1. Classification of olecranon fractures

No generally accepted classification of olecranon fractures has been presented in the orthopaedic literature.

A simple classification of fractures of adult olecranon is proposed by

C.L. Colton and used as a basis for making recommendations about treatment

1. Non displaced or displacement less than 2mm.

2. Displaced fractures

a. Avulsion Fractures.

b. Oblique Fractures.

c. Comminuted Fractures

d. Fracture - Discolations.

3 Major classification systems,1,4

1. The AO classification system

2. The Mayo Classification System, and

3. The Schatzker-Schmeling Classification System, have dominated the published data, with each system having both advantages and disadvantages.

The Schatzker-Schmeling classification system for olecranon fractures focuses specifically on fracture morphology and the biomechanical concerns related to each type of internal fixation.

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 flexed elbow with indirect forces generated by the strong contraction of the triceps muscle.

Combination of direct and indirect violence.

Classification of olecranon fractures taken for study,

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 flexion to 900 with extension against gravity.

Displaced fractures:

Avulsion fractures:

A transverse fracture line separates a small proximal fragment of the olecranon process from the rest of the ulna.

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.

A. 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.

B. 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.

Fig.1: Olecranon fractures taken for study

2. Treatment

Later the practitioners slowly began to use the position of mid-flexion but, this frequently led to nonunion because of wide separation of fracture fragments, resulting in decreased power of the triceps mechanism3.

The dilemma for nonunion and stiffness led Lister to choose the fracture of olecranon to be the first fracture treated by open reduction and internal fixation using his method of asepsis with a wire loop2. Modifications 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 fixation have been proposed for olecranon fractures and the commonly used are-

1. Open reduction and fixation with a figure- of-eight wire loop.

2. Intramedullary fixation.

3. A combination of medullary pin or screw and tension bands.

4. Ao plate fixation.

The choice of the method of internal fixation 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 fixation include-

1. This method provides an anatomical reduction of the fracture and a congruous articular surface.

2. Rigid fixation allows for an early range of motion.

3. Elbow stability is preserved.

4. The extensor power of the triceps muscle is maintained.

3. 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.

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 traffic accidents, assault, fall from a height, industrial injury or domestic accident were specifically 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.

4. Selection of cases for krishner wires with tension band wiring and oleranon hook plate

Following points were considered -

a) 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 2.5 cms 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 figure- 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 1800and tap the cut ends back into the proximal fragment. Accuracy of reduction was 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 Cefixime 200mg daily for 5 days. Some cases were treated with Inj. Amikacin 500mg daily for 3 days.

b) Anti inflammatory analgesics, Inj. Diciofenac for 3 days followed by Tab Diclofenac 50mg twice daily.

c) Affected limb was elevated and patient was asked to perform finger movements on day 1. Elbow movements was adviced from 3rd postoperative day.

d) For comminuted fractures and unstable fixations, the limb was immobilized in A/E POP posterior slab with elbow in 900flexion 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 flexion-extension and pronation-supination without loading.

Patients were instructed to carry out physiotherapy in the form of active flexion extension and pronation supination without loading.

Check x-ray were taken and when final 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.)58 for functional outcome and Standard radiographs for radiological out come.

Fig 2- Instruments For Surgical Management of Olecranon Fractures

Lateral positioning of patientSkin incision posterolateral approach

Exposure of fracture site

Transverse drilling for cerclage wireCerclage wire passed through drill hole

K-wires through tip of olecranon Application of tension band wiring in figure of eight manner

Wound closed in layersSkin closure

Figure 3- Intra Operative of Surgical management of Olecranon fracture

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. All cases were followed up periodically during the period. The following are the observations made and the available data are analysed as follows.

1) Age incidence:

Table 1. Showing the age incidence

The ageofthi spatien tsranged from 21-60 years, with fracture association being most common in 3rd decade i.e. 8 cases (32%) and mean age of 40.5 years.

In this series, 6(24%) patients between 21-30 years, 8 (32%) patients between 31-40 years, 4 (16%) patients between 41-50 years andpatients below 51-60 years were 7(28%).

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2) Sex incidence:

Table 2. Sex incidence

In the present series, males were 17 (68%) and females were 8 (32%) with M:F ratio of 2.2:1.

Table 3. Side of involvement

Of olecranon on right side of the patient in 16

In this series, fracture (64%) cases and left side of patients in 9 (36%) cases.

3) Mode of injury:

Table 4. Mode of injury

In this series 13 cases (52%) were due to road traffic accidents, 11 cases (44%) were due to fall and 1(4 %) patient due to assault.

4) Type of fractures: (colton's classification)

Table 5. Type of fractures

olecranon fractures were oblique and In the present series, 19 (76%) and 1(4%) avulsion fractures. No cases of un displaced fractures and fracture- dislocation were observed.

5) Duration:

Table 6. Showing the time interval between injury and surgery

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.

6) Associated injury:

Table 7. Associated injury

In the present series, two patients had radial head fracture, one patient underwent radial head excision and one patient underwent k-wire fixation.

7) Incision:

All the cases were operated upon by Campbell's posterolateral approach.

8) Immobilization:

Two cases of oblique fractures of the olecranon where in it was difficult to obtain rigid fixation 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.

9) 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.

Table 8. Time of union

11. Mayo elbow performance score (meps) section -1 pain intensity

Table 9. Pain intensity