Malpositioned olecranon fracture tension-band wiring results in proximal radioulnar synostosis

Post-traumatic radioulnar synostosis: a retrospective case series of 10 patients in Kuwait

BACKGROUND

The development of radioulnar synostosis due to post-traumatic injuries of the elbow or forearm can lead to debilitating outcomes. Several treatment options are available to hinder the progression and prevent recurrence. We used a combination of these treatments in a series of patients and observed the outcomes.

METHODS

We conducted a retrospective study of 10 patients with post-traumatic radioulnar synostosis (9 men and 1 woman) who required surgical intervention in a tertiary orthopedic center. All of these patients were subjected to the same treatment combination (preoperative radiotherapy, tissue interposition after heterotopic ossification resection, and adjuvant indomethacin postoperatively). Improvement in range of motion (flexion, extension, and rotation) and the Mayo score was assessed and compared preoperatively and postoperatively via statistical analysis.

RESULTS

In comparison to the patients' preoperative state, which ranged from poor to fair, all 10 patients reported excellent Mayo scores after intervention with the triple therapy combination, with a mean Mayo score of 36 ± 10.2 points. Flexion, extension, and rotation improved by mean values of 55.2° ± 38.7°, 50.2° ± 34.0°, and 47.9° ± 40.0°, respectively. There was 1 complication that has subsided on follow-up.

CONCLUSION

The triple therapy combination was found to provide good functional and prophylactic results preventing recurrence.

Comparison of all suture fixation with tension band wiring and plate fixation of the olecranon

BACKGROUND

Tension band wiring and plate fixation are common techniques used to stabilize simple olecranon fractures and osteotomies of the olecranon. All suture fixation is an alternative technique but has not been compared previously to these traditional methods. The aim of this study was to compare the clinical and radiographic outcomes of the three techniques.

METHODS

One hundred and sixty-eight consecutive Mayo type 1 and 2 olecranon fractures (n = 138) and olecranon osteotomies (n = 30) with a minimum follow-up time of one year were compared. The primary outcome measure was the rate of re-operation. Secondary outcome measures were the incidence of complications, rate of radiographic union and incidence of radiographic reduction loss.

RESULTS

Fixation was performed using tension band wiring in 89 patients, plating in 38 patients and suture fixation in 41 patients. There was no significant difference in the fracture type according to the Mayo classification between the groups. The re-operation rate was significantly higher in the tension band wiring group (36%) compared with both the plate group (11%, p = 0.03) and the suture group (2%, p = 0.002). There were two revision fixations in the tension band wiring group and one in the suture group. There was one asymptomatic non-union in the suture group. All other fractures and osteotomies achieved radiographic union.

CONCLUSION

Suture fixation of simple olecranon fractures and osteotomies was reliable in providing stable union and had a significantly lower re-operation rate when compared with tension band wiring.

Application of a novel shape-memory alloy concentrator in displaced olecranon fractures: a report of the technique and mid-term clinical results

Purpose

Olecranon fracture is a common upper limb fracture, and several surgical approaches have been advocated for its fixation. To overcome the complications associated with common techniques, we present a novel shape-memory alloy concentrator, an alternative for tension band compression, to fix olecranon fracture.

Methods

Fifty-seven patients (26 men and 31 women) with olecranon fracture, with a mean age of 45 years, were included in this study. Each patient had undergone open reduction and internal fixation using the Nitinol (Ni-Ti) arched shape-memory connector (ASC). The clinical assessments were performed using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance (MEP) score, which were both recorded at the final follow-up visit.

Results

The patients were followed up for 44 months on average (range, 31 to 56 months). No patients were lost to follow-up, and all of the olecranon fractures healed in an average of 15 weeks (range, 10 to 34 weeks). The mean DASH score was 8.6 (range, 0 to 32.4), and the mean MEP score was 92.5 (range, 74 to 100). Nine patients showed postoperative complications: prominent hardware (2), infection (1), loss of the range of functional motion (5), and heterotopic ossification (1).

Conclusion

The ASC may serve as a favorable device for multi-fragmented and comminuted fractures with rare hardware irritation and may also provide continuous concentrative compression to accelerate osseous healing, thereby aiding the restoration and permitting an early rehabilitation with a low incidence of postoperative complications.

Synostosis after fracture of both forearm bones treated by intramedullary nailing

This study evaluated the risk of radioulnar synostosis after fracture of both forearm bones at the same level. We hypothesized that (i) the incidence of synostosis in both-bone forearm fractures at the same level is low with intramedullary nailing (IMN); (ii) the type of fracture (open/closed) and type of reduction (open/closed) affect time to union. Seventy-eight patients who had been treated with IMN for fracture of both forearm bones and had at least 1 year of follow-up were included in the study retrospectively. All the patients were treated by IMN following closed reduction or open surgery. Patients were followed clinically and radiologically. Age, open or closed fracture, time to union, and occurrence of synostosis were documented. The mean age of the patients was 33.4 years. Fifty-three (68%) patients were male. Forty-eight (61.5%) patients had high velocity injuries. The mean follow-up was 26.4 (12-46) months. According to the Grace and Eversmann scoring system, 95% had good or excellent outcomes. The mean DASH score was 10.5 (0-56). Union rate was 100%. Only one patient (1.2%) had a radioulnar synostosis at middle third level. IMN is a safe method that yields a high union rate and contributes to a low incidence of synostosis. Open fracture and open reduction during surgery have no effect on time to union.

Pediatric Radioulnar Synostosis after Olecranon Fracture: A Case Report

Radioulnar synostosis which develops after treatment of isolated olecranon fracture is a rare complication. The aim of this study was to determine the clinical findings and postoperative outcomes of radioulnar synostosis after isolated olecranon fracture in a child patient. A 14-year-old girl was evaluated after falling on her left elbow. She had pain, edema, and motion limitation in her left elbow. After radiologic examinations, diagnosis of olecranon fracture was made. Olecranon fracture was fixated by open reduction and internal fixation with tension band wiring method via the posterior approach. When the patient came to the control to remove the implants 9 months after the first operation, there was a limitation in the supination and pronation movements. In the radiographs, synostosis was observed in the proximal region between the radius and ulna. The patient was reoperated to remove the implants. In the same session, synostosis was excised by using the posterior approach, and a barrier between the bones was constituted with bone wax and early elbow range of motion exercises started. In the postoperative first month, the patient had full flexion and extension but with 30 degrees of supination deficit. Radioulnar synostosis is rare but can be seen after isolated olecranon fractures. Early elbow motion after radioulnar synostosis surgery helps the patient to increase joint movement.

Fractures of the proximal ulna: current concepts in surgical management

Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex).

In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity.

Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first).

The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation.

For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint.

Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability.

Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function.

The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness.

Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.

Use of an Additional Nonlocking Screw in Olecranon Fracture Osteosynthesis Changes Failure Mechanism

Hardware-related complications can occur when plate fixation is used to stabilize osteoporotic fractures involving the olecranon. The use of an additional nonlocking screw, placed retrograde into the proximal fracture segment, may improve stability under load. The purpose of this study was to conduct a biomechanical comparison of olecranon repair constructs with and without this additional retrograde screw. Nine matched pairs of elderly fresh-frozen cadaveric upper extremities were used. Two-part olecranon fractures were modeled, and fracture stabilization was performed. Olecranon plates were implanted either with the standard surgical technique (CTRL) or with an additional retrograde screw (EXPT). Dynamic extensions of increasingly loaded forearms were performed, and comparisons of sustained cycles, maximum load, and total work were made. Relative motion of bone segments was tracked, and modes of failure were assessed. Seventy-eight percent of specimens from the CTRL group failed due to relative fragment displacement exceeding 3 mm, while 78% of EXPT specimens failed due to instantaneous catastrophic failure. There were no significant differences in terms of number of survived cycles, maximum load, or work performed between the groups. The addition of a retrograde screw in this plating technique changes the failure mode from fracture displacement to catastrophic failure. The use of a 3.5-mm retrograde screw in the relatively small proximal ulnar fragment should be avoided, but screws with a smaller diameter may still have potential to improve fixation. Further biomechanical and clinical research is necessary to improve strategies for plate fixation of olecranon fractures in the elderly population. [Orthopedics. 2019; 42(1):e74-e80.].