Intramedullary Screw Fixation for Simple Olecranon Fractures.

Background: Olecranon fractures are common injuries that often require surgical fixation to maintain elbow function. Nonoperative management of these injuries may be indicated in the elderly, as a recent randomized controlled trial found that 81% (9) of 11 operatively managed olecranon fractures in the elderly had complications¹. While traditional techniques such as tension-band wiring and plate fixation produced satisfactory functional outcomes, they are associated with high rates of complications². Intramedullary screw fixation has gained popularity as an alternative technique for transverse olecranon fractures. The goal of this procedure is to reduce complication rates associated with olecranon open reduction and internal fixation while maintaining optimal functional outcomes.

Description: The patient is positioned in the lateral decubitus position with the arm placed over a padded Mayo stand. A direct posterior incision is made to the olecranon. Following irrigation and hematoma evacuation, the fracture is reduced. Pointed reduction clamps are used to reduce the fracture and hold a provisional reduction. A 2 to 2.5-cm longitudinal incision is made over the footprint of the triceps insertion. Next, a 3.5-mm drill is passed from the olecranon tip to the proximal ulnar diaphysis. The proximal ulna is then opened with a 4.5-mm drill, and a 6.5-mm calibrated tap is used to sound the ulna. Then a 6.5-mm, solid, partially threaded screw with a washer is placed across the fracture. Reduction aids are removed, and the surgical site is closed. The arm is splinted for 2 weeks to allow for soft-tissue healing, after which immediate full, active range of motion is allowed.

Alternatives: Alternatives include nonoperative treatment such as immobilization with a posterior long-arm splint, operative treatment with tension-band wiring, and operative treatment with plate and screw fixation.

Rationale: Because of the high rates of stiffness, contracture, and joint involvement associated with nonoperative treatment of olecranon fractures, operative treatment of these injuries is often recommended³. The most common types of surgical fixation include tension-band wiring or a plate-and-screw construct. Both techniques successfully lead to fracture healing and satisfactory functional outcomes; however, the main drawback of these procedures is their high rate of complications². A prior study reported complications in 19 (63%) of 30 patients with tension-band wiring and in 12 (38%) of 32 patients with plate-and-screw constructs. Symptomatic hardware, skin breakdown, and subsequent infection made up most of these complications². In contrast, intramedullary screw fixation utilizes low-profile hardware that is seated within the osseous cortex. This reduces soft-tissue irritation in a region that contains low proportions of subcutaneous tissue. However, fixation with an intramedullary screw alone is contraindicated for comminuted fracture patterns or olecranon fractures associated with elbow instability. The presently described technique is largely indicated for simple, transverse olecranon fractures or for the repair of olecranon osteotomies.

Expected outcomes: Patients who underwent intramedullary screw fixation for an olecranon fracture have had promising results. Although literature investigating the use of intramedullary screws is sparse, current reports indicate that the vast majority of patients progress to complete fracture healing with satisfactory patient outcomes. Patients largely achieve full range of motion, good functional outcomes, and low failure rates that are comparable with traditional techniques^4-8. Notably, patients who undergo intramedullary screw fixation have significantly lower rates of complications, with a reoperation rate of 18% (35 of 199 patients). When controlling for confounding factors, intramedullary screw fixation reduced the odds of a secondary surgical procedure by 54%, compared with the use of a plate-and-screw construct. Overall, the reoperation rates for the different constructs were as follows: intramedullary screw fixation, 18% (35 of 199); tension band, 24% (31 of 128); and plate construct, 13% (29 of 229)⁹.

Important tips: When utilizing the posterior approach, curve the incision laterally along the elbow in order to prevent ulnar nerve injury and subsequent scar irritation when leaning on the elbow.An incorrect entry point or screw trajectory can cause premature engagement of the screw with the ulnar cortex, which can lead to fracture gapping and/or cortical perforation.Pointed reduction clamps and adjuvant fixation can be helpful to maintain fracture reduction while the intramedullary screw is passed.Appropriate postoperative care and early range of motion are key to a successful outcome.

Acronyms and abbreviations: CT = computed tomography.