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Olecranon fractureOlecranon fracture
Lonnie Froberg, MD, Ph.DLonnie Froberg, MD, Ph.D
Rigshospitalet, Copenhagen University HospitalRigshospitalet, Copenhagen University Hospital
�� 20% of forearm fracture20% of forearm fracture
�� 12 per 100.000 persons per year12 per 100.000 persons per year
�� LowLow--energy fallenergy fall
�� Increased risk >50 yearsIncreased risk >50 years
�� 90% AO 21.B1.190% AO 21.B1.1
�� Dickworth et al. Injury 2012;43:343Dickworth et al. Injury 2012;43:343--346 346
�� Why operate?Why operate?
�� Methods of fixationMethods of fixation
–– KK--wire, cerklagewire, cerklage
–– PlatingPlating
�� OutcomeOutcome
�� SummarySummary
Why operate?Why operate?
�� Restore articular surfaceRestore articular surface
�� Achieve absolute stabilityAchieve absolute stability
�� Commence early active movementCommence early active movement
�� Preservation of range of motion and Preservation of range of motion and
powerpower
�� Avoidance of complicationsAvoidance of complications
Methods of fixation?Methods of fixation?
Methods of fixation?Methods of fixation?
�� Cadaveric elbow jointCadaveric elbow joint
�� Standard osteotomiesStandard osteotomies
�� Five different fixation Five different fixation techniquestechniques
�� Loads applied comparable to Loads applied comparable to clinical situationsclinical situations
�� Displacements measuredDisplacements measured
Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367--372372
Methods of fixation?Methods of fixation?
Fracture typeFracture type
TransverseTransverse
ObliqueOblique
ComminutedComminuted
Fixation techniqueFixation technique
Tension band 1.0 mm, 1 Tension band 1.0 mm, 1
knot, Kknot, K--wire 2.0 mmwire 2.0 mm
Tension band 1.0 mm, 2 Tension band 1.0 mm, 2
knots, Kknots, K--wire 2.0 mmwire 2.0 mm
Tubular plateTubular plate
Cancellous screw, washerCancellous screw, washer
Cancellous screw, washer, Cancellous screw, washer,
tension bandtension band
Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367--372372
Methods of fixation?Methods of fixation?
Fracture typeFracture type Fixation techniqueFixation technique
TransverseTransverse Tension band, 2 knotsTension band, 2 knots
ObliqueOblique Tension band, 2 knotsTension band, 2 knots
or tubular plateor tubular plate
ComminutedComminuted Tubular plateTubular plate
Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367--372372
KK--wire and cerklagewire and cerklage
How to place the KHow to place the K--wires?wires?
�� Proximal ulnar canal?Proximal ulnar canal?
�� Anterior cortex?Anterior cortex?
�� Distal ulnar canal?Distal ulnar canal?
Huang et al. J Trauma. 2010.68;1:173Huang et al. J Trauma. 2010.68;1:173--176176
How to place the KHow to place the K--wires?wires?
Proximal ulnar Proximal ulnar
(n=24)(n=24)Anterior cortexAnterior cortex
(n=28)(n=28)
Distal ulnar Distal ulnar
(n=26)(n=26)
Average followAverage follow--
up/monthsup/months34.5 s.d 7.234.5 s.d 7.2 34.0 s.d 5.934.0 s.d 5.9 29.6 s.d 7.229.6 s.d 7.2
Symptomatic Symptomatic
implant removalimplant removal8 (33%)8 (33%)
*p=0.03*p=0.03
3 (11%)3 (11%) 2 (8%)2 (8%)
Proximal Proximal
migration of Kmigration of K--
wire/mmwire/mm
4.08 s.d. 1.894.08 s.d. 1.89
*p=0.001*p=0.001
1.53 s.d 0.561.53 s.d 0.56 1.31 s.d 0.541.31 s.d 0.54
Satisfactory Satisfactory
functionel functionel
outcomeoutcome
21 (88%)21 (88%) 26 (93%)26 (93%) 26 (100%)26 (100%)
How to place the KHow to place the K--wires?wires?
�� Inserted as close as possible to the Inserted as close as possible to the articular surfacearticular surface
�� Back 1 cm from final position, cut Back 1 cm from final position, cut obliquely, bent obliquely, bent
�� Incisions with lines in tricepsIncisions with lines in triceps
�� KK--wires are impacted into ulnawires are impacted into ulna
Newman et al. 2009. Injury; 40(6): 575Newman et al. 2009. Injury; 40(6): 575--581581
How to place the KHow to place the K--wires?wires?
�� KK--wire penetration wire penetration more than 10 mm more than 10 mm beyond the anterior beyond the anterior cortex increases cortex increases risk for penetration risk for penetration of median nerve of median nerve and ulnar arteryand ulnar artery
Prayson et al. Shoulder Elbow Surg. Prayson et al. Shoulder Elbow Surg. 2008.17;1:1212008.17;1:121--125125
Which kind of tension band?Which kind of tension band?
FailureFailure
(> 2 mm movement (> 2 mm movement
across osteotomy)across osteotomy)
CompressionCompression
Stainless steel wireStainless steel wire 0% 0% 71%71%
Ethibond No. 2Ethibond No. 2 100%100% 66%66%
Ethibond No. 5Ethibond No. 5 40%40% 40%40%
Fiber wireFiber wire 0%0% 43%43%
Lalliss et al. Jour Bone Joint Surg (Br).2010.92B;2:315-319
PlatingPlating
PlatingPlating
�� When to plate?When to plate?
–– Tension band is not appropriateTension band is not appropriate
–– Oblique fractures distal to the Oblique fractures distal to the
midpoint of the troclear notchmidpoint of the troclear notch
–– CoCo--existing coronoid fractureexisting coronoid fracture
–– Associated with Monteggia Associated with Monteggia
fracture dislocationfracture dislocation
Newman et al. 2009. Injury; 40(6): 575Newman et al. 2009. Injury; 40(6): 575--581581
Which kind of plate?Which kind of plate?
�� Cadaveric studyCadaveric study
�� Comminute fractureComminute fracture
�� No difference in No difference in failure rate (>2 mm failure rate (>2 mm gap of fracture)gap of fracture)
Buijze et al. Arch Orthop Trauma Buijze et al. Arch Orthop Trauma Surg.2010;130:459Surg.2010;130:459--464464
Which kind of plate?Which kind of plate?
�� Advantage of locking compression Advantage of locking compression
plate to conventionel plate:plate to conventionel plate:
–– Angular and axial stabilityAngular and axial stability
–– Preserves periosteal blood supplyPreserves periosteal blood supply
–– No toggling of unlocked screws (improves No toggling of unlocked screws (improves
fixation in osteoporotic fractures and fixation in osteoporotic fractures and
comminution)comminution)
Which kind of plate?Which kind of plate?
�� Stainless steel or titanium?Stainless steel or titanium?
�� More screw in proximal fragment More screw in proximal fragment
better than fewer screws?better than fewer screws?
�� Larger screws better than small Larger screws better than small
screws?screws?
Which kind of plate?Which kind of plate?
�� Accumed stainless stellAccumed stainless stell
�� Synthes stainless stellSynthes stainless stell
�� Synthes titaniumSynthes titanium
�� US ImplantsUS Implants
�� ZimmerZimmer
Which kind of plate?Which kind of plate?
�� No statistical difference between No statistical difference between
maximum load and cycles survivedmaximum load and cycles survived
�� Edwards et al. J Orthop Trauma 2011;25(5):306Edwards et al. J Orthop Trauma 2011;25(5):306--311311
Outcome Outcome –– Cochrane reviewCochrane review
Veillette et al. Orthop Clin N Am. 2008;39:229Veillette et al. Orthop Clin N Am. 2008;39:229--236236
Short termShort term
(2(2--3 years)3 years)
*only plate fixation*only plate fixation
LongLong--termterm
(15(15--25 years)25 years)
PainPain 1 1
(VAS score)(VAS score)
6% severe daily 6% severe daily
symptomssymptoms
Motion compared to Motion compared to
nonnon--affected armaffected armDecreased supinationDecreased supination Decreased flexion and Decreased flexion and
extension extension
(5 degrees)(5 degrees)
Radiographic Radiographic
evaluationevaluation8% OA8% OA 5% OA5% OA
1% non1% non--unionunion
PatientPatient--rated outcomerated outcome 9.79.7
(VAS score)(VAS score)
96% excellent or good96% excellent or good
Summary Summary –– Tension band Tension band
fixationfixation
�� Fracture: Transverse or Fracture: Transverse or
obliqueoblique
�� KK--wire: Anterior cortex or wire: Anterior cortex or
distal ulnar canaldistal ulnar canal
�� KK--wire penetration: <10 wire penetration: <10
mm beyond the anterior mm beyond the anterior
cortex cortex
�� Tension band: 1.0 mm Tension band: 1.0 mm
stainless steel wire, 2 stainless steel wire, 2
knotsknots
Summary Summary -- PlatingPlating
�� Fractures: Distal to the Fractures: Distal to the
midpoint of the troclear midpoint of the troclear
notch, conotch, co--existing coronoid existing coronoid
fracture, Monteggia fracture, Monteggia
�� Locking compression plate Locking compression plate
theoretically superior to theoretically superior to
conventionel plateconventionel plate
Thank youThank you
TechniqueTechnique
TechniqueTechnique
TechniqueTechnique