Orthopaedic Journal of Sports Medicine | 2019
Surgical Treatment of Displaced Olecranon Fracture Through a Persistent Physis: Case Report and Review of the Literature
Abstract
The patient in this case report was a 16-year-old, healthy, right-hand dominant male who presented to the emergency department with right elbow pain and swelling after a fall while playing basketball earlier the same day. He landed directly on his right elbow, which resulted in immediate pain, swelling, and inability to use the extremity. No other injuries were sustained. He had no history of injury or pain to the right elbow. He also had no history of tobacco or drug use. On physical examination, there was mild swelling and tenderness to palpation of the olecranon along with a palpable gap at the fracture site. He was neurovascularly intact distally. Compartments of the arm were soft and compressible. Initial anteroposterior and lateral radiographs of the right elbow demonstrated a persistent olecranon apophysis determined by smooth, rounded edges without cortical interruption and bony separation through the olecranon apophysis involving approximately 40% of the joint surface with 1.5-cm displacement (Figure 1, A and B). Contralateral elbow radiographs confirmed that the left olecranon physis was closed (Figure 2). The decision was made to proceed with open reduction and internal fixation (ORIF). There was an underlying elbow flexion contracture of approximately 15 preoperatively during examination under anesthesia. A posterior approach was utilized, with a longitudinal curvilinear incision centered over the olecranon. Fullthickness flaps were developed down to the fracture site. On visualization of the fracture site, it was apparent that the fracture extended through a persistent olecranon physis because of rounded bony edges, smooth cartilage in place of cancellous intramedullary bone, and fractured cartilage at the joint surface, suggesting preinjury physeal deformity and nonunion. The fracture site was subsequently debrided and the persistent physeal cartilage was removed. Indirect articular reduction was first attempted by lining up the dorsal olecranon surfaces using a tenaculum clamp with a drill hole in the dorsal cortex of the distal fragment. K-wires were then used for provisional fixation, and reduction was checked on multiplanar fluoroscopy (Figure 3). Obvious deformity at the articular surface was noted on fluoroscopy when using the posterior olecranon cortical surface as a reference. Subsequently, provisional fixation was removed and direct reduction was then performed by aligning the elbow articular cartilage. K-wires were used again for provisional fixation, and a congruent joint surface was achieved. Although the articular cartilage was in nearanatomic alignment and a smooth elbow range of motion (ROM) was noted, there was a mismatch between the posterior bone edges of the dorsal olecranon because of the chronic injury of the olecranon physis after removal of the persistent cartilage. An olecranon variable-angle plate (Trimed Inc) was then placed and affixed into position without complication (Figure 4). The olecranon plate was used because of concerns that a tension band construct may cause gapping at the articular surface in this case where a gap was noted dorsally. The aforementioned dorsal cortex mismatch and fracture gap was filled with 3 mL of demineralized bone matrix allograft to help stimulate fracture healing and minimize nonunion via its osteoconductive and osteoinductive Address correspondence to Joseph J. King, MD, Orthopaedics and Sports Medicine Institute, University of Florida, 3450 Hull Road, Gainesville, FL 32611, USA (email: [email protected]). *Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida, USA. The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.