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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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Patient 2: 85-year-old female after fall with olecranon fracture Mayo type IIb, Schatzker type B in prone position on the operating table. The arm is placed on an arm table.
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Figure 5: Patient 2: 85-year-old female after fall with olecranon fracture Mayo type IIb, Schatzker type B in prone position on the operating table. The arm is placed on an arm table.

Mentions: 36 patients were women and 44 were men, with a mean age of 54 years (range 20-89 years, standard deviation (SD) 17.9). The average age of the 36 women was 59 years, compared with 46 years in men. 28 of these injuries were the result of a fall from a standing height and 52 were caused by a higher-energy accident, including 17 falls from a substantial height, 14 falls down stairs, 13 sports accidents and 8 motor vehicle accidents. Retrospective review of all operative reports and radiographs/computed tomography (CT) scans identified all patients whose fracture pattern demonstrated presence of an intermediate fragment [Figures 1, 2, 3]. For stable fixation traditional figure-of-eight tension band wiring or plate fixation with or without an additional intramedullary so called "home run" screw was utilized [Figure 4] dependent on fracture pattern and classification. Operative technique of common figure-of-eight tension band wire fixation is well known and not described repeatedly within this study. Osteosynthesis with plate fixation and an additional "home run" screw was performed as follows: The patient was positioned in prone position on the operating table, and the arm was placed on an additional arm table [Figure 5]. A tourniquet was applied to the upper arm. The arm was washed and draped under sterile conditions and the tourniquet was inflated. A midline posterior approach was performed with skin incision over the dorsal aspect of the distal humerus approximately 3 cm proximal to the olecranon tip with a lateral curve around the radial aspect of the olecranon [Figure 6]. Skin incision is not placed over the olecranon to avoid secondary problems with skin healing and scar formation. The deep fascia was incised in the midline and the proximal ulna and the olecranon were exposed. Following irrigation and debridement of the fracture hematoma, fracture fragments, specifically the intermediate fragment, were desimpacted under direct view. Reduction of the intermediate fragment was performed using a clamp between the distal and proximal fragment of the fracture into the interface between trochlear notch of the olecranon and the humerus trochlea [Figure 7].


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)

Patient 2: 85-year-old female after fall with olecranon fracture Mayo type IIb, Schatzker type B in prone position on the operating table. The arm is placed on an arm table.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 5: Patient 2: 85-year-old female after fall with olecranon fracture Mayo type IIb, Schatzker type B in prone position on the operating table. The arm is placed on an arm table.
Mentions: 36 patients were women and 44 were men, with a mean age of 54 years (range 20-89 years, standard deviation (SD) 17.9). The average age of the 36 women was 59 years, compared with 46 years in men. 28 of these injuries were the result of a fall from a standing height and 52 were caused by a higher-energy accident, including 17 falls from a substantial height, 14 falls down stairs, 13 sports accidents and 8 motor vehicle accidents. Retrospective review of all operative reports and radiographs/computed tomography (CT) scans identified all patients whose fracture pattern demonstrated presence of an intermediate fragment [Figures 1, 2, 3]. For stable fixation traditional figure-of-eight tension band wiring or plate fixation with or without an additional intramedullary so called "home run" screw was utilized [Figure 4] dependent on fracture pattern and classification. Operative technique of common figure-of-eight tension band wire fixation is well known and not described repeatedly within this study. Osteosynthesis with plate fixation and an additional "home run" screw was performed as follows: The patient was positioned in prone position on the operating table, and the arm was placed on an additional arm table [Figure 5]. A tourniquet was applied to the upper arm. The arm was washed and draped under sterile conditions and the tourniquet was inflated. A midline posterior approach was performed with skin incision over the dorsal aspect of the distal humerus approximately 3 cm proximal to the olecranon tip with a lateral curve around the radial aspect of the olecranon [Figure 6]. Skin incision is not placed over the olecranon to avoid secondary problems with skin healing and scar formation. The deep fascia was incised in the midline and the proximal ulna and the olecranon were exposed. Following irrigation and debridement of the fracture hematoma, fracture fragments, specifically the intermediate fragment, were desimpacted under direct view. Reduction of the intermediate fragment was performed using a clamp between the distal and proximal fragment of the fracture into the interface between trochlear notch of the olecranon and the humerus trochlea [Figure 7].

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