Clinical Anatomy 20:407–410 (2007)

ORIGINAL COMMUNICATION

Radiographic Measurements of Normal Elbows:

Clinical Relevance to Olecranon Fractures
FAROKH WADIA,1* SRINATH KAMINENI,1,2 SATISH DHOTARE,2 AND A. AMIS2
1
Department of Orthopaedics, Hillingdon Hospital, Uxbridge, United Kingdom
2
Department of Orthopaedic Biomechanics, Imperial College, London, United Kingdom

This study aims to calculate a clinically relevant and intra-operatively accessible

measure of olecranon length that could be reliably applied by the operating surgeon
to optimise fixation of comminuted olecranon fractures. One hundred normal adult
antero-posterior and lateral radiographs of the elbow were studied with respect to
the proximal olecranon height (OH), trochlear notch width (TW) on lateral views,
and trans-epicondylar distance (TED) and trochlear width distance (TWD) on AP
views. Three mean ratios were then derived: TWD/TW, TED/TW and OH/TW. The
average OH was 26.2 mm (range 21–29), TW was 24.7 mm (range 21–32), TED
was 58.7 mm (range 49–74), and the TWD was 27.0 mm (range 22–32). The aver-
age ratio of TWD: TW was 1.08 (SD ¼ 0.08), that of TED: TW was 2.38 (SD ¼ 0.18)
and OH/TW was 1.06 (SD ¼ 0.08). Comminuted fractures of the olecranon are a
surgical challenge since it is often impossible to gauge the correct length to achieve
in reconstruction of the olecranon process. Our data can be easily applied to the
clinical situation, by taking intra-operative radiographs, and calculating the ratios as
demonstrated above. These will guide the surgeon to obtain a more reliable length
of the olecranon intra-operatively. Clin. Anat. 20:407–410, 2007. V 2006 Wiley-Liss, Inc.
C

Key words: humerus; fracture; reconstruction; orthopaedics; radiographs;

bony dimensions

INTRODUCTION A radiographic study of normal elbows was carried out to

Comminuted fractures of the olecranon have always been
a difficult condition to treat and present a surgical challenge.
The goal of treatment for olecranon fractures is an anatomic
reduction of the articular surface with rigid, stable fixation
that allows early recovery of range of motion. However, this
is not always possible. In the presence of severe comminu-
tion of the central third segment of the olecranon (Mayo
type II and III), the articular surface is difficult to recon-
struct. An option is to excise the comminuted central por-
tion, shorten the trochlear notch and approximate the olec-
ranon to the ulnar shaft (Fern and Brown, 1993). However,
this would invariably result in loss of movement, predictable
of over-tightened joints with intricate and highly conforming
articular surfaces, notably the humero-ulnar joint (Morrey,
1995; Ikeda et al., 2001; Fornalski et al., 2003). Another
treatment option is to reconstruct the trochlear notch by
bone grafting, but no objective parameters are available to
judge the width (longest dimension) of the trochlear notch
and the adequacy of reconstruction (Ikeda et al., 2001).
calculate a clinically relevant and intra-operatively accessible
measure of olecranon length that could be applied reliably by
the operating surgeon to guide the maintenance of articular
geometry during the fixation of comminuted olecranon fractures.
MATERIALS AND METHODS
Normal anteroposterior (AP) and lateral (Lat) radiographs of
the elbow of 100 adults were studied. Image of one elbow in
each adult was available. These had been obtained for various
*Correspondence to: Mr. Farokh Wadia, c/o Mr. Kamineni’s Secre-
tary, Department of Orthopaedics, Hillingdon Hospital, Pield Heath
Road, Uxbridge, UB8 3NN, UK. E-mail: fdwadia@aol.com
Received 1 April 2006; Revised 30 August 2006; Accepted 6
September 2006
Published online 27 October 2006 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20431

V
C 2006 Wiley-Liss, Inc.
408 Wadia et al.

reasons such as contralateral comparisons following an elbow

injury, for soft tissue injuries, for injuries distal to and excluding
the elbow joint, and for injuries around the elbow not directly
affecting the olecranon or distal humerus, that is, radial head
fractures. All elbows with rotation or obliquity of view were
excluded and only those with true AP and true lateral were
included in the study (Simon et al., 1987). There were 33 males
and 67 females with an average age of 38 years (range: 24–
48). There were 37 left and 63 right elbows.
The following parameters were studied in each set of ra-
diographs:
1. Olecranon height (OH): the distance from the tip of the
olecranon process to the angle of the olecranon at the
subcutaneous border as seen on lateral view (Fig. 1)
2. Trochlear notch width (TW): the oblique distance from
the tip of the olecranon process to the tip of the coro-
noid process as seen on lateral view (Fig. 1)
3. Trans-epicondylar distance (TED): the distance from
the tip of the medial epicondyle to the tip of the lateral
epicondyle as seen on an AP view (Fig. 2)
4. Trochlear width distance (TWD): the distance from the
medial trochlear ridge to the trochleo-capitular groove
as seen on an AP view (Fig. 2).

Fig. 2. Anteroposterior view of elbow. ME, medial

epicondyle; LE, lateral epicondyle; MT, medial edge of
trochlea; TCG, Trochlea-capitulum groove. Trans-epicon-
dylar distance (TED) ¼ Distance from ME to LE. Trochlear
width distance (TWD) ¼ Distance from ME to TCG.

For each subject, three ratios were derived from these

parameters:

1. The ratio of trans-epicondylar distance to the trochlear

notch width (TED/TW)
2. The ratio of trochlear width distance to the trochlear
notch width (TWD/TW)
3. The ratio of olecranon height to the trochlear notch
width (OH/TW).

The four lines were measured by a single reviewer in 20

elbow radiographs separated by an interval of 4 weeks to test
for intra-observer (test–retest) reliability. An intra-class cor-
relation coefficient was determined for each of the measure-
ments and a value of >0.70 was considered as acceptable.
Internal consistency (inter-observer reliability) was de-
termined by two reviewers making all the four measure-
ments in twenty elbows and these were correlated by
Cronbach’s alpha. A Cronbach alpha value of >0.60 was
considered acceptable.

Fig. 1. Lateral view of elbow. TO, tip of olecranon pro- RESULTS

cess; TC, tip of coronoid process; SO, subcutaneous border
of olecranon. Olecranon height (OH) ¼ Distance from TO to The mean trochlear width was 24.7 mm, the mean olecra-
SO. Trochlear notch width (TW) ¼ Distance from TO to TC. non height was 26.2 mm, the transepicondylar distance was
 Radiographic Measurements at the Elbow 409

TABLE 1. Linear Measurements on Anteroposterior TABLE 3. Intra-observer and Inter-observer

and Lateral Radiographs of the Elbow Reliability for the Four Measurements
Mean SD 95% Range Intra-class
(mm) (mm) CI (mm) (mm) correlation Cronbach’s
Lines coefficients alpha
Olecranon height
(OH) 26.2 2.01 25.7–26.6 21–29 Trochlear width 0.92 0.70
Trochlear width Olecranon height 0.72 0.72
(TW) 24.7 1.21 24.3–25.1 21–32 Transepicondylar
Trans-epicondylar distance 0.98 0.69
distance (TED) 58.7 2.23 57.6–59.7 49–74 Trochlear width
Trochlear width distance 0.71 0.65
distance (TWD) 27.0 2.24 26.4–27.5 22–32

58.7 mm, and the trochlear width distance was 27.0 mm.
Their confidence intervals and ranges are summarized in Ta-
ble 1. The ratios thus derived were TWD/TW ¼ 1.08, TED/TW
¼ 2.38, and OH/TW ¼ 1.06. Their standard deviations, confi-
dence interval, and their distribution as mean 6 2SD are
summarized in Table 2.
The test–retest reliability as measured by intra-class cor-
relation coefficient was acceptable (0.71–0.98 for different
measures); so was the Cronbach’s alpha which ranged from
0.65 to 0.72 for the different measures. These are outlined
in Table 3.
DISCUSSION
The issue of olecranon fixation versus excision has still not
been resolved. McKeever (1947) wrote that up to 80% of the
olecranon can be excised without causing instability of the
elbow in comminuted fractures of the olecranon. An et al.
(1986), however, showed experimentally that excision of as lit-
tle as 25% of the olecranon had significant effects on trochlea-
ulna stability. They concluded that the resistance of the
humero-ulnar joint to various displacements is reduced in pro-
portion to the amount of the olecranon excised (An et al.,
1986). They did not, however, specify the exact amount of
olecranon that can be excised safely without causing instability.
In contrast, many recent studies favor fixation of com-
minuted olecranon fractures (Ring et al., 1997; Nowinski
et al., 2000; Bailey et al., 2001), but none describes objec-
tive parameters to check that the reduction has been accu-
rate. Most have described subjective criteria such as recon-
struction of the bare area or the use of the trochlear articular
surface as a template for olecranon reconstruction.
Considering the biomechanics and force transmission
across the humero-ulnar articulation (Fornalski et al., 2003),
it would be quite logical to presume that any ‘‘shortening,’’
‘‘compression,’’ ‘‘lengthening,’’ or ‘‘tilting’’ of the trochlear
notch would predispose to increased joint contact stresses
and early osteoarthritis.
Murphy et al. (1987) in their study of olecranon fractures
recognized that post-operative displacement or mal-reduc-
tion of >2 mm was associated with poor outcome. Bailey
TABLE 2. The Three Ratios
Mean SD 95% CI Mean 6 2 SD
TWD: TW ratio 1.08 0.08 1.07–1.11 0.92–1.24
TED: TW ratio 2.38 0.18 2.34–2.41 2.02–2.74
OH: TW ratio 1.06 0.08 1.04–1.08 0.90–1.22
et al. (2001) stressed the importance of restoring the normal
contour of the trochlear notch, especially the anterior and
posterior facets of the olecranon. They also mentioned, how-
ever, that a gap may occur between these facets in severe
comminution and that shortening the olecranon does not
affect the outcome as long as the contour of the trochlear
notch is maintained. There is, however, inadequate data to
corroborate the latter issue. Fern et al. (1993), in a case
report followed up for only 9 months, described an olecranon
advancement osteotomy for severely comminuted olecranon
fractures wherein they reported shortening of the olecranon
and therefore of the sigmoid notch.
Ikeda et al. (2001) have described a technique using iliac
crest bone grafts along with multiple tension band wiring in
10 patients with severely comminuted fractures of the olecra-
non. Their description of operative technique, however, did
not give details of how they assessed the required dimensions
of the reconstruction. When using a bone graft, it would be
even more critical to restore the trochlear notch width accu-
rately.
In the present study, we describe radiological measure-
ments that are simple and easily made from an anteroposte-
rior and a lateral radiograph, or a fluoroscopic image obtained
intra-operatively. The measurements were found to be reli-
able when tested for intra-observer and inter-observer reli-
ability.
The trochlear width as seen on lateral view is the line that
will be most affected in olecranon fractures. It will be short-
ened or lengthened with the tilting of the fragments, or with
creation of gaps at the site of comminution. It is the single
most important parameter to be reconstructed. We have ex-
trapolated this line into three ratios keeping it as a common
denominator so as to eliminate the effects of magnification.
The magnification we are referring to is the magnification
error that normally occurs with any radiograph depending on
the distance between the patient and the X-ray tube. The
conversion of the data into ratios is an attempt to standardize
the measurements so that they can be applied to any patient
of any size irrespective of the magnification produced by X-
rays. We realize, however, that in two of the ratios, the nu-
merator is measured on the AP view and the denominator is
measured on the lateral view. With this use of two separate
radiographs, we acknowledge and indicate that an element of
magnification error occurs. The potential for a metal plate or
wires obscuring the anatomical landmarks and thus making it
difficult to draw lines and derive ratios can be minimized by
accepting only a true AP or a true lateral view in which case
any applied plate tends not to obscure the useful features.
Ultimately a prospective study will be required to test the effi-
cacy of application of these ratios in a clinical setting.
410 Wadia et al.
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