Olecranon fraktur

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29 Νοε 2013 (πριν από 3 χρόνια και 11 μήνες)

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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

Tension band, 2 knots

Oblique

Tension band, 2 knots

or tubular plate

Comminuted

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?

Proximal ulnar
(n=24)

Anterior cortex

(n=28)

Distal ulnar
(n=26)

Average follow
-
up/months

34.5 s.d 7.2

34.0 s.d 5.9

29.6 s.d 7.2

Symptomatic
implant removal

8 (33%)

*p=0.03

3 (11%)

2 (8%)

Proximal
migration of K
-
wire/mm

4.08 s.d. 1.89

*p=0.001

1.53 s.d 0.56

1.31 s.d 0.54

Satisfactory
functionel
outcome

21 (88%)

26 (93%)

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

100%

66%

Ethibond No. 5

40%

40%

Fiber wire


0%

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








Edwards
et
al. J
Orthop

Trauma
2011;25(5
):306
-
311


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

Veillette

et al.
Orthop

Clin

N Am. 2008;39:229
-
236


Short term

(2
-
3 years)

*only plate fixation

Long
-
term

(15
-
25 years)

Pain

1

(VAS score)

6% severe daily
symptoms

Motion compared to
non
-
affected arm

Decreased supination

Decreased flexion and
extension

(5 degrees)

Radiographic
evaluation


8% OA

5% OA

1% non
-
union

Patient
-
rated outcome

9.7

(VAS score)

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

Thank you

Technique

Technique

Technique