What is Olecranon fracture?
The elbow joint is formed by three bones, humerus (upper arm bone), ulna and radius
(Forearm bones). Olecranon is a part of ulna that acts a cup (of elbow joint) in which lower end of the humerus fits in creating a hinge for the elbow movement. It is the bony tip of the elbow positioned just under the skin and triceps muscle, responsible for straightening your elbow is attached. Olecranon fracture is the discontinuation or breaks at the olecranon (bony tip) of the ulna (forearm bone).
Olecranon fractures account for 5% of all fractures of the elbow and 10% of all fractures of upper extremities. They are usually caused by direct blow or injury to the elbow or due to falling on an outstretched arm, and rarely as a stress injury in throwing athletes or gymnasts. Olecranon fractures ranges from simple avulsion fracture (forceful contraction of triceps) to multifragmentary injury with elbow dislocation (high energy injuries).
What are the symptoms of Olecranon fracture?
You will feel sudden and intense pain in the back of the elbow. The pain is felt more with the movement of the joint. You will not be able to straighten the arm. Swelling is present at the tip of the elbow on the back side. Tenderness is also common. Bruising is seen around the elbow that may extend up to the shoulder or down to the forearm towards the wrist. The deformity is not present until the fracture is associated with dislocation in the elbows. You may also feel numbness in one or more fingers. Feeling of instability and popping out of the elbow is also present in some cases.
How is it diagnosed?
Your orthopaedic surgeon will diagnose it by evaluating your complete medical history, physical examination, and X-ray. An X-ray of the elbow and in some cases CT scan is helpful to detect the type and pattern of fracture and other associated ailments of the elbow.
What happens if nothing is done?
If the olecranon fracture is left untreated, there may be non-union or mal-union of the fractures with persistent pain. There may be a reduction in the normal range of motion of the elbow. You may also suffer from elbow instability or elbow stiffness or post-traumatic arthritis.
How is it treated?
Surgical treatment is the mainstay treatment for olecranon fractures. Conservative treatment is only applied in the cases of incomplete/non-displaced fractures or in selected cases in elderly people. It includes rest, ice packs, immobilization by a sling, medications, and physiotherapy.
Surgery is indicated in
- Displaced fractures
- Complex fractures
- Elbow dislocation
- Open fractures
- Vascular injury
- Floating elbow (associated humerus fracture)
- Nerve injury
- Pathologic fracture
What are the non-operative treatments?
- Rest- rest and modification of activities is advised to the patient to relieve pain and avoid any activity that can trigger pain.
- Icepacks – ice-packs is applied to the affected joint in order to relieve pain and swelling of the joint for 20-30 minutes twice or thrice a day.
- Immobilization- A polysling is applied to help with fracture healing. Except for physiotherapy, the arm is rested in the sling for 4-6 weeks.
- Physiotherapy- it is recommended to prevent the stiffness and restore the lost range of motion. These exercises are gradually progressed to strenuous and strengthening exercises in order to restore full function of the joint. This is done under the supervision of the surgeon and physiotherapist with help of periodic X-rays.
- Medicines- painkillers like paracetamol or codeine and anti-inflammatory medicines like aspirin and ibuprofen are given to the patient to manage pain and inflammation. However, they can just relieve the symptoms but cannot cure the condition completely.
What does the operation involve?
The main goal of the surgery is to reconstruct the elbow joint and to help with the triceps functioning.
- Surgery is usually performed as a day case under general anaesthetic, a cut is made in the skin over the fracture site at the back of the elbow and the fragments are first repositioned to their normal position.
- Then, internal fixation of the fragments is done with the help of plates and screws to keep the bone in proper position during healing. In some cases with multiple fracture fragments, bone substitutes are used to accelerate healing and to bridge the gap.
- The skin is stitched using absorbable sutures and a bulky dressing is applied over the arm. The surgical time is usually 1-2hrs and a majority of the patients go home the same day.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and the shoulder. This is necessary to prevent stiffness and to maintain the strength of the muscles near your shoulder after healing.
- The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks
- The patient is reviewed at 2 weeks and referred for physiotherapy.
- The fracture union is confirmed by x-rays at regular intervals, usually 6 weeks, 12 weeks and 6 months. However in selected cases x-rays are taken in first few weeks to assess displacement/union.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
- Your surgeon will restrict some of the activities related to your elbow such as lifting heavy loads, pushing or pulling activities like opening doors, pushing up while lifting from a chair. You can use your arm for dressing, bathing and feeding activities.
- The physical therapy in olecranon fractures begins immediately after surgery with gentle exercises and is progressed to strengthening exercices around 8 weeks. This will be guided by your surgeon and is based on radiographic (X-ray) and clinical union of the fracture. It is advisable to avoid sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.
Are there any risks?
- Elbow stiffness
- Elbow instability
- Heterotopic ossification
- Hardware failure
- Nerve injury (Ulnar)
- Injuries to ligaments
What are the results of the operation?
The outcome of the surgery is excellent with minimal serious complications (<1%). The outcome following this surgery depends on grade and severity of the injury, associated injuries, treatment involved and adherence to physiotherapy. However is more predictable in the author’s experience.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury. You should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality. Your physician will be able to advise you.
- Olecranon fracture
- Based on the fracture configuration, it could be treated by either Tension band wiring (above) or Plates and screws (below).