Elbow (Olecranon) Fractures
When you bend your elbow, you can easily feel its "tip," a bony prominence that extends from one of the lower arm bones (the ulna). That tip is called the olecranon (oh-lek'-rah-nun). It is positioned directly under the skin of the elbow, without much protection from muscles or other soft tissues. It can easily break if you experience a direct blow to the elbow or fall on a bent elbow.
The elbow is a joint made up of three bones. It bends and straightens like a hinge. It is also important for rotation of the forearm; that is, the ability to turn our hands up (like accepting change from a cashier) or down (like typing or playing piano).
Bones of the elbow. (Reproduced with permission from Tashjian RZ, Katarincic JA: Complex Elbow Instability. J Am Acad Orthop Surg 2006;14:278-286.)
The elbow consists of portions of all three bones:
The elbow is held together by three main things:
The elbow is held together by ligaments, muscles, tendons and the shape of the bones themselves.
When the elbow structure is altered, either by breaking a bone or by tearing ligaments, muscles, or tendons, or a combination of those problems, then the elbow will not function normally. It can become very painful and stiff, and can cause a feeling of instability ("my elbow feels like it wants to pop out.").
Cause A. Anterior fracture-disclocations of the olecranon. B. Posterior fracture-dislocations of the olecranon.
There are many types of elbow fractures (breaks). Olcranon fractures are common. Although they usually occur in isolation (that is, there are no other injuries), they can be a part of a more complex elbow injury.
Olecranon fractures can occur in a number of ways:
A patient with an olecranon fracture will typically go to the emergency room because the elbow will be very painful and unable to move. During the examination the doctor will:
X-rays will be taken of the elbow to confirm that a fracture has occurred. X-rays can also reveal other fractures or dislocations. X-rays may also be taken of the upper arm, forearm, shoulder, wrist, and/or hand, based upon the doctor's judgment and based upon the patient's complaints. These X-rays may reveal other injuries, such as other fractures or dislocations.
While in the emergency room, the doctor will treat an olecranon fracture with ice, pain medicine, a splint (like a cast), and a sling to keep the elbow in position.
Whether or not the fracture requires surgery will be determined. Not all olecranon fractures require surgery.
Some olecranon fractures require just a splint or sling to hold the elbow in place during the healing process. The doctor will closely monitor the healing of the fracture, and have the patient return to clinic for X-rays fairly frequently.
If none of the bone fragments are "out of place" after a few weeks, the doctor will allow the patient to begin gently moving the elbow. This may require visits with a physical therapist.
The patient will not be allowed to lift anything with the injured arm for a few weeks.
A nonsurgical approach to olecranon fracture may require long periods of splinting or casting. The elbow may become very stiff and require a longer period of therapy after the cast is removed to regain motion.
If the fracture shifts in position, the patient may require surgery to put the bones back together.
Surgery to treat an olecranon fracture is usually necessary when:
Techniques. Surgery can be done under general anesthesia (going to sleep) or under regional anesthesia (using medicines like novocaine that numb the arm), or both.
During surgery the patient may lie on his/her back, side, or stomach. If the patient lies on his/her belly, the face (lips, eyelids) may be swollen for a few hours after the operation is over. This is normal and temporary.
The surgeon will typically make an incision over the back of the elbow and then put the pieces of bone back together. There are several ways to hold the pieces of bone in place. The surgeon may choose to use:
An olecranon fracture may be held together with a tension band fixation (illustration and X-ray). A single medullary screw keeps the fractured bones together. Plates and screws may be used to hold the broken bones in place.
If some of the bone is missing or crushed beyond repair (pieces of bone lost through a wound during an accident), the fracture may require bone filler. Bone filler can be bone supplied by the patient (typically taken from the pelvis) or bone from a bone bank (from a donor), or an artificial calcium-containing material.
The incision is typically closed with sutures or staples. Sometimes, a splint is placed on the arm, but not always.
Considerations Surgery has some risks. If surgery is recommended, the doctor feels that the possible benefits of surgery outweigh the risks.
Surgery does not guarantee healing of the fracture. A fracture may pull apart, or the screws, plates, or wires may shift or break. This can occur for a variety of reasons, including:
If the fracture fails to heal, further surgery may be needed.
The eventual goal of treatment for an olecranon fracture is to regain full motion of the elbow, as it was prior to the injury.
Most patients will return to normal activities (except sports and heavy labor) within about 4 months, although full healing can take more than a year. Many patients report that, although their X-rays show full healing, they are not at 100% but are improving over time.
After surgery, the patient's elbow may be splinted or casted for a short period of time. The patient may wear a sling if it provides comfort. Pain medications may be provided. The surgeon usually removes stitches or staples 10 to 14 days after surgery.
The patient is often restricted from lifting objects with the injured arm for at least six weeks. Motion exercises for the elbow and forearm should begin shortly after surgery, sometimes as early as the day after surgery.
Especially early after surgery, some patients may not be able to straighten their injured elbow on their own. To straighten the elbow, the patient needs to use his/her uninjured arm to help out, or assistance from another person.
Full recovery from an olecranon fracture requires a lot of work. It is extremely important that exercises, once started, are performed multiple times a day, every day. Physical therapy will sometimes be prescribed. If so, the patient should still do exercises at home on days he or she does not work with the therapist. The exercises only make a difference if they're done regularly. Recovering strength often takes longer than expected; sometimes, 6 months or more.
Restrictions on driving are generally based on the arm that is injured (the right arm is used for shifting, for example) and on use of pain medications. Narcotics, such as morphine or codeine, impair judgment and therefore they impair the ability to drive a vehicle just like alcohol does.
Even after the fracture has healed, full motion of the elbow may not be possible. In most of these cases, the patient cannot fully straighten his or her arm. Typically, loss of a few degrees of straightening will not have an impact on how well the arm will work in the future, including for sports or heavy labor. Loss of a significant amount of motion may require intensive physical therapy, special bracing, or further surgery to correct this problem. This is uncommon for olecranon fractures.
Elbow arthritis causes the elbow joint to become stiff and painful. It is an unfortunate, but relatively common, long-term outcome of olecranon fractures. Elbow arthritis can occur rapidly following an olecranon fracture, or it may take years to develop. It occurs if the lining of the elbow joint (cartilage) was damaged from the fracture, or if the fracture leads to the lining wearing away over time. Keep in mind that not everyone who breaks their olecranon will develop elbow arthritis. In addition, elbow arthritis is not always painful. It does not always limit an individual's ability to use the arm, and if it is not bothersome, it does not require medical treatment.