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).
Figure 1.
Initial injury radiographs, (A) anteroposterior and (B) lateral, demonstrating
displaced olecranon apophyseal fracture.
Figure 2.
Contralateral left elbow lateral radiograph demonstrating no olecranon
physis.
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. Full-thickness 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.
Figure 3.
Fluoroscopic lateral radiograph showing the reduction by lining up the posterior
cortical surface with provisional fixation, which demonstrates malalignment of
the articular surface.
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 near-anatomic 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 properties. Although bone autograft
is widely considered the gold standard because of its osteoinductive, osteoconductive,
and osteogenic capabilities, allograft was selected to avoid donor-site morbidity,
particularly when employed in a pediatric patient in order to fill in the gap created
by
the removal of the persistent physis. An anterior elbow splint preventing more than
15°
of elbow flexion was then applied (Figure 5).
Figure 4.
Fluoroscopic lateral radiograph showing reduction with articular congruity and
fixation achieved with K-wires and olecranon plate. Dorsal olecranon gapping is
noted with adequate articular congruity because of the fracture going through a
persistent olecranon physis.
Figure 5.
Final radiographs, (A) anteroposterior and (B) lateral, of reduction using
olecranon plate.
Two weeks postoperatively, the patient underwent physical therapy for progressive
ROM,
without motion restrictions. Six weeks postoperatively, the patient had 15° to 110°
of
elbow flexion as well as full pronation and supination without pain, with maintained
reduction on radiographic imaging (Figure 6).
Figure 6.
(A) Anteroposterior and (B) lateral radiographs 10 months postoperatively showing
improved union across the fracture site.
The patient continued to progress clinically and started playing basketball 3 months
postoperatively. Progressive radiographic obliteration of the fracture gap signifying
bony healing was noted, and during his last appointment (10 months postoperatively),
he
was found to have a painless elbow ROM ranging from 8° to 150° of flexion and no
tenderness at the fracture site. His Mayo Elbow Performance Score was 100, and his
pain
rating on a visual analog scale was 0. A follow-up was obtained through telephone
2.5
years postoperatively; the patient continues to have no issues of hardware prominence
and continues to play basketball without symptoms.
Discussion
Elbow fractures represent approximately 5% to 10% of all pediatric fractures.
7
Of these, the incidence of an isolated olecranon fracture is 12% to 20%,
7,24
with physeal injury still rarely described in the orthopaedic literature.
6,10,11,17,29,31
The olecranon initially forms as multiple ossification centers which are
first radiographically apparent at age 9 to 11 years and fuse by 13 to 17 years.
5,6,10,14,17,28
This process begins on the anterior border of the olecranon and progresses in
a proximal-to-distal direction.
11,17
As is the case in a substantial set of pediatric fractures, avulsion forces
at tendinous insertions are a common cause and mechanism of injury. With regard to
olecranon anatomy and pattern of injury, there exists some debate as to the exact
insertion of the triceps expansion, with some authors describing its location distal
to the olecranon physis
28,36,39
and others describing the insertion directly into the olecranon physis.
31,33
Because of the rarity and infrequency of physeal fractures at the olecranon, there
is
no accepted standard method or indication for treatment. The most commonly cited
indication for operative intervention is the degree of fracture displacement, but
this varies between studies from displacements greater than 2 to 5 mm on initial radiographs.
3,10,14,18,21,27,31,34
Still others advocate for surgery when there is any incongruence of the
articular surface
31
or if palpation of the olecranon defect during elbow ROM demonstrates any instability.
39
More commonly seen than displaced persistent olecranon physeal fractures are mildly
displaced fractures of the physis in younger children. One study of 16 adolescent
baseball players with symptomatic persistent olecranon physes showed a high success
rate of nonoperative treatment with activity modification if there was simple
widening of the olecranon physis compared with the contralateral side. However, the
4 patients that had significant sclerosis at the physis at the time of presentation
did not have resolution of symptoms or physeal closure with nonoperative treatment
(all eventually underwent surgery).
26
Fractures that are deemed operative have traditionally been treated with a
tension band technique, with overall good clinical outcomes.
‡
Minimal loss of extension has been commonly reported.
1,10,12,15,18,29,31
There exist some well-described complications, including K-wire migration,
symptomatic hardware, and loss of reduction.
10,19,21
The tension band implants typically are removed postoperatively, as they are
commonly prominent. In a long-term clinical follow-up study of pediatric olecranon
fractures treated with casting or with open reduction and tension band techniques,
Karlsson et al
21
demonstrated that a tension band technique in fractures displaced more than 4
mm resulted in promising clinical outcomes up to 25 years after injury, even with
cases of small articular incongruity. Another long-term follow-up study of 39
patients with primarily nonoperatively treated pediatric olecranon fractures showed
good clinical results at an average of 24 years after injury. Additionally, these
patients' previous injury did not influence their choice of occupation.
3
Several case series and case reports of painful persistent olecranon physes have been
described, mostly in overhead athletes such as baseball players,
4,9,13,25,26,30
weight lifters,
38
and tennis players.
32
In our review of the literature, the prevalence of bilateral persistent
olecranon physis was not well documented; however, almost all studies that included
a contralateral elbow radiograph had complete fusion of the olecranon, as in our
patient.
Although the exact cause is unknown, a preoperative elbow flexion contracture of 15°
to 30° is common in these cases.
4,25,30,32
Perhaps genetic predisposition or repetitive microtrauma (possibly creating a
persistent physis) also contributed to the development of a soft tissue flexion
contracture. The possibility also exists that abnormal elbow mechanics resulting
from lack of full extension alters the position of the limb during injury,
transmitting abnormal forces across the joint. In our patient, there was no mention
of previous elbow ROM limitations in the medical history. Ten months
postoperatively, our patient was noted to have an elbow ROM ranging from 8° to 150°,
an improvement from his preoperative examination under anesthesia (a flexion
contracture of 15°). Although no anterior soft tissue release was performed, by
closing the persistent physeal gap, there was likely a decrease in posterior
olecranon fossa impingement allowing for improved elbow extension. In these cases,
ORIF with or without bone grafting is typically performed after months of failed
nonoperative treatment,
4,9,13,25,26,30,38
most commonly with a tension band construct, although nonoperative treatment
has been successfully attempted in young patients.
25,32
Good outcomes have been obtained with ORIF, with a high healing rate.
4,9,13,25,26,30,38
The most common complications are hardware prominence and subsequent need for
hardware removal.
4,13,25
Nonunion appears to be rare after ORIF of persistent nondisplaced olecranon
physes.
Only 8 cases of displaced persistent physeal fractures have been reported in adults
4,8,23,35,37
; the case details are outlined in Table 1. One 26-year-old soccer player had
a displaced olecranon fracture after a fall on his previously asymptomatic elbow and
was treated with ORIF with tension band wiring that developed a nonunion.
35
The patient subsequently underwent a wedge-shaped osteotomy and revision
internal fixation with a tension band construct that united. One case series
reported 3 patients with displaced persistent olecranon physes after direct trauma.
23
All underwent ORIF with tension band construct after curettage of the physeal
surfaces, and each patient went on to nonunion, with 2 patients undergoing revision
ORIF with bone grafting and 1 refusing subsequent surgery.
23
Enishi et al
8
reported on a 36-year-old former baseball player with a displaced fracture
through a persistent olecranon physis; the patient underwent ORIF with a tension
band construct with iliac crest autograft that ultimately united with removal of
internal fixation 13 months postoperatively. Charlton et al
4
reported a case of a displaced persistent olecranon fracture in an
18-year-old baseball pitcher who underwent ORIF using tension band construct and
autograft iliac crest bone graft. This healed uneventfully and hardware removal was
performed, although the reason for removal was not reported. Turtel et al
37
reported on 2 cases of similar displaced olecranon fractures treated with
ORIF with tension band technique, with both resulting in a fibrous union but good
clinical outcomes. In all of these previously reported cases of displaced fractures
through persistent olecranon physes, the final outcomes were good, but ORIF using
a
K-wire and tension band construct resulted in a 75% nonunion or fibrous union rate
(6 of 8 cases). The only cases that healed were the 2 cases in which primary iliac
crest bone autograft was used at the time of initial fixation, while none of the
nonunion cases reported the use of bone graft of any type (Table 1).
Table 1
Review of all Reported Cases of Displaced Persistent Olecranon Physes
a
Case
Age/ Sex
Dominant Side?
Mechanism
Sport
Fixation
Complication
Subsequent Surgery Needed
Outcome
Kovach 1985
23
21 y/male
Yes
Direct impact
Football
K-wire tension band construct (curettage of physeal
surfaces)
Nonunion at 4 months
Curettage with bone grafting and revision K-wire tension band
construct
Was able to return to collegiate football
Kovach 1985
23
32 y/male
Yes
Direct impact
Prior gymnastics, football, and baseball
K-wire tension band construct (curettage of physeal
surfaces)
Nonunion
Refused nonunion surgery
Asymptomatic 3 years postoperatively with fibrous union
Kovach 1985
23
18 y/male
Yes
Direct impact
Football and prior baseball and wrestling
K-wire tension band construct (curettage of physeal
surfaces)
Nonunion at 4.5 months
Curettage with ICBG and revision ORIF with cancellous screw
Normal function 11 years postoperatively with a 5-degree flexion
contracture. Employed as a railroad laborer
Skak 1993
35
26 y/male
Unknown
Direct impact
Soccer
K-wire tension band construct
Nonunion at 6 months postoperatively
Wedge-shaped excision osteotomy + revision tension band
construct (also with subsequent ROH)
Returned to work and soccer. United 5 months postoperatively
from revision
Turtel 1995
37
26 y/male
Yes
Direct impact
Baseball pitcher
K-wire tension band construct
Fibrous nonunion (asymptomatic)
None
Continued to play baseball without symptoms at 3.5 years of
follow-up
Turtel 1995
37
31 y/male
Unknown
Direct impact
Physical education teacher
K-wire tension band construct
Fibrous nonunion (asymptomatic)
ROH for unknown reason
No complaints 2 years postoperatively with fibrous union
Charlton 2003
4
20 y/male
Yes
Acute displacement during a throw
Baseball pitcher
Tension band construct with cancellous ICBG
Unknown
ROH for unknown reason
Returned to same level of play without symptoms
Enishi 2015
8
36 y/male
Unknown
Direct impact
Prior Baseball
K-wire tension band construct with ICBG
None
ROH for unknown reason
No pain and returned to work
Current Study
16 y/male
Yes
Direct impact
Basketball
Plate fixation with DBM
None
None
Returned to same level of play 3 months postoperatively without
symptoms
a
DBM, demineralized bone matrix; ICBG, iliac crest bone graft
(autograft); ORIF, open reduction and internal fixation; ROH, removal of
hardware.
To our knowledge, no other cases in the literature describe the initial treatment
of
a displaced persistent olecranon physis in a healthy adolescent with a plate and
screw construct, although some cases may be included in the case series that were
not identified as persistent physes. In this case, the tension band technique would
be difficult given the lack of bony contact because of a dorsal fracture gap (from
persistent physeal cartilage removal), thus preventing adequate apposition at the
fracture site and resulting in an incongruous articular surface. The advantages of
plate and screw fixation with bone allograft of the associated defect in these cases
are that stable fixation is achieved to allow for union across the gap created by
removal of the persistent epiphysis, and reduction can be maintained at the
articular surface. In addition, some studies have reported lower rates of
symptomatic hardware with a plate and screw construct.
Although less frequently described in the literature for pediatric fractures, plate
and screw fixation is widely utilized in the adult population, with good outcomes
reported.
2,20,22
In addition, lower rates of symptomatic hardware are seen with a plate and
screw construct.
20
A plate and screw construct was used in our patient to give adequate fixation
to hold the reduction to allow for healing across the fracture gap caused by removal
of the persistent olecranon physis.
Displaced physeal fractures of the olecranon are relatively rare. However, this case
highlights that it is difficult to reduce a displaced persistent olecranon physis
based on standard methods of aligning the posterior cortex given the preinjury
deformity. There is often greater intra-articular displacement seen intraoperatively
than is initially appreciated on radiographic imaging,
14
and special attention should be paid to the articular surface during
reduction to allow for a congruent joint with minimal articular depression despite
potential gapping at the olecranon fracture site.
10,16
In addition, the cartilage needs to be removed on both sides of the physis
before fixation and, given the literature review, we recommend supplemental use of
allograft or autograft of the subsequent defect to allow for bony healing in cases
of a persistent physis.
Conclusion
Olecranon physeal fractures in healthy adolescents are rare. Outcomes after ORIF are
generally good, but some loss of extension is common. Displaced olecranon fractures
through a persistent physis can be successfully treated with ORIF using a variety
of
techniques; however, given the cases reported in the literature, there can be a
consideration for a plate and screw construct and bone grafting to fill the gap at
the time of initial surgery, as well as complete removal of persistent physeal
cartilage. We recommend the use of any form of bone graft to fill the defect left
by
removal of the physeal cartilage because of the high nonunion rate (100% nonunion
rate in 6 cases) reported in the literature in cases without bone graft. In
addition, we present this case as an illustration of the importance of using the
articular cartilage as a guide for anatomic reduction and to allow full ROM, which
led to an excellent clinical result in this case.