Primary Surgery Vol.2 – Trauma: FRACTURES OF THE OLECRANON

FRACTURES OF THE OLECRANON

ACTIVE MOVEMENTS TREATMENT

INDICATIONS (1) All patients in whom the triceps mechanism is intact, as described above, even if the fragments have separated slightly. (2) A patient who is too oId to notice that active extension is lost, for example, he will never need to reach to lift a jam jar from a high shelf.

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Figure 72.25: EXCISING THE FRAGMENTS OF THE OLECRANON. This is only necessary if a patient has lost the use of the extensor mechanism of his elbow and if more than half his olecranon fossa is intact. After Robb and Smith with kind permission.

METHOD Put the patient’s arm in a sling for a few days, and give him analgesics. Encourage him to use his arm, and to take it out of the sling from time to time and let it dangle. Encourage him to return early to light work.

CAUTION! Don’t splint his elbow, especially not in extension.

His elbow will heal rapidly. if there was less than 5 mm displacement, there will be bony union. Otherwise, there will be a slightly unstable fibrous union with an excellent range of movement.

EXCISING FRAGMENT(S) IN OLECRANON FRACTURES

INDICATIONS (1) Loss of the extensor mechanism of a patient’s elbow caused by a fracture involving half or less of his olecranon fossa. More than half of his olecranon fossa remains intact on the shaft. (2) Any fracture of his olecranon in which the extensor mechanism is lost and the equipment for tension band wiring is not available.

If possible, refer him. However, if you cannot refer him, proceed as follows.

INCISION Exsanguinate the patient’s arm with an Esmarch bandage (3.8). Place a blood pressure cuff around his arm as high as possible. Lie him on his back and fold his arm over his chest so that his elbow lies uppermost.

Incise and expose his olecranon, as described below for tension band wiring. Remove the bone fragments, and cut them away from the tendon of his triceps. Drill two holes in the shaft of his ulna. If you don’t have a drill, you can make holes at the edge of his ulna with a strong towel clip. Pass strong sutures through these holes, and then through his triceps tendon, as in A, Fig. 72-24.

CAUTION! Watch his ulnar nerve. Find and gently retract it.

TENSION BAND WIRING FOR OLECRANON FRACTURES

INDICATIONS Loss of the extension mechanism of the elbow, due to a fracture involving more that half the patient’s olecranon fossa, with a single proximal fragment suitable for wiring. If possible refer the patient. If you cannot refer him, proceed as follows.

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Figure 72.26: THE MECHANICS OF TENSION BAND WIRING. The stiff Kirschner wires maintain alignment, while the figure of eight of soft wire holds the fragments together. From the AO handbook.

EQUIPMENT Kirschner wire, 0.35 mm stainless steel wire, Faraboef’s rougine, pliers, wire cutters, scoop, bone hooks or towel clips.

INCISION Make an 8 cm longitudinal incision just lateral to the point of the patient’s elbow (A, in Fig. 72-27). incise the periosteum and scrape it away from the fracture site with a rougine. Expose the smaller fragment. It may be in smaller pieces than the X–rays suggest. Open the joint and clear away any blood clot (B).

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Figure 72.27: TENSION BAND WIRING. If less than half the patient’s olecranon fossa is intact, fix the two fragments of his olecranon by tension band wiring like this. From the AO handbook.

Hold the fragments together with a bone hook or towel clip so as to close up the joint line. Hold the hook so that it presses in the long axis of the ulna. Try to obtain hair–line reduction. The fracture line will be easier to see if you have previously stripped away the periosteum from around it. Drill in two Kirschner wires (C). Drill the olecranon transversely for the insertion of the tension band (D).

Thread the wire in a figure of eight through the hole in the ulna and round the Kirschner wires (E). Twist the ends of the wire loosely together. Bend the ends of a Kirschner wire upwards at 90 $\ensuremath{^\circ }$ with pliers (F).

Cut the first Kirschner wire, leaving a few millimetres of its bent end projecting (G). Do the same thing for the other Kirschner wire. Turn the bent cut ends of both of them back against the bone. Twist the ends of the tension band together and cut them off (H).

POSTOPERATIVE CARE (bath methods) Put the patient’s arm in a collar and cuff and start active movements early.

CAUTION! Don’t let him try to extend his arm actively against resistance for at least a month.

DIFFICULTIES WITH OLECRANON FRACTURES

If the patient is a CHILD (rare), immobilize his elbow in extension for 5 weeks. Stiffness is unlikely to be a problem.