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    Transolecranon Fracture-Dislocation in an Older Female Patient

    A fall at home sends a 70-year-old woman to the emergency department. Imaging reveals a transolecranon fracture with significant comminution of the olecranon, as well as comminution and dislocation of the radial head with fracture. What’s the best treatment option for this patient’s injury?

    Authors

    Jeffrey Lu, BS, and J. Gabriel Horneff, MD

    Introduction

    Originally described by Biga and later expanded on by Ring et al, a transolecranon fracture-dislocation refers to a constellation of injuries in the elbow, including transolecranon fracture, dislocation of the radial head relative to the capitellum, and resulting instability of the elbow joint. [1-3]

    This injury is different from a Monteggia fracture, in which the ulnar fracture is typically distal to the coronoid and there is dislocation of the radiocapitellar and proximal radioulnar joints. There are also variations of these fracture-dislocations, with overlapping characteristics of both injuries. In general, preservation versus dissociation of the proximal radioulnar joint is the distinction between the injury types, with Monteggia fractures demonstrating the latter characteristic.

    A transolecranon fracture-dislocation typically occurs via an axial load on the dorsal aspect of the forearm with the elbow in mid-flexion. [2] If untreated, this injury leaves patients at high risk of recurrent instability due to disruption of the major osseous contributor to elbow stability.

    Olecranon fractures account for approximately 10% of upper extremity fractures in adults, with an incidence of 11.5 per 100,000 per year. [4,5] They seem to occur most frequently in the sixth decade, but recent studies have reported increasing incidence in the older population. [6,7] Concurrent injuries, including coronoid fracture and radial head fracture, have been reported. [1-3,8] The goals of treatment of a transolecrenon fracture-dislocation include: [9,10]

    • Anatomic restoration of the articular surface
    • Restoration of joint stability
    • Restoration of joint motion
    • Prevention of stiffness
    • Restoration of the greater sigmoid notch

    Several methods of treatment have been described, each with different indications. We present a case of a posterior Monteggia variant transolecranon fracture-dislocation with significant coronoid and olecranon comminution in addition to significant radial head comminution. The injury required plate fixation, radial neck plate fixation, radial head replacement, and lateral ulnar collateral ligament repair.

    Case Presentation

    After a fall at home, a 70-year-old female patient presented to the emergency department with the chief complaint of right elbow pain. She had no prior history of elbow pain, instability, or joint trauma.

    Per the emergency department report, the patient had comminution of the proximal ulna and radius with a posterior dislocation of the ulnohumeral joint. She was given conscious sedation by the emergency department staff and her elbow was reduced to a more acceptable alignment. She was placed in a posterior splint before an orthopaedic evaluation.

    History and Physical Examination

    • History significant for deep vein thrombosis and pulmonary embolism
    • Significant swelling and bruising of the right elbow with a large, hemorrhagic blister on the medial aspect of the elbow
    • Significant tenderness to palpation about the elbow
    • Full range of motion (ROM) in the right wrist and hand; elbow ROM evaluation deferred due to the concern for gross instability
    • Neurovascularly intact in the distal right extremity
    • 5/5 strength in the median, radial, ulnar, anterior, and posterior interosseous nerve distribution
    • Sensation intact to light touch in the median, radial, ulnar, anterior and posterior interosseous distributions

    Differential Diagnosis

    • Transolecranon fracture-dislocation
    • Bado II Monteggia fracture-dislocation
    • Terrible triad
    • Isolated radial head fracture
    • Isolated olecranon fracture
    • Distal humeral fracture

    Imaging

    Anteroposterior (AP) and lateral views of the elbow were obtained in the emergency department. There is significant comminution of the olecranon and radial head, with the proximal radioulnar joint dislocated posteriorly (Figure 1).

    Figure 1. Initial AP and lateral views of the elbow obtained in the emergency department.

    The fracture was splinted in the emergency department. Post-reduction radiographs were obtained (Figure 2).

    Figure 2. Post-reduction radiographs.

    A post-reduction CT scan was also obtained, and the images showed marked comminution of the radial head and neck, as well as coronoid and olecranon fracture (Figure 3).

    Figure 3. Post-reduction CT scans. The arrow points to the butterfly fragment of the proximal radial shaft (left), while the axial view (right) shows that the proximal radioulnar joint remains together.

    Diagnosis

    • Transolecranon fracture-dislocation

    Treatment

    Non-operative management of a transolecranon fracture-dislocation is possible, which eliminates the risks associated with surgery. However, there are significant disadvantages:

    • Prolonged immobilization period that would likely lead to significant elbow stiffness
    • Increased risk of malunion or non-union
    • Increased risk of recurrent instability

    We discussed non-operative versus operative treatment with the patient, and she consented to surgery. She was scheduled for open reduction and internal fixation (ORIF) of the olecranon and coronoid with radial head replacement. ORIF can be done through tension band wiring or plate fixation. Radial head fractures can be treated with ORIF or radial head arthroplasty.

    Tension Band Wiring

    Advantages

    • Stable fixation and high union rates for simple, non-comminuted olecranon fractures
    • Allows earlier elbow motion by transferring the pull of the triceps to compression of the fracture

    Disadvantages

    • Irritation from hardware
    • Risk of anterior interosseous nerve injury with K-wire placement
    • Risk of injury of the ulnar artery via anterior cortex perforation
    • Impaired forearm rotation
    • Inadequate compressive fixation for fracture comminution

    Locking Plate Fixation

    Advantages

    • Good ROM and strength compared with uninjured arm
    • Earlier progression with elbow ROM, allowing for decreased rate of elbow stiffness
    • Lower rate of non-union

    Disadvantages

    • Impaired forearm supination
    • Potential for larger soft tissue dissection, depending on the length of the plate
    • Potential for soft tissue hardware irritation

    Radial Head ORIF

    Advantages

    • Maintains joint anatomy
    • Increased fixation
    • Earlier ROM possible

    Disadvantages

    • Neurovascular injury risk
    • Hardware irritation
    • Risk of infection
    • Increased stiffness and non-union with increased comminution of the fracture
    • Greater potential for heterotopic ossification compared with radial head arthroplasty

    Radial Head Excision

    Advantages

    • Immediate pain relief for patients with limited use of their arms
    • No increase in stiffness following surgery

    Disadvantages

    • Proximal radial migration with axial load
    • Decreased joint stability
    • Wrist pain secondary to proximal migration of the radius

    Radial Head Arthroplasty

    Advantages

    • Less risk of revision surgery or hardware removal
    • Can be used in comminuted radial head fractures
    • Decreased stiffness with earlier ROM

    Disadvantages

    • Does not preserve the anatomy, leading to increased wear on the capitellum
    • Osteolysis around the radial replacement

    Due to the comminution of the radial head and neck and the olecranon fracture, radial head arthroplasty and plate fixation of the ulna were preferred.

    Radial head ORIF is usually reserved for simple fractures with fewer than 3 fragments for optimal outcomes. In this case, significant comminution required radial head arthroplasty. An advantage of radial head arthroplasty over ORIF is that the arthroplasty prevents the joint from being overstuffed.

    Below, we describe the steps in the surgical procedure for radial head arthroplasty and plate fixation of the ulna.

    Surgical Procedure

    • Place the patient in the left lateral decubitus position, with the right side up in a beanbag positioner.
    • Position the fluoroscopic C-arm at the head of the table.
    • After the patient receives general endotracheal anesthesia and perioperative intravenous antibiotics, place a tourniquet as high on the operative arm as possible and inflate the pressure to 250 mmHg.
    • Make the first incision on the posterior aspect of the elbow. It’s important to curve the incision laterally around the tip of the elbow to prevent breakdown of skin over the olecranon tip.
    • Evacuate any swelling, hematoma, or edema in the subcutaneous tissue down to the level of the triceps fascia.
    • Identify the proximal fracture. If a hematoma is found at the fracture site, careful dissection and evacuation should be performed, taking care to maintain as many fracture fragments as possible. Smaller fragments should not be completely excised of their soft tissue attachments so that they maintain some blood supply.
    • Make an incision between the flexor carpi ulnaris and the extensor carpi ulnaris bellies to expose the ulna.
    • Gain access to the ulnar humeral joint and radiocapitellar joint via the fracture and evaluate the radial head. Ensure that any radial head fragments incarcerated in the joint are completely excised. Replacement is suggested over ORIF if there is significant comminution of the radial head with 3 or more fragments or if there is elbow dislocation.
    • If there is significant fracture propagation distally though the radial neck, continue dissection through the annular ligament to allow for placement of a buttress plate, which will ensure stability of the radial head arthroplasty. Care should be taken to avoid injury to the posterior interosseous nerve.
    • In the case presented, a mini fragment T-shaped plate was used to gain control of a large butterfly fragment of the proximal radial shaft. This created a stable base for placement of a radial head arthroplasty. Care was taken to ensure that screw fixation of this plate did not impede the stem of the radial head replacement.

    Attention is then be turned to the ulna.

    • Evaluate the coronoid process for stability, and if it is unstable, use K-wires to hold it in place. We left 1 threaded K-wire in to maintain congruity and stability into the largest of the coronoid fragments.
    • Reconstruct the trochlear notch to re-establish good joint congruity. This can be performed with K-wires followed by screws using a lag by technique.
    • In general, ORIF is recommended over tension wire fixation for comminuted fractures. We prefer the use of a pre-contoured, 3.5-mm locking olecranon plate.
    • A longitudinal incision (“pita pocket technique”) should be performed at the triceps insertion to allow the plate to be as close to the bone as possible.
    • In cases of significant comminution, it is important to achieve good bicortical fixation in the distal aspect of the olecranon plate.
    • Once ORIF is complete, assess the lateral ulnar collateral ligament. If the ligament has been injured, it can be repaired to increase lateral stability of the elbow joint.
    • In this instance, we used a large posterior incision to gain initial exposure of the olecranon fracture. A large subcutaneous flap was created laterally to access Kocher’s interval for lateral ulnar collateral ligament repair. Alternatively, dual skin incisions can also be considered, based on surgeon preference.
    • We also used non-absorbable suture to secure the lateral ulnar collateral ligament remnant on the humerus to the radial aspect of the plate to increase lateral stability. Significant comminution of ulnar attachment site on the lateral ulnar collateral ligament prevented separate anchor/transosseous fixation.
    • Take the forearm through full ROM to ensure adequate stability.
    • Following lateral ulnar collateral ligament repair, perform layered closure to decrease the risk of wound dehiscence.
    • Once the procedure is complete, immobilize the patient’s arm at 90° with a posterior arm splint in neutral forearm rotation.

    Postoperative Course

    Immediate Postoperative Course

    The patient tolerated the procedure well without complications. After she was assessed in the recovery room and found to be neurovascularly intact, she was given a postoperative regional block. She was discharged to home on the same day as surgery.

    First Postoperative Visit, 2 Weeks after Surgery

    The split was removed in the office and the patient was taken through passive ROM from -45° of extension to 100° of flexion. She had some stiffness at the end ROM but no mechanical block. Radiographs showed intact hardware and a stable joint (Figure 4).

    Figure 4. Two weeks after surgery, the patient had intact hardware and a stable joint.

    The patient was placed in a new splint due to concerns about instability. She was advised to continue with elevation, anti-inflammatory medication, and icing. The next postoperative visit was scheduled in 1 week for close evaluation.

    Second Postoperative Visit, 3 Weeks after Surgery

    The splint was again removed in the office and the patient was taken through passive ROM from -40° of extension to 100° of flexion. She had no increase in pain before passive ROM but reported more pain toward the end of the motion arch. The patient also had 60° of supination and 40° of pronation with no mechanical block. As a result, she was allowed to begin physical therapy with both passive and active ROM.

    The patient was fitted with a hinged elbow brace that limited extension to -20° and flexion up to 120°. She was given a script for physical therapy to begin passive and active assisted ROM, and she was advised to avoid lifting anything heavier than a coffee cup.

    Third Postoperative Visit, 6 Weeks after Surgery

    The patient was pleased with her progress. Her active elbow motion was 30° to 100 degrees° and she had 40° of pronation and 60° of supination with no mechanical block. Radiographs demonstrated a well-fixed plate and no signs of dislocation (Figure 5).

    Figure 5. Radiographs obtained at the 3-month postoperative visit showed a well-fixed plate with no signs of dislocation.

    Fourth Postoperative Visit, 3 Months after Surgery

    By 3 months after surgery, the patient was feeling very good about her progress. Her active elbow motion was -10° to 135°, with 80° of pronation and supination and no mechanical block. She was encouraged to continue with physical therapy for progressive strengthening for 6 more weeks and then to return to activities as tolerated.

    Potential Surgical Complications

    Fortunately, this patient did not develop any postoperative complications. Surgeons who are managing patients with a transolecranon fracture-dislocation should be aware of these possible complications:

    • Infection
    • Compartment syndrome
    • Neurovascular injury: The radial/posterior interosseous nerve is at risk with the posterolateral approach
    • Post-surgical joint stiffness: A common complication that usually does not alter functional capabilities; however, it may require surgical release if extreme
    • Heterotopic ossification: Indomethacin can be used as prophylaxis but can decrease healing rates; surgical revision is reserved for patients with severe loss of motion and decreased function
    • Non-union/malunion: May require revision
    • Postoperative instability: May be the result of non-union of bony fragments; consider prolonged immobilization of the joint, depending on patient factors such as age, activity before surgery, degree of fracture; may require revision

    Author Information

    Jeffrey Lu, BS, is a medical student at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. J. Gabriel Horneff III, MD, is a board-certified orthopaedic surgeon specializing in the treatment of shoulder and elbow conditions at The Rothman Institute, Philadelphia, Pennsylvania. He is also an Assistant Professor of Orthopaedic Surgery at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.

    Disclosures: The authors have no disclosures relevant to this article.

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