbow motion from the third postoperative day.

10) DURATION OF FRACTURE UNION
The fracture was considered united when clinically there was no tenderness and no subjective complaints and radiologically when the fracture line was not visible.
Fractures, which healed 6 months later without an additional operative procedure was considered as delayed union.Fractures which did not unite after 6 months or that needed additional operative procedure to unite was considered nonunion.Poor (Score below 60) -- In the present series of study the patients with excellent results were18(60%).4 cases (16%) with good results, fair results was noticed in 3 cases (28%).No cases seen in poor results.

Symptomatic metal prominence 4 16
The complications of the present study, super cial infection was in 3(12%) patients, which was treated with broad spectrum antibiotics.The symptomatic metal prominence was noticed in 4 (16%) patients.

Discussion
The main aim of the treatment of fracture is not only achieving union but to preserve the optimum function of the adjacent soft tissues and joints.In the management of intra articular fractures like fractures of the olecranon, a perfect anatomical reduction of the fragments to obtain articular congruity and rigid xation of the fragments is of utmost importance, if early movements are to be instituted to prevent complications like traumatic arthritis and joint stiffness.
Tension band wiring with 2 intramedullary Kirschner wires provides the strength of xation i.e. by converting tensile force to compressive force at the fracture site and for comminuted fractures Olecranon hook plate is used.
In our study 25 cases of fractures of the olecranon were treated with Tension band wiring and Kirschner wires for simple transverse and oblique fractures and Olecranon hook plate for comminuted fractures.Our experience with this method of xation has given favourable results.The ndings, the end results and various other data will be analysed and compared in the following discussion.In this study, the patients with Road tra c accident were 13 (52%) patients, with Fall from height were 11 (44%) patients and 1 (4%) patient was Assault.
Where as according to Jiang Xieyuan series, the patients with tra c accidents were 9 (60%) and patients with fall from height were 6 (40%) and according to Wolfgang et al, 22 (48.88%)patients were fall from height 20 (44.44%) were due to motor vehicle accident 4 (6.66%)we re due to direct blow.The results were evaluated according to the Mayo elbow performance score.The results obtained in our series were excellent in 18 (72%) patients, good in 4 (16%) patients, fair in 3(12%) patients and no poor results.
The results in our series is almost accordance with the studies of Murphy et al and Jiang Xieyuan.

Summary
Twenty ve cases of fractures of the olecranon treated by Kirschner wire with tension band wiring technique for Transverse and Oblique fractures and Olecranon hook plate for Comminuted fractures at the Chigateri General Hospital and Bapuji Hospital, attached to J.J.M. Medical College, Davangere have been presented.Special attention was made to mobilize the affected elbow early.
A review of literature on fractures of the olecranon has been presented.
The anatomy of the elbow joint with particular reference to olecranon has been discussed in detail.
The principle of tension band has been discussed in detail.
The mechanism of injury, classi cation of olecranon fractures and management have been described.

Figure 2 See image above for gure legend Figure 3 Fig
Figure 2 See image above for gure legend

Figure 4 Lateral
Figure 4 Lateral positioning of patient

20 See
Figure 6 Exposure of fracture site No generally accepted classi cation of olecranon fractures has been presented in the orthopaedic literature.
55simple classi cation of fractures of adult olecranon is proposed by C.L.Colton and used as a basis for making recommendations about treatment55

TABLE -
In the present series 18(72%) patients were pain free and 7(28%) patients had mild aching pain.No patients had moderate or severe pain.
In the present series 23(92%) patients were having stable elbow, 2(8%) had moderate instability and no patient had gross instability.Section-4 FUNCTIONAL EVULATION

TABLE -
The average age incidence; in the present study was found to be 40.05years.This is well in accordance with the authors Jiang Xieuan (2000) is his study average age was 38 years and Macko Donald and Szabo California (1985) average age was 35.5 years (15-76 years).The present study of fracture olecranon revealed greater incidence in males (68%).Similarly male predominance was found in the study of Jiang Xieyuan, Hume and Wiss and Garry Wolfgang et al series.
31 the present series super cial infection in 3(12%) patients, which was seen in diabetic patients probably due to decreased immunity which was treated with broad spectrum antibiotic.The symptomatic metal prominence in 4 (16%) where as complications in Murphy et al31is only symptomatic metal prominence