Fig. 35.—Radiogram of Fracture of Olecranon Process, showing marked degree of displacement.
(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)
When there is little displacement, bony union may result, but in many cases the fragments are united only by fibrous tissue. The upper fragment sometimes forms attachments to the shaft of the humerus, and this leads to stretching of the fibrous band between the fragments and to marked wasting of the triceps.
Separation of the olecranon epiphysis is one of the rarest forms of epiphysial detachment (Poland). When the epiphysis is displaced upwards and unites in this position, it may interfere with complete extension of the elbow.
Treatment.—It would appear that too much stress has hitherto been laid on the necessity of bringing the fragments into perfect apposition, and too little attention paid to the importance of maintaining the functions of the triceps and the movements of the elbow-joint.
Massage and movements are carried out from the first, and the forearm is supported in a sling. Full flexion is the last movement to be attempted. In carrying out the movements, the tip of the olecranon is pressed down with the thumb, so that it is obliged to follow the movements of the ulna, and is prevented from adhering to the humerus.
It was formerly the practice to have the arm almost, but not quite, fully extended, and a Gooch splint, extending from the lower border of the axilla to the finger-tips, and cut to the shape of the extended limb, applied anteriorly and fixed in position by a bandage, the region of the elbow being covered by a convergent spica.
Operative Treatment.—Operative treatment may be had recourse to, particularly in cases in which there is wide separation of the fragments. The fracture is exposed, the joint cavity opened up and cleared of clots, and silver-wire sutures passed through the fragments without encroaching upon the articular cartilage. The limb is fixed with the elbow-joint in the position of almost complete extension. Movement may be commenced at the end of a week, the angle at which the joint is fixed being changed morning and evening. During the day the flexed position should be maintained and the arm carried in a sling; during the night the limb is fixed to a pillow in the extended position. The patient is allowed to use the joint cautiously within a fortnight.
Old-standing Fracture.—When union fails to take place, the interval between the fragments tends to increase by the contraction of the triceps gradually stretching the intermediate fibrous tissue, so that a wide gap comes to separate the fragments. It is quite common that the function of the arm is all that can be desired in spite of a gap between the fragments, but, if this is not the case, the fragments may be united by operation.