Proximal Ulna Fractures – Causes, Diagnosis, Treatment

Proximal ulna fractures account for 20% of all proximal forearm fractures.[ There are many options available for the treatment of such fractures, such as cast immobilization, plate, and screw fixation, tension band wiring and intramedullary screw fixation, depending on the fracture pattern.[– Undisplaced proximal ulna fracture with intact extensor mechanism can be treated with cast immobilization, while simple transverse fractures are best treated via tension band wiring and intramedullary screw fixation. The use of plate and screw fixation is more appropriate in comminuted fractures of the proximal ulna. Due to the subcutaneous nature of the proximal forearm, it is vulnerable to open injuries over the dorsal aspect of the proximal ulna.

Bones Of Upper Limb Anatomy and Arm Muscle And Bone Muscles Of The Pectoral Girdle And Upper Limbs – Human Diagram Chart

 

Classifications of Proximal Ulna Fractures

There are several classifications that describe different forms of olecranon fractures, yet none of them have gained widespread acceptance:[rx]

Mayo Classification

Based on the stability, the displacement and the comminution of the fracture. It is composed of three types, and each type is divided into two subtypes: subtype A (non-comminuted) and subtype B (comminuted).

  • Type I: Non-displaced fracture – It can be either non-comminuted ones (Type IA) or comminuted (Type IB).
  • Type II: Displaced, stable fractures – In this pattern, the proximal fracture fragment is displaced more than 3 mm, but the collateral ligaments are intact. That is why there is no elbow instability. It can be either non-comminuted ones (Type IIA) or comminuted (Type IIB).
  • Type III: Displaced unstable fracture – In this case, the fracture fragments are displaced and the forearm is unstable in relation to the humerus. It is a fracture -dislocation. It also may be either non-comminuted (Type IIIA) or comminuted (Type IIIB).

AO Classification

This classification incorporates all fractures of the proximal ulna and radius into one group, subdivided into three patterns:

  • Type A: Extra-articular fractures of the metadiaphysis of either the radius or the ulna
  • Type B: Intra-articular fractures of either the radius or ulna
  • Type C: Complex fractures of both the proximal radius and ulna

Colton Classification

  • Type I – Nondisplaced – Displacement does not increase with elbow flexion
  • Type II – Avulsion (displaced)
  • Type III – Oblique and Transverse (displaced)
  • Type IV – Comminuted (displaced)
  • Type V – Fracture dislocation

Schatzker Classification

  • Type A – Simple transverse fracture
  • Type B – Transverse impacted fracture
  • Type C – Oblique fracture
  • Type D – Comminuted fracture
  • Type E – More distal fracture, extra-articular
  • Type F – Fracture-dislocation

Mechanism of Proximal Ulna Fractures

Olecranon fractures are common. Typically they are caused by direct blows to the elbow (e.g. motor vehicle accidents), and due to falls when the triceps are contracted.[rx][rx] “Side-swipe” injury when driving a motor vehicle with an elbow projecting outside the vehicle resting on an open window’s edge is an example.[rx]

Direct trauma – This can happen in a fall with landing on the elbow or by being hit by a solid object. Trauma to the elbow often results in comminuted fractures of the olecranon.

Indirect trauma – by falling and landing with an outstretched arm.

Powerful pull of the triceps muscle can also cause avulsion fractures.

Causes of Proximal Ulna Fractures

 

  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of broken proximal ulna fractures.
  • Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis – a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in snow or on the ice –  or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms of Proximal Ulna Fractures

People with olecranon fractures present with intense elbow pain after a direct blow or fall.[rx] Swelling over the bone site is seen and an inability to straighten the elbow is common. Due to the proximity of the olecranon to the ulnar nerve, the injury and swelling may cause numbness and tingle at the fourth and fifth fingers.[rx] The examination can bring out a palpable defect at the site of the fracture.[rx]

  • Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
  • Swelling
  • Tenderness
  • Bruising
  • Obvious deformity, such as a bent wrist
  • Pain
  • Bruising
  • Tenderness
  • The wrist hanging in a deformed way
  • Pain, especially when flexing the ulnar styloid fracture

Diagnosis of Proximal Ulna Fractures

History

Your doctor in the emergency department may ask the following questions

  • How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
  • When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
  • What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit,  anabolic steroid uses for athletes, etc?

Physical

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.

  • Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion and pulses, and the integrity of nerve function.
  • Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side. Sensory 2-point discrimination
  • Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
  • Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).

Lab Test

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

The classic proximal ulna fractures have the following characteristics:[rx]

  • Transverse fracture of the ulnar
  • dorsal displacement and dorsal angulation, together with radial tilt[rx]
  • Radial-ulnar styloid fracture shortening
  • Loss of ulnar inclination≤
  • Radial angulation of the wrist
  • Comminution at the fracture site
  • Associated fracture of the ulnar styloid process in more than 60% of cases.

Differential Diagnosis/ Associated Injuries

  • Scapholunate ligament tear
  • Median nerve injury
  • TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
  • Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
  • Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
  • Compartment syndrome
  • Ulnar styloid fracture
  • DRUJ (Distal Radial Ulnar Joint) Instability
  • Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures[rx]

Plain radiographs

  • Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for proximal ulna fractures must include two views-a postero-anterior (PA) view and lateral view.[]
  • The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[] The palm is maintained flat against the cassette

Computed Tomography

  • CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment,[] assessments of fracture healing as well as post-surgical evaluation.[]
  • CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

  • Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
  • MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Ulnar Lower End Fracture

Ulnar Lower End Fracture

Treatment available can be broadly

  • Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your shoulder area, then get medical care immediately. Proximal ulna fractures cause significant pain in the front part of your shoulder, closer to the base of your neck. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness and tingling in the arm/hand.
  • Apply ice to your fractured clavicle – After you get home from the hospital proximal ulna fractures (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your clavicle for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
    Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your arm and shoulder in all different directions. Don’t aggravate the proximal ulna fractures so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light calisthenics and then progress to holding light weights (five-pound weights to start). Your proximal ulna fractures need to move a little bit during the later phases of the injury to stimulate complete recovery.
  • Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
  • Get a supportive arm sling – Due to their anatomical position, proximal ulna fractures can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. A figure-eight splint wraps around both shoulders and the base of your neck in order to support the injured shoulder and keep it positioned up and back. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body. You’ll need to wear the sling constantly until there is no pain with arm movements, which takes between two to four weeks for children or four to eight weeks for adults.
  • Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder and upper chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and shoulder movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements and flexibility
  • Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a distal radius locking plate, coracoclavicular screws, Knowles pin fixation.
  • Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vicryl tape, dacron arterial graft for coracoclavicular ligament reconstruction.

Rest your Hand

Once you’re discharged from the hospital in an arm sling, your top priority is to rest your shoulder and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.
  • Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
  • Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the fractured clavicle.
  • Athletes in good health are typically able to resume their sporting activities within two months of breaking they’re ulnar styloid depending on the severity of the break and the specific sport.
  • Sleeping on your back (with the sling on) is necessary to keep the pressure off your shoulder and prevent stressing the clavicle injury.

Eat nutritiously during your recovery

All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including ulnar styloid. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your clavicle. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

Physical therapy

  • Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.  After a proximal ulna fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-up care

  • You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Breathing Exercise

  • To elevate breathing problem or remove the lung congestion.

Ulnar Lower End Fracture

Do no HARM for 72 hours after injury

  • Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
  • Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
  • Running and movement – Running and walking may cause further damage, and causes healing delay.
  • Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Fracture (left) and repair (right) with three pins, wires, and incision closure with staples

Nondisplaced Fractures

  • In fractures with little or no displacement, immobilization with a posterior splint may be sufficient.[rx] Elbows be immobilized at 45-90º of flexion for 3 weeks, followed by limited (90º) flexion exercises.

Displaced Fractures

  • Most olecranon fractures are displaced and are best treated surgically:

Tension Band Fixation

  • Tension band fixation is the most common form of internal fixation used for non-comminuted olecranon fractures.[rx] It is typically reserved for noncomminuted fractures that are proximal to the coronoid.[rx] This procedure is performed using Kirschner wire (K-wires) which converts tensile forces into compressive force.[rx]

Intramedullary Fixation and Plates

  • Single intramedullary screws can be used to treat simple transverse or oblique fractures.[rx] Plates can be used for all proximal ulna fracture types including Monteggia fractures, and comminuted fractures.[rx]

Excision and triceps advancement

  • This method is indicated for cases when open reduction and internal fixation is unlikely to be successful. For example: extensive comminutions, elderly patients with osteoporotic bone, and small or non-union fractures.[rx][rx]

Open reduction and internal fixation. This is the procedure most often used to treat ulnar styloid fracture fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

  • Plates and screws – After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone. After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.
  • Pins or screws –  Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
    Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
  • Precontoured locking plates
  • Hook plate
  • Distal radius plates
  • Ulnar styloid fracture screws
  • Flexible coracoclavicular fixation
  • Arthroscopic treatment
  • Intra-medullary fixation
  • Tension band fixation

Closed Reduction and Casting

  • All fractures characterized by minor comminution, without or with minimal displacements can be considered for closed reduction and cast immobilization. Mainly type I and type IIA Melone’s fracture can be managed conservatively. The fracture should be kept under closed observation to look for any re-displacement.
  • Despite the widespread acceptance of immobilization in a plaster cast, questions remain regarding the optimum position, the duration of immobilization and the need to extend the cast proximal to the ulna. No clear consensus exists as to the best position for immobilizing the wrist in plaster. Sarmiento et al.[] advocated immobilization in a position of supination to decrease the deforming force of the brachioradialis, which may cause loss of reduction.

Pins and Plaster Technique

  • Placement of pins in the metacarpals and forearm was initially advocated by Bohler in 1923, but it gained popularity after the report by Green, who showed good or excellent results in 86% of his patients.[]
  • However, he noted a high incidence of minor or major complications, one-third of which were related to pin site only. Other researchers also noted that one-third of the complications were related to pins and 16% of the patients needed reoperation for complications.[]

Percutaneous Pinning

  • Extra-articular fractures of the distal end of the ulna with extensive comminution or the fractures that have no more than two articular fragments, in which anatomical reduction is obtainable, are amenable to percutaneous pinning of the fracture fragments and application of a plaster cast. A single pin placed through the radial styloid as a means of stabilizing the displaced fracture fragment was first suggested by Lambotte in 1908.[,]

External Fixation

  • External fixation is generally accepted as superior to plaster immobilization in the young patients with an intra-articular comminuted fracture of the distal radius. Other indications for external fixation include some unstable extra-articular fractures with significant comminution and failure to maintain reduction after an initial attempt at closed management in a cast, certain situations of multiple trauma, the presence of dysfunctional contralateral limb, severe open fractures with significant soft tissue injury and neurovascular compromise, and bilateral injuries.[]

Limited Open Reduction

  • In intra-articular fractures that have more than 2 mm of displacement, the radio-carpal joint may be incongruent despite adequate attempts at reduction. The incongruency usually involves the lunate part of the distal end of the radius.
  • The ulna styloid process and scaphoid facet are more amenable to reduction through ligamentotaxis or by manipulation and reduction.
  • A new technique of combining external fixation with open reduction of the displaced lunate fossa through a small, longitudinal incision and elevation of the impacted fragment without direct visualization of the surface of the joint has been described.[]

Open Reduction and Internal Fixation

  • One of the recent advances in the treatment of distal ulna fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.

Arthroscopic-Assisted Fracture Reduction

  • Intra-articular fractures of the radius can be arthroscopically assessed, and reduction of the particular components and assessment and repair of ligamentous injury can then be undertaken.[,,] The ideal timing for arthroscopically assisted distal radius surgery is 3 to 7 days after injury.

I. Non-operative methods of treating radial head fractures

A. Immediate mobilization vs. cast in flexion vs. cast in extension

  • One randomized controlled trial (CoE level II) was identified that compared patients treated with immediate mobilization with immobilization.6
  • The least pain and loss of elbow extension were seen in people treated with immobilization, but these differences were not statistically significant.
  • Comparisons between treatments may be limited by small sample sizes and study biases.

B. Aspiration of the elbow versus no aspiration

  • One randomized controlled trial (CoE level II) was identified that compared patients with radial head fractures treated with elbow aspiration versus those who were not treated with aspiration.7
  • Ninety-two percent of the patients who received aspiration reported immediate and lasting relief from pain following the treatment.

II. Non-operative versus operative methods

A. Closed reduction versus ORIF in children

  • One retrospective cohort study on children was identified that compared closed reduction versus open reduction for radial neck fractures.8, 9
  • Compared with children treated with open reduction and internal fixation, those treated with immobilization/closed reduction experienced significantly less pain (15% versus 65%; RR=0.2, 95% CI, 0.1–0.4), avascular necrosis (4% versus 24%; RR = 0.2, 95% CI, 0.05–0.6), and had more good or excellent overall clinical results (99% versus 55%); RR = 1.8, 95% CI, 1.3–2.5).

B. Closed reduction versus ORIF in adults

  • One retrospective cohort study in adults was identified that compared closed versus open reduction for radial head fractures.9
  • Patients who received closed reduction were more likely to report pain than those treated with open reduction, but this was not statistically significant (RR = 2.0, 95% CI, 0.9–4.5).
  • Patients treated with open reduction were more likely to have had a good or excellent clinical result (90%) than patients treated with closed reduction (46%), but, again, these were not statistically significantly different.

III. Operative methods of reducing olecranon fractures

A. Tension band wiring versus plate fixation

  • One randomized controlled trial was identified that compared tension band wiring with plate fixation as treatment of olecranon fractures.10
  • Plate fixation resulted in higher percentage of “good” clinical (no more than occasional pain; loss of movement in elbow less than 15°) and x-ray (no articular step-off or gap; no loss of reduction) results.
  • Many more tension band wiring patients reported complications (74%) compared with patients who received plate fixation (5%), a statistically significant difference (RR= 16.2, 95% CI, 2.3–112). To prevent one complication, one to 2 patients would need to be treated with plate fixation
  • Results may be limited by small sample size.

B. Netz pins versus Kirschner pins

  • One randomized controlled trial was identified that compared Netz pins with Kirschner pins as treatment of olecranon fractures.11
  • Median fracture healing time was similar for both groups (six weeks for Netz pins versus seven weeks for Kirschner pins).
  • More Kirschner (68%) than Netz (52%) pins had to be removed by the end of follow-up, but this difference was not statistically significant.

C. Tension band wiring versus figure of eight wiring

  • One study was found that compared tension band wiring with figure of eight wiring to treat olecranon fractures.2
  • No statistically or clinically significant differences were found between the two treatment groups in terms of pain, loss of strength, range of motion, or osteoarthritis.
  • Patients in the tension band wiring group (81%) experienced significantly more hardware removal than those in the figure of eight wiring group (43%); RR = 1.9, 95% CI, 1.3–1.9)).

IV. Operative versus operative methods for radial head fractures

A. Resection versus open reduction and fixation

  • One retrospective cohort study was identified that compared resection versus open reduction and internal fixation.12
  • Patients who received open reduction and internal fixation reported less pain (P = .02) and greater functional recovery (P = .003) than those who received resection.

B. Primary radial head excision versus delayed excision

  • One retrospective cohort study was identified that compared primary versus delayed excision as treatment of radial head fractures.13
  • No difference was found between immediate (10%) and delayed (11%) treatment in terms of daily pain (RR = 0.9, 95% CI, 0.2–4.6).

C. Biodegradable polylactide pins versus standard metal mini-fragment implants

  • One randomized controlled trial (CoE II) was identified that compared the use of polylactide pins with standard metal mini-fragment implants for treatment of displaced radial head fractures.14
  • No difference in postsurgical complications or in clinician-based outcomes at the two year follow-up was found between the use of biodegradable pins or standard metal lag screws.
  • At two years follow-up, a five times greater risk for osteoloysis was seen in polylactide patients (17%) compared with patients treated using standard metal devices (3%) (RR = 5.4, 95% CI, 1.3–23, NNT = 21). Of patients who developed osteolysis, the osteolysis was mild or moderate in eleven (92%) of those with polylactide pins and one of the two patients with metal devices.

V. Rehabilitation following radial head fractures

  • One study was identified that compared immediate to delayed mobilization for rehabilitation following radial head fractures.
  • No statistically or clinically significant differences were found between pain or range of motion scores at week twelve.
  • In olecranon fractures, osteoarthritis of the elbow joint, occurring after about 5% of these fractures, and the necessity of a second operation to remove hardware, required in 56-85% of olecranon fractures, are two common complications that result from operative treatments.
  • The most common complication of radial head fractures is a loss of joint motion as a result of avascular necrosis, which occurs in 10–20% of radial head fractures.1 No studies comparing prognosis were identified for radial head fractures.
  • Complications of treated Monteggia fractures include recurrent radial head dislocation, malunion, posterior interosseous nerve palsy, and Volkmann’s ischemic contracture. No comparative studies were found on prognosis following Monteggia fractures.

Overall, the quality of evidence on proximal forearm fractures is limited, and definitive statements regarding treatment are not possible. However, the following observations may be helpful:

  • Aspiration of radial head fractures consistently relieved pain.
  • Studies comparing operative to non-operative methods of treating proximal forearm fractures suggest non-operative methods may be better than operative methods in terms of pain, avascular necrosis, and clinical outcomes for radial neck fractures in children. However, in adults, operative methods had better results in terms of pain and clinical results.
  • Tension band wiring, compared with plate fixation, may result in more complications when used as a treatment for olecranon fractures.
  • Tension band wiring of forearm fractures also resulted in greater rates of hardware removal when compared with a figure of eight wiring.
  • Open reduction and internal fixation of radial head fractures seems to have better results than resection
  • Biodegradable pins or standard metal screws for ORIF may result in comparable outcomes but there may be a greater risk of developing a mild degree of osteolysis.

Rehabilitation Guideline for Non-Operative/Conservative rehabilitation [rx]

Acute Stage (0-8 weeks)

Goals

  • Protection with short-arm cast
  • Control pain and edema
  • Maintain range in digits, elbows, shoulder

Interventions

  • AROM and PROM of digits, elbow, shoulder
  • Elevation of hand and digits to control edema
  • Cast removal between 6-8 weeks

Sub Acute Stage

Goal

  • Control pain and edema (TENS, ice)
  • Increase ROM
  • Increase activities of daily living (ADLs)

Interventions

  • AROM and PROM of digits, elbow, shoulder
  • AROM wrist flexion/ extension, forearm supination/ pronation
  • PROM of low load and prolonged stretch

Settled Stage

Goals

  • Regain full ROM
  • Begin strengthening
  • Return to activity

Interventions

  • Continue all ROM exercises
  • Progress to the strengthening of all joints[rx]

Rehabilitation Guideline for External Fixation by Pho et al

Acute Stage (1-6 weeks)

Goals

  • Control pain and edema (TENS, ice)
  • Protect surgical site
  • Maintain ROM of digits, elbow, shoulder

Interventions

  • Elevation
  • AROM of digits, elbow, shoulder
  • AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

Goal

  • Protect fracture site
  • Control pain and edema (TENS, ice)
  • ROM of involved and uninvolved joints

Interventions

  • AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

Goal

  • Regain full ROM
  • Begin strengthening
  • Increase tolerance to ADLs

Interventions

  • ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
  • PROM of low load and prolonged stretching of wrist motions
  • Grip strengthening
  • ADL training within tolerance[rx]

Cryotherapy

  • Cryotherapy is an effective modality for controlling edema in the acute phase after trauma and during rehab due to its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid[rx]. Cryotherapy can also be combined with compression and elevation in the treatment of edema.[rx]
  • To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post application.[rx]Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.[rx] Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobulinemia, Cold urticaria.[rx]

Electrical Stimulation

  • The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.[rx]
  • Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.[rx]
  • The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.

Supervised Active rehabilitation program used in Study

ISOMETRIC EXERCISE

  • Wrist flexors and extensors

ACTIVE RANGE OF MOTION EXERCISE

  • Assisted stretch to forearm flexors and extensor musculature and radial/ulnar deviation
  • Weight-bearing wrist extension exercise(hand on the table with the patient leaning forward on them) to patient tolerance
  • Active stretch to shoulder girdle and rotator cuff musculature
  • Active stretch to elbow flexor and extensor musculature

INTRINSIC HAND MUSCLE EXERCISE

  • Thumb/digit opposition
  • Repetitive squeezing of therapy
  • repetitive towel wringing exercise

STRENGTHENING ROUTINE

  • Biceps curl with 1,5-2 pound weights bilaterally
  • Shoulder abduction, flexion and extension reps with 2-pound weights bilaterally
  • Repetitive squeezing of a rubber ball in affected wrist
  • Flexion and extension of wrist using 1,5-pound weights increasing as tolerated

FUNCTIONAL ACTIVITIES

  • The patient is encouraged to resume pre-accident activities that involve the affected extremity (eg. writing, typing, cooking, etc.)

Complications of 

There were no major complications such as neurovascular injury, infection, or impaired wound healing. Surgery-related complication at 2-year follow-up included nonunion in 3 patients (11%),

  • DRUJ subluxation in 3 patients (11%),
  • Implant migration in 4 patients (14%),
  • Radiographic resorption of the ulnar styloid in 4 patients (14%).
  • Radiographic nonunion was noted in 1 patient in group A (8%) and 2 in group B (13%). Residual DRUJ subluxation was noted in 3 patients; all were in group B (20%).
  • Partial or complete radiographic resorption of the ulna was found in 1 patient in group A (8%) and 3 in group B (20%).
  • Implant migration was noted in 1 patient in group A (8%), and 2 in group B (13%).
  • Subsequent removal surgery due to implant irritation occurred in 13 patients (46%), with 4 in group A (31%) and 8 in group B (53%).
  • A total of 11 patients (39%) with surgery-related complications included 5 (38%) in group A and 12 (80%) in group B, with a significant difference

There are risks associated with any type of surgery. These include

  • Nonunion (1-5%)
  • Infection (~4.8%)
  • 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
  • Bleeding
  • Problems with wound healing
  • Blood clots
  • Damage to blood vessels or nerves
  • Reaction to anesthesia
  • Hardware prominence
  • Malunion with cosmetic deformity
  • Restriction of ROM
  • The difficulty with bone healing
  • Hardware irritation
  • Fracture comminution (Z deformity)
  • Fracture displacement
  • Increased fatigue with overhead activities
  • Dissatisfaction with appearance
  • The difficulty with shoulder straps, backpacks and the like
  • ~30% of patient request plate removal
  • Superior plates associated with increased irritation
  • Superior plates associated with increased risk of subclavian artery or vein penetration

References

Proximal ulna fractures