Olecranon fractures

Cite this article as:
Becky Platt. Olecranon fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21080

14-year old Noah was rocking on his chair while daydreaming his way through a maths lesson this morning… and fell off.  He reports that he landed directly on his left elbow and that it has been painful throughout the day.  He attends your ED this afternoon with his unamused mother.

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

You ensure Noah has been given analgesia before examining him.  His pain score is 5 and he seems comfortable after paracetamol and ibuprofen when his arm is resting.  His elbow is notably bruised and swollen. He is particularly tender over the olecranon and any movement is painful.  His neurovascular status is normal with good radial and ulnar pulses, normal sensation in the radial, ulnar and median nerve distributions and as he’s able to make the rock, paper, scissors and ok hand signs, you’re happy he has full motor function.  You order AP and lateral films of his elbow and pop him in a broad arm sling for comfort before sending him round for his x-rays.

Epidemiology and mechanism of injury

Olecranon fractures in children are rare, comprising around 5% of elbow fractures. Compare this with supracondylar fractures which comprise over half of all elbow fractures in the paediatric population. Olecranon fractures may result from a fall onto an outstretched hand (FOOSH), direct trauma or, occasionally, a stress fracture from repetitive throwing motion in athletes.

They can be classified according to the Mayo classification.

Examination findings

In addition to pain, there will almost certainly be generalised swelling around the elbow, usually with visible evidence of trauma, such as bruising or abrasion, over the olecranon process.  Point tenderness over the olecranon is often a feature, but the degree of swelling can sometimes make this difficult to appreciate.  Inability to fully extend the elbow is common, and pain on extension, supination and pronation is expected.  In those with comminuted or significantly displaced fractures it may be possible to feel crepitus over the olecranon.

Radiology

Interpreting children’s elbow x-rays can be mind boggling. Epiphyses ossify at different rates and so it can be easy to confuse a normal olecranon epiphysis with a fracture.  The olecranon epiphysis normally appears around 9 years and fuses at 15-17 years.   Be sure to refer to the CRITOE rules and if you’re not sure whether you’re seeing a normal epiphysis or a fracture, seek senior advice.  The olecranon can be best assessed on the lateral film.

This x-ray shows a normal olecranon epiphysis:

Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 26814

Some olecranon fractures are obvious…

…but some can be incredibly subtle as illustrated in this series from Radiology Assistant:

Some olecranon fractures may only be visible on one view.  This may be the AP or the lateral.  The below elbow x-rays show a transverse olecranon fracture visible on the AP view only (arrow).  Note the raised anterior and posterior fat pads on the lateral view.  And an extra bonus point to those who spotted the subtle radial neck fracture.

Management

The majority of olecranon fractures (around 80%) are either undisplaced or minimally displaced (less than 2mm); these can be managed conservatively with an above elbow back-slab with good functional outcome.

Minimally displaced (<2mm) fracture in a 7 year old, requiring conservative management only. Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 23650

Complications

In children with a displaced olecranon fracture, there is risk of complications including delayed or non-union, ongoing elbow stiffness and impaired function.  Refer any child who has an olecranon fracture with these features as they’re likely to require surgical intervention:

  • >2-4mm displacement
  • angulation of >30°
  • intra-articular involvement
  • extensor mechanism disruption
  • instability on extension
  • comminution

Olecranon fracture with >30 degrees of displacement, requiring surgical fixation. From Orthobullets.com.

The practitioner seeing injured children in the ED must be aware of the potential for these.  Displaced olecranon fractures can cause growth disturbances resulting in fixed flexion deformity of the elbow joint and associated morbidity into adulthood.

The ulnar nerve is particularly at risk of injury with olecranon fracture. Ensure you carry out a thorough neurovascular assessment, in particular checking sensation over the little finger and that the small muscles of the hand are functioning normally (the “scissors” sign).

A significant proportion of olecranon fractures are associated with concomitant injury, including radial neck fracture and /or supracondylar fracture and any co-existing injury is prognostic for poorer outcome.  When interpreting the x-ray, it is important therefore to have a systematic approach.

Bullets of wisdom 

  • Don’t confuse an unfused olecranon epiphysis with a fracture
  • But don’t forget that olecranon fractures can be subtle – maintain a high index of suspicion in children with direct trauma and inability to extend their elbow
  • Olecranon fractures are sometimes only visible on one view and this can be the lateral or the AP
  • Displaced fractures can have devastating consequences and must be referred to orthopaedics as they may need surgical intervention
  • Document neurovascular status and be sure to check ulnar nerve function
  • And look for a concomitant radial neck or supracondylar fracture

Noah returns from X-Ray and you review his films. He has a posterior fat pad sign and on closer scrutiny you spot an intra-articular fracture of the olecranon. You recognise that this type of fracture can be associated with complications and refer him to the orthopaedic team.  You ensure that his pain score and neurovascular status are being assessed regularly.

 

References

Cabanela M.E. & Morrey B.F. (1993) The Elbow and Its Disorders. 2nd ed. Philadelphia, PA, USA: WB Saunders cited in Sullivan, C. W., & Desai, K. (2019). Classifications in Brief: Mayo Classification of Olecranon Fractures. Clinical Orthopaedics and Related Research, 477(4), 908–910.

Caterini, R., Farsetti, P., DʼArrigo, C., & Ippolito, E. (2002). Fractures of the Olecranon in Children. Long-Term Follow-Up of 39 Cases. Journal of Pediatric Orthopaedics B, 11(4), 320–328.

Corradin, M., Marengo, L., Andreacchio, A., Paonessa, M., Giacometti, V., Samba, A., … Canavese, F. (2016). Outcome of isolated olecranon fractures in skeletally immature patients: comparison of open reduction and tension band wiring fixation versus closed reduction and percutaneous screw fixation. European Journal of Orthopaedic Surgery and Traumatology, 26(5), 469–476.

Degnan, A. J., Ho-Fung, V. M., Nguyen, J. C., Barrera, C. A., Lawrence, J. T. R., & Kaplan, S. L. (2019). Proximal radius fractures in children: evaluation of associated elbow fractures. Pediatric Radiology, 1–8.

Edgington, J. & Andras, L. (2019) Olecranon fractures – pediatric https://www.orthobullets.com/pediatrics/4010/olecranon-fractures–pediatric?expandLeftMenu=true

Hill, C. E., & Cooke, S. (2017). Common Paediatric Elbow Injuries. Open Orthopaedics Journal, 11, 1380–1393.

Kraus, R. (2014). The pediatric vs. the adolescent elbow. Some insight into age-specific treatment. European Journal of Trauma and Emergency Surgery, 40(1), 15–22.

Nicholson, L. T., & Skaggs, D. L. (2019). Proximal Radius Fractures in Children. The Journal of the American Academy of Orthopaedic Surgeons, 00(00), 1–11.

Pace, A., Gibson, A., Al-Mousawi, A., & Matthews, S. J. (2005). Distal humerus lateral condyle mass fracture and olecranon fracture in a 4-year-old female – Review of literature. Injury Extra, 36(9), 368–372.

Perkins, C. A., Busch, M. T., Christino, M. A., Axelrod, J., Devito, D. P., Fabregas, J. A., … Willimon, S. . (2018). Olecranon fractures in children and adolescents: outcomes based on fracture fixation. Journal of Children’s Orthopaedics, 12, 497–501.

Rath, N. K., Carpenter, E. C., Ortho, F., & Thomas, D. P. (2011). Traumatic Pediatric Olecranon Injury. A Report of Suture Fixation and Review of the Literature. Pediatric Emergency Care, 27(12), 1167–1169.

DFTB in EMA #5 – Sticks and stones may break some bones

Cite this article as:
Andrew Tagg. DFTB in EMA #5 – Sticks and stones may break some bones, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8055

This month in the EMA the DFTB team look at how we might treat a simple forearm fracture.

“Up to a quarter of the paediatric population of the UK present to an ED annually with a large number being due to falls. High-risk activities such as scooter riding, climbing on monkey bars and backyard trampolines are partially to blame although the implementation of safety netting for trampolines has led to a reduction in injuries.”

You can read the article here.

Reference:

Tagg, A., Goldstein, H., Davis, T., and Lawton, B. (2016) Sticks and stones may break some bones.Emergency Medicine Australasia, doi: 10.1111/1742-6723.12531.

Trampoline injuries

Cite this article as:
Andrew Tagg. Trampoline injuries, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.7954

4-year-old Calvin received the best Christmas present ever – a trampoline of his very own! After spending the morning bouncing with his older brother, Iggy, he started to complain of pain in his left knee.  The trampoline was safety-netted so his parents were happy that he couldn’t have fallen out and so, mystified that he still refuses to walk, he is brought in to the emergency department.

 

Bottom line

  • Prevention is better than cure so employ these trampoline rules:
    • Only one child on the trampoline at a time
    • Always have adult supervision
    • Make sure the trampoline is in good working order
    • Keep it away from walls and other potential hazards

 

How common are trampoline injuries?

Trampoline related injuries are uncommon in adults. There were only 50 reported in Victoria between 2007 and 2013 with lower limb injuries being the most prevalent. 2200 children presenting to Victorian emergency departments within a similar time-frame. Victorian data demonstrated an 18% increase in multi-user injuries with an over-representation in children under 4 years old.  With Christmas approaching and trampolines being on many children’s’ wish lists the Victorian State Government has put out a press release to make parents more aware of the dangers.

 

Has legislation made any difference?

The Australian trampoline standard (AS 4989-2006) is a voluntary industry standard that recommends the protection of sharp edges, spring and frame padding. The Standards Australia Trampoline Committee is looking to make these standards mandatory.

Whilst injuries related to the makeup of the trampoline itself (i.e. spring and frame injuries), as well as fall injuries has decreased, there has been an increase in injuries related to one or more users. The use of safety-netting to stop kids falling off has not been shown to decrease the number of injuries. Parents may be falsely reassured that they do not need to supervise their kids once they are enclosed.

 

How are these kids injured?

Injuries occur to:

  • Multiple users
  • Falls from the trampoline
  • Impact with the frame or springs

Some of them fall into the structural framework of the apparatus but they are more likely to bump into each other or sustain a lower limb injury as a result of a double-bounce. If you really want to look into the physics of the double-bounce then read this riveting paper.

 

Are there any trampoline specific injury patterns?

Lower limb injuries are more common than upper and subtle proximal tibial physeal fractures may be difficult to detect on initial x-rays and require a bone-scan to make a delayed diagnosis. As the child bounces, often with another occupant, the knee hyperextends as is subjected to an axial load leading to a small torus or buckle fracture in the region of the physis. They may present with reluctance to walk after playing in the yard.

Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 20622

There are some less common injury patterns such as manubrio-sternal dislocations, vertebral artery dissection (due to cervical hyperextension and rotation) and atlanto-axial subluxation.

 

An X-ray revealed no obvious abnormality, even when the anterior tilt angle was taken into consideration. He was placed in an above-knee back-slab and referred on to orthopaedic outpatients for evaluation. A bone scan performed a few days after the injury, made the diagnosis of small fracture more likely. There were no adverse sequelae of this delay in diagnosis.

 

References

3AW talk to Warwick Teague (@doctorwozza) – Director of Trauma at the RCH, Melbourne

Arora V, Kimmel LA, Yu K, Gabbe BJ, Liew SM, Kamali Moaveni A. Trampoline related injuries in adults. Injury. 2015 Sep 11. pii: S0020-1383(15)00539-2.

Ashby K, Eager D, D’Elia A, Day L. Influence of voluntary standards and design modifications on trampoline injury in Victoria, Australia. Inj Prev. 2015 Oct;21(5):314-9.

Ashby K, Pointer S, Eager D, Day L. Australian trampoline injury patterns and  trends. Aust N Z J Public Health. 2015 Oct;39(5):491-4.

Briskin, Susannah, et al. “Trampoline safety in childhood and adolescence.”Pediatrics 130.4 (2012): 774-779.

Stranzinger, Enno, et al. “The anterior tilt angle of the proximal tibia epiphyseal plate: A significant radiological finding in young children with trampoline fractures.” European journal of radiology 83.8 (2014): 1433-1436.