FRACTURE OF THE RADIAL NECK &FRACTURES OF THE OLECRANON Dr. D. N. Bid [PT]
FRACTURE OF THE RADIAL NECK• In adults, a displaced fracture of the radial neck may need open reduction;• if so, a mini-plate can be applied, making sure not to damage the articular surface.• An alternative is to use oblique headless screws.
FRACTURES OF THE OLECRANON• Two broad types of injury are seen: – (1) a comminuted fracture which is due to a direct blow or a fall on the elbow; and – (2) a transverse break, due to traction when the patient falls onto the hand while the triceps muscle is contracted. – These two types can be further sub-classiﬁed into • (a) displaced and • (b) undisplaced fractures. – More severe injuries may be associated also with subluxation or dislocation of the ulno-humeral joint.
• The fracture always enters the elbow joint and therefore damages the articular cartilage.• With transverse fractures, the triceps aponeurosis sometimes remains intact, in which case the fracture fragments stay together.
Clinical features• A graze or bruise over the elbow suggests a comminuted fracture; the triceps is intact and the elbow can be extended against gravity.• With a transverse fracture there may be a palpable gap and the patient is unable to extend the elbow against resistance.
X-ray• A properly orientated lateral view is essential to show details of the fracture, as well as the associated joint damage.• Always check the position of the radial head – it may be dislocated.
Treatment• A comminuted fracture with the triceps intact should be treated as a severe ‘bruise’.• Many of these patients are old and osteoporotic, and immobilizing the elbow will lead to stiffness.• The arm is rested in a sling for a week; a further x-ray is obtained to ensure that there is no displacement and the patient is then encouraged to start active movements.
• An undisplaced transverse fracture that does not separate when the elbow is x-rayed in ﬂexion can be treated closed.• The elbow is immobilized by a cast in about 60 degrees of ﬂexion for 2–3 weeks and then exercises are begun.• Repeat x-rays are needed to exclude displacement.
• Displaced transverse fractures can be held only by splinting the arm absolutely straight – but stiffness in that position would be disastrous.• Operative treatment is therefore strongly recommended.• The fracture is reduced and held by tension band wiring.• Oblique fractures may need a lag screw, neutralised by a tension band system or plate.
• Displaced comminuted fractures need a plate and often bone graft.• In the osteoporotic bone of low-demand elderly patients, good results can be achieved with excision of fragments and reattachment of triceps to the ulna.• If the coronoid portion of the joint is intact it will reduce the risk of instability.• Following operation, early mobilization should be encouraged.
Complications• Stiffness used to be common, but with secure internal ﬁxation and early mobilization the residual loss of movement should be minimal.• Non-union sometimes occurs after inadequate reduction and ﬁxation.• If elbow function is good, it can be ignored; if not, rigid internal ﬁxation and bone grafting will be needed.
• Ulnar nerve symptoms can develop.• These usually settle spontaneously.• Osteoarthritis is a late complication, especially if reduction is less than perfect.• This can usually be treated symptomatically.