Olecranon Fracture

When you bend your elbow, you can easily feel its "tip," a bony prominence that extends from one of the lower arm bones (the ulna). That tip is called the olecranon (oh-lek'-rah-nun). It is positioned directly under the skin of the elbow, without much protection from muscles or other soft tissues. So it can easily break if you experience a direct blow to the elbow or fall on a bent elbow.

Signs and symptoms

Sudden, intense pain.

Bruising around the elbow.

Rupture or abrasion of the overlying skin.

Possible deformity, if there is also a dislocation of the bone.

Tenderness and swelling over the bone site.

Numbness in one or more fingers.

Pain with movement of the joint.

Evaluation and classification

It is important to see a physician and verify that there is no associated damage to nerves or blood vessels. Your physician will use X-rays to confirm the diagnosis and classify the type of fracture. Fractures are generally divided into three types, depending on the stability of the joint and the amount of separation among the broken pieces of bone. (Note: Some fractures can have characteristics of more than one category.)

Type I fractures are generally stable with little displacement. These fractures can generally be treated nonsurgically.

Type II fractures are the most common. They are relatively stable, although there is displacement of the bone pieces.

Type III fractures are displaced and involve more than 50 percent of the joint surface, resulting in joint instability.

Treatment

Treatment depends on the type of fracture.

A type I fracture can usually be treated with a splint or sling to hold the elbow at a 90 degree angle. The physician will request a second set of X-rays after 10 days to make sure that the broken pieces have not become displaced. Gentle motion is permitted, and hand and wrist exercises should be done daily.

A type II fracture is best treated surgically. The Orthopedic surgeon will use a plate or a combination of wires and pins or screws to hold the bones in place. Physical therapy to maintain range of motion will start a day or two after the operation, and continue for at least six weeks.

Type III fractures are also treated surgically, usually with a plate that fits under the ulna and around the tip of the elbow. Screws hold the plate in place. You will have to wear a splint for a couple of days, then physical therapy to maintain range of motion will begin.

Fractures of the tip of the olecranon that do not involve the joint are may be treated by removing the small fragment and repairing the tendon that has pulled off. Elderly people who experience a type II or type III fracture may be treated with a sling and early range of motion instead of surgery. Athletes who have stress fractures of the olecranon are treated with activity restriction, stretching and range of motion exercises, and substitution activities for 8 to 12 weeks, although complete recovery may take three to six months.

What is an olecranon fracture?

An olecranon fracture is a relatively uncommon condition characterized by a break in the bony prominence situated at the back of the elbow known as the olecranon (figure 1).

The forearm comprises of 2 long bones, known as the radius and the ulna, which are situated beside each other (figure 2). The ulna bone lies on the inner aspect of the forearm and forms joints with the humerus (upper arm bone) (at the elbow), the radius (near the elbow and wrist) and several small carpal bones in the wrist (figure 2). The bony prominence of the ulna situated at the back of the elbow is known as the olecranon (figure 1).

During certain activities such as a direct impact to the back of the elbow, or a fall onto an outstretched hand, stress is placed on the olecranon. When this stress is traumatic and beyond what the bone can withstand a break in the olecranon may occur. This condition is known as an olecranon fracture.

Sometimes a fracture to the olecranon occurs in combination with other injuries such as a triceps strain or tear, a sprained or dislocated wrist or elbow, a fractured radius (Colles' fracture), or other fractures of the hand, wrist or forearm (such as following trauma).

Olecranon fractures can vary in location, severity and type including avulsion fracture, stress fracture, displaced fracture, un-displaced fracture, greenstick, comminuted etc.

Causes of an olecranon fracture

An olecranon fracture most commonly occurs due to a direct impact to the point of the elbow or a fall onto the outstretched hand. Olecranon fractures may also occur from a forceful triceps contraction against a fixed ulna. Olecranon fractures are relatively common in sports whereby a fall onto a hard surface is common and unforgiving such as snowboarding, skateboarding, ice skating, cycling, running and jumping sports involving change of direction such as football, soccer, rugby, basketball and netball.

Signs and symptoms of an olecranon fracture

Patients with an olecranon fracture typically experience a sudden onset of sharp, intense elbow, pain at the time of injury. This often causes the patient to cradle the affected arm so as to protect the injury. Pain is usually felt at the back of the elbow and can occasionally settle quickly leaving patients with an ache at the site of injury that is particularly prominent at night or first thing in the morning. Patients with an olecranon fracture may also experience swelling, bruising and pain on firmly touching the affected region of the bone. Pain may also increase during certain movements of the elbow, wrist or shoulder or during weight-bearing activity (such as pushing) through the affected arm. Usually there is pain with either stretching or contracting the triceps muscle as well as an inability to straighten the elbow joint due to pain. Occasionally, pins and needles or numbness may be present in the elbow, forearm, hand or fingers. In severe olecranon fractures (with bony displacement), an obvious deformity may be detected.

Diagnosis of an olecranon fracture

A thorough subjective and objective examination from a physiotherapist or doctor is essential to assist with diagnosis of an olecranon fracture. An X-ray is required to confirm diagnosis. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of injury.

Treatment for an olecranon fracture

For those olecranon fractures that are displaced, treatment typically involves anatomical reduction (i.e. re-alignment of the fracture by careful manipulation under anesthetic) followed by surgical internal fixation to stabilize the fracture (using tension band wiring). Early movement exercises are usually started within 1 week of surgery.

For those isolated olecranon fractures that are not displaced treatment typically involves immobilization of the arm in a posterior splint for approximately 2 - 3 weeks. This is usually followed by the use of a removable splint and early range of movement exercises.

Evaluation of the fracture with follow up X-rays is important to ensure the fracture is healing in an ideal position. Once healing is confirmed and the treating surgeon has indicated it is safe to do so, rehabilitation can begin as guided by the treating physiotherapist.

One of the most important components of rehabilitation following an olecranon fracture is that the patient rests sufficiently from any activity that increases their pain. Activities which place large amounts of stress through the olecranon should also be avoided particularly lifting, weight bearing, pushing activities or leaning on the back of the elbow. Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months with direction from the treating physiotherapist.

Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the olecranon fracture altogether.

Patients with a fractured olecranon should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important, as soft tissue flexibility and strength are quickly lost with immobilization and disuse. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Prognosis of an olecranon fracture

Patients with a fractured olecranon usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in weeks to months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged.

Physiotherapy for an olecranon fracture

Physiotherapy treatment is vital in all patients with a fractured olecranon to hasten healing and ensure an optimal outcome. Treatment may comprise:

• soft tissue massage

•  joint mobilization

•  electrotherapy (e.g. ultrasound)

•  taping or bracing

•  exercises to improve strength and flexibility

•  education

•  activity modification

•  a graduated return to activity plan

Other intervention for an olecranon fracture

Despite appropriate physiotherapy management, some patients with this condition do not improve adequately and may require other intervention. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, extended periods of immobilization or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the fractured olecranon. Occasionally, patients who are initially managed conservatively may require surgery to stabilize the fracture and a bone graft to aid fracture healing.

What is an olecranon fracture?

Most often a broken elbow is a crack or break in the part of the elbow called the olecranon. The olecranon is the bony tip that you feel directly under the skin of the elbow. It is at the end of the lower arm bone called the ulna.

What is the cause?

A broken elbow usually happens from a fall or a direct hit to the elbow.

What are the symptoms?

Symptoms may include:

•  pain, especially when you move your elbow

•  trouble bending or straightening the elbow

•  swelling

How is it diagnosed?

Your provider will ask about your symptoms and how the injury happened. He or she will examine you. You will have X-rays of the elbow.

How is it treated?

The treatment depends on the injury.

•  If just a small piece of bone is broken at the end of the bone it may be treated with a splint or cast.

•  If a larger part of the bone is broken, or if the break goes into the joint, surgery may be needed to repair the bone. Your healthcare provider may use a pin or screw to keep the broken bone in place.

•  Sometimes the injured bone gets dislocated, which means it has moved out of place in the elbow joint. This is called a dislocation. If the joint is dislocated, then it will need to be put back into place.

While it heals, the injured arm will be in a splint or cast. The injured arm may also need to be in a sling to keep it from moving while it heals.

How can I take care of myself?

Follow the full course of treatment your healthcare provider prescribes. Also:

•  To keep swelling down and help relieve pain, your healthcare provider may tell you to:

  •  Put an ice pack, gel pack, or package of frozen vegetables wrapped in a cloth on the injured area every 3 to 4 hours for up to 20 minutes at a time for the first day or two after the injury.

  •  Keep the injured arm up on pillows when you sit or lie down.

  •  Take pain medicine, such as ibuprofen, as directed by your provider. Nonsteroidal anti-inflammatory medicines (NSAIDs), such as ibuprofen, may cause stomach bleeding and other problems. These risks increase with age. Read the label and take as directed. Unless recommended by your healthcare provider, do not take for more than 10 days.

•  If you have a cast, make sure the cast does not get wet. Cover the cast with plastic when you bathe. Avoid scratching the skin around the cast or poking things down the cast. This could cause an infection.

When your arm has been in a splint or cast, your joints may get stiff and your muscles get weaker. After the splint or cast is removed, your healthcare provider or physical therapist may recommend exercises to help your arm get stronger and more flexible. Follow your provider’s instructions for doing exercises.

Keep all appointments for provider visits or tests. Call your healthcare provider right away if:

•  You have more pain, redness, warmth, or swelling.

•  You have a fever.

•  You have a loss of feeling in the injured area.

•  The injured area looks pale or blue or feels cold.

How long will the effects last?

Complete healing may take weeks or months, depending on the injury.

How can a broken elbow be prevented?

Many elbow injuries are caused by falls or blows that are not easy to prevent. Knee pads, elbow pads, and a helmet can help prevent injuries during biking, rollerblading, or skateboarding.

Anatomy

The olecranon is the end of the ulna and forms the tip of the elbow. The ulna is one of two bones that form the forearm - the other bone is called the radius. The radius and the ulna both move against (or articulate) with the distal end of the humerus (upper arm bone), to form the elbow joint. The olecranon is important for two reasons: 1) the large triceps muscle tendon attaches to the olecranon; when this muscle contracts it straightens the elbow and 2) part of the olecranon is covered with articular cartilage; it helps form part of the joint surface of the elbow.

Signs and Symptoms

An olecranon fracture is usually caused by a fall directly on the elbow. There is immediate pain in the elbow area. Your may be able to feel a gap at the tip of the elbow if the olecranon has been pulled away from the elbow by the triceps muscle contraction. You will probably not be able to straighten the elbow. There is usually bleeding from the fracture into the tissues of the elbow and swelling occurs around the elbow.

Evaluation

The primary goals of the clinical evaluation of an olecranon fracture are to decide whether the fracture consists of only two fragments or multiple fragments (a bone broken into multiple fragments is called comminuted) and to decide whether those fragments are separated enough to need surgery.

The fracture is evaluated by taking several x-rays of the elbow. Special imaging studies such as a CAT Scan or MRI Scan are usually unnecessary. Your provider will also want to make sure that there has been no damage to the ulnar nerve. This can usually be accomplished with a careful physical examination.

Treatment

Most olecranon fractures require surgery. Olecranon fractures typically displace (meaning that the fragments separate) too much to expect the fracture to heal. The pull of the triceps muscle tends to make the displacement worse and holds the fragments in the displaced position. The fragments must be reduced (meaning returned to their original position) and held there until healing occurs. This usually requires surgery to reduce the fracture and some type of fixation to hold the fragments while healing occurs. Because the olecranon makes up part of the elbow joint, the joint surface needs to be repaired as close to normal as possible to reduce the risk of developing osteoarthritis (wear-and-tear arthritis) of the elbow joint.

Nonsurgical

Olecranon fractures can be treated without surgery if the fragments remain in close connection with narrow cracks through the bone between the fragments. The ligaments and soft tissue around the fracture may be strong enough to keep the fragments from separating. If your surgeon decides that the fracture can be treated without surgery a splint is usually applied for the first one or two weeks. Unlike a cast, a soft, bulky splint allows for changes in the amount of swelling that occurs during the first few days or weeks. After the swelling has subsided, a long arm cast or fracture brace is usually recommended. The cast or fracture brace will remain in place until the fracture shows signs of healing. This usually occurs at six or eight weeks.

X-rays are normally taken after one or two weeks to make sure that the fracture fragments are not separating and again several times throughout the treatment period to assess whether the fracture is healing. Once your surgeon thinks that the fracture has healed, the cast or fracture brace are discontinued and you will work with a physical therapist to regain the motion and strength in the arm.

Surgery

Olecranon fractures normally require surgery. If your provider makes the assessment that the fracture will NOT heal and give you good elbow function without surgery, surgical treatment will be recommended. If the fracture cannot be held in acceptable position with a cast or fracture brace and the fragments begin to separate, surgery may be suggested after several days or weeks of attempting nonsurgical treatment.

Surgical treatment of olecranon fractures usually involves making an incision over the back of the elbow, putting the fracture fragments back in their normal position, and holding them there with some type of fixation. Depending on the fracture pattern, your surgeon may choose to use a large screw, metal pins, metal wire, or a metal plate and screws to hold the fragments together. This type of surgery is called an Open Reduction and Internal Fixation (ORIF)

Because the olecranon is superficial (meaning that there is only a thin layer of skin covering the bone) the hardware used to hold the fragments together may be annoying after the fracture has healed. We commonly rest our elbows on tables and chairs. This can cause irritation and pain as the skin is the caught between the hardware and the surface of the table or chair. For this reason, many patients elect to have the hardware removed after the fracture has healed.

In some severely comminuted fractures of the olecranon, the multiple fragments may simply not be repairable. The damage to the articular surface and the risk of osteoarthritis may be too great to consider trying to fix the fracture. This is more likely to occur in elderly patients. In this case, your surgeon may suggest removing the fracture fragments and reattaching the tendon of the triceps muscle to the remaining bone of the ulna. The procedure actually works very well; it stabilizes the elbow joint and restores the ability to straighten the elbow. The risk of osteoarthritis and a stiff elbow is reduced, but you may lose some of the strength in extension (or straightening) of the elbow.

Complications

Nearly all fractures can result in damage to nerves and blood vessels. Damage to the Ulnar nerve is uncommon after an olecranon fracture, but it is one of the complications that your surgeon will watch for carefully. The fracture fragments may fail to heal; this is referred to as a nonunion. The fracture fragments may also heal in an unacceptable alignment; this is called malunion. Both of these complications are rare in olecranon fractures but if they occur they may result in pain, loss of strength, and a decreased range of motion of the elbow. A second operation may be needed to treat the complication. Because the olecranon makes up part of the elbow joint surface, a fracture of the olecranon may damage the articular cartilage surface. This may lead to osteoarthritis (wear-and-tear arthritis) of the elbow joint months or years after the fracture has healed. You will always have some risk of developing osteoarthritis after an olecranon fracture because of the damage to the articular surface caused by the fracture. Osteoarthritis of the elbow may result in pain and stiffness of the elbow joint and may require additional treatment or surgery if the symptoms are severe.

Rehabilitation

The prognosis for olecranon fractures is generally excellent. Olecranon fractures heal in about three months. Your shoulder may become somewhat stiff because you will not be using the joint normally. Physical therapy is usually recommended to regain both strength and range of motion in the shoulder and elbow.

Rehabilitation will begin once your surgeon feels that the fracture is stable enough to begin regaining the range of motion in your shoulder and elbow. If surgery has been required, the rehabilitation program will be modified to protect the fixation of the fracture fragments. Your surgeon will communicate with your physical therapist to make sure that your rehabilitation program does not risk causing the fixation to fail. If the surgeon feels that the fixation is very solid, you may be able progress your program quickly; if the fixation is not so solid, the speed at which you progress may need to be slowed until more healing occurs.