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Internal Fixation of Olecranon fracture using Synthes LCP Olecranon plate

    Overview

    Learn the Internal Fixation of Olecranon fracture using Synthes LCP Olecranon plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Internal Fixation of Olecranon fracture using Synthes LCP Olecranon plate surgical procedure.
    Olecranon fractures comprise around 10% of all fractures around the elbow. They have a bimodal distribution and usually occur as high energy injuries in the young, and low energy falls in the elderly.
    These can occur as a direct blow, resulting in comminuted fractures, or indirectly, as a fall onto an outstretched hand, resulting in transverse or oblique fractures.
    The position of the elbow can influence the pattern of injury. Radial head and coronoid fractures have been shown to occur in laboratory testing at flexion of less than 80 degrees, olecranon fractures at 90 degrees of flexion and distal humeral fractures at greater than 110 degrees (Amis AA, Miller JH. The mechanism of elbow fractures: an investigation using impact tests in vitro. Injury 1995;26:163–8).
    Anatomically it is worth remembering that the olecranon, with the coronoid process, form the greater sigmoid notch and form the ulno-humeral articulation that acts as a primary stabilisers of the elbow (along with the medial and lateral collateral ligament). The olecranon receives the insertion of the triceps, as well as the anconeus on the lateral side.
    For displaced fractures of the olecranon, surgical fixation is recommended unless the patient is functionally of low demand or medically at high risk undergoing general anaesthetic. The method of fixation is essentially determined by the fracture pattern. My preference is in most cases either for olecranon plating or tension band fixation. Tension band fixation is the commonest method of internal fixation used for non-comminuted olecranon fractures. The principles of tension band fixation involve converting the tension force on the dorsal aspect of the fracture into a dynamic compressive force at the articular surface. However, there are caveats if using the tension band principle as to when it may not be appropriate for fixation as follows:
    1 – Comminution. If there is comminution, there is not enough inherent stability and the fixation is at risk of biomechanical failure as the tension forces are unable to be transferred into a compressive force.
    2 – Obliquity of the fracture. The more oblique the fracture, the more the acting forces deviate from the line of action. This introduces a flexion moment and again, is theoretically less robust.
    3 – Fractures distal to the centre of rotation to the elbow joint. Fractures that occur distal to the centre of rotation, again introduce a flexion moment to the fracture and can affect stability, and therefore risk failure.
    4 – Associated fractures. Coronoid fractures, radial head fractures and Monteggia type fractures can increase instability in the elbow that a tension band fixation is not designed to neutralise.
    If all these factors are satisfied, tension band fixation is a good option. If all the criteria are not satisfied, it does not exclude tension band fixation as a fixation method. It requires, like all surgery, weighing up the pros and cons of the fixation method.
    In my own practice, if these criteria are not satisfied, I opt for pre-contoured Synthes anatomic locking plates. The design of the plate allows more screw options particularly with regard to hold in the proximal fragment, which can be small and multi-fragmentary in some cases. I believe that these plates also offer superior fixation as a result of the fixed-angle construct. This is especially the case if there is concern regarding bone quality in terms of osteoporosis and osteopaenia.

    Author : Mr Samuel Chan FRCS (Tr & Orth)
    Institution :The Queen Elizabeth Hospital, Birmingham ,UK.
    Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
    In the USA contact: fda.gov
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    Indications

    INDICATIONS
    Surgical management is reserved for displaced and unstable fractures of the olecranon. The aim is to restore the extensor mechanism to optimise extension strength and function.
    SYMPTOMS & EXAMINATION
    Patients usually present after sustaining a direct blow to the elbow or due to a fall onto an outstretched hand.
    The patient may be unable to extend their elbow.
    It is important to assess the soft tissues and carefully examine the skin to exclude an open fracture.
    It is common to find significant bruising and swelling and it may be possible to palpate the fracture due to the subcutaneous nature of the olecranon. There can be associated soft tissue contusions and abrasions. There may be significant displacement and deformity and it is important to correct this rapidly to take the tension off the soft tissue and limit secondary damage of the soft tissue envelope.
    A neurovascular assessment is important, with particular reference to the ulnar nerve, which can be compromised.
    In high energy injuries, although uncommon, it is important to exclude a compartment syndrome.

    IMAGING
    Anteroposterior and lateral radiographs of the elbow should be obtained.
    Although olecranon fractures are usually isolated injuries, it is important to look for and exclude associated injuries including coronoid fractures, radial head fractures and Monteggia fracture dislocations. These associated injuries can affect the stability of the elbow.
    If the fracture pattern is more complex, a CT scan with coronal and sagittal reconstructons is helpful for surgical planning.
    Classifications
    Numerous classification systems have been described and are largely based on the level of displacement, comminution and stability of the elbow, although none have gained widespread acceptance.
    Colton Classification
    (Colton CL. Fractures of the olecranon in adults: classification and management. Injury 1973;5(2):121–9)
    • Type I: Undisplaced and stable (does not displace with elbow flexion)
    • Type II:
    A – avulsion
    B – oblique/transverse
    C – comminuted
    D – fracture dislcation
    Mayo Classification
    (Morrey BF, JBJS 77A: 718-21, 1995)
    Type 1 – Undisplaced fracture, simple or comminuted (12%)
    Type 2 – Displaced fracture, simple or comminuted (82%)
    Type 3 – Unstable (6%)
    Other classifications include Schatzker and AO.
    ALTERNATIVE OPERATIVE TREATMENT
    Tension band fixation
    Tension band wire fixation is the commonest method of internal fixation used for non-comminuted olecranon fractures. The principles of tension band wiring involve converting the tension force on the dorsal aspect of the fracture into a dynamic compressive force at the articular surface.
    The exclusion criteria for this technique have been described in the overview. Concerns regarding hardware prominence have led to techniques using suture material with good results.
    Plate fixation
    In the literature, types of plates have been used including one-third tubular, 3.5 mm contoured limited contact dynamic compression, 3.5 mm reconstruction, hook plates as well as pre-contoured anatomic locking plates. There is currently insufficient evidence to suggest that any type of plate fixation is superior to other forms of plate fixation.
    In both cases, there is concern regarding hardware prominence due to the subcutaneous nature of the ulna. Metalwork may need to be removed once the bone has united if it is clinically symptomatic.
    Intramedullary nailing
    Intramedullary screws and nailing systems have been described in the literature, although is less common. Published results are good and comparable to alternative fixation methods.
    Fragment excision and triceps advancement
    This method is usually reserved for elderly patients with osteoporotic bone, extensive comminution
    or a fragment too small for internal fixation. The triceps tendon is sutured to the anterior edge of the ulna to create a smooth sling for articulation.
    Advantages of the technique include avoiding non-union and post-traumatic arthritis. Fragment excision can only be performed if the coronoid, medial collateral ligament, interosseous membrane and distal radio-ulnar joint are intact to prevent instability.
    McKeever and Buck suggested that up to 80% of the trochlear notch could be excised without appreciably compromising elbow stability. Inhofe and Howard showed good or excellent outcomes in 11 of 12 cases treated with excision of up to 70% of the trochlear notch.
    However, An et al. showed a reduction in elbow stability when over 50% of the trochlear notch was excised.
    It is accepted that a reduction in triceps strength occurs.

    NON-OPERATIVE MANAGEMENT
    Undisplaced and stable olecranon fractures can be treated non-operatively. Undisplaced fractures are generally defined as up to 2mm of displacement, although clinical correlation and assessment of the patient is required before a treatment plan can be recommended.
    Patients can be immobilised in a backslab in 45–90 degrees of flexion for 2-3 weeks to allow the swelling and soft tissues to settle down before commencing physiotherapy.
    However, in elderly patients of low functional demand, good functional outcomes can be achieved despite significant displacement. In a series of 13 patients treated non-operatively of mean age 81.8 years with >5 mm displacement, Veras Del Monte et al. found only one patient had a poor functional outcome.
    CONTRAINDICATIONS
    Patients of low functional demand or medically unfit would be relative contra-indications. As part of informed consent, a discussion of outcomes of conservative and operative methods is essential for treatment planning.

    Setup

    The procedure is performed under general anaesthetic and can be supplemented with a nerve block performed by the anaesthetist. It is usually necessary to supplement this with local anaesthetic and adrenaline infiltrated to the operative field to optimise pain relief and to optimise the field of view.
    The patient is placed in a lateral decubitus position with the affected arm uppermost. The position of the shoulder is checked to ensure it is in an appropriate and comfortable postion. The arm is placed in a short ulnar gutter support. Care is taken to ensure that chest wall is well protected from any clamps and metal equipment using gel pads and padding. The elbow can be manipulated during the procedure and can cause pressure areas if not appropriately protected. A surgical prescrub prior to routine skin preparation may be performed.
    A high arm tourniquet is applied and secured to maintain a bloodless field during the procedure. The skin is prepared using Chlorohexidine solution starting at the hand, then onto the whole of the upper limb, up to and including the shoulder. Standard adhesive drapes are used. During this process, the upper limb is elevated and once complete, the tourniquet can be inflated.
    Intermittent calf compression Flotron devices are used during surgery to reduce the risk of thromboembolic disease unless there are any contraindications. Intravenous antibiotics are administered by the anaesthetist.

    Operation – 1

    This 70 year old female sustained the above closed injury after a fall onto an outstretched hand.
    The radiographs reveal a simple transverse fracture of the olecranon.
    Due to the fracture being sited close to the level of the coronoid, I felt that a plate fixation would be more biomechanically robust.

    The patient is set up in a lateral decubitus position with the body stabilised. The alignment of the spine is perpendicular to the table but is set close to the edge of the table as is practicable. This is to allow clearance of the table as well as for access to fluoroscopy if indicated.
    A short ulna gutter is used to support the arm. Care is taken to ensure the arm is set up in a stable position and that there is enough clearance to flex and extend the elbow.
    This is usually with the humerus in a position parallel to the floor and level with the shoulder.
    The height of the table is set to ensure a comfortable operating position.
    A high arm tourniquet is applied over a layer of wool to ensure that the operative field of view is clear and the sterile field is maximised. If there is any concern regarding the adequacy of the operative field, a sterile tourniquet may be applied.

    The whole arm is prepped and U drapes are applied at the level of the tourniquet to maximise the sterile field.
    The hand is covered in a stockinette and wrapped with four inch crepe to isolate the hand. This also keeps the hand clear of any blood.

    The radial and ulnar aspect of the upper arm is marked as a aide for orientation during the surgery.
    The landmarks are identified, including the medial and lateral epicondyles. The ulnar nerve (UN) is palpated and marked to ensure that it is protected. The outline of the olecranon is palpated and marked.
    A longitudinal posterior midline incision is marked, centred over the fracture site. The incision starts at the tip of the olecranon and extends distally, curving radially to avoid aligning the incision over a “weight-bearing” surface.

    The incision is made using a 15 surgical blade through skin and subcutaneous fat down to the level of the muscle fascia and the fasciocutaneous flaps are developed.

    The deeper exposure is developed through the whole length of the incision.
    West retractors help to expose the field of view, and placed well subcutaneously. Diathermy to bleeding vessels is applied to achieve haemostasis.

    Once the appropriate plane at the level of the muscle fascia is identified (anconeus (A) radially, flexor carpi ulnaris (B) ulnarly), fasciocutaneous flaps are raised to allow adequate exposure of the olecranon.
    The fracture site is identified and haematoma is evacuated.
    Note the anconeus fascia is ruptured from the zone of injury.

    Any in-folded periosteum (depicted by forceps) or soft tissue is either removed or reflected back so that it does not compromise reduction of the fracture.

    The fracture can be distracted and retracted using either a bone hook or Langenbeck retractor.
    The fracture surface is curetted and any fracture haematoma is washed out so as to better characterise and define the fracture edges.

    This image shows the soft tissue dissection medially. This can be performed using McIndoe scissors or a blade.
    There is usually an appreciation of the location of the ulnar nerve without formal exposure.
    If there is any concern with regard to the ulnar nerve, it is appropriate to extend the incision proximally and formally expose the nerve.
    It is important to define and see the medial and lateral extent of the fracture to ensure there is no soft tissue interposition and to confirm adequate fracture reduction in alignment and rotation.
    There can be medial or lateral wall comminution that may not be appreciated on simple radiographs.
    The fracture edges are curetted to allow anatomical reduction of the fracture.

    The length of plate is measured and appropriately sized.

    The proximal fragment can be everted to expose the articular surface using the Langenbeck retractors or bone hook.
    Any residual fracture haematoma can be evacuated.
    The articular surface can be inspected and any damage or comminution can be noted.

    Here, the radial aspect of the fracture is exposed. The radial head is just coming into view adjacent to the Langenbeck retractor.

    A trial reduction shows anatomical reduction of the fracture.
    The anconeus fascia is incised adjacent to the crest of the ulna and elevated anteriorly to expose the proximal ulna.

    A pilot hole is drilled through one cortex to allow application of a pointed fracture reduction clamp.
    This is sited distal to the fracture by 3-4 centimetres.

    The pointed reduction clamped is next applied to maintain the reduction.
    Without the pilot hole, it is difficult to maintain purchase of the distal fragment and the clamp often slips.

    Stability can be augmented with a 1.6mm Kirschner wire.
    Some forward planning is helpful when siting this so as not to interfere with plate placement.
    The entry point can be off centre radially or ulnarly, or sited centrally so that the wire can be passed through the hole corresponding to the longitudinal screw.

    The Kirschner wire is advanced so that it engages in the distal fragment.
    The wire can be engaged in the anterior cortex for better purchase.

    The appropriate sized Synthes LCP olecranon plate is chosen and the locking drill sleeve is threaded into the proximal locking hole.
    These plates come in 2, 4 6, 8, 10 and 12 hole lengths. Usually, the 2 hole olecranon plate is adequate.
    Note that these plates are anatomic plates and are side specific.

    As shown in the image, once the threaded guided is secured onto the plate, the graduated 2.8mm drill bit is used to pre-drill the bone, and a direct measurement can be taken.
    Note that when threaded onto to the plate, the proximal screws are angled proximally as well as divergently from each other.

    Once the plate is placed in position, it needs to be held securely whilst the drill is used to pre-drill for the first screw.
    This can be held by the assistant +/- Kirschner wires +/- reduction clamps.
    When drilling, once the dorsal cortex is breached, care is taken not to breach the second cortex as it may enter the joint space.
    I tend to apply the plate to the dorsal surface of the ulna as this is the tension side of the olecranon and is more biomechanically robust.
    Plating the medial and/or lateral ulna may minimise the risk of hardware problems. However, plating of the dorsal plating has been shown to be biomechanically 48% stronger than plating the medial or lateral surface (Gordon MJ, Budoff MD, Yeh ML, Luo Z-P, Noble PC. Comminuted olecranon fractures: a comparison of plating methods. J Shoulder Elbow Surg 2006;15:94–9).

    The 3.5mm locking screw is applied using a Stardrive screwdriver with a 1.5Nm torque limiter to prevent cold welding of the screw to the plate.

    A second hole is pre-drilled in the proximal fragment.
    By applying the second locking screw, it secures the hold in the proximal fragment and controls the alignment.

    Once in place, the plate and proximal fragment are reduced onto the distal fragment and alignment is checked.
    The universal drill sleeve is applied to the distal aspect of the combi-hole to allow compression of the fracture when the screw is applied through the plate.

    The 2.5mm drill is used to pre-drill the channel for the cortical screw.

    Operation – 2

    If the screw is not self tapping, the hole has to be tapped.
    It is important to use the universal drill sleeve to maintain the position so that the tap does not deviate from the drill trajectory.
    If the screw hole has been drilled correctly through the centre of the bone, there should be resistance from tapping through the near and far cortex.

    The 2.5mm cortical screw is applied to the plate.
    Before the screw head engages into the plate, it is worth checking that the fracture remains reduced. As there is potential mobility of the fracture before the screw is fully applied, there can be translation of the bony fragments. This can be corrected before final tightening.
    As the screw head engages into the plate, it should compress the fracture site to improve bony contact.

    The fluoroscopy images show satisfactory reduction of the fracture fragments.
    It is important to check on the image intensifier that the screws are orientated onto the ulna shaft and not directed anterolaterally. This is to minimise the risk of screw impingement on the proximal radioulnar joint.
    This can be checked for clinically by ensuring that there is no crepitus on pronation and supination.

    The remaining cortical/locking screws are applied to ensure that there is satisfactory hold in the distal fragment. This should usually include 6 cortices.
    Supplementary screws can be applied to the proximal fragment if able. Fracture pattern and configuration usually preclude the possiblity of any further screws.

    A final check is made on fluoroscopy that the fracture position is satisfactory and that the articular surface remains congruent.
    Note that a common feature from the design of the plate is that it sits away from the tip of the olecranon proximally. This is due to the insertion of the triceps.
    The operative technique does suggest that you can incise the attachment of triceps to allow the plate to be seated closer to the bone. Howver, my preference is to avoid unnecessary damage to the triceps insertion.
    At this stage, although not shown in this case, there can be some opening of the articular side of the fracture as the bone conforms to the shape of the plate.
    The subsequent steps in the operative technique can help correct this.

    The arm is then rotated into the horizontal plane and a 2.5mm drill is applied to the dorsal longitudinal screw hole.
    The hole is drilled under image guidance with the surgeon’s preference of aiming for the anterior cortex, and avoiding any of the shaft screws.
    It is important to palpate the ulna shaft to get an idea of the trajectory of the drill so as not to exit too early radially or ulnarly.
    Fluoroscopy also helps avoid too steep a trajectory with penetration into the elbow joint.
    Due to the length of screw required, a drill sleeve is not usually compatible with this technique.
    Due to the quality of the bone, it is not usually necessary to overdrill the proximal fragment using a 3.5mm drill.

    The screw length is determined using the depth gauge and can be confirmed under fluoroscopy.

    The 3.5mm cortical screw is applied, and as it engages in the anterior cortex, any residual opening on the articular side of the fracture should be corrected.

    The proximal tab on the plate can be removed if it is not utilised as it can cause triceps/soft tissue irritation on flexion/extension.
    The solid threaded pin can be threaded into position.

    The proximal tab is pliable enough to be able to flex it 90 degrees by hand using the solid threaded pin.
    By doing this 2-3 times, the tab should fatigue and break off easily.
    Extreme care should be excercised during this to avoid effecting reduction or fixation.

    The final position of the plate is checked and any debris is washed.

    The fluoroscopy images are satisfactory.
    It is noted that in this case, the longitudinal screw is slightly more ulnarly deviated than desired (but accepted).
    In this case, the patient has an associated radial head fracture that is minimally displaced. There was no loss of pronation/supination and this was managed conservatively.

    The soft tissues are closed in layers.
    The muscle fascia layer is closed as best possible using 1 vicryl, although the plate tends to limit full closure of this layer.

    The skin is sutured using 3-0 monocryl and 1/2 inch steristrips are applied.

    A waterproof dressing is applied with the arm in flexion before wool and crepe bandages are applied.
    A backslab is not usually indicated unless there is concern with regard to the stability of the fracture and fixation.

    At 6 months, the fracture has radiologically united.
    The patient has regained a range of movement from +15 to 130 degrees.

    Post Operative

    As mentioned, the rehabillitation protocol depends on the stability of fixation, condition of the soft tissues and patient compliance.
    If the fixation is satisfactory, the patient is not formally immobilised in plaster. A heavy wool and crepe bandage is applied with the elbow in 45-90 degress of flexion and supported in a sling.
    The bandages are taken down at 5–7 days and passive and gentle active movements are commenced at this point.
    Active movements against resistance should be avoided until there is evidence of bony healing at approximately 6–8 weeks.

    Recommended Reading

    Karlsson MK, Hasserius R, Karlsson C, Besjakov J, Josefsson PO. Fractures of the
    olecranon: a 15–25 year follow up of 73 patients. Clin Orthop Relat Res 2002;403:205–12
    Karlsson et al. reviewed 73 cases, with 84% treated with internal fixation, showing 96% of patients had a good or excellent outcome at 15–25 years follow up. It was noted that degenerative change was found to be more common following olecranon fracture (50%), when compared to patient’s uninjured elbow(11%).
    The main complication following internal fixation of olecranon fractures is hardware irritation.
    This is mostly related to tension band wiring although has been reported with the use of plate fixation.
    Loss of motion is commonly described after olecranon fracture fixation, particularly in extension. However, it is rarely functionally limiting.
    Elbow motion outcomes are worse in cases with associated fractures of the radial head, capitellum, coronoid or Monteggia fracture-dislocations.
    Hak DJ, Golladay GJ. Olecranon fractures: treatment options. J Am Acad Orthop Surg 2000;8:266–75.
    Non-union is rare has been reported in 1% of cases.
    The risk of iatrogenic neurovascular injury is present, particularly with anterior cortical penetration in tension band wiring. Structures at risk include the interior interosseous nerve, median nerve and ulnar artery, although it is noted that the wires would have to protrude beyond 10mm.
    Prayson MJ, Iossi MF, Buchalter D, Vogt M, Towers J. Safe zone for anterior cortical perforation of the ulna during tension-band wire fixation: a magnetic resonance imaging analysis. J Shoulder Elbow Surg 2008;17(1):121–5.

    Reference

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