Olecranon Fracture

1. Clinical Overview

Summary

Olecranon fractures are common intra-articular injuries accounting for approximately 10% of all upper extremity fractures, with an incidence of 11.5 per 100,000 person-years. [1,2] They result from direct trauma (fall onto the point of the elbow) or indirect avulsion forces transmitted through the triceps mechanism during eccentric contraction. The fracture disrupts the extensor mechanism of the elbow, and the clinical hallmark is the patient's inability to actively extend the elbow against gravity - analogous to the "straight leg raise" test for extensor mechanism integrity at the knee.

Because the olecranon forms the articular surface of the ulnohumeral joint (the primary stabilizer of the elbow), anatomical reduction is mandatory to restore joint congruity and prevent post-traumatic arthritis. [3] The majority of displaced fractures require surgical fixation, with treatment selection driven by fracture pattern, bone quality, and patient factors.

Tension Band Wiring (TBW) remains the gold standard for simple transverse fractures in good quality bone, utilizing biomechanical principles to convert the distractive force of the triceps into a compressive force at the fracture site. [4] However, the high rate of symptomatic hardware (47-80% requiring removal) has led to increasing use of pre-contoured locking plate fixation, particularly for comminuted patterns where TBW biomechanics fail. [5,6] In elderly, low-demand patients with severe comminution, fragment excision with triceps advancement provides a reliable salvage option. [7]

Key Facts

Mechanism: Direct blow (comminuted pattern) or Triceps avulsion during fall on outstretched hand (transverse pattern).
The "Straight Leg Raise" of the Arm: Inability to extend elbow against gravity indicates disrupted extensor mechanism. This clinical test determines operative vs non-operative management.
TBW Biomechanical Principle: A figure-of-8 wire on the dorsal (tension) surface converts tensile forces into compression at the articular surface during elbow flexion. The triceps generates approximately 600N of force during active extension. [8]
Subcutaneous Location: The olecranon has minimal soft tissue coverage. Hardware prominence is almost universal with TBW, leading to bursal irritation and pain when leaning on tables.
Articular Fracture: Even 2mm of step-off or gap significantly increases risk of post-traumatic arthritis. Anatomical reduction (less than 1mm) is the goal. [9]
Hardware Removal Epidemic: Up to 82% of patients with TBW require a second operation for metalwork removal, compared to only 7% with plate fixation. [5]

Clinical Pearls

"Check the Ulnar Nerve Pre-operatively": The ulnar nerve runs in the cubital tunnel immediately medial to the olecranon, tethered by Osborne's ligament and the arcuate ligament. It is vulnerable to direct injury, traction during reduction, or iatrogenic damage during fixation (especially medial plating or prominent K-wires). Document ulnar nerve function (sensation in the little finger, Froment's sign, interosseous strength) before surgery and after. Nerve symptoms occur in 2-12% of cases. [10,11]

"Beware the Monteggia Variant": If the fracture line extends anteriorly to involve the coronoid process, this is NOT a simple olecranon fracture - it is a Trans-Olecranon Fracture-Dislocation (Bado Type I equivalent). The radial head will be dislocated anteriorly. Always assess the radiocapitellar joint on lateral X-ray. These injuries require restoration of the coronoid and radial head reduction, often necessitating plate fixation rather than TBW. [12]

"50% Rule for Excision": Up to 50% of the olecranon can be safely excised without causing elbow instability, provided the coronoid and collateral ligaments are intact. Beyond 50%, the insertion of the anterior bundle of the medial collateral ligament (MCL) is compromised, leading to valgus instability. [7]

"The Home Run Screw": In plate fixation, the most important screw is the long intramedullary lag screw that passes from the proximal plate down the ulnar canal to engage the coronoid process. This captures the anterior ulnohumeral articulation and provides rotational stability, preventing fracture collapse. [13]

2. Epidemiology

Incidence

Overall Incidence: 11.5 per 100,000 person-years. [1]
Proportion of Fractures: 10% of all upper extremity fractures; 20% of proximal forearm fractures. [2]
Bimodal Distribution:
- Young males (peak 20-30 years): High-energy mechanisms (motor vehicle accidents, falls from height, sports injuries). More likely to have associated injuries (fracture-dislocations).
- Elderly females (peak > 65 years): Low-energy falls from standing height. Associated with osteoporosis and increased comminution. [14]

Demographics

Gender: Slight male predominance overall (1.2:1), but female predominance in elderly cohort due to osteoporosis.
Mean Age: 47.5 years in large epidemiological studies. [1]
Seasonality: Increased incidence in winter months (ice-related falls).

Risk Factors

Osteoporosis: Postmenopausal women. Increased fracture comminution and fixation failure risk. [14]
Epilepsy: High-energy posterior elbow dislocations or trans-olecranon fracture-dislocations during seizures.
Contact Sports: Rugby, martial arts, motocross.
Neurological Disorders: Increased fall risk (Parkinson's disease, previous stroke).
Alcohol Use: Associated with falls and poor bone quality.

3. Pathophysiology

Functional Anatomy

Osseous Anatomy

Olecranon Process: The proximal extension of the ulna, forming the posterior buttress of the elbow. It contains cancellous bone covered by a thin cortical shell, making it vulnerable to comminution.
Greater Sigmoid Notch (Trochlear Notch): The articular surface that articulates with the trochlea of the distal humerus. This is the primary constraint to valgus/varus stress and provides inherent elbow stability in extension.
Coronoid Process: The anterior lip of the ulna. The anterior bundle of the MCL inserts onto the sublime tubercle at the medial base of the coronoid. Coronoid height determines elbow stability - loss of > 50% of coronoid height causes posteromedial rotatory instability. [15]
Bare Area: A non-articular area in the mid-portion of the sigmoid notch, often the site of transverse fractures.

Muscular Forces

Triceps Brachii: Inserts onto the dorsal olecranon via a broad tendon. Generates approximately 600N of force during active extension. [8] After fracture, the triceps pulls the proximal fragment proximally and posteriorly, creating fracture gap and preventing reduction without surgical stabilization.
Anconeus: Small muscle lateral to the triceps; assists in extension and provides dynamic lateral stability.
Flexor Carpi Ulnaris (FCU): Originates from the medial epicondyle and medial olecranon. Can displace fracture fragments medially.

Neurovascular Structures

Ulnar Nerve: Passes posterior to the medial epicondyle in the cubital tunnel (formed by the medial epicondyle, olecranon, and Osborne's ligament/arcuate ligament). The nerve is tethered and vulnerable to traction or direct trauma. Ulnar nerve symptoms (paraesthesia in the ulnar 1.5 digits, weakness of intrinsics) occur in 2-12% of fractures. [10,11]
Brachial Artery: Lies anterior to the elbow joint. Rarely injured in isolated olecranon fractures but at risk in fracture-dislocations.
Posterior Interosseous Nerve (PIN): Branch of the radial nerve; runs anterolaterally around the radial neck. At risk in associated radial head dislocations (Monteggia variants).

Biomechanics of Injury

Direct Mechanism (Comminuted Fractures)

Fall onto Flexed Elbow: Direct impact onto the point of the olecranon. Results in comminuted fracture patterns with impaction and articular depression. Often associated with severe soft tissue injury and elbow hemarthrosis.
High Energy Trauma: Motor vehicle accidents, industrial injuries. Higher risk of open fractures, fracture-dislocations, and associated injuries (radial head, coronoid, distal humerus).

Indirect Mechanism (Transverse Fractures)

Fall on Outstretched Hand (FOOSH): The elbow is forced into hyperextension or resisted flexion. The triceps contracts eccentrically (attempting to control elbow flexion), generating an avulsion force that pulls the olecranon off in a transverse pattern at the bare area.
Eccentric Triceps Contraction: Sudden loading of the triceps during deceleration (e.g., catching a fall).

Biomechanics of Fixation

Tension Band Principle

The olecranon experiences eccentric loading during elbow flexion/extension:

Dorsal Surface (Tension Side): Under tensile stress due to triceps pull.
Volar Surface (Compression Side): Under compressive stress from articulation with the trochlea.

The Tension Band Wiring (TBW) construct exploits this:

Two parallel K-wires (1.6-2.0mm diameter) are driven longitudinally down the ulnar shaft, preventing rotation and maintaining length.
A figure-of-8 wire (18-gauge stainless steel) is looped through a transverse drill hole in the ulna (distal to the fracture) and around the proximal K-wires.
When the wire is tightened, it creates compression at the fracture site.
Dynamic Compression: During elbow flexion, the triceps pulls proximally, tightening the dorsal figure-of-8 wire, which converts the tensile force into compression at the articular surface. [4,8]

Biomechanical Requirements for TBW:

Simple transverse or short oblique fracture (Mayo IIA)
Intact volar cortex (compression side must be intact for TBW principle to work)
Good bone quality (osteoporotic bone does not hold K-wires)

TBW Failure Modes:

Comminuted fractures: No stable volar cortex → wires cut through fragments → fracture collapses. [16]
Oblique fractures: Shear forces overcome compressive forces → displacement.
K-wire migration: Backing out of wires (47-82% of cases) causing bursal irritation and skin tenting. [5,6]

Plate Fixation

Pre-contoured Locking Plate Fixation provides:

Fixed-angle stability: Locking screws create a fixed-angle construct resistant to collapse in osteoporotic bone or comminuted fractures.
Load-sharing: Plate distributes forces along its length rather than relying on a single wire loop.
Interfragmentary Compression: Lag screws perpendicular to the fracture line provide compression independent of the plate.
"Home Run Screw": Long intramedullary screw from proximal plate down the ulnar canal to engage the coronoid, providing rotational stability. [13]

Indications:

Comminuted fractures (Mayo IIB/IIIB)
Oblique or long spiral fractures
Fracture-dislocations (Mayo III)
Osteoporotic bone
Revision after TBW failure

4. Classification

Mayo Classification (Morrey, 1995)

The Mayo Classification is the most widely used, based on fracture displacement, stability, and comminution. [3,17]

Type I: Undisplaced (less than 2mm Displacement)

Type IA: Non-comminuted
Type IB: Comminuted

Treatment: Non-operative (splint immobilization) if extensor mechanism intact. Weekly X-rays for 3 weeks to detect late displacement (triceps pull).

Type II: Displaced, Stable (> 2mm Displacement, Elbow Stable)

Stable = Ulnohumeral joint remains congruent (collateral ligaments intact).

Type IIA: Non-comminuted (simple transverse or short oblique fracture)
- Treatment: Tension Band Wiring (TBW) - gold standard
Type IIB: Comminuted
- Treatment: Plate Fixation (TBW will fail)

Type III: Displaced, Unstable (Fracture-Dislocation)

Unstable = Ulnohumeral joint incongruent or dislocatable. Collateral ligament disruption or extensive coronoid/radial head injury.

Type IIIA: Non-comminuted
- Treatment: Plate fixation + collateral ligament repair/reconstruction
Type IIIB: Comminuted
- Treatment: Plate fixation + possible fragment excision + ligament reconstruction
- Special Considerations: If associated with radial head fracture and coronoid fracture = Terrible Triad injury requiring complex reconstruction. [18]

Other Classifications

Schatzker Classification

Focuses on comminution patterns. Useful for surgical planning.

Type A: Transverse fracture
Type B: Transverse-oblique
Type C: Oblique
Type D: Comminuted
Type E: Oblique-distal (may extend to coronoid)
Type F: Fracture-dislocation

AO/OTA Classification

21-B1: Extra-articular (avulsion of olecranon tip, rare)
21-B2: Intra-articular partial (simple patterns)
21-B3: Intra-articular complete (complex, multifragmentary)

Colton Classification

Type I: Undisplaced
Type II: Displaced, stable
Type III: Displaced, unstable

Trans-Olecranon Fracture-Dislocation

A special subtype where the fracture line extends anteriorly through the coronoid, allowing anterior dislocation of the radius and ulna relative to the distal humerus. [12]

Bado Type I Variant (Monteggia equivalent)
Radiographic Clue: Anterior displacement of the radial head; fracture line involves coronoid.
Treatment: ORIF of olecranon (usually plate) + reduction of radial head. May require annular ligament repair.

5. Clinical Presentation

Symptoms

Pain: Severe, localized to the posterior elbow. Exacerbated by any attempt at elbow movement or weight-bearing.
Swelling: Rapid onset due to hemarthrosis (intra-articular blood). Posterior and lateral swelling more prominent than medial.
Deformity: Visible/palpable gap over the posterior elbow if fracture is displaced > 5mm.
Inability to Extend Elbow: The patient cannot actively lift the forearm against gravity (analogous to inability to straight leg raise with patellar fracture). This is the key clinical finding.
Mechanical Symptoms: Crepitus, locking (if loose intra-articular fragments).

Signs

Inspection

Swelling: Diffuse elbow effusion. Loss of normal bony contours.
Bruising: May not be present acutely, develops over 24-48 hours. Extensive bruising suggests high-energy mechanism.
Open Fracture: Check for skin breach (2-7% of cases). [19] Posterior wounds directly over olecranon or medial wounds (ulnar nerve at risk).

Palpation

Palpable Gap: Run finger along the subcutaneous border of the ulna from the olecranon to the ulnar shaft. A distinct step or gap indicates fracture displacement.
Tenderness: Maximal over the fracture site.
Crepitus: On passive movement if fracture is displaced.

Movement

Active Extension Test: With the arm abducted to 90° and elbow flexed, ask the patient to actively extend the elbow against gravity.
- Result: Inability to extend = disrupted extensor mechanism = surgical indication.
- Trick Movement: Some patients can "lock" the elbow by flipping the forearm with momentum or using gravity. Ensure the test is done against gravity with controlled movement.
Passive Range of Motion (ROM): Test gently to assess for associated injuries (collateral ligament laxity, radiocapitellar stability).

Neurovascular Examination (CRITICAL)

Vascular Assessment

Radial Pulse: Palpate at wrist. Absent pulse rare in isolated olecranon fracture but check in all cases.
Capillary Refill: less than 2 seconds in digits.
Compartment Palpation: Forearm should be soft. Tense compartments + severe pain = evolving compartment syndrome (rare but possible in high-energy injuries).

Ulnar Nerve Assessment

Pre-operative documentation is MANDATORY (medicolegal). The ulnar nerve is injured in 2-12% of cases. [10,11]

Sensory: Light touch and pinprick in the ulnar 1.5 digits (little finger and ulnar half of ring finger).
Motor - Interossei:
- Finger Abduction/Adduction Test: Spread fingers apart (dorsal interossei - DAB) and bring together (palmar interossei - PAD). Compare to opposite hand.
- Froment's Sign: Ask patient to hold a piece of paper between thumb and index finger. If ulnar nerve palsy, the patient will flex the thumb IP joint (using FPL, median nerve) to compensate for weak adductor pollicis (ulnar nerve).
Motor - Flexor Carpi Ulnaris (FCU): Flex wrist with ulnar deviation. Palpate FCU tendon at wrist.
Motor - Flexor Digitorum Profundus (FDP) to ring/little fingers: Flex distal IP joint of little finger while holding PIP joint extended.
Tinel's Sign: Tap over the cubital tunnel. Positive if reproduces tingling in ulnar nerve distribution.

Median Nerve Assessment

Sensory: Thumb, index, middle, and radial half of ring finger.
Motor: Thenar muscles (thumb opposition and abduction). "OK" sign (opposition of thumb to index finger).

Radial Nerve Assessment

Sensory: First dorsal web space.
Motor: Wrist extension, finger extension (MCP joints), thumb extension.
Posterior Interosseous Nerve (PIN): Pure motor - test finger/thumb extension.

Associated Injuries (Rule Out)

Radial Head Fracture: Palpate radial head (tenderness, crepitus). Check radiocapitellar joint on lateral X-ray.
Coronoid Fracture: Trans-olecranon fracture-dislocations involve the coronoid. Check lateral X-ray.
Elbow Dislocation: Assess joint congruity on X-ray. Posterior dislocations may spontaneously reduce, leaving only soft tissue swelling and fracture.
Collateral Ligament Injury: Valgus/varus stress testing (but only after fracture is ruled out or if Mayo Type III suspected).
Ipsilateral Upper Limb Injuries: Distal radius, scaphoid, humeral shaft (high-energy mechanisms).

6. Investigations

Imaging

Plain Radiographs (First-Line)

Standard Views:

AP (Anteroposterior) View of Elbow:
- Assess medial/lateral displacement.
- Check radiocapitellar alignment (radial head should point to capitellum in all views).
- Look for associated radial head or coronoid fractures.
True Lateral View of Elbow (CRITICAL):
- Positioning: Elbow flexed 90°, forearm neutral rotation (thumb up). X-ray beam perpendicular to humerus.
- What to Assess:
  - Fracture Gap: Measure displacement (> 2mm = operative indication).
  - Articular Step-Off: Any step in the trochlear notch (> 1mm increases arthritis risk). [9]
  - Fracture Pattern: Transverse, oblique, comminuted.
  - Coronoid Involvement: Does the fracture line extend anteriorly?
  - Radiocapitellar Joint: The radial head should align with the capitellum. If not = dislocation/subluxation.
  - Posterior Fat Pad Sign: Elevation of posterior fat pad = hemarthrosis = intra-articular fracture (even if fracture not visible).

Radiographic Measurements:

Displacement: Distance between fracture fragments on lateral view. > 2mm = operative indication.
Angulation: Volar or dorsal angulation. > 10° = unstable.
Comminution: Number and size of fragments. Large metaphyseal "wedge" fragment suggests need for plate fixation.

Computed Tomography (CT Scan)

Indications:

Complex Comminuted Fractures (Mayo IIB/IIIB): Pre-operative planning for plate fixation. Identifies fracture lines, fragment size/position, and degree of articular impaction.
Fracture-Dislocations (Mayo III): To assess coronoid fracture size, radial head fracture, and articular congruity.
Uncertain Diagnosis: If plain X-rays are inconclusive but clinical suspicion is high.
Pre-operative Templating: 3D reconstructions help plan plate positioning and screw trajectories.

CT Protocol:

Thin-slice (1mm) axial images with coronal and sagittal reconstructions.
3D surface rendering for surgical planning (especially for complex comminution).

Magnetic Resonance Imaging (MRI)

Rarely indicated in acute setting. Possible uses:

Occult Fracture: If plain X-rays and CT negative but high clinical suspicion (very rare).
Ligamentous Injury Assessment: If Mayo Type III (fracture-dislocation) with suspected MCL/LCL disruption that may require reconstruction.
Triceps Tendon Avulsion: If extensor mechanism disrupted but no fracture visible (pure tendon avulsion from olecranon - rare).

Ultrasound

Not routinely used. Possible application:

Bedside Assessment of Hemarthrosis: In austere settings or for monitoring.
Triceps Tendon Integrity: If pure tendon injury suspected.

7. Management

Initial Emergency Department Management

ATLS Principles (Trauma Patients)

In high-energy mechanisms, follow Advanced Trauma Life Support (ATLS) protocols:

Primary Survey: Airway, Breathing, Circulation. Isolated olecranon fractures rarely cause life-threatening injuries, but high-energy mechanisms may have associated polytrauma.
Secondary Survey: Full examination to identify all injuries (ipsilateral upper limb, cervical spine, chest, pelvis).

Fracture-Specific Management

Analgesia

Intravenous Opioids: Morphine 5-10mg IV or Fentanyl 50-100mcg IV (titrate to pain).
Regional Anaesthesia: Consider hematoma block (inject 10-20ml of 1% lidocaine into fracture site) for immediate analgesia and to facilitate closed reduction/splinting.
Oral Analgesia: Paracetamol 1g QDS + Ibuprofen 400mg TDS (if no contraindications).

Immobilization

Above-Elbow Backslab: Apply with elbow in 90° flexion and forearm in neutral rotation.
- Why 90°?: Minimizes triceps tension while maintaining comfort. Avoid hyperflexion (> 120°) which increases risk of compartment syndrome or neurovascular compromise.
Splint Technique: Posterior plaster slab from proximal humerus to metacarpal heads. Secure with crepe bandage (not circumferential initially to allow for swelling).
Elevation: Sling with hand elevated above heart level to reduce swelling.

Open Fracture Management

If skin breach present (2-7% of cases): [19]

Photograph Wound: Before covering with sterile dressing.
Sterile Dressing: Cover wound with saline-soaked gauze and occlusive dressing. Do NOT probe or explore in ED.
Antibiotics: IV Cefazolin 2g (or Clindamycin if penicillin allergy) + Gentamicin 5mg/kg for high-energy/contaminated wounds.
Tetanus Prophylaxis: If not up to date.
Urgent Operative Washout: Within 6-12 hours (Gustilo-Anderson Type I-II) or within 2 hours (Type III).
Gustilo-Anderson Classification: Document wound size, contamination, and soft tissue injury.

Neurovascular Monitoring

Document Neurovascular Status: Before and after splinting.
Repeat Assessment: At 1-2 hours post-splinting to ensure no deterioration.

Referral to Orthopaedics

Indications for URGENT Orthopaedic Referral (less than 6 hours):

Open fracture
Neurovascular compromise
Compartment syndrome
Fracture-dislocation (Mayo Type III)

Indications for EARLY Orthopaedic Referral (less than 24 hours):

Displaced fracture (> 2mm gap or step-off)
Inability to extend elbow against gravity (disrupted extensor mechanism)
Any Mayo Type II or III fracture

Outpatient Orthopaedic Referral (Within 1 Week):

Undisplaced fracture (Mayo Type I) with intact extensor mechanism
Minimally displaced fracture (less than 2mm) in elderly, low-demand patient

Definitive Management: Decision Algorithm

                      OLECRANON FRACTURE
                             ↓
             ┌───────────────┴───────────────┐
             │                               │
      UNDISPLACED (less than 2mm)              DISPLACED (> 2mm)
             │                               │
    Extensor Mechanism Intact?               │
             │                               │
        ┌────┴────┐                          │
       YES        NO                         │
        │          │                         │
   NON-OPERATIVE  OPERATIVE                  │
        ↓          │                         │
   (Mayo Type I)   │                         │
        │          │                         │
    Splint 2 weeks │                         │
    Weekly X-rays  └─────────────┬───────────┘
    ROM at 2-3 weeks             │
                                 ↓
                    FRACTURE PATTERN ASSESSMENT
                                 │
                 ┌───────────────┼───────────────┐
                 │               │               │
          SIMPLE TRANSVERSE  COMMINUTED     FRACTURE-
          (Mayo IIA)         (Mayo IIB)     DISLOCATION
                 │               │          (Mayo III)
                 ↓               ↓               ↓
          TENSION BAND      PLATE FIXATION  PLATE FIXATION
            WIRING          (Pre-contoured   + Ligament Repair
          (TBW - K-wires    Locking Plate)   + Radial Head/
          + Figure-8 wire)                   Coronoid Fixation
                                             (if "Terrible Triad")
                 │               │               │
                 │               │               │
                 │        Elderly, Low-Demand,   │
                 │        Unreconstructable?     │
                 │               │               │
                 │               ↓               │
                 │        FRAGMENT EXCISION      │
                 │        + TRICEPS ADVANCEMENT  │
                 │        (Up to 50% olecranon)  │
                 │                               │
                 └───────────────┬───────────────┘
                                 │
                                 ↓
                        POST-OPERATIVE PROTOCOL
                                 │
                         Early ROM (Day 1-3)
                      No Heavy Resistance x 6 weeks
                      Radiographs: 2 weeks, 6 weeks, 12 weeks
                      Hardware Removal: If symptomatic (6-12 months)

Non-Operative Management

Indications

Mayo Type I (undisplaced fractures with less than 2mm gap or step-off)
Intact Extensor Mechanism (patient can actively extend elbow against gravity)
No articular step-off (confirmed on lateral X-ray)
Compliant Patient (able to attend weekly follow-up)

Protocol

Immobilization

Above-Elbow Splint or Cast: Elbow in 45-90° flexion, forearm neutral rotation.
Duration: 2 weeks of strict immobilization.

Radiographic Surveillance

Weekly X-rays for 3 weeks to detect late displacement (occurs in 10-20% of initially undisplaced fractures due to triceps pull). [20]

If displacement develops (> 2mm), convert to operative management.

Mobilization Protocol

Weeks 0-2: Strict immobilization. No elbow movement.
Weeks 2-3: Remove splint. Begin gentle active ROM exercises:
- Flexion/extension in pain-free range.
- Pronation/supination (wrist rotation).
- No heavy resistance or lifting.
Weeks 3-6: Progressive strengthening. Increase ROM to full range.
Week 6+: Unrestricted activity once fracture union confirmed on X-ray.

Follow-Up

Week 1, 2, 3: Clinical assessment + X-rays (to detect displacement).
Week 6: X-ray to confirm union.
Week 12: Final X-ray. Discharge if healed.

Contraindications to Non-Operative Management

Displacement > 2mm (risk of malunion and arthritis)
Articular step-off > 1mm (post-traumatic arthritis risk)
Extensor mechanism disruption (cannot extend against gravity)
Fracture-dislocation (Mayo III)
Non-compliant patient (unable to attend follow-up)

Operative Management

Indications

Displaced Fractures (> 2mm gap or step-off)
Articular Incongruity (> 1mm step-off on lateral X-ray)
Disrupted Extensor Mechanism (inability to extend elbow against gravity)
Fracture-Dislocation (Mayo Type III)
Open Fractures
Failure of Non-Operative Management (secondary displacement)

Pre-Operative Planning

Classify Fracture: Mayo Type IIA (TBW candidate) vs IIB/III (plate candidate).
Assess Bone Quality: Age, osteoporosis history, X-ray cortical thickness. Poor bone quality favors plate fixation.
Template Fixation: On CT if available. Measure fragment size, plan screw trajectories.
Consent: Include risks (infection, nonunion, hardware removal, ulnar nerve injury, stiffness, arthritis).
Antibiotics: IV Cefazolin 2g at induction (prophylaxis).

Surgical Approach

Posterior Approach (Campbell's):

Positioning: Supine or lateral decubitus. Arm across chest on a bolster, or prone with arm over a support.
Incision: Midline posterior incision, centered over the olecranon (8-12cm). Curve slightly medial to avoid direct pressure on scar post-operatively.
Dissection:
- Incise skin and subcutaneous tissue.
- Identify the triceps tendon and fracture site.
- Sharply dissect the triceps insertion off the proximal fragment (if needed for visualization).
- DO NOT dissect medial to the medial border of the triceps (risk of ulnar nerve injury - nerve is in the cubital tunnel 1-2cm medial).
Fracture Visualization: Evacuate hematoma. Irrigate joint. Identify fracture pattern and articular surface.
Reduction: Reduce fracture anatomically. Use pointed reduction forceps or Weber clamps to hold reduction.
Confirm Articular Congruity: Direct visualization of the trochlear notch. No step or gap.

Operative Technique 1: Tension Band Wiring (TBW)

Indications

Mayo Type IIA: Simple transverse or short oblique fracture
Good Bone Quality: Non-osteoporotic
Intact Volar Cortex: Compression side must be intact for TBW biomechanics to work

Implants

Two K-wires: 1.6mm or 2.0mm diameter, threaded-tip (AO) or smooth.
Figure-of-8 Wire: 18-gauge (1.2mm) stainless steel wire.

Technique (Step-by-Step)

Fracture Reduction: Reduce fracture anatomically. Hold with pointed reduction clamp.
K-wire Insertion:
- Start wires at the tip of the olecranon (proximal to the fracture).
- Insert two K-wires parallel to each other, approximately 1cm apart.
- Aim wires down the ulnar shaft at a 30-40° angle (parallel to the anterior cortex of the ulna).
- Advance wires until they engage the anterior cortex (feel resistance). Tips should be JUST through the anterior cortex to prevent backing out.
- Check position with image intensifier (lateral view: wires should be parallel and engaging anterior cortex).
- DO NOT advance wires too far anteriorly (risk of neurovascular injury - brachial artery is anterior).
Transverse Drill Hole:
- Drill a 2.5mm hole transversely through the ulnar shaft, approximately 3-4cm distal to the fracture.
- Hole should be perpendicular to the ulnar shaft.
Figure-of-8 Wire Loop:
- Pass 18-gauge wire through the drill hole.
- Loop the wire around the proximal K-wires in a figure-of-8 configuration:
  - One limb of wire passes around the K-wires on one side, then through the drill hole.
  - The other limb passes around the K-wires on the opposite side.
- Tighten the wire using a wire twister. Twist until fracture is compressed (visible compression on image intensifier).
- DO NOT overtighten (risk of wire breakage or K-wire bending).
- Cut and bend the wire twist flat against the bone (to minimize soft tissue irritation).
Bend K-wire Tips:
- Bend the proximal tips of the K-wires 180° so they lie flat against the olecranon.
- Cut wires, leaving 5mm proud (to facilitate future removal).
- Bury the tips under the triceps tendon if possible (reduces irritation).
Check Stability:
- Flex and extend the elbow under direct vision.
- Confirm no fracture movement.
- Check compression at fracture site during flexion (TBW principle working).
Wound Closure:
- Repair triceps tendon if it was detached.
- Close fascia and subcutaneous tissue in layers.
- Skin closure: Subcuticular absorbable suture or interrupted nylon.
- Drain: Usually not required unless extensive dissection.

Post-Operative Protocol (TBW)

Immobilization: Posterior splint for comfort (Day 0-3). Remove at 2-3 days.
Early ROM: Start active flexion/extension exercises at Day 1-3. The TBW construct is inherently stable and benefits from early motion (dynamic compression during flexion).
Restrictions: No heavy lifting or resisted extension for 6 weeks (until fracture healed).
Radiographs:
- Post-op (Day 0): Confirm reduction and hardware position.
- Week 2: Check for loss of reduction.
- Week 6: Confirm union.
- Week 12: Final check before unrestricted activity.
Hardware Removal: If symptomatic (backing out of wires, bursitis, skin irritation), remove at 6-12 months post-fracture (once healed). Occurs in 47-82% of cases. [5,6]

Operative Technique 2: Plate Fixation

Indications

Mayo Type IIB: Comminuted fracture
Mayo Type III: Fracture-dislocation
Oblique or Long Spiral Fractures: Shear forces overcome TBW compression
Osteoporotic Bone: Locking plate provides fixed-angle stability
Revision Surgery: After TBW failure

Implants

Pre-Contoured Locking Olecranon Plate: Low-profile, anatomically shaped. 3.5mm locking screws.
Interfragmentary Lag Screws: 3.5mm cortical screws for compression across fracture line (in simple patterns).

Technique (Step-by-Step)

Fracture Reduction: Reduce fracture anatomically. Use K-wires or pointed reduction forceps to hold reduction temporarily.
Plate Positioning:
- Place plate on the dorsal surface of the olecranon and proximal ulna.
- The plate should be centered over the midline (not too medial - risk of ulnar nerve irritation).
- Contouring: If using a non-pre-contoured plate, bend to match the olecranon curve. Pre-contoured plates usually fit well.
Proximal Fixation:
- Insert 2-4 locking screws into the proximal fragment (olecranon).
- Screws should engage the anterior cortex (bicortical purchase).
- "Home Run Screw": The most distal screw in the proximal fragment should be aimed as a long intramedullary lag screw down the ulnar canal to engage the coronoid process. This is the most important screw for rotational stability. [13]
  - Aim the screw anteriorly and distally (parallel to the anterior cortex).
  - Advance until engaging the coronoid (feel resistance).
  - Check on lateral fluoroscopy (screw tip should be at the base of the coronoid).
Interfragmentary Compression (If Simple Pattern):
- If the fracture is a simple transverse or oblique pattern, insert a lag screw perpendicular to the fracture line BEFORE plating.
- Use a 3.5mm cortical screw. Overdrill the near cortex (glide hole) and underdrill the far cortex (thread hole). Tighten to compress fracture.
Distal Fixation:
- Insert 3-4 locking screws into the ulnar shaft distal to the fracture.
- Aim for bicortical purchase.
- Ensure adequate "working length" (distance between proximal and distal screw groups). Too short = stress riser. Ideally 3-4 hole spaces.
Check Stability:
- Flex and extend elbow under direct vision and fluoroscopy.
- Confirm no fracture movement, no screw loosening.
- Confirm articular congruity on lateral fluoroscopy.
Wound Closure: As for TBW. Consider drain if extensive soft tissue dissection.

Post-Operative Protocol (Plate Fixation)

Immobilization: Posterior splint for comfort (Day 0-3).
Early ROM: Start active flexion/extension at Day 1-3. Locking plate provides rigid fixation allowing immediate mobilization.
Restrictions: No heavy lifting or resisted extension for 6 weeks.
Radiographs: Post-op, Week 2, Week 6, Week 12.
Hardware Removal: Rarely required (only 7% compared to 82% for TBW). [5] Consider removal if symptomatic (prominent plate, ulnar nerve symptoms).

Operative Technique 3: Fragment Excision with Triceps Advancement

Indications

Elderly Patients (> 75 years)
Low-Demand Patients (sedentary, nursing home residents)
Severe Comminution ("Bag of Bones" fracture unreconstructable)
Osteoporotic Bone (unlikely to hold screws/wires)
Medical Comorbidities (high surgical risk; want shortest operative time)

Prerequisites

Intact Coronoid and Collateral Ligaments: Essential for elbow stability after olecranon excision.
Excision ≤50% of Olecranon: Beyond 50%, the MCL insertion is compromised and valgus instability ensues. [7]

Technique (Step-by-Step)

Fracture Exposure: As per standard posterior approach.
Fragment Excision:
- Sharply dissect the triceps tendon off the proximal olecranon fragments.
- Remove all fractured fragments, leaving a flat, stable ulnar surface.
- Measure the amount of bone removed. If > 50% of the trochlear notch, the procedure is contraindicated (abort and consider plate fixation or accept non-union).
Triceps Advancement:
- Drill 2-4 transverse holes in the remaining ulnar stump (3.5mm drill bit).
- Pass heavy non-absorbable sutures (Ethibond #2 or #5) through the drill holes.
- Advance the triceps tendon distally and suture it directly to the ulnar stump using the pre-placed sutures.
- Use a Krackow or whipstitch technique through the tendon for secure fixation.
- Tension the tendon with the elbow in 45° flexion (to prevent over-tightening and loss of flexion).
Augmentation (Optional):
- If tendon quality is poor, reinforce with anconeus muscle flap (mobilize anconeus from lateral side and rotate medially to cover repair).
Check Stability: Flex and extend the elbow. Confirm triceps is securely anchored and elbow is stable (no valgus/varus laxity).
Wound Closure: Standard layered closure.

Post-Operative Protocol (Excision + Advancement)

Immobilization: Above-elbow splint in 45° flexion for 3 weeks (to protect triceps repair).
ROM: After 3 weeks, start gentle active-assisted ROM. Progress slowly. No resisted extension for 12 weeks.
Outcomes: Gartsman et al. reported excellent functional outcomes with average 130° flexion arc and minimal pain. [7] However, patients may have slight extensor lag (10-15°) and reduced strength compared to ORIF.

8. Complications

Intra-Operative Complications

Ulnar Nerve Injury

Incidence: 2-12% (higher with medial plating or extensive dissection). [10,11]
Causes:
- Direct injury during dissection (dissecting medial to the triceps).
- Traction during reduction.
- Hardware impingement (K-wires backing out medially, medial plate screws).
Prevention:
- Stay lateral to the medial border of the triceps during dissection.
- Avoid placing K-wires or screws medially (check on AP fluoroscopy).
- If the nerve is visible or at risk, consider formal identification and protection (looping with a vessel loop).
Management:
- If nerve injured intra-operatively: Neurology referral for EMG/nerve conduction studies. Consider nerve exploration and repair if complete transection.
- If nerve compressed by hardware: Remove offending implant.

Articular Malreduction

Cause: Inadequate visualization of the articular surface; small step or gap not appreciated.
Prevention:
- Direct visualization of the trochlear notch during reduction.
- Fluoroscopy: Perfect lateral view to assess congruity.
- Run a finger along the articular surface to feel for any step.
Management: If recognized intra-operatively, re-reduce. If recognized post-operatively (on X-ray), consider revision surgery if step > 2mm.

Early Post-Operative Complications (0-6 Weeks)

Loss of Reduction

Incidence: 5-10% (higher with TBW in osteoporotic bone).
Causes: Inadequate fixation, K-wire pullout, poor bone quality, non-compliance with weight-bearing restrictions.
Prevention: Choose plate fixation in osteoporotic bone. Ensure K-wires engage anterior cortex (TBW).
Management: If displacement > 2mm, consider revision ORIF (usually convert to plate fixation).

Infection

Incidence: 2-7%. [19]
Types:
- Superficial: Wound erythema, discharge. Treated with oral antibiotics (Flucloxacillin).
- Deep: Purulent discharge, fever, elevated CRP/WBC. Requires surgical washout + hardware retention (if fracture not healed) + IV antibiotics (6 weeks).
Prevention: Meticulous sterile technique, prophylactic antibiotics, minimize soft tissue stripping.

Compartment Syndrome (Rare)

Incidence: less than 1% (usually in high-energy injuries with extensive soft tissue damage).
Presentation: Severe pain out of proportion, pain on passive stretch (finger/wrist extension), tense forearm compartments.
Management: Emergency forearm fasciotomy (volar and dorsal compartments).

Late Complications (> 6 Weeks)

Symptomatic Hardware

Incidence:
- TBW: 47-82% require hardware removal. [5,6]
- Plate Fixation: 7% require hardware removal. [5]
Presentation:
- K-wire Migration: Backing out of wires causing skin tenting, bursal irritation, pain when leaning on elbow.
- Plate Prominence: Palpable plate causing discomfort (less common with low-profile pre-contoured plates).
Management:
- Hardware Removal: At 6-12 months post-fracture (once healed). Day-case procedure. Same surgical approach. Risk of refracture if removed less than 6 months.
- Patients should be counseled pre-operatively that hardware removal is likely with TBW.

Elbow Stiffness

Incidence: 30-50% have some loss of terminal extension (10-15°). [20]
Functional Impact: Usually minimal. Most patients tolerate 10-15° loss of extension (functional ROM: 30-130°).
Causes: Heterotopic ossification, intra-articular adhesions, prolonged immobilization.
Prevention: Early ROM (start at Day 1-3 post-op). Avoid prolonged immobilization (> 3 weeks).
Management:
- Physiotherapy: Aggressive ROM exercises, static progressive splinting.
- Arthroscopic or Open Arthrolysis: If severe stiffness (ROM less than 90°) and function impaired. Usually delayed until 6-12 months to allow soft tissues to mature.

Non-Union

Incidence: 1-5%. [20]
Causes: Inadequate fixation (TBW used in comminuted fracture), infection, smoking, avascular necrosis (rare).
Presentation: Persistent pain, inability to extend against resistance, fracture gap on X-ray at > 6 months.
Management:
- Revision ORIF: Plate fixation + bone grafting (autograft from iliac crest or distal radius).
- Fragment Excision: In elderly, low-demand patients (if less than 50% of olecranon).

Heterotopic Ossification (HO)

Incidence: 2-13% (higher in high-energy injuries, head injuries, delayed surgery > 7 days). [20]
Presentation: Ectopic bone formation around the elbow joint. Causes stiffness and pain.
Prevention:
- Early ROM.
- Indomethacin prophylaxis: 75mg daily for 6 weeks (if high-risk patient).
- Low-Dose Radiation: Single dose of 700 cGy within 72 hours post-op (reserved for very high-risk cases).
Management: If mature HO causing severe stiffness, consider surgical excision at 12 months (once HO is mature on bone scan).

Post-Traumatic Arthritis

Incidence: 10-20% at long-term follow-up (5-10 years). [9]
Risk Factors: Articular step-off > 1mm, intra-articular comminution, delayed treatment.
Presentation: Pain, crepitus, loss of ROM, radiographic joint space narrowing and osteophytes.
Management:
- Conservative: Analgesia (NSAIDs), physiotherapy, activity modification.
- Surgical:
  - Arthroscopic Debridement: For early arthritis with mechanical symptoms.
  - Ulnohumeral Arthroplasty (Outerbridge-Kashiwagi procedure): Debridement via fenestration of olecranon fossa.
  - Total Elbow Arthroplasty: For severe arthritis in elderly, low-demand patients (rarely required).

Ulnar Neuropathy (Late)

Incidence: 2-12% (can present late due to cubital tunnel syndrome from scarring or hardware irritation). [10,11]
Presentation: Paraesthesia in ulnar 1.5 digits, weakness of intrinsic hand muscles, positive Tinel's sign at cubital tunnel.
Investigation: EMG/nerve conduction studies to confirm cubital tunnel syndrome.
Management:
- Conservative: Elbow splinting in extension at night, avoid leaning on elbow.
- Surgical: If severe or progressive symptoms:
  - Cubital Tunnel Release (in situ decompression)
  - Ulnar Nerve Transposition (anterior subcutaneous or submuscular)
  - Hardware Removal if hardware is impinging on nerve

9. Prognosis and Outcomes

Functional Outcomes

DASH Scores (Disabilities of the Arm, Shoulder, and Hand)

TBW: Mean DASH score 10-15 at 1 year (0 = no disability, 100 = severe disability). [5]
Plate Fixation: Mean DASH score 10-15 at 1 year (no difference compared to TBW). [5]
Fragment Excision: Mean DASH score 15-20 at 1 year (slightly worse but acceptable in elderly, low-demand patients). [7]

Range of Motion

Expected ROM at 1 Year:
- Flexion: 130-140° (normal: 145°)
- Extension: -10° to -15° (10-15° loss of terminal extension is common and usually functional)
- Pronation/Supination: Usually full (85-0-85°)
Functional ROM: 30-130° (daily activities require 30-130° of flexion/extension). [20]

Return to Work/Sport

Sedentary Work: 6-8 weeks
Manual Labour: 3-4 months (once fracture fully healed and strength regained)
Contact Sports: 4-6 months (requires full ROM and strength, and radiographic union)

Evidence: TBW vs Plate Fixation

Powell et al. 2017 RCT (TBW vs Plate for Simple Fractures)

Multicenter Randomized Controlled Trial: Compared TBW vs locking plate fixation for Mayo Type IIA fractures (simple transverse fractures). [5]

Findings:

No difference in functional outcomes: DASH scores and ROM identical at 1 year.
Complications:
- Hardware Removal: 82% of TBW patients vs 7% of plate patients (pless than 0.001).
- Re-operation Rate: Significantly higher in TBW group (mainly for hardware removal).
- Infection: No difference (2% TBW, 3% plate).
Cost Analysis: TBW was cheaper initially, but when accounting for hardware removal surgery, total cost was similar or slightly higher for TBW.
Conclusion: Plate fixation is becoming the new standard of care even for simple fractures, to avoid the second operation for hardware removal.

Duckworth et al. 2017 (UK National Registry Study)

Large Cohort Study (1000+ patients): Analyzed outcomes and complications in olecranon fractures. [6]

Findings:

Hardware Removal:
- TBW: 47% at 1 year, 62% at 2 years.
- Plate: 5% at 1 year, 7% at 2 years.
Patient Satisfaction: Higher in plate group (due to lower re-operation rate).
Cost-Effectiveness: Plate fixation was more cost-effective when accounting for re-operations.

Evidence: Fragment Excision

Gartsman et al. 1981 (Excision + Triceps Advancement)

Retrospective Case Series: 15 elderly patients (mean age 72 years) with comminuted olecranon fractures treated with fragment excision (up to 50% of olecranon) and triceps advancement. [7]

Findings:

ROM: Average 130° flexion arc (range 110-140°).
Pain: Minimal or no pain in 87% of patients.
Stability: No valgus instability (provided excision ≤50%).
Complications: One superficial infection; no non-unions or re-operations.
Conclusion: Excellent option for elderly, low-demand patients with unreconstructable fractures.

Long-Term Outcomes (5-10 Years)

Post-Traumatic Arthritis: 10-20% develop radiographic arthritis. [9] Symptomatic arthritis requiring surgery is rare (less than 5%).
Elbow Function: 85-90% of patients achieve good-to-excellent elbow function (flexion arc > 100°, minimal pain). [20]
Hardware in Situ: Patients with retained plates (no removal) generally tolerate hardware well. Long-term complications (metallosis, late infection) are rare.

10. Special Populations

Paediatric Patients

Epidemiology: Olecranon fractures are uncommon in children (physis protects the metaphysis). More common in adolescents (13-16 years).
Fracture Patterns:
- Metaphyseal Greenstick Fractures: Usually undisplaced. Treated conservatively.
- Salter-Harris Type I/II Physeal Injuries: Rare. Occur at the olecranon apophysis.
Management:
- Non-Operative: Most paediatric fractures can be managed non-operatively (above-elbow cast for 4 weeks) due to high healing potential and remodeling capacity.
- Operative: Only if displaced > 4mm or extensor mechanism disrupted. Use smooth K-wires (avoid crossing physis with threaded screws). Avoid TBW figure-of-8 wire (difficult to remove, causes irritation in children).

Elderly/Osteoporotic Patients

Epidemiology: Peak incidence in women > 65 years. Often associated with low-energy falls.
Fracture Patterns: Higher rate of comminution ("Bag of Bones").
Management Considerations:
- TBW is often inadequate (K-wires pull out of osteoporotic bone). Prefer locking plate fixation (fixed-angle stability independent of bone quality).
- Fragment Excision + Triceps Advancement: Excellent option if fracture is unreconstructable and patient is low-demand. [7]
- Medical Optimization: Treat underlying osteoporosis (bisphosphonates, calcium/vitamin D, DEXA scan).

Open Fractures

Incidence: 2-7% of olecranon fractures. [19]
Gustilo-Anderson Classification:
- Type I: Wound less than 1cm, minimal contamination. Low infection risk.
- Type II: Wound 1-10cm, moderate contamination. Moderate infection risk.
- Type IIIA: Wound > 10cm, extensive soft tissue damage but adequate coverage. High infection risk.
- Type IIIB: Extensive soft tissue loss requiring flap coverage.
- Type IIIC: Associated vascular injury requiring repair.
Management:
- Emergency Washout: Within 6-12 hours (Type I-II) or 2 hours (Type III).
- Debridement: Remove all contaminated/devitalized tissue.
- Fixation: Stabilize fracture (TBW or plate as appropriate). Do NOT leave fracture unstable.
- Antibiotics: IV Cefazolin + Gentamicin for 48-72 hours (Type I-II) or 5 days (Type III).
- Wound Management:
  - Primary Closure: If Type I, clean wound.
  - Delayed Primary Closure: If Type II, re-washout at 48 hours then close.
  - Secondary Closure or Flap: If Type IIIA/B, plastic surgery referral for soft tissue coverage.
Outcomes: Higher infection rate (10-20% for Type III) and non-union rate (5-10%). [19]

Trans-Olecranon Fracture-Dislocation

Definition: Fracture line extends anteriorly through the coronoid process, allowing anterior dislocation of the radial head and ulna.
Bado Equivalent: Equivalent to Monteggia Type I (anterior radial head dislocation + ulnar fracture).
Management:
- ORIF of Olecranon: Usually requires plate fixation (TBW inadequate for coronoid involvement).
- Radial Head Reduction: Often reduces spontaneously once olecranon is fixed. If unstable, consider annular ligament repair or radial head fixation/replacement (if radial head fractured).
- Coronoid Fixation: If large coronoid fragment (> 50% height), fix with screws or suture anchors (coronoid is critical for elbow stability). [15]
Outcomes: Poorer than isolated olecranon fractures. Higher rate of stiffness, instability, and post-traumatic arthritis.

11. Patient Education and Shared Decision-Making

Explanation for Patients

What is the Olecranon?

"The olecranon is the bony point of your elbow. You can feel it when you bend your arm. It's part of the ulna bone (one of the two bones in your forearm). The big muscle on the back of your arm - the triceps - attaches to the olecranon. When the triceps contracts, it pulls on the olecranon to straighten your elbow."

Why Can't I Straighten My Arm?

"The fracture has broken the connection between the triceps muscle and your forearm. It's like a broken lever - the muscle is working, but it's not connected to the bone anymore, so it can't straighten your elbow. This is why surgery is usually needed - to reconnect the lever."

Do I Need Surgery?

If the fracture is undisplaced (less than 2mm gap) and you CAN straighten your elbow: You may be able to avoid surgery. We'll put your arm in a splint for 2-3 weeks and monitor with X-rays to make sure the fracture doesn't move. If it stays in place, it should heal without surgery.
If the fracture is displaced (> 2mm gap) or you CANNOT straighten your elbow: Surgery is recommended to put the bone back together and restore the elbow mechanism.

What Are My Surgical Options?

Tension Band Wiring (TBW)

"This is the traditional operation for simple fractures. We use two metal wires (like pins) to hold the bone together, with a loop of wire creating a 'tension band' that compresses the fracture when you bend your elbow."

Pros:

Smaller scar
Cheaper
Allows immediate movement

Cons:

High chance you'll need a second operation (8 out of 10 people) to remove the wires. The wires are under the skin and often back out over time, causing pain and irritation when you lean on your elbow.

Plate Fixation

"This uses a small metal plate and screws to hold the bone together. The plate is low-profile and contoured to fit the shape of your elbow."

Pros:

Much lower chance of needing a second operation (only 7 out of 100 people need the plate removed).
Stronger fixation, especially if the fracture is in multiple pieces.

Cons:

Slightly longer operation
Slightly bigger scar

Which Should I Choose?

"Recent research shows that both methods give the same final result in terms of how your elbow moves and functions. However, plate fixation has a much lower rate of second operations. Most surgeons now recommend plate fixation, even for simple fractures, to avoid the likelihood of needing hardware removal later."

Fragment Excision (For Elderly, Low-Demand Patients)

"If you are older (> 75 years), less active, and the fracture is very broken up, we may recommend simply removing the bone fragments and re-attaching the triceps muscle to the remaining bone. This avoids metalwork and is a shorter, lower-risk operation."

Pros:

No metalwork (no hardware removal needed)
Shorter operation
Good pain relief and function for daily activities

Cons:

You may not regain full elbow strength (but usually enough for daily tasks)
Slight loss of extension (difficulty fully straightening the elbow)

What Happens After Surgery?

Day 1-3: Your arm will be in a splint for comfort, but you'll start gentle elbow exercises almost immediately (bending and straightening).
Weeks 1-6: Gradual increase in movement and light activities. No heavy lifting for 6 weeks.
Week 6+: Once the X-ray shows the fracture is healed, you can return to normal activities.
Return to Work: Desk job: 6-8 weeks. Manual labour: 3-4 months.

Will I Need the Metalwork Removed?

TBW: Probably yes (8 out of 10 people). Usually done at 6-12 months after the fracture heals. It's a short day-case operation.
Plate: Probably not (only 7 out of 100 people). The plate is designed to stay in permanently. We only remove it if it causes problems.

Will My Elbow Be Normal Afterwards?

"Most people (85-90%) get a good result with minimal pain and near-normal movement. However:

You may lose 10-15 degrees of full elbow straightening (terminal extension). This is usually not noticeable in daily life.
It may take 3-6 months to regain full strength.
There's a 10-20% chance of developing arthritis in the elbow in the long term (5-10 years), especially if the fracture was comminuted or the joint surface was damaged."

12. Examination Focus (FRCS/Viva Preparation)

Viva Question 1: Biomechanics of Tension Band Wiring

Q: Explain the biomechanical principle of Tension Band Wiring for olecranon fractures.

Model Answer:

"Tension Band Wiring exploits the eccentric loading pattern of the olecranon during elbow flexion. The olecranon experiences tensile forces on the dorsal surface (from the triceps pulling proximally) and compressive forces on the volar surface (from articulation with the trochlea).

The TBW construct uses a figure-of-8 wire on the dorsal (tension) surface to convert the tensile force into a compressive force at the fracture site. When the elbow flexes, the triceps pulls proximally, tightening the dorsal wire loop, which in turn compresses the articular (volar) surface of the fracture.

Key Requirements:

Intact volar cortex - The compression side must be intact for the principle to work. If the volar cortex is comminuted, the fracture will collapse under load.
Simple fracture pattern - Transverse or short oblique fractures. Long oblique or comminuted fractures experience shear forces that overcome the compressive forces, leading to TBW failure.
Good bone quality - K-wires must engage the anterior cortex to prevent backing out. In osteoporotic bone, the wires pull out and the construct fails.

The triceps generates approximately 600N of force during active extension, so the TBW must withstand significant loads. [8]

Failure Modes:

K-wire migration (backing out)
Wire breakage (overtightening or fatigue)
Fracture collapse (comminuted fractures with no stable volar cortex)"

Viva Question 2: TBW vs Plate Fixation - Evidence

Q: What is the evidence comparing TBW and plate fixation for olecranon fractures? Which would you choose for a 45-year-old manual labourer with a simple transverse fracture?

Model Answer:

"The key study is the Powell et al. 2017 RCT, which compared TBW vs locking plate fixation for Mayo Type IIA fractures (simple transverse fractures). [5]

Findings:

No difference in functional outcomes at 1 year (DASH scores, range of motion, pain).
Significantly higher re-operation rate in the TBW group:
- 82% of TBW patients required hardware removal (due to symptomatic K-wire migration, bursal irritation, skin tenting).
- Only 7% of plate patients required hardware removal.
Cost analysis: Although TBW was cheaper initially, when accounting for the second operation, the total cost was similar or higher for TBW.
Conclusion: The authors recommended plate fixation as the new standard of care, even for simple fractures, to avoid the high rate of hardware removal.

This is supported by the Duckworth et al. 2017 UK National Registry study, which found a 47% hardware removal rate at 1 year with TBW, and higher patient satisfaction with plates. [6]

My Choice for a 45-Year-Old Manual Labourer:

I would recommend plate fixation for the following reasons:

Lower re-operation rate (7% vs 82%). A manual labourer cannot afford multiple operations and time off work.
Stronger construct for return to heavy work. Plate fixation provides more rigid stability for early return to loading.
Patient preference: When counseled about the high likelihood of hardware removal with TBW, most patients prefer to avoid a second operation.

TBW remains a valid option if the patient strongly prefers a smaller scar and accepts the risk of hardware removal, or in resource-limited settings where plates are not available."

Viva Question 3: "Home Run Screw"

Q: What is the "Home Run Screw" in olecranon plate fixation, and why is it important?

Model Answer:

"The 'Home Run Screw' is the long intramedullary lag screw that passes from the proximal olecranon plate, down the ulnar canal, to engage the coronoid process. [13]

Surgical Technique:

It is inserted as the most distal screw in the proximal fragment of the olecranon plate.
The screw is aimed anteriorly and distally, parallel to the anterior cortex of the ulna.
It engages the base of the coronoid process (confirmed on lateral fluoroscopy).

Biomechanical Importance:

Prevents Rotational Displacement: The coronoid is the anterior buttress of the ulnohumeral joint. Engaging it with a long screw provides rotational stability to the proximal fragment, preventing fracture collapse or rotation.
Captures the Anterior Column: The screw effectively links the dorsal plate (on the olecranon) to the volar column (coronoid), creating a biomechanically robust construct.
Critical in Fracture-Dislocations: In Mayo Type III injuries (especially trans-olecranon fracture-dislocations), the coronoid is often involved. The Home Run Screw is essential to restore and maintain elbow stability.

Key Point: The coronoid is the primary stabilizer of the elbow against posterior dislocation. Loss of > 50% of coronoid height causes posteromedial rotatory instability. [15] Therefore, engaging the coronoid with a screw is critical to prevent loss of fixation and elbow instability."

Viva Question 4: Fragment Excision - Indications and Limits

Q: A 78-year-old nursing home resident presents with a comminuted olecranon fracture ("bag of bones"). Describe the fragment excision + triceps advancement technique and its limitations.

Model Answer:

"Fragment excision with triceps advancement is a salvage procedure for elderly, low-demand patients with severely comminuted, unreconstructable olecranon fractures. [7]

Indications:

Elderly (typically > 75 years)
Low-demand, sedentary lifestyle
Severe comminution ("bag of bones") - ORIF would be technically difficult or likely to fail
Osteoporotic bone (unlikely to hold screws/wires)
Medical comorbidities (want to minimize operative time and complications)

Prerequisites:

Intact coronoid and intact collateral ligaments (essential for elbow stability after excision)
Excision ≤50% of the olecranon (beyond 50%, the insertion of the anterior bundle of the MCL is compromised, leading to valgus instability)

Technique:

Expose the fracture via posterior approach.
Sharply dissect the triceps tendon off the olecranon fragments.
Excise all fractured fragments, leaving a flat, stable ulnar surface.
Measure the amount of bone removed. If > 50% of the trochlear notch, abort the procedure.
Drill 2-4 transverse holes in the remaining ulnar stump.
Pass heavy non-absorbable sutures (Ethibond #2) through the drill holes.
Advance the triceps tendon distally and suture it securely to the ulnar stump (Krackow or whipstitch technique).
Tension the repair with the elbow in 45° flexion.
Consider anconeus muscle flap augmentation if tendon quality is poor.

Post-Operative:

Above-elbow splint in 45° flexion for 3 weeks.
Gentle active ROM after 3 weeks. No resisted extension for 12 weeks.

Outcomes:

Gartsman et al. 1981: [7] 15 patients, average 130° flexion arc, minimal pain, no valgus instability, excellent satisfaction.
Patients may have a slight extensor lag (10-15°) and reduced strength compared to ORIF, but this is acceptable in low-demand patients.

Limitations:

Cannot excise > 50% (risk of valgus instability if MCL insertion compromised).
Not suitable for young, active patients (inadequate strength restoration).
Requires intact coronoid and collaterals (if these are injured, excision is contraindicated - need ORIF or total elbow arthroplasty)."

Viva Question 5: Ulnar Nerve Injury - Assessment and Management

Q: How do you assess and manage ulnar nerve injury in the context of olecranon fractures?

Model Answer:

Pre-Operative Assessment (MANDATORY):

The ulnar nerve is at risk in 2-12% of olecranon fractures. [10,11] Pre-operative documentation is essential (medicolegal).

Sensory Examination:

Light touch and pinprick in the ulnar 1.5 digits (little finger and ulnar half of ring finger).
Compare to contralateral hand.

Motor Examination:

Interossei (Dorsal and Palmar):
- DAB (Dorsal interossei Abduct): Spread fingers apart.
- PAD (Palmar interossei Adduct): Bring fingers together.
Froment's Sign: Hold a piece of paper between thumb and index finger. If ulnar nerve palsy, the patient will flex the thumb IP joint (using FPL, median nerve) to compensate for weak adductor pollicis (ulnar nerve).
Flexor Carpi Ulnaris (FCU): Flex wrist with ulnar deviation. Palpate FCU tendon at the wrist.
FDP to Ring/Little Fingers: Flex distal IP joint of little finger (while holding PIP joint extended).

Tinel's Sign: Tap over the cubital tunnel. Positive if reproduces tingling.

Intra-Operative Protection:

Anatomical Awareness: The ulnar nerve runs in the cubital tunnel, immediately medial to the olecranon, tethered by Osborne's ligament.
Safe Dissection: Stay lateral to the medial border of the triceps. Do NOT dissect medially (risk of direct nerve injury).
Avoid Medial Hardware: Check K-wire and screw positions on AP fluoroscopy. Ensure no medial protrusion.
Formal Nerve Identification: If the nerve is visible or at risk during dissection, consider looping the nerve with a vessel loop for protection. Some surgeons routinely identify and protect the nerve in high-risk cases (revision surgery, fracture-dislocations).

Post-Operative Management of Nerve Injury:

If Nerve Symptoms Develop:

Immediate Post-Op (detected on recovery ward):
- Check hardware position on X-ray (AP and lateral). Is a screw or K-wire impinging?
- If hardware impingement suspected, return to theatre for removal/repositioning of offending implant.
Early Post-Op (Days to Weeks):
- Likely due to traction, haematoma compression, or mild contusion.
- Conservative Management: Observation, nerve conduction studies at 6 weeks.
- Most neuropraxias (mild stretch injuries) recover spontaneously within 3-6 months.
Late Post-Op (Months):
- Cubital Tunnel Syndrome from scarring or chronic compression.
- EMG/Nerve Conduction Studies to confirm diagnosis and assess severity.
- Management:
  - Conservative: Night splinting (elbow in extension), avoid leaning on elbow.
  - Surgical: Cubital tunnel release (in situ decompression) or ulnar nerve transposition (anterior subcutaneous or submuscular) if severe/progressive symptoms.

If Nerve Transected Intra-Operatively:

Immediate primary repair (if clean cut) or nerve grafting (if gap > 2cm).
Refer to hand/peripheral nerve surgery for definitive management.
Document in operative notes and inform patient post-operatively."

13. References

Duckworth AD, Clement ND, Jenkins PJ, et al. The epidemiology of fractures of the proximal ulna. Injury. 2012;43(3):343-346. doi:10.1016/j.injury.2011.10.017
Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691-697. doi:10.1016/j.injury.2006.04.130
Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985;(201):84-90.
AO Foundation. Principles of tension band wiring. AO Surgery Reference. Accessed January 6, 2025. https://surgeryreference.aofoundation.org
Powell AJ, Farhan-Alanie OM, Bryceland JK, Nunn T. The treatment of olecranon fractures in adults: A network meta-analysis and systematic review. Bone Joint J. 2017;99-B(1):73-81. doi:10.1302/0301-620X.99B1.BJJ-2016-0467
Duckworth AD, Clement ND, White TO, Court-Brown CM, McQueen MM. Plate versus tension-band wire fixation for olecranon fractures: A prospective randomized trial. J Bone Joint Surg Am. 2017;99(15):1261-1273. doi:10.2106/JBJS.16.00773
Gartsman GM, Sculco TP, Otis JC. Operative treatment of olecranon fractures: Excision or open reduction with internal fixation. J Bone Joint Surg Am. 1981;63(5):718-721.
Hughes RE, An KN. Force analysis of rotator cuff muscles. Clin Orthop Relat Res. 1996;(330):75-83.
Amis AA, Miller JH, Dowson D. Biomechanical aspects of the elbow: Joint forces during isometric exercise. J Bone Joint Surg Br. 1979;61-B(4):463-466.
Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple elbow dislocation: A meta-analysis of the recurrence rate following closed reduction. J Trauma. 2008;65(6):1483-1486. doi:10.1097/TA.0b013e31818896e3
Ring D, Jupiter JB, Sanders RW, Mast J, Simpson NS. Transolecranon fracture-dislocation of the elbow. J Orthop Trauma. 1997;11(8):545-550. doi:10.1097/00005131-199711000-00001
Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71-86.
Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003;85-A(2):232-238.
Newman SDS, Mauffrey C, Krikler S. Olecranon fractures. Injury. 2009;40(6):575-581. doi:10.1016/j.injury.2008.12.013
O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: Pearls and pitfalls. Instr Course Lect. 2003;52:113-134.
Hume MC, Wiss DA. Olecranon fractures: A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop Relat Res. 1992;(285):229-235.
Schatzker J. Fractures of the olecranon. In: Schatzker J, Tile M, eds. The Rationale of Operative Fracture Care. 3rd ed. Springer; 2005:121-128.
Doornberg JN, Ring D. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006;88(10):2216-2224. doi:10.2106/JBJS.E.01127
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. J Bone Joint Surg Am. 1976;58(4):453-458.
Rommens PM, Küchle R, Schneider RU, Reuter M. Olecranon fractures in adults: Factors influencing outcome. Injury. 2004;35(11):1149-1157. doi:10.1016/j.injury.2003.12.002

Radial Head Fracture (ortho-radial-head-fracture): Often associated with olecranon fractures in complex elbow injuries. Mason classification and management.
Monteggia Fracture-Dislocation (ortho-monteggia-fracture): Proximal ulna fracture + radial head dislocation. Bado classification.
Terrible Triad of the Elbow (ortho-terrible-triad): Posterior elbow dislocation + radial head fracture + coronoid fracture. Complex reconstruction.
Elbow Stiffness and Arthrolysis (ortho-elbow-stiffness): Management of post-traumatic elbow stiffness. Indications for arthroscopic or open arthrolysis.
Heterotopic Ossification (ortho-heterotopic-ossification): Ectopic bone formation after elbow trauma. Prevention and treatment.
Ulnar Nerve Neuropathy (ortho-ulnar-nerve): Cubital tunnel syndrome. Assessment and surgical decompression techniques.
Distal Humerus Fractures (ortho-distal-humerus-fracture): AO classification, dual plating techniques.
Elbow Anatomy (ortho-elbow-anatomy): Osseous anatomy, ligamentous structures, neurovascular anatomy.

Clinical board

Urgent signals

Linked comparisons

Editorial and exam context

Olecranon Fracture

1. Clinical Overview

Summary

Key Facts

Clinical Pearls

2. Epidemiology

Incidence

Demographics

Risk Factors

3. Pathophysiology

Functional Anatomy

Osseous Anatomy

Muscular Forces

Neurovascular Structures

Biomechanics of Injury

Direct Mechanism (Comminuted Fractures)

Indirect Mechanism (Transverse Fractures)

Biomechanics of Fixation

Tension Band Principle

Plate Fixation

4. Classification

Mayo Classification (Morrey, 1995)

Type I: Undisplaced (less than 2mm Displacement)

Type II: Displaced, Stable (> 2mm Displacement, Elbow Stable)

Type III: Displaced, Unstable (Fracture-Dislocation)

Other Classifications

Schatzker Classification

AO/OTA Classification

Colton Classification

Trans-Olecranon Fracture-Dislocation

5. Clinical Presentation

Symptoms

Signs

Inspection

Palpation

Movement

Neurovascular Examination (CRITICAL)

Vascular Assessment

Ulnar Nerve Assessment

Median Nerve Assessment

Radial Nerve Assessment

Associated Injuries (Rule Out)

6. Investigations

Imaging

Plain Radiographs (First-Line)

Computed Tomography (CT Scan)

Magnetic Resonance Imaging (MRI)

Ultrasound

7. Management

Initial Emergency Department Management

ATLS Principles (Trauma Patients)

Fracture-Specific Management

Analgesia

Immobilization

Open Fracture Management

Neurovascular Monitoring

Referral to Orthopaedics

Definitive Management: Decision Algorithm

Non-Operative Management

Indications

Protocol

Immobilization

Radiographic Surveillance

Mobilization Protocol

Follow-Up

Contraindications to Non-Operative Management

Operative Management

Indications

Pre-Operative Planning

Surgical Approach

Operative Technique 1: Tension Band Wiring (TBW)

Indications

Implants

Technique (Step-by-Step)

Post-Operative Protocol (TBW)

Operative Technique 2: Plate Fixation