1. Olecranon fracture Lonnie Froberg, MD, Ph.D Odense University Hospital

2. 20% of forearm fracture 20% of forearm fracture 12 per 100.000 persons per year 12 per 100.000 persons per year Low-energy fall Low-energy fall Increased risk >50 years Increased risk >50 years 90% AO 21.B1.1 90% AO 21.B1.1 Duckworth et al. Injury 2012;43:343-346 Duckworth et al. Injury 2012;43:343-346

3. Why operate? Why operate? Methods of fixation Methods of fixation –K-wire, cerklage –Plating Outcome Outcome Summary Summary

4. Why operate? Restore articular surface Restore articular surface Achieve absolute stability Achieve absolute stability Commence early active movement Commence early active movement Preservation of range of motion and power Preservation of range of motion and power Avoidance of complications Avoidance of complications

5. Methods of fixation?

6. Cadaveric elbow joint Cadaveric elbow joint Standard osteotomies Standard osteotomies Five different fixation techniques Five different fixation techniques Loads applied comparable to clinical situations Loads applied comparable to clinical situations Displacements measured Displacements measured Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367-372

7. Methods of fixation? Fracture type Transverse Oblique Comminuted Fixation technique Tension band 1.0 mm, 1 knot, K-wire 2.0 mm Tension band 1.0 mm, 2 knots, K-wire 2.0 mm Tubular plate Cancellous screw, washer Cancellous screw, washer, tension band Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372

8. Methods of fixation? Fracture type Fixation technique Transverse Tension band, 2 knots Oblique or tubular plate Comminuted Tubular plate Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372

9. K-wire and cerklage

10. K-wire with or without eyelets? No significant difference in postoperative pain or in rate of hard ware removal No significant difference in postoperative pain or in rate of hard ware removal Kim et al. Kim et al. J Hand Surg Am. 2013.Jul 9

11. How to place the K-wires? Proximal ulnar canal? Proximal ulnar canal? Anterior cortex? Anterior cortex? Distal ulnar canal? Distal ulnar canal? Huang et al. J Trauma. 2010.68;1:173-176

12. How to place the K-wires? Proximal ulnar (n=24) Anterior cortex (n=28) Distal ulnar (n=26) Average follow- up/months 34.5 s.d 7.2 34.0 s.d 5.9 29.6 s.d 7.2 Symptomatic implant removal 8 (33%) *p=0.03 3 (11%) 2 (8%) Proximal migration of K- wire/mm 4.08 s.d. 1.89 *p=0.001 1.53 s.d 0.56 1.31 s.d 0.54 Satisfactory functionel outcome 21 (88%) 26 (93%) 26 (100%)

13. How to place the K-wires? Inserted as close as possible to the articular surface Inserted as close as possible to the articular surface Back 1 cm from final position, cut obliquely, bent Back 1 cm from final position, cut obliquely, bent Incisions with lines in triceps Incisions with lines in triceps K-wires are impacted into ulna K-wires are impacted into ulna Newman et al. 2009. Injury; 40(6): 575-581

14. How to place the K-wires? K-wire penetration more than 10 mm beyond the anterior cortex increases risk for penetration of median nerve and ulnar artery K-wire penetration more than 10 mm beyond the anterior cortex increases risk for penetration of median nerve and ulnar artery Prayson et al. Shoulder Elbow Surg. 2008.17;1:121-125

15. Which kind of tension band? Failure (> 2 mm movement across osteotomy) Compression Stainless steel wire 0%71% Ethibond No. 2 100%66% Ethibond No. 5 40%40% Fiber wire 0%43% Lalliss et al. Jour Bone Joint Surg (Br).2010.92B;2:315-319

16. Plating

17. Plating When to plate? When to plate? –Tension band is not appropriate –Oblique fractures distal to the midpoint of the troclear notch –Co-existing coronoid fracture –Associated with Monteggia fracture dislocation Newman et al. 2009. Injury; 40(6): 575-581

18. Which kind of plate? Cadaveric study Cadaveric study Comminute fracture Comminute fracture No difference in failure rate (>2 mm gap of fracture) No difference in failure rate (>2 mm gap of fracture) Buijze et al. Arch Orthop Trauma Surg.2010;130:459-464

19. Which kind of plate? Advantage of locking compression plate to conventionel plate: Advantage of locking compression plate to conventionel plate: –Angular and axial stability –Preserves periosteal blood supply –No toggling of unlocked screws (improves fixation in osteoporotic fractures and comminution)

20. Which kind of plate? Stainless steel or titanium? Stainless steel or titanium? More screw in proximal fragment better than fewer screws? More screw in proximal fragment better than fewer screws? Larger screws better than small screws? Larger screws better than small screws?

21. Which kind of plate? Accumed stainless stell Accumed stainless stell Synthes stainless stell Synthes stainless stell Synthes titanium Synthes titanium US Implants US Implants Zimmer Zimmer Edwards et al. J Orthop Trauma 2011;25(5):306-311 Edwards et al. J Orthop Trauma 2011;25(5):306-311

22. Which kind of plate? No statistical difference between maximum load and cycles survived No statistical difference between maximum load and cycles survived Edwards et al. J Orthop Trauma 2011;25(5):306-311 Edwards et al. J Orthop Trauma 2011;25(5):306-311

23. Outcome – Cochrane review Veillette et al. Orthop Clin N Am. 2008;39:229-236 Short term (2-3 years) *only plate fixation Long-term (15-25 years) Pain1 (VAS score) 6% severe daily symptoms Motion compared to non-affected arm Decreased supination Decreased flexion and extension (5 degrees) Radiographic evaluation 8% OA 5% OA 1% non-union Patient-rated outcome 9.7 (VAS score) 96% excellent or good

24. Summary – Tension band fixation Fracture: Transverse or oblique Fracture: Transverse or oblique K-wire: Anterior cortex or distal ulnar canal K-wire: Anterior cortex or distal ulnar canal K-wire penetration: <10 mm beyond the anterior cortex K-wire penetration: <10 mm beyond the anterior cortex Tension band: 1.0 mm stainless steel wire, 2 knots Tension band: 1.0 mm stainless steel wire, 2 knots

25. Summary - Plating Fractures: Distal to the midpoint of the troclear notch, co-existing coronoid fracture, Monteggia Fractures: Distal to the midpoint of the troclear notch, co-existing coronoid fracture, Monteggia Locking compression plate theoretically superior to conventionel plate Locking compression plate theoretically superior to conventionel plate

26. Thank you

27. Technique

28. Technique

29. Technique