Between 2005 and 2007, nineteen consecutive patients with an acute comminuted olecranon fracture were managed with a titanium 3.5-mm locking compression plate (LCP; Synthes, Zeist, The Netherlands) by the senior author (P.K.). The fixation technique consisted of contoured dorsal locking compression plate fixation with a proximally inserted 3.5-mm intramedullary screw and a minimum of two unicortical locking screws distal to the fracture (Figs. 1-A, 1-B, and 1-C). Our medical ethics committee approved the study protocol. All patients gave consent to participate in the present study and were followed at regular intervals at least until the time of osseous healing, defined as the presence of crossing trabeculae on both anteroposterior and lateral radiographs. Fracture union was assessed by the treating physician (P.K.) and a radiologist.
All patients were invited to return for assessment of the elbow at a minimum duration of follow-up of twelve months, and sixteen patients returned after a mean duration of follow-up of twenty-two months (range, twelve to forty-eight months). At the time of the latest follow-up, the ranges of motion of the elbow and forearm, varus-valgus instability, nerve injury, and physician-rated forearm strength were assessed by an independent evaluator (G.B.) who was not involved in the initial treatment and rehabilitation. Forearm strength in flexion, extension, pronation, and supination was rated subjectively with use of a 6-point Likert scale ranging from 0 (no contraction) to 5 (normal strength). Patients rated the outcome with use of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire16, the Mayo Elbow Performance Index (MEPI)17, the Broberg and Morrey rating system18, and 10-point visual analog scales for patient satisfaction and pain. Furthermore, anteroposterior and lateral radiographs were evaluated by an independent radiologist and arthritis was graded by an experienced elbow surgeon who was not involved in their care. Arthritis was classified according to the system of Broberg and Morrey19 as Grade 0 (normal joint), Grade 1 (slight joint-space narrowing with minimal osteophyte formation), Grade 2 (moderate joint-space narrowing with moderate osteophyte formation), or Grade 3 (severe degenerative change with gross destruction of the joint). Finally, the results of the study were analyzed by an independent data analyst (G.B.). Statistical analysis of the measurements of the range of motion of the elbow before and after hardware removal was performed with a paired t test, with the level of significance set at p < 0.05.
Source of Funding
Stichting Wetenschappelijk Onderzoek Orthopaedische Chirurgie (Foundation for Scientific Research in Orthopaedic Surgery) provided financial support for the materials (e.g., radiographs) used in this study.
The study group included eleven women and eight men with an average age of fifty-six years (range, nineteen to eighty-seven years). There were nineteen acute fractures (including four Monteggia fractures), two of which were open and were classified as Gustilo-Anderson grade II20. The coronoid process was involved in five patients, all of whom had a type-3 fracture according to the system of Regan and Morrey21. Two patients had a posterior fracture-dislocation, and one had an anterior trans-olecranon fracture-dislocation. Nine fractures involved the right upper extremity, and ten involved the left. According to the AO system, there were four extra-articular fractures (type A), including one multifragmentary metaphyseal ulnar fracture (type A1.3) and three multifragmentary metaphyseal ulnar fractures with a simple proximal radial fracture (type A3.2); fourteen intra-articular proximal ulnar fractures (type B), including three multifragmentary olecranon fractures (type B1.1), four simple fractures of both the olecranon and the coronoid process (type B1.2), and seven multifragmentary combined intra-articular and extra-articular ulnar fractures (type B1.3); and one multifragmentary fracture involving the proximal parts of both the ulna and radius (type C3.1). The mechanism of injury was a fall from a height for thirteen patients, a bicycle accident for three patients, a motorcycle accident for two patients, and physical abuse for one patient. The mean interval between the injury and operative treatment was three days (range, zero to eight days).
Bone graft was used in two patients because of severe impaction of the articular surface. Local graft was used in one patient, and an iliac crest bone graft was used in the other. In one patient, a cerclage wire loop was used to stabilize the comminuted medial and lateral metaphyseal walls because there was not enough bone proximally for a small buttressing plate. Two patients had a radial head fracture. One was managed nonoperatively, and the other underwent radial head excision and the placement of a radial head prosthesis.
All fractures healed. The mean time to union was four months (range, two to nine months). Complications occurred in two patients: one patient had a wound infection that resolved after débridement and treatment with antibiotics, and one patient had a preoperative ulnar and median neuropathy that did not resolve. Three patients were lost to follow-up: one was incarcerated and exiled, one died of unrelated causes, and one had development of severe Alzheimer disease. These patients were followed at least until osseous union, for a mean of three months (range, two to four months), but did not have additional assessments.
For the remaining sixteen patients, the postoperative arc of flexion at the time of the latest follow-up was from a mean extension deficit of 13° (range, 0° to 50°; median, 10°) to a mean flexion of 136° (range, 120° to 150°; median, 140°). The arc of rotation of the forearm was from a mean supination of 71° (range, 10° to 80°; median, 80°) to a mean pronation of 74° (range, 10° to 80°; median, 80°). None of the patients had elbow instability. Forearm strength was rated as normal in thirteen patients, as 4 of 5 (movement against resistance) in two patients, and as 3 of 5 (movement against gravity) in one. In seven patients, the injury involved the dominant arm.
The mean DASH score was 13 (range, 0 to 42), with 0 representing a perfectly functioning arm and 100 representing the worst score. The mean MEPI score was 93 (range, 70 to 100), with higher scores indicating better function; according to this system, twelve patients had an excellent result, three had a good result, and one had a fair result. The average Broberg and Morrey score was 93 (range, 45 to 100); according to this system, nine patients had an excellent result, six had a good result, and one had a fair result. Extensive heterotopic ossification, grade-3 osteoarthritis, and a lack of postoperative functional exercises were the major causes of the severely decreased forearm motion that produced the one fair result. The mean visual analog scale pain score was 1.0 (range, 0 to 4), with 0 correlating with no pain and 10 correlating with the worst pain. The average visual analog scale satisfaction rating was 8.8 (range, 4 to 10), with 10 representing complete satisfaction. The two unsatisfactory ratings for satisfaction (4 and 5) were due to severe ulnar neuropathy in the case of one patient and higher expectations in the case of one patient. Radiographs that were made at the time of the latest follow-up confirmed articular congruity in all cases. Ulnohumeral osteoarthritis was present in seven of the sixteen patients, including five with a Broberg and Morrey grade of 1 and two with a grade of 3. Nine patients underwent hardware removal as outpatients at a mean of twelve months (range, five to eighteen months) postoperatively because of pain at the site of the hardware. After hardware removal, the mean elbow extension deficit in these patients improved significantly (p < 0.05) from 34° (range, 5° to 80°) to 10° (range, 0° to 50°). The mean flexion improved from 118° (range, 90° to 140°) to 138° (range, 120° to 150°), but this difference was not significant. No capsular release or manipulation with the patient under anesthesia was performed.
Note: The authors appreciate the support from Stichting Wetenschappelijk Onderzoek Orthopaedische Chirurgie (Foundation for Scientific Research in Orthopaedic Surgery) for its financial contribution to the study and thank Dr. David Ring for evaluating the radiographs.