Olecranon Fractures: Treatment Options

David J. Hak, MD, and Gregory J. Golladay, MD

Abstract

Fractures of the olecranon process of the ulna typically occur as a result of a humerus against distal translation
motor-vehicle or motorcycle accident, a fall, or assault. Nondisplaced fractures on the proximal ulna. Injury to the
can be treated with a short period of immobilization followed by gradually coronoid process may result in
increasing range of motion. Open reduction and internal fixation is the stan- instability of the elbow, which
dard treatment for displaced intra-articular fractures. Stable internal fixation greatly increases the complexity of
with figure-of-eight tension-band wire fixation for simple transverse fractures the injury and adversely affects the
allows early motion to minimize stiffness. Use of two knots produces symmet- prognosis. The olecranon prevents
ric tension at the fracture site and provides more rigid fixation than a single anterior translation of the ulna
knot. Care should be taken to ensure that the tension-band wire and the proxi- with respect to the distal humerus.3
mal ends of the Kirschner wires are positioned deep to the triceps fibers to pre- The articular portions of the olec-
vent wire migration. If the anterior cortex is engaged, overpenetration of the ranon and coronoid process are
wires into the soft tissues should be avoided. Plate fixation is appropriate for covered by hyaline cartilage. There
severely comminuted fractures, distal fractures involving the coronoid process, may be a transverse bare area de-
oblique fractures distal to the midpoint of the trochlear notch, Monteggia frac- void of cartilage midway between
ture-dislocations of the elbow, and nonunions. For comminuted fractures and the olecranon and the coronoid
nonunions, a dorsally applied limited-contact dynamic-compression plate with process.4,5 Overcompression of this
supplemental bone graft should be utilized to support comminuted depressed region during fracture reduction in
articular fragments. A one-third tubular hook-plate can be used for fractures an attempt to appose the articular
with a small proximal fragment for which additional fixation of the olecranon cartilage is a technical error that
tip is desired. Fragment excision and triceps advancement is appropriate in will result in narrowing of the olec-
selected cases in which open reduction seems unlikely to be successful, such as ranon fossa and an incongruous
in osteoporotic elderly patients with severely comminuted fractures. reduction. The olecranon articu-
J Am Acad Orthop Surg 2000;8:266-275 lates with the trochlea of the hu-
merus. The triceps inserts into the
posterior third of the olecranon and
proximal ulna, blending through a
Olecranon fractures, which are rela- the variability of fracture pattern broad expansion with the aponeu-
tively common in adults, are a di- and associated injuries, no single
verse group of injuries ranging from treatment method is appropriate
simple nondisplaced fractures to for all fractures.
complex fracture-dislocations of the Dr. Hak is Assistant Professor of Orthopaedic
Surgery, University of California - Davis
elbow. They are all intra-articular
School of Medicine, Sacramento. Dr. Golladay
injuries requiring anatomic restora- Anatomy is Chief Resident, Section of Orthopaedic
tion of the articular surface. Sev- Surgery, University of Michigan Medical
eral methods of internal fixation The elbow is a complex hinge joint School, Ann Arbor.
are commonly utilized, including in which the major stabilizers to
tension-band wiring, plate fixation, valgus stress are the anterior band Reprint requests: Dr. Hak, Department of
Orthopaedic Surgery, University of California -
intramedullary screw fixation, and of the ulnar collateral ligament and
Davis, Suite 3800, 4860 Y Street, Sacramento,
fragment excision with triceps ad- the radial head. The major stabilizer CA 95817.
vancement. Fixation must be se- against varus stress is the lateral col-
cure enough to permit early motion lateral ligament complex, including Copyright 2000 by the American Academy of
in order to avoid significant stiff- the ulnohumeral ligament.1,2 The Orthopaedic Surgeons.
ness of the elbow joint. Because of coronoid process stabilizes the

266 Journal of the American Academy of Orthopaedic Surgeons

 David J. Hak, MD, and Gregory J. Golladay, MD

rosis of the anconeus muscle and contusion, and axillary artery rup- and comminution. Type I fractures
the common extensor origin. The ture. Ipsilateral extremity injuries are nondisplaced with minimal or
periosteum of the olecranon is inti- should be carefully assessed, as no comminution. Type II fractures
mately associated with the triceps fractures of the coronoid process or are displaced, but the elbow joint
tendon. radial head and Monteggia fracture- remains stable; sufficient anterior
The ulnar nerve lies on the me- dislocations have a significant im- joint surface remains to maintain
dial aspect of the elbow, posterior to pact on elbow stability. Occasion- stability, and the anterior portion of
the ulnar collateral ligament, and ally, articulated external fixation the medial collateral ligament also
sweeps anteriorly to join the ulnar may be required to treat an unstable remains intact. Type III fractures
artery. The brachialis inserts broadly fracture, so as to provide adequate render the elbow unstable and
on the midportion of the anterior stability and allow early range-of- involve a large portion of the olec-
coronoid and the proximal ulnar motion. 13 When a supracondylar ranon. They are frequently com-
metaphysis.6 The ulnar neurovascu- humerus fracture occurs in conjunc- minuted and may have an associated
lar bundle may be at risk for anterior tion with an olecranon fracture, radial head fracture. Type II and
cortical penetration by Kirschner exposure of the humerus can be type III fractures are subclassified
wires used during tension-band obtained by utilizing the olecranon as noncomminuted (subtype A)
wiring. fracture site. and comminuted (subtype B). In a
review of 100 consecutive fractures
at the Mayo Clinic, 12 were nondis-
Mechanism of Injury Classification Systems placed (type I), 82 were displaced
with a stable elbow joint (type II),
Olecranon fractures may occur as a Although numerous classification and 6 were displaced with an un-
result of direct trauma, indirect systems have been described for stable elbow joint (type III).
trauma, or a combination of both.7 olecranon fractures, none has been Schatzker’s classification of olec-
The subcutaneous location of the universally accepted. Classifica- ranon fractures15 includes mechan-
olecranon renders it susceptible to tions serve several purposes, in- ical considerations related to the
direct trauma, in which the olecra- cluding improving communication type of internal fixation required
non is impacted against the distal among surgeons, determining treat- (Fig. 1). There are six types: type A
humerus, often resulting in com- ment, and predicting prognosis. is a simple transverse fracture; type
minuted fractures with depression Some classification systems have B, a complex transverse fracture
of a portion of the joint surface. incorporated associated injuries to with impaction of the central por-
Indirect trauma results from force- the radial head and supracondylar tion of the articular surface; type C,
ful contraction of the triceps muscle humerus, which may have a signifi- a simple oblique fracture; type D, a
during a fall on an outstretched cant impact on prognosis.11,13 comminuted fracture; type E, an
hand and usually produces a trans- The AO classification system oblique fracture distal to the mid-
verse or short oblique fracture. The divides fractures of the proximal ra- point of the trochlear notch (Schatz-
most common causes of injury dius and ulna into three broad cate- ker states that this pattern requires
include motor vehicle and motorcy- gories. Type A are extra-articular one or two interfragmentary lag
cle accidents, falls, and assaults.8-11 fractures involving the metaphysis screws and a 3.5-mm dynamic-
Open fractures have been reported of either the radius or the ulna. compression plate rather than a
to occur in 2% to 31% of cases.11,12 Type B fractures are intra-articular one-third tubular plate, which is
fractures of either the radius or the not strong enough to resist the tor-
ulna, with type B1 being an intra- sional forces); type F, a fracture of
Associated Injuries articular fracture of the olecranon the olecranon with associated radial
alone. Type C fractures are intra- head fracture, which is frequently
Although olecranon fractures are articular fractures of both the radial associated with a rupture of the
usually isolated injuries, a high head and the olecranon.14 The Or- medial collateral ligament.
index of suspicion for associated thopaedic Trauma Association clas- No single classification system is
injuries should be present in the sification system for olecranon frac- universally applicable, and any clas-
evaluation of the polytrauma pa- tures follows the AO system. sification is subject to interobserver
tient. Wolfgang et al11 reported a Morrey 13 reported the Mayo variability. However, a working
20% incidence of associated injuries, classification of olecranon fractures, knowledge of the existing classifica-
including long-bone fractures, skull which is based on degree of dis- tion systems is essential in assessing
fracture, splenic injury, pulmonary placement, elbow joint stability, fractures radiographically and se-

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Olecranon Fractures

subject of considerable research.

Tension-band wiring, as recom-
mended in the AO manual, is
designed to convert the tensile dis-
traction force of the triceps into a
A: Transverse B: Transverse-impacted C: Oblique compressive force at the articular
surface.13
Rowland and Burkhart17 recom-
mended modification of the stan-
dard AO technique to minimize the
possibility that the articular fracture
D: Comminuted E: Oblique-distal F: Fracture-dislocation surface may not be adequately com-
pressed. They argued, on the basis
Figure 1 Schatzker classification of olecranon fractures. (Adapted with permission from of free-body analysis, that the distal
Browner BD, Jupiter JB, Levine AM, Trafton PG [eds]: Skeletal Trauma. Philadelphia: WB drill hole for the figure-of-eight wire
Saunders, 1992, p 1137.)
should be placed anterior to the long
axis of the ulna rather than through
its subcutaneous border, to increase
lecting appropriate treatment. For view may be helpful for delineation static compression at the articular
these purposes, the Schatzker classi- of radial head or capitellar shear surface. Roe18 challenged the math-
fication may be the most useful to fractures. ematical validity of this technical
the practicing orthopaedist. modification, and Paremain et al19
failed to demonstrate an increase in
Treatment Options static resistance to gap formation at
Diagnostic Evaluation the fracture site when the proposed
The goals of olecranon fracture modification was used.
Most olecranon fractures are isolated treatment include anatomic recon- Several studies have tested fixa-
injuries. When present, concomi- struction of the articular surface, tion strength of olecranon fractures
tant injury most often involves the preservation of motor power, res- in vitro. Prayson et al20 tested four
ipsilateral extremity. A careful ex- toration of stability, prevention of different tension-band constructs in
amination of the upper extremity, joint stiffness, and minimization of simulated transverse fractures.
including the clavicle, shoulder, hu- morbidity.16 They demonstrated that bicortical
merus, elbow, forearm, wrist, and Kirschner-wire purchase and braided
hand, is essential. The elbow typi- Nonoperative Treatment cable reduced fracture displacement
cally has both soft-tissue swelling Nondisplaced fractures in which more than traditional intramedul-
and an effusion. The subcutaneous the elbow extensor mechanism is in- lary Kirschner wires and monofila-
location of the fracture often makes tact may be treated nonoperatively. ment figure-of-eight wire.
it easily palpable, with a depression Controversy exists about the amount Horner et al21 reported on a ca-
present when the fracture is signifi- of acceptable articular displacement. daveric study of 10 oblique distal
cantly displaced. The skin should Although immobilization in full olecranon fractures. They found
be carefully inspected for an open extension may improve fracture that fixation with a one-third tubu-
fracture. Function of the median, reduction, it often results in dimin- lar plate was approximately three
ulnar, radial, and posterior interos- ished flexion. Immobilization of the times more rigid than tension-band
seous nerves should be examined. elbow in 45 to 90 degrees of flexion wiring in resisting the deforming
The presence of radial and ulnar for approximately 3 weeks has been forces of the biceps and brachialis.
pulses should be documented. recommended for nondisplaced Fyfe et al22 assessed movement at
Standard anteroposterior and fractures.7 Motion is then begun, the fracture site in cadaveric elbows
lateral radiographs of the elbow are limiting flexion to 90 degrees until with transverse, oblique, and commi-
sufficient for evaluation of isolated there is radiographic evidence of nuted olecranon osteotomies tested
olecranon fractures. Direct supervi- fracture healing. by slow loading with the elbow in
sion of the radiographs may be nec- 90 degrees of flexion. Transverse
essary to ensure that true antero- Operative Treatment osteotomies were most rigidly fixed
posterior and lateral radiographs The ideal construct for fixation with a tension-band wire construct
are obtained. A radiocapitellar of olecranon fractures has been the with two tightening knots. Oblique

268 Journal of the American Academy of Orthopaedic Surgeons

 David J. Hak, MD, and Gregory J. Golladay, MD

osteotomies were fixed equally well incision. Some authors recommend ullary screw fixation alone, or plate
with either a tension-band plate or a a curvilinear incision to avoid plac- fixation. Separate interfragmentary
one-third tubular plate. In commi- ing a scar over the tip of the olecra- compression screws may be re-
nuted osteotomies, plate fixation was non. On the medial side, the mus- quired for certain fracture patterns.
found to be slightly more rigid than cular origin of the flexor digitorum Occasionally, excision of the frag-
fixation with a tension band. Fixa- profundus, flexor digitorum super- ments and advancement of the tri-
tion with a cancellous screw was ficialis, and deep head of the prona- ceps may be indicated.
found to be erratic, depending on tor teres may be elevated if neces- After internal fixation is com-
the match between screw diameter sary. The location of the ulnar pleted, the elbow should be taken
and medullary canal size. Augmen- nerve can usually be identified by through a range of motion to con-
tation with a single figure-of-eight palpation. Rarely is it necessary to firm stability and guide postopera-
wire improved screw fixation. The isolate or transpose the ulnar nerve. tive rehabilitation. Pronation and
validity of this study is compro- The fracture site is cleared of hema- supination should be examined to
mised by the fact that specimens toma, and the periosteum is elevated confirm that there is no blockage
were tested with more than one approximately 2 mm from the due to malpositioned hardware.
technique, and slow loading (rather edges of the fracture. The fracture
than the more physiologic rapid is reduced and held with a tenacu- Tension-Band Wiring
loading) was used. lum. Placement of a small oblique Tension-band wire fixation can
Murphy et al23 tested the fixation drill hole in the ulnar shaft distal to be effectively utilized for most sim-
strength of transverse olecranon the fracture will aid in anchoring ple noncomminuted transverse olec-
osteotomy at the midpoint of the the distal tine of the tenaculum. ranon fractures. The tension-band
semilunar notch in fresh cadaver Fixation alternatives include ten- technique converts the extensor
specimens by rapid loading to fail- sion-band wire fixation with Kirsch- force of the triceps to a dynamic
ure. An intramedullary screw plus ner wires or in combination with compressive force along the articu-
a tension-band wire was found to an intramedullary screw, intramed- lar surface (Fig. 2).14
have the greatest energy to failure.
The authors described the modes of
failure of the four methods of fixa-
tion they tested. The figure-of-eight
wire failed by breakage at the tight-
ening loop. The cancellous screw
pulled out or bent. AO tension-band
wiring failed because of pullout or
breakage of the Steinmann pins.
The screw-and-wire combination
failed by wire displacement and
screw breakage.

Surgical Techniques

The patient is commonly posi-

tioned supine with the arm draped
across the chest or supported on an
arm holder placed across the chest.
Alternatively, a lateral decubitus or
prone position may be used with
the arm draped over a well-padded
support. Either general or regional Figure 2 Tension-band wire fixation of a transverse olecranon fracture. Static compres-
anesthesia (Bier block or axillary sion is achieved dorsally (paired thin arrows). The extensor force of the triceps (single
block) may be utilized. thick arrow) is converted into dynamic compression just below the articular surface
(paired thick arrows). (Adapted with permission from Müller ME, Allgöwer M, Schneider
With the tourniquet applied high R, Willenegger H [eds]: Manual of Internal Fixation: Techniques Recommended by the AO-ASIF
on the upper arm, the olecranon is Group, 3rd ed. Berlin: Springer-Verlag, 1991, p 19.)
approached through a posterior

Vol 8, No 4, July/August 2000 269

Olecranon Fractures

Several technical tips are helpful sharply with a scalpel at the site of Following fixation, the elbow
in achieving optimal results with the Kirschner wires to allow the cut should be examined to confirm full
the tension-band wire technique. and bent ends to be impacted range of motion, including prona-
One-point 6-mm Kirschner wires against the cortex (Fig. 3, A). If the tion and supination, and to confirm
are utilized, as their ends can be bent end of the Kirschner wire is fixation stability. Plain radio-
easily bent. Some surgeons prefer left superficial to the triceps fibers, graphs should be obtained in the
to place the Kirschner wires in the routine postoperative elbow exten- operating room. It is important to
intramedullary canal; others prefer sion may cause the Kirschner wire confirm that the tension-band wire
to angle the wires volarly, engaging to back out (Fig. 3, B). is properly looped proximally
the anterior cortex to provide An intravenous catheter is uti- around the Kirschner wires, as oc-
greater resistance to wire migration. lized to pass an 18-gauge wire casionally the wire may be passed
The most important factor in pre- beneath the fibers of the triceps. The dorsal to one or both of the wires
venting wire migration is ensuring needle and plastic cannula are and may engage only the triceps
that the bent proximal end of the inserted deep to the triceps tendon, tendon.
wire is buried beneath the fibers of adjacent to the bone, beneath the Wolfgang et al11 treated 45 frac-
the triceps. If the anterior cortex is two Kirschner wires (Fig. 3, C). The tures with tension-band wiring
engaged, care should be taken to insertion needle is removed, leaving with or without supplemental fixa-
avoid overpenetration of the wires, the plastic cannula in place. The 18- tion, depending on the fracture
as they may cause neurovascular gauge wire can then be inserted into configuration. Excellent or good
damage, restrict forearm rotation, the end of the plastic cannula, and results were reported in 98% of
or incite heterotopic ossification or both cannula and wire are pulled cases. Tension-band wiring both
radioulnar synostosis. Full prona- back, passing the wire deep to the with Kirschner wires engaging the
tion and supination should be triceps fibers. The wire is passed anterior cortex and with use of a
ensured after the wires have been through a transverse drill hole double-loop 18-gauge figure-of-
inserted. The length of the wire placed distal to the fracture. Two eight wire is adequate for all sim-
should be noted at the point where twisted knots are placed in the wire, ple transverse fractures for which
it engages the second cortex. Once one radial and one ulnar, and each is internal fixation is chosen. Braided
the wire penetrates the far cortex, it tightened to produce symmetric ten- cable has been shown in a cadaveric
should be partially backed out and sion at the fracture site. Placing two model to be stronger than mono-
bent 180 degrees at the previously knots results in more rigid fixation filament wire; however, it may fray
measured position. The excess wire than using a single knot.22 The ends and increase the risk of sympto-
should then be cut off. The fibers of of the twisted wires are then cut and matic hardware prominence.20 An
the triceps tendon should be split bent down against the cortex. interfragmentary lag screw is use-

A B C

Figure 3 Technique for tension-band wiring. A, Fibers of the triceps tendon should be split to allow the bent end of the Kirschner wires
to be impacted firmly against bone. B, If the ends of the Kirschner wires are left superficial to the triceps tendon, elbow extension may
cause migration or fatigue failure of the Kirschner wires. C, A 16-gauge or larger intravenous catheter is used to pass the tension-band
wire deep to the triceps fibers.

270 Journal of the American Academy of Orthopaedic Surgeons

 David J. Hak, MD, and Gregory J. Golladay, MD

ful when an oblique fracture plane Plate Fixation

is present. Plate fixation is most commonly
recommended for comminuted frac-
Intramedullary Screw Fixation tures in which tension-band wire
The use of a single large-diameter fixation is not feasible. It is also indi-
intramedullary cancellous screw cated for oblique fractures distal to
has also been advocated.13 In one the midpoint of the trochlear notch,
study, a higher rate of fixation loss fractures that involve the coronoid
was reported after intramedullary process, and those associated with
screw fixation alone compared Monteggia fracture-dislocations of
with tension-band wiring.24 Some the elbow.15,28 Oblique fractures are
authors recommend supplementa- best treated with one or two inter-
tion of intramedullary screw fixa- fragmentary compression screws in
tion with a tension-band wire conjunction with plate fixation to
around the screw head.23,25 In the resist torsional forces.15
frontal plane, there is approximately Some authors have reported use
4 degrees of valgus angulation of of one-third tubular, dynamic com-
the ulnar shaft with respect to the pression, and pelvic reconstruction A B
sigmoid notch. If an intramedullary plates for fixation of comminuted Figure 4 A, Proper placement of an
screw is used, care must be exer- olecranon fractures. The proximal intramedullary screw. B, Placement of an
cised to properly place the screw end of the one-third tubular plate intramedullary screw slightly off the
intramedullary axis results in fracture
along the intramedullary shaft axis can be modified to make a hook- malreduction.
and thus avoid displacement of the plate that will provide additional
fracture (Fig. 4). fixation for small proximal fracture
Johnson et al26 reported good re- fragments. In severely comminuted
sults in 24 patients treated with a fractures, one-third tubular plates more likely to result in either articu-
6.5-mm cancellous screw with or may not provide sufficient strength, lar incongruity greater than or equal
without supplementary tension leading to hardware fatigue failure.28 to 2 mm or loss of reduction. The
banding. Sixteen patients (67%) While the subcutaneous location authors concluded that strong con-
had motion within 15 degrees of of the hardware raises concern sideration should be given to plating
full range by postoperative week 9. about prominence necessitating of olecranon fractures.8 Simpson et
The authors reported four operative subsequent removal, the frequency al28 reported 73% good or excellent
complications: one poor reduction, of hardware prominence may actu- results in a retrospective study of the
one loss of compression, one fixa- ally be higher after tension-band use of a dorsally applied 3.5-mm
tion failure, and one bent screw. wiring than after plate fixation.8 In limited-contact dynamic-compression
For large displaced fractures or most cases, the plate is placed (LC-DC) plate for fixation of 13 com-
osteotomy fixation, Wadsworth 27 along the dorsal surface of the olec- plex proximal ulna fractures and 24
recommended use of a partially ranon and contoured around the
threaded intramedullary screw with tip of the olecranon (Fig. 5). The
or without a washer. He reported dorsal ulna is the tension side of
100% union in six patients and no the bone and as such is biomechan-
complications with this technique ically best suited to plating. A
and emphasized the importance of screw placed in the most proximal
early motion. hole may either engage the coro-
The indications for intramedul- noid process or be inserted down
lary screw placement mirror those the intramedullary canal. If this
for tension-band wiring (e.g., sim- screw is intramedullary, the other
ple noncomminuted transverse screws in the plate must be angled
fractures). An intramedullary slightly radially or ulnarly. Figure 5 Plate fixation of a comminuted
screw may be best suited for fixa- In a prospective, randomized olecranon fracture. (Adapted with permis-
tion of an olecranon osteotomy, as study of 41 patients with displaced sion from Mast JW, Jakob R, Ganz R:
Planning and Reduction Techniques in
predrilling the screw prior to fractures treated with either tension- Fracture Surgery. Berlin: Springer-Verlag,
osteotomy helps guide anatomic band wiring or one-third tubular 1989.)
reduction later. plates, tension-band wiring was

Vol 8, No 4, July/August 2000 271

Olecranon Fractures

Monteggia fracture-dislocations. Excision of Fragment and reported lower complication and

Only one patient had problems with Triceps Advancement reoperation rates following excision
hardware prominence. They recom- Excision of the fracture fragment compared with internal fixation and
mend plate fixation if the fracture ex- and reattachment of the triceps ten- concluded that excision is the pre-
tends to the metaphyseal-diaphyseal don may be indicated in a select ferred treatment alternative provided
junction or if the coronoid process group of elderly patients with os- the coronoid process remains intact.
is involved. The LC-DC plate is teoporotic bone in whom the olec- Although weakening of the extensor
lower in profile and easier to contour, ranon fracture fragments involve apparatus has been a criticism of the
and its screw holes allow greater less than 50% of the joint surface13,29 technique of fragment excision and
screw angulation than those of the and are too small or too comminuted triceps advancement, Gartsman et al
standard dynamic-compression for successful internal fixation. The found no differences in isometric
plate. integrity of the medial collateral lig- strength between patients treated by
In severely comminuted frac- ament, the interosseous membrane, excision and those treated with inter-
tures, care must be taken not to and the distal radioulnar joint must nal fixation. Although that series did
narrow the olecranon-to-coronoid be established before consideration provide some comparison between
distance.16 Because there is no ar- is given to excision; otherwise, excision and internal fixation, the
ticular cartilage in the midportion instability will result.30 The triceps treatment was not randomized, and
of the sigmoid notch, aligning the tendon is reattached with nonab- selection bias requires cautious inter-
remaining articular surfaces in sorbable sutures that are passed pretation of the conclusions. Other
comminuted fractures will result in through the drill holes in the proxi- authors have recommended excision
narrowing of the olecranon-to- mal ulna. Cabanela and Morrey16 only as a last resort in cases in which
coronoid distance. 4,5 The dorsal recommend that the triceps be re- open reduction and internal fixation
cortical fragments may serve as a attached adjacent to the remaining is not possible.10,11
guide to reconstruct the correct articular surface, creating a sling for Excision should be reserved for
anatomic alignment. Use of an AO the trochlea (Fig. 6). Triceps reat- selected cases in which open reduc-
universal distractor may aid in re- tachment in this manner creates a tion seems unlikely to be successful.
duction and provisional stabiliza- smooth, congruent transition from Open reduction and internal fixa-
tion.28 The congruency of the artic- the triceps tendon to the articular tion should be attempted in most
ular surface should be meticulously cartilage of the olecranon but de- cases, as it permits early motion
restored. Bone graft should be uti- creases the moment arm and may and allows bone-to-bone healing.
lized to support the articular sur- result in greater extensor weakness. Excision and triceps advancement
face after elevation of depressed McKeever and Buck29 stated that can still be performed as a salvage
fragments. Supplemental Kirschner- as much as 80% of the trochlear procedure if internal fixation fails.
wire fixation may also be required. notch can be excised without com-
Plate fixation is appropriate for promising elbow stability, provided
severely comminuted fractures, dis- the coronoid and distal trochlea are
tal fractures involving the coronoid preserved. Gartsman et al 12 re-
process, oblique fractures distal to ported one case of anterior instabil-
the midpoint of the trochlear notch, ity in a patient in whom approxi-
Monteggia fracture-dislocations of mately 75% of the articular surface
the elbow, and nonunions. In com- had been excised. An et al3 evalu-
minuted fractures and nonunions, a ated elbow stability with varying
dorsally applied LC-DC plate with degrees of proximal ulnar resection
supplemental bone graft should be in vitro. They found linear de-
utilized to support comminuted creases in elbow constraint with
depressed articular fragments that increasing amounts of resection
have been elevated. A one-third and suggested that resection of
tubular hook-plate can be used to more than 50% of the articular sur- Figure 6 When excision and triceps
advancement is performed, the triceps
achieve additional fixation of the face may result in instability. should be attached adjacent to the articular
olecranon tip for fractures with a Inhofe and Howard 31 reported surface. (Adapted with permission from
small proximal fragment. A portion good or excellent results in 11 of 12 Cabanela ME, Morrey BF: Fractures of the
proximal ulna and olecranon, in Morrey BF
of the triceps insertion may need to patients with adequate follow-up [ed]: The Elbow and Its Disorders, 2nd ed.
be incised to allow apposition of the after excision of as much as 70% of Philadelphia: WB Saunders, 1993, p 416.)
plate to the bone. the articular surface. Gartsman et al12

272 Journal of the American Academy of Orthopaedic Surgeons

 David J. Hak, MD, and Gregory J. Golladay, MD

Postoperative wire breakage, or fracture displace- ossification in 27 complex fractures

Rehabilitation ment may occur with tension-band of the proximal ulna. Ilahi et al33
wiring.32 Kirschner wires should found a 0% incidence of grade II,
Operative management of olecra- be firmly seated against the olecra- III, or IV heterotopic ossification
non fractures should provide suffi- non through slits in the triceps ten- about the elbow when unstable
ciently stable fixation to allow early don, and the wire knots should be elbow fractures were operated on
motion. The ideal time to start positioned away from the subcuta- within 48 hours of injury, com-
motion has not been addressed in neous border of the ulna. Preopera- pared with a 33% incidence when
any prospective study; therefore, tive patient counseling should the delay between injury and surgi-
the surgeon must consider fixation include the possibility of sympto- cal treatment exceeded 48 hours.
stability, patient compliance, and matic hardware prominence and Nonunion of olecranon fractures
wound healing. Patients typically the potential need for hardware re- is infrequent, and patients typically
are placed in a posterior splint or moval. Hume and Wiss8 reported a present with pain, instability, or
sling, and active motion is instituted higher incidence of painful hard- loss of motion. Papagelopoulos
as early as postoperative day 1.11 ware prominence after tension- and Morrey 34 reported only two
Immediate supervised gravity- band wiring than after compression nonunions in 196 fractures initially
assisted range-of-motion exercises plating. No cases of symptomatic treated at the Mayo Clinic over a
are effective for all fractures with hardware prominence were reported 10-year period. Treatment options
stable internal fixation. 28 Unless by Simpson et al28 after LC-DC plat- for nonunions include excision,
there are wound-healing problems, ing. Hardware failure or loss of fix- osteosynthesis with a compression
a removable posterior splint is ap- ation occurs more commonly in plate or lag screw, or elbow arthro-
plied, and the patient is instructed comminuted fractures and in pa- plasty in cases of severe posttrau-
in range-of-motion exercises on the tients with poor bone stock. matic arthritis. Cancellous bone
first postoperative day. More com- Loss of motion is a common graft or a corticocancellous bone
plex or comminuted fractures may problem after fractures about the plate fixed with screws may be use-
require longer periods of immobi- elbow but is rarely significant in ful. Papagelopoulos and Morrey
lization, and more stiffness can be patients with isolated olecranon also reported on the treatment of 24
anticipated. Distraction devices fractures.8,11 Patients with isolated patients with olecranon nonunion,
may be helpful in the postoperative injuries typically lose 10 to 15 de- most of whom had been referred
regimen for unstable, comminuted grees of extension.13 However, in from other institutions. After use
fractures, followed by the use of patients with associated fractures of of one or more of the treatment
adjustable splints to help regain the radial head, capitellum, or coro- options mentioned, the results
motion.13 Muscle strengthening is noid or with a Monteggia fracture- were excellent in 12 patients (50%),
begun when bone healing is ade- dislocation, the range of motion good in 4 (17%), fair in 6 (25%), and
quate, generally 6 weeks from may be more severely compro- poor in 2 (8%). In another study,
surgery.28 Patients may return to mised.27,30 Comminuted fractures Danziger and Healy35 reported that
work involving rigorous use of the and open injuries are also more likely union was achieved in all five cases
extremity at 3 to 4 months. to result in stiffness. Some gains in treated by either tension-band plat-
motion may be achieved with ag- ing or wiring and bone graft.
gressive physical therapy. Patients Poorer results have been reported
Complications with a functional deficit related to with intra-articular step-off of more
stiffness may be treated with pro- than 2 mm, but few studies have
Hardware prominence requiring gressive splinting, a turnbuckle- sufficient follow-up to document
removal is one of the most frequent type brace, or capsulectomy. the long-term incidence of post-
complications after internal fixation Heterotopic ossification may oc- traumatic arthrosis.25 Gartsman et
of olecranon fractures. Symptoms cur after olecranon fractures, par- al12 reported a 20% rate of arthrosis
due to hardware prominence have ticularly in patients with significant following olecranon fractures
been reported in 3% to 80% of associated soft-tissue injuries and in regardless of whether they were
cases.25,28 The wide range of symp- those with closed head injuries. treated by excision or internal fixa-
tomatic hardware prominence is Wolfgang et al11 reported a 13% rate tion.
likely related both to technical fac- of heterotopic ossification, mainly in The reported rates of infection
tors and to varying definitions of patients with an associated radial after operative olecranon fracture
prominence. Wire migration, soft- head dislocation. Simpson et al28 treatment range from 0% to 6%.12,34
tissue irritation, olecranon bursitis, reported a 14% rate of heterotopic Papagelopoulos and Morrey34 re-

Vol 8, No 4, July/August 2000 273

Olecranon Fractures

ported two cases of transient reflex screw alone, and 10 with tension- Summary
sympathetic dystrophy in their band wire fixation. The average
series of 24 olecranon nonunions. ratings for the three groups were Fractures of the olecranon process
Ulnar neurapraxia has been report- similar: 17.7 for intramedullary may present in isolation or in combi-
ed in 2% to 5% of cases. Ulnar neu- screw plus wire treatment, 17.2 for nation with more complex injuries
ritis may occasionally occur. 10 intramedullary screw fixation, and about the elbow. Generally good or
Symptoms usually resolve with 16.7 for tension-band wire fixation. excellent results have been reported
conservative treatment, but late Gartsman et al12 reported a ret- with all forms of treatment of simple
neurolysis or transposition may rospective review of a series of 107 olecranon fractures. Nondisplaced
occasionally be required. isolated olecranon fractures in 53 fractures may be treated nonopera-
patients treated by excision and 54 tively. Excision and triceps advance-
treated by internal fixation (primar- ment may be indicated for patients
Outcomes ily screw or tension-band fixation). with small extra-articular fragments
Pain, subjective function, isometric or severely comminuted fractures, as
Generally good and excellent re- strength, isokinetic work, range of well as for elderly patients with os-
sults have been reported for all motion, stability, and the incidence teoporotic bone. Open reduction
types of olecranon fracture treat- of degenerative changes were simi- and internal fixation is preferred for
ment. However, prospective stud- lar between the two groups at an displaced intra-articular fractures.
ies in which validated outcomes average follow-up of 3.6 years. Tension-band wire fixation is com-
measures were used to compare Thirteen patients who underwent monly utilized for simple fractures.
different forms of treatment have internal fixation had complications, Plate fixation is recommended for
not yet been reported. compared with only 2 in the exci- comminuted or unstable oblique
Murphy et al25 performed a ret- sion group. Thirteen patients in fractures. Intramedullary screw fixa-
rospective study of patients with the internal fixation group required tion has also been recommended.
simple transverse or oblique olecra- reoperation for hardware removal. Because of its subcutaneous location,
non fractures, using a 19-point scale Because of the high rates of compli- hardware may need to be removed
to evaluate pain, function, range of cations and reoperation after inter- after union is achieved. Although
motion, and radiographic findings. nal fixation, the authors concluded minor losses of motion are common,
Of the 33 patients, 10 were treated that excision is the preferred treat- most patients can be expected to
with an intramedullary screw plus ment alternative provided the coro- have good results provided early
wire, 13 with an intramedullary noid process is intact. controlled motion can be instituted.

References
1. Cohen MS, Hastings H II: Rotatory the ulnar coronoid process: An ana- Surgical treatment of displaced olecra-
instability of the elbow: The anatomy tomical study with radiographic corre- non fractures by tension band wiring
and role of the lateral stabilizers. J lation. Clin Orthop 1995;320:154-158. technique. Clin Orthop 1987;224:192-204.
Bone Joint Surg Am 1997;79:225-233. 7. Hotchkiss RN: Fractures of the olecra- 12. Gartsman GM, Sculco TP, Otis JC:
2. O’Driscoll SW, Bell DF, Morrey BF: non, in Rockwood CA Jr, Green DP, Operative treatment of olecranon frac-
Posterolateral rotatory instability of Bucholz RW, Heckman JD (eds): Rock- tures: Excision or open reduction with
the elbow. J Bone Joint Surg Am 1991; wood and Green’s Fractures in Adults, internal fixation. J Bone Joint Surg Am
73:440-446. 4th ed. Philadelphia: JB Lippincott, 1981;63:718-721.
3. An KN, Morrey BF, Chao EYS: The 1996, pp 984-996. 13. Morrey BF: Current concepts in the
effect of partial removal of proximal 8. Hume MC, Wiss DA: Olecranon frac- treatment of fractures of the radial
ulna on elbow constraint. Clin Orthop tures: A clinical and radiographic com- head, the olecranon, and the coronoid.
1986;209:270-279. parison of tension band wiring and J Bone Joint Surg Am 1995;77:316-327.
4. Shiba R, Sorbie C, Siu DW, Bryant JT, plate fixation. Clin Orthop 1992;285: 14. Müller ME, Allgöwer M, Schneider R,
Cooke TDV, Wevers HW: Geometry 229-235. Willenegger H (eds): Manual of Inter-
of the humeroulnar joint. J Orthop Res 9. Macko D, Szabo RM: Complications nal Fixation: Techniques Recommended by
1988;6:897-906. of tension-band wiring of olecranon the AO-ASIF Group, 3rd ed. Berlin:
5. Stormont TJ, An KN, Morrey BF, Chao fractures. J Bone Joint Surg Am 1985; Springer-Verlag, 1991.
EY: Elbow joint contact study: Com- 67:1396-1401. 15. Schatzker J: Fractures of the olecranon,
parison of techniques. J Biomech 1985; 10. Rettig AC, Waugh TR, Evanski PM: in Schatzker J, Tile M (eds): The Ra-
18:329-336. Fracture of the olecranon: A problem of tionale of Operative Fracture Care. Berlin:
6. Cage DJN, Abrams RA, Callahan JJ, management. J Trauma 1979;19:23-28. Springer-Verlag, 1987, pp 89-95.
Botte MJ: Soft tissue attachments of 11. Wolfgang G, Burke F, Bush D, et al: 16. Cabanela ME, Morrey BF: Fractures of

274 Journal of the American Academy of Orthopaedic Surgeons

 David J. Hak, MD, and Gregory J. Golladay, MD

the proximal ulna and olecranon, in 22. Fyfe IS, Mossad MM, Holdsworth BJ: 29. McKeever FM, Buck RM: Fracture of
Morrey BF (ed): The Elbow and Its Methods of fixation of olecranon frac- the olecranon process of the ulna:
Disorders, 2nd ed. Philadelphia: WB tures: An experimental mechanical study. Treatment by excision of fragment and
Saunders, 1993, pp 405-428. J Bone Joint Surg Br 1985;67:367-372. repair of triceps tendon. JAMA 1947;
17. Rowland SA, Burkhart SS: Tension 23. Murphy DF, Greene WB, Gilbert JA, 135:1-5.
band wiring of olecranon fractures: A Dameron TB Jr: Displaced olecranon 30. Teasdall R, Savoie FH, Hughes JL:
modification of the AO technique. fractures in adults: Biomechanical Comminuted fractures of the proximal
Clin Orthop 1992;277:238-242. analysis of fixation methods. Clin radius and ulna. Clin Orthop 1993;292:
18. Roe SC: Tension band wiring of olec- Orthop 1987;224:210-214. 37-47.
ranon fractures: A modification of the 24. Helm RH, Hornby R, Miller SWM: 31. Inhofe PD, Howard TC: The treatment
AO technique [letter]. Clin Orthop The complications of surgical treat- of olecranon fractures by excision of
1994;308:284-286. ment of displaced fractures of the olec- fragments and repair of the extensor
19. Paremain GP, Novak VP, Jinnah RH, ranon. Injury 1987;18:48-50. mechanism: Historical review and
Belkoff SM: Biomechanical evaluation 25. Murphy DF, Greene WB, Dameron TB report of 12 fractures. Orthopedics
of tension band placement for the Jr: Displaced olecranon fractures in 1993;16:1313-1317.
repair of olecranon fractures. Clin adults: Clinical evaluation. Clin 32. Horne JG, Tanzer TL: Olecranon frac-
Orthop 1997;335:325-330. Orthop 1987;224:215-223. tures: A review of 100 cases. J Trauma
20. Prayson MJ, Williams JL, Marshall 26. Johnson RP, Roetker A, Schwab JP: 1981;21:469-472.
MP, Scilaris TA, Lingenfelter EJ: Bio- Olecranon fractures treated with AO 33. Ilahi OA, Strausser DW, Gabel GT: Post-
mechanical comparison of fixation screw and tension bands. Orthopedics traumatic heterotopic ossification about
methods in transverse olecranon frac- 1986;9:66-68. the elbow. Orthopedics 1998;21:265-268.
tures: A cadaveric study. J Orthop 27. Wadsworth TG: Screw fixation of the 34. Papagelopoulos PJ, Morrey BF: Treat-
Trauma 1997;11:565-572. olecranon after fracture or osteotomy. ment of nonunion of olecranon fractures.
21. Horner SR, Sadasivan KK, Lipka JM, Clin Orthop 1976;119:197-201. J Bone Joint Surg Br 1994;76:627-635.
Saha S: Analysis of mechanical factors 28. Simpson NS, Goodman LA, Jupiter JB: 35. Danziger MB, Healy WL: Operative
affecting fixation of olecranon frac- Contoured LCDC plating of the proxi- treatment of olecranon nonunion. J
tures. Orthopedics 1989;12:1469-1472. mal ulna. Injury 1996;27:411-417. Orthop Trauma 1992;6:290-293.

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