Transcript Olecranon fraktur
Olecranon fracture
Lonnie Froberg, MD, Ph.D
Odense University Hospital
20% of forearm fracture 12 per 100.000 persons per year Low-energy fall Increased risk >50 years 90% AO 21.B1.1
Duckworth et al. Injury 2012;43:343-346
Why operate?
Methods of fixation – K-wire, cerklage – Plating Outcome Summary
Why operate?
Restore articular surface Achieve absolute stability Commence early active movement Preservation of range of motion and power Avoidance of complications
Methods of fixation?
Methods of fixation?
Cadaveric elbow joint Standard osteotomies Five different fixation techniques Loads applied comparable to clinical situations Displacements measured Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367-372
Methods of fixation?
Fracture type
Transverse Oblique Comminuted
Fixation technique
Tension band 1.0 mm, 1 knot, K-wire 2.0 mm Tension band 1.0 mm, 2 knots, K-wire 2.0 mm Tubular plate Cancellous screw, washer Cancellous screw, washer, tension band Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372
Methods of fixation?
Fracture type Fixation technique
Transverse Oblique Comminuted Tension band, 2 knots Tension band, 2 knots or tubular plate Tubular plate Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372
K-wire and cerklage
K-wire with or without eyelets?
No significant difference in postoperative pain or in rate of hard ware removal Kim et al. J Hand Surg Am. 2013.Jul 9
How to place the K-wires?
Proximal ulnar canal?
Anterior cortex?
Distal ulnar canal?
Huang et al. J Trauma. 2010.68;1:173-176
How to place the K-wires?
Average follow up/months Symptomatic implant removal Proximal migration of K wire/mm Satisfactory functionel outcome Proximal ulnar (n=24) 34.5 s.d 7.2
8 (33%) *p=0.03
4.08 s.d. 1.89
*p=0.001
21 (88%) Anterior cortex (n=28) 34.0 s.d 5.9
3 (11%) 1.53 s.d 0.56
26 (93%) Distal ulnar (n=26) 29.6 s.d 7.2
2 (8%) 1.31 s.d 0.54
26 (100%)
How to place the K-wires?
Inserted as close as possible to the articular surface Back 1 cm from final position, cut obliquely, bent Incisions with lines in triceps K-wires are impacted into ulna Newman et al. 2009. Injury; 40(6): 575-581
How to place the K-wires?
K-wire penetration more than 10 mm beyond the anterior cortex increases risk for penetration of median nerve and ulnar artery Prayson et al. Shoulder Elbow Surg. 2008.17;1:121-125
Which kind of tension band?
Failure (> 2 mm movement across osteotomy) Compression Stainless steel wire 0% 71% Ethibond No. 2 Ethibond No. 5 Fiber wire 100% 40% 0% 66% 40% 43% Lalliss et al. Jour Bone Joint Surg (Br).2010.92B;2:315-319
Plating
Plating
When to plate?
– Tension band is not appropriate – Oblique fractures distal to the midpoint of the troclear notch – Co-existing coronoid fracture – Associated with Monteggia fracture dislocation Newman et al. 2009. Injury; 40(6): 575-581
Which kind of plate?
Cadaveric study Comminute fracture No difference in failure rate (>2 mm gap of fracture) Buijze et al. Arch Orthop Trauma Surg.2010;130:459-464
Which kind of plate?
Advantage of locking compression plate to conventionel plate: – Angular and axial stability – Preserves periosteal blood supply – No toggling of unlocked screws (improves fixation in osteoporotic fractures and comminution)
Which kind of plate?
Stainless steel or titanium?
More screw in proximal fragment better than fewer screws?
Larger screws better than small screws?
Which kind of plate?
Accumed stainless stell Synthes stainless stell Synthes titanium US Implants Zimmer
Which kind of plate?
No statistical difference between maximum load and cycles survived Edwards et al. J Orthop Trauma 2011;25(5):306-311
Outcome – Cochrane review
Pain Motion compared to non-affected arm Radiographic evaluation Short term (2-3 years) *only plate fixation 1 (VAS score) Decreased supination 8% OA Long-term (15-25 years) 6% severe daily symptoms Decreased flexion and extension (5 degrees) 5% OA 1% non-union Patient-rated outcome 9.7
(VAS score) Veillette et al. Orthop Clin N Am. 2008;39:229-236 96% excellent or good
Summary – Tension band fixation
Fracture: Transverse or oblique K-wire: Anterior cortex or distal ulnar canal K-wire penetration: <10 mm beyond the anterior cortex Tension band: 1.0 mm stainless steel wire, 2 knots
Summary - Plating
Fractures: Distal to the midpoint of the troclear notch, co-existing coronoid fracture, Monteggia Locking compression plate theoretically superior to conventionel plate