The olecranon is the part of the ulna that forms the elbow.
There are different types of olecranon fractures, ranging from simple undisplaced fractures to complex and displaced fractures of the elbow joint.
The olekranon fracture is relatively common, since especially this bone protrudes at the elbow and therefore, if you slip, a direct trauma occurs on the olekranon.
Most direct trauma to the elbow and falls with the forearm bent affect this part of the ulna and can cause a fracture of the bone.
Olekranon breaks far less frequently in children because it is shorter and more stable than the lower end of the humerus in the first years of life.
Most children are more likely to have supracondylar humeral fractures than adults.
Open fractures occur in about 15% of cases.
Neurological damage to the spoke nerve (radial nerve) or elbow nerve (ulnar nerve) rarely occurs.
Compression or overstretching of the ulnar nerve was reported in 2-5% of cases.
In general, the symptoms disappear with conservative treatment. Sometimes, however, surgery may be necessary to clear the nerve.
The elbow is a complex hinge joint.
The olecranon prevents protrusion of the ulna in relation to the humerus.
The anterior surface of the ulna is covered with articular cartilage.
That is why all fractures (except the rare ones at the top) are intra-articular.
The olecranon forms a joint with the humerus roller (trochlea). The triceps attaches to the posterior third of the olecranon and in the proximal region of the ulna.
The periosteum of the olecranon merges with the triceps.
The elbow nerve is located on the back of the elbow behind the medial collateral ligament.
It nestles in front of the ulnar artery.
The nerve cord and blood vessels of the ulna may be at risk when fixed with Kirschner wire.
Dislocation of the fracture is essentially due to the tension of the triceps muscle, which tends to pull the broken fragment upwards.
The combination of fibers of the collateral ligaments of the elbow, the joint capsule and some fibers of the triceps, which fuse with the periosteum, form a fibrous protective shell.
If this fibrous shell does not rupture during the impact, there is no tendency to dislocation, even if there is a debris fracture.
Most olecranon fractures have no displacement.
Displacement of a fragment by more than 1.5 cm is rare even with a complete lesion of the bone and soft tissues.
Most often, a large separation of fragments indicates an old fracture with an injury to the fibrous shell.
In this case, the triceps can pull the fracture fragment upwards.
The elbow allows not only the bending of the arm, but also the pronation and supination (in and out rotation) of the hand.
Causes of olecranon fracture
The most common mechanism for an olecranon fracture is a fall on the angled and supinated forearm (with the hand facing upwards).
When the hand hits the ground, the muscles remain tense to absorb the fall, and the triceps exerts significant force on the olecranon above the lower end of the humerus, tearing out a piece of bone.
The second most common cause of an olecranon fracture is direct trauma, for example, a fall directly on the elbow when slipping on snow or ice and falling backwards.
Rarely, the olecranon can rupture in trauma with a stretched arm, sometimes in conjunction with elbow dislocation in adults or with a condylar humeral fracture in children.
The olekranon may break due to muscle tension after a litter.
Usually, olecranon fractures are separate injuries, but in patients with multiple trauma, other lesions associated with them may occur.
20% of patients with severe trauma show associated injuries (e.g. other bone fractures, skull fracture, rupture of the spleen, pneumothorax, rupture of the axillary artery).
The most common fracture passes transversely or slightly obliquely near the base of the olekranon.
In oblique fractures, the fracture line runs downwards and backwards, and then reappears on the outer edge of the olekranon. In other cases, a small piece of bone of the proximal olecranone is torn out.
Signs and symptoms of olecranon fracture
The olecranon fracture causes pain at the level of the elbow, massive restriction of movement, hematomas and swelling.
In the first two days, the pain is unbearable even at rest.
Subsequently, the pain subsides considerably and if a plaster cast is attached, you may not feel any discomfort at all.
The pain recurs when the cast is removed and you begin to move your elbow, wrist and arm again.
The swelling remains for a few months, depending on the severity of the fracture.
With an injury to the ulnar nerve, a loss of sensitivity and strength in the little finger and ring finger is noticed. In addition, you feel pain and tingling in this hand region.
Diagnosis of olecranon fracture
Most olecranon fractures occur separately.
Nevertheless, further injuries to the same limb may occur.
It is important to make a thorough examination of the shoulder, collarbone, upper arm, wrist, hand and forearm. Typically, the elbow has injuries to the surrounding muscles and tendons.
It is also important to examine the skin, radial and ulnar pulse and nerve functions (ulnar, median and interosseus posterior).
Then it is necessary to evaluate the isolated fractures, such as the fracture of the coronoid process, the radius head and the displaced Monteggia fractures, which can lead to instability of the elbow.
Radiography helps determine if there is an elbow fracture.
This examination may also reveal other fractures or dislocations.
X-rays may also be taken of the upper arm, forearm, shoulder, wrist and hand, depending on the patient’s symptoms.
Treatment of an olecranon fracture
In the emergency room, the fracture is treated with ice, painkillers and immobilization by a plaster cast.
Later, the fracture must be repositioned, i.e. the bone fragments must be aligned, if it is displaced.
Not all olecranon fractures require surgical intervention.
For some olecranon fractures, applying an orthosis or support bandage is sufficient to keep the elbow fixed during the healing process.
The doctor often needs to examine the development of the fracture and conduct regular X-ray examinations.
If after 3-4 weeks none of the bone fragments has shifted, the doctor allows the patient to start careful movements of the arm.
This can be done with the help of an experienced physiotherapist.
The patient must not lift anything with the injured arm for at least 3-4 weeks.
Conservative treatment of an olekranon fracture may require a very long immobilization.
As a result, the elbow can stiffen and it then requires lengthy physiotherapy treatment after the cast has been removed.
If the stumps of the fracture shift, the bones will likely need to be surgically bandaged.
Surgery to treat an olecranon fracture is usually necessary in the following cases:
- The fracture is accompanied by a dislocation. The triceps attaches to the olecranon to stretch the elbow. The stumps must be bandaged to allow the elbow to be stretched.
- It is an “open” fracture; here the risk of infection is greater.
The doctor injects an antibiotic through the vein (intravenously).
The patient should be immediately taken to the operating room so that the wounds can be carefully cleaned.
On this occasion, the bone is also fixed.
- Fractures with a significant displacement (> 2 mm) or shattering must be treated surgically.
The operation can be performed under general anesthesia or local anesthesia.
During the operation, the patient lies on his back, stomach or in a supported lateral position. If the patient lies on his stomach, his face may be swollen for a few hours after surgery.
This condition is perfectly normal and only temporary.
Usually, the surgeon makes an incision over the back of the elbow to reposition the fragments of the fracture.
There are several ways to hold the bone fragments in position.
The surgeon has the following options:
- Kirschner wires (flexible metal wires)
- Plates and screws
- Sutures on the bone or tendons
A single medullary screw can hold the bone fragments together.
Plates and screws can be used to fix the fragments of the cubit.
If pieces of bone have been crushed or lost in the accident or trauma (injury in an accident), a bone graft may be required. The insert can consist of the patient’s own bone (usually taken from the pelvis or fibula) or bones from a donor bank.
The incision is usually closed with seams or staples. Sometimes a splint is applied to the arm to immobilize it.
Surgery carries some risks, but if the surgical procedure has been recommended, it means that the doctor assumes that the possible benefits of the procedure are greater than the risks.
Contraindications to surgery are:
- Infection. Every operation carries a risk of infection.
- Ache. In the operating room, the pain is controlled by the anesthesiologist, who can decide whether to perform general or local anesthesia. After surgery, the pain is kept under control by a combination of painkillers.
- Damage to nerves and blood vessels. There is a very low risk of damage to nerves and blood vessels in the elbow area.
Surgery is not a guarantee that the fracture will heal. Screws, plates or wires can shift or break.
This can have various causes, including:
- The patient does not follow the instructions after the operation.
- The patient suffers from other health problems that delay healing, such as smoking or diabetes.
- Open fractures often heal more slowly.
If the fracture does not heal, further surgery may be required.
Contraindications to surgery
Conservative treatment is often indicated in patients suffering from very serious concomitant diseases.
Healing soft tissue bruises is fundamental.
Conservative treatment of olecranon fractures is also indicated in severe diseases, the use of steroids and dementia.
After surgery, the patient’s elbow can be immobilized (plastered) for a short time.
The surgeon usually removes the sutures or staples 10-15 days after surgery.
Often, after the operation of an olecranon fracture, the metal pins, wires and screws must be removed.
There is little soft tissue above the outer area of the elbow and these metal implants can cause discomfort, especially if you lean on the elbow.
Then the implants are removed about a year after surgery.
The ultimate goal of treating an olecranon fracture is to restore extensive elbow mobility.
Most patients return to their normal activities within 4 months of surgery (except in sports or heavy work), although complete healing may take longer than a year. Many patients report that they have not regained 100% mobility of the elbow even after complete fracture healing.
The patient should avoid lifting objects with the injured arm for at least six weeks.
Mobilization exercises for elbows and forearm should be started immediately the day after surgery.
Immediately after surgery, some patients cannot independently stretch the operated elbow.
To stretch the elbow, the patient must use the healthy arm or get help from another person.
Full recovery after an olecranon fracture requires a great deal of personal commitment.
It is extremely important that the exercises are performed several times a day and every day.
The movement exercises must be performed independently by the patient in the days when he does not go to the physiotherapist.
The recovery of power often takes even longer (up to 6 months).
Patients are usually immobilized for a short period of time, but the goal is to start mobilizing the elbow as soon as possible.
The possible range of motion depends on the reliability of the restoration of the fracture and surrounding bone.
The total time it takes for a fracture to heal is about 12 weeks.
Often patients do not regain the 100 percent mobility of the operated elbow.
If the mobilization of the elbow begins immediately after surgery, greater mobility can be regained.
Other possible combinations are:
- poor healing of the fracture;
- displacement of the screws and plates used in the operation;
- Elbow pain.