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The pivotal role of the intermediate fragment in initial operative treatment of olecranon fractures.

von Rüden C, Woltmann A, Hierholzer C, Trentz O, Bühren V - J Orthop Surg Res (2011)

Bottom Line: Functional outcome demonstrated a total PREE score of 9 points on average in 45 of 80 patients.Consideration, desimpaction and anatomic reduction of the intermediate fragment are necessary preconditions for anatomic restoration of the trochlear notch.There is no clear benefit for plating versus tension band wiring according to our data.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Trauma Surgery, Murnau Trauma Center, Germany. vonrueden@bgu-murnau.de

ABSTRACT

Background: In order to improve initial operative treatment of complex olecranon fractures we searched for new determining details. We assumed that the intermediate fragment plays a decisive role for anatomic restoration of the trochlear notch and consecutive outcome of initial operative treatment.

Methods: 80 patients operated with diagnosis of complex olecranon fracture were identified in an 8-year-period from trauma unit files at two European Level 1 Trauma Centers. Retrospective review of all operative reports and radiographs/computer-tomography scans identified patients with concomitance of an intermediate fragment. The Patient-Rated Elbow Evaluation Score was calculated for 45 of 80 patients at a minimum of 8 months postoperatively (range 8-84 months).

Results: 29 patients were treated with stable internal fixation with figure-of-eight tension band wire fixation and 51 patients with posterior plate osteosynthesis with/without intramedullary screw. An intermediate fragment was seen in 52 patients. In 29 of these 52 patients, the intermediate fragment was described in operative report. 24 of these 29 patients were treated with posterior plate osteosynthesis, and 5 patients with figure-of-eight tension band wiring. Complications included superficial infection (2 patients), secondary dislocation (3 patients) and heterotopic ossifications (1 patient). Functional outcome demonstrated a total PREE score of 9 points on average in 45 of 80 patients.

Conclusion: An extraordinary amount of patients showed an intermediate fragment. Consideration, desimpaction and anatomic reduction of the intermediate fragment are necessary preconditions for anatomic restoration of the trochlear notch. There is no clear benefit for plating versus tension band wiring according to our data. In the operative report precise description of the fracture pattern including presence of an intermediate fragment is recommended.

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Postoperative biplanar X-rays show situation after internal fixation.
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Figure 14: Postoperative biplanar X-rays show situation after internal fixation.

Mentions: Reduction was verified by biplanar X-ray imaging. In order to restore the trochlear notch, temporary fixation of the intermediate fragment in anatomical position on the contour of the notch with respect to the distal aspect of the humerus was performed using K-wires and/or bone clamps [Figure 8]. For osteosynthesis a conventional plate contoured to the posterior surface of the ulna (standard, long proximal, 8-12 hole) or an pre-contoured locking plate was utilized [Figure 9]. One or two screws (2.7 mm) were inserted into the ulna shaft. An intramedullary 3.5 mm "home run" screw was inserted into the plate at the tip of the olecranon from proximal to distal into the ulna shaft. It was not advisable to utilize fixed angle screws in the ulna shaft prior to inserting the "home run" screw since the screws that are used to stabilize the plate to the ulna shaft may impair insertion of the intramedullary screw. Insertion of a distal screw into the ulna shaft using excentric drilling position exerted compression on the fracture and the trochlear notch. Additional interfragmentary screw fixation of single fragments may in single cases be necessary [Figure 10]. Insertion of the remaining shaft screws into the ulna completed the stable osteoynthesis [Figure 11]. A wound drainage (10 Charrière) was inserted, the wound was closed in layers, and a sterile wound dressing was applied [Figure 12]. A cast-splint was applied for three to four days during the initial wound healing phase. Careful postoperative treatment with active and active-assisted physiotherapy with range of motion limited by pain and discomfort was initiated. Postoperative X-ray control was performed after drainage removal [Figures 13, 14]. Clinical and radiological follow-up studies were performed in intervals after three, six and twelve weeks. The German version of the Patient-Rated Elbow Evaluation Score (PREE) includes a 20-item questionnaire designed to assess elbow pain and disability in activities of daily living and was calculated for 45 out of 80 patients at a minimum of 8 months postoperatively (range 8-84 months). Criteria of the PREE score include pain, function in specific activities and function in every day activities [18]. A total score out of 100 is computed by equally weighting the pain score (sum of five items) and the disability score (sum of fifteen items, divided by 3). No standard values for the total PREE score have been published yet [18]. Higher score indicates more pain and functional disability. In this study, a total score of 0 to 20 out of 100 points was considered to be an excellent result; 21 to 30 points, a good result; 31 to 40 points, a fair result; and >40 points, a poor result.


The pivotal role of the intermediate fragment in initial operative treatment of olecranon fractures.

von Rüden C, Woltmann A, Hierholzer C, Trentz O, Bühren V - J Orthop Surg Res (2011)

Postoperative biplanar X-rays show situation after internal fixation.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3044106&req=5

Figure 14: Postoperative biplanar X-rays show situation after internal fixation.
Mentions: Reduction was verified by biplanar X-ray imaging. In order to restore the trochlear notch, temporary fixation of the intermediate fragment in anatomical position on the contour of the notch with respect to the distal aspect of the humerus was performed using K-wires and/or bone clamps [Figure 8]. For osteosynthesis a conventional plate contoured to the posterior surface of the ulna (standard, long proximal, 8-12 hole) or an pre-contoured locking plate was utilized [Figure 9]. One or two screws (2.7 mm) were inserted into the ulna shaft. An intramedullary 3.5 mm "home run" screw was inserted into the plate at the tip of the olecranon from proximal to distal into the ulna shaft. It was not advisable to utilize fixed angle screws in the ulna shaft prior to inserting the "home run" screw since the screws that are used to stabilize the plate to the ulna shaft may impair insertion of the intramedullary screw. Insertion of a distal screw into the ulna shaft using excentric drilling position exerted compression on the fracture and the trochlear notch. Additional interfragmentary screw fixation of single fragments may in single cases be necessary [Figure 10]. Insertion of the remaining shaft screws into the ulna completed the stable osteoynthesis [Figure 11]. A wound drainage (10 Charrière) was inserted, the wound was closed in layers, and a sterile wound dressing was applied [Figure 12]. A cast-splint was applied for three to four days during the initial wound healing phase. Careful postoperative treatment with active and active-assisted physiotherapy with range of motion limited by pain and discomfort was initiated. Postoperative X-ray control was performed after drainage removal [Figures 13, 14]. Clinical and radiological follow-up studies were performed in intervals after three, six and twelve weeks. The German version of the Patient-Rated Elbow Evaluation Score (PREE) includes a 20-item questionnaire designed to assess elbow pain and disability in activities of daily living and was calculated for 45 out of 80 patients at a minimum of 8 months postoperatively (range 8-84 months). Criteria of the PREE score include pain, function in specific activities and function in every day activities [18]. A total score out of 100 is computed by equally weighting the pain score (sum of five items) and the disability score (sum of fifteen items, divided by 3). No standard values for the total PREE score have been published yet [18]. Higher score indicates more pain and functional disability. In this study, a total score of 0 to 20 out of 100 points was considered to be an excellent result; 21 to 30 points, a good result; 31 to 40 points, a fair result; and >40 points, a poor result.

Bottom Line: Functional outcome demonstrated a total PREE score of 9 points on average in 45 of 80 patients.Consideration, desimpaction and anatomic reduction of the intermediate fragment are necessary preconditions for anatomic restoration of the trochlear notch.There is no clear benefit for plating versus tension band wiring according to our data.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Trauma Surgery, Murnau Trauma Center, Germany. vonrueden@bgu-murnau.de

ABSTRACT

Background: In order to improve initial operative treatment of complex olecranon fractures we searched for new determining details. We assumed that the intermediate fragment plays a decisive role for anatomic restoration of the trochlear notch and consecutive outcome of initial operative treatment.

Methods: 80 patients operated with diagnosis of complex olecranon fracture were identified in an 8-year-period from trauma unit files at two European Level 1 Trauma Centers. Retrospective review of all operative reports and radiographs/computer-tomography scans identified patients with concomitance of an intermediate fragment. The Patient-Rated Elbow Evaluation Score was calculated for 45 of 80 patients at a minimum of 8 months postoperatively (range 8-84 months).

Results: 29 patients were treated with stable internal fixation with figure-of-eight tension band wire fixation and 51 patients with posterior plate osteosynthesis with/without intramedullary screw. An intermediate fragment was seen in 52 patients. In 29 of these 52 patients, the intermediate fragment was described in operative report. 24 of these 29 patients were treated with posterior plate osteosynthesis, and 5 patients with figure-of-eight tension band wiring. Complications included superficial infection (2 patients), secondary dislocation (3 patients) and heterotopic ossifications (1 patient). Functional outcome demonstrated a total PREE score of 9 points on average in 45 of 80 patients.

Conclusion: An extraordinary amount of patients showed an intermediate fragment. Consideration, desimpaction and anatomic reduction of the intermediate fragment are necessary preconditions for anatomic restoration of the trochlear notch. There is no clear benefit for plating versus tension band wiring according to our data. In the operative report precise description of the fracture pattern including presence of an intermediate fragment is recommended.

Show MeSH
Related in: MedlinePlus