History
Patients who have sustained olecranon fractures typically present with deformity, swelling, and pain; often, they are unable to extend the elbow. In some cases, however, symptoms of stress fractures may be vague, lacking deformity and swelling, and the ability to extend the elbow may be preserved (though extension is usually painful). The clinician should have a high index of suspicion for stress fracture in throwing athletes who present with olecranon soreness or pain. [6]
The clinician should have a high index of suspicion for open fractures because the ulnar border is subcutaneous and even superficial wounds can expose the underlying bone.
Physical Examination
Although most olecranon fractures are isolated, additional injuries to the same extremity are possible. Careful examination of the extremity (including assessment of the shoulder, clavicle, humerus, wrist, hand, and forearm) is essential.
Typically, the elbow incurs both soft-tissue injury and joint effusion. Examine the skin, the radial and ulnar pulses, and the function of the ulnar, median, and posterior interosseous nerves. The ulnar nerve is at especially high risk because of its relatively superficial position on the medial aspect of the elbow. Although this is a rare occurrence, the forearm should always be evaluated for compartment syndrome.
Careful assessment of isolated injuries is vital. Fracture of the coronoid process or the radial head and Monteggia fracture-dislocations have a significant impact on elbow stability. When a supracondylar humerus fracture occurs in conjunction with an olecranon fracture, exposure of the humerus can be obtained by using the olecranon fracture site. Similarly, when an associated coronoid or radial head fracture exists, reduction and fixation can be achieved via a direct posterior approach through the displaced olecranon fragment.
A high index of suspicion for associated injuries is warranted in the evaluation of patients with multiple injuries. Some 20% of patients with high-energy trauma have associated injuries (eg, long-bone fracture, skull fracture, splenic injury, pulmonary contusion, axillary artery rupture).
A transverse or slightly oblique break near the base of the olecranon is the usual fracture. In oblique fractures, the fracture line tends to slope down and back and emerges on the posterior border of the olecranon. In other instances, a small piece of bone is pulled off of the proximal end of the olecranon.
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Lateral radiograph of elbow in 78-year-old man who fell on his outstretched hand. Displaced fracture of olecranon was noted.
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Drawing depicting radial bow of proximal third of ulna.
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Anteroposterior radiograph following reduction and internal fixation of fracture with 7.3-mm cannulated screw and 1.6-mm cable.
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Lateral radiograph demonstrating threads of screw engaging cortices of ulna.
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Typical relatively transverse olecranon fracture.
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Pediatric olecranon fracture.
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Olecranon process consists of bone of proximal ulna from base of coronoid process (down arrow) proximally. Trochlear notch (up arrows; also called semilunar notch) is articular surface shown between two arrows.
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Incorrect tension band technique: pins should be anchored in anterior cortex and not placed down medullary canal.
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Transverse olecranon fracture without comminution.
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Transverse olecranon fracture treated with tension band technique (ideally, both K-wires should have been anchored in anterior cortex).
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Lateral plate position for olecranon fracture fixation.
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Posterior plate position for olecranon fracture.
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Example of distal olecranon fracture.
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Plate fixation of distal olecranon fracture.
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Comminuted olecranon fracture.
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Plate fixation of comminuted olecranon fracture.
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Example of specialized olecranon plate.
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20-year-old man with comminuted olecranon fracture extending distally into ulnar shaft from gunshot injury.
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Bridge plating of comminuted olecranon fracture extending into proximal ulna diaphysis after gunshot injury.
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Monteggia-variant fracture-dislocation: olecranon and radial head fractures.
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Monteggia-variant fracture-dislocation treated with fixation of both fractures.
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Monteggia-variant fracture of proximal ulna and radial head.
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Monteggia-variant fracture-dislocation treated with plate fixation of olecranon and proximal ulna and replacement of radial head.
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Example of intramedullary screw fixation of olecranon fracture. In this case, screw diameter was too small and loss of fixation has occurred.
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Intramedullary rod fixation of olecranon osteotomy used in repair of distal humerus fracture.
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79-year-old man with olecranon fracture.
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AP radiograph of tension band wiring of olecranon fracture in 79-year-old man.
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Lateral radiograph of tension band wiring in 79-year-old man with olecranon fracture. Note excellent technique with anatomic reduction, K-wires anchored in anterior cortex, and tension band wire placed dorsally.
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Nonunion of olecranon fracture in 79-year-old man despite excellent tension band wiring technique.
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Excision of olecranon after nonunion of fracture in 79-year-old man.
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Comminuted olecranon fracture.
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Comminuted olecranon fracture plated with proximal edge off bone to allow two more screws in proximal segment and fixed angled intramedullary screw (bending plate distorts locking hole).
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Healed comminuted olecranon fracture after removal of prominent plate fixation.
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Olecranon nonunion after nonoperative treatment.
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Repair of olecranon nonunion with double-plate technique (original fracture was treated nonoperatively).
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AP radiograph of healed olecranon nonunion after original nonoperative treatment; repaired with double-plate technique.
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Lateral radiograph of healed olecranon nonunion after original nonoperative treatment; repaired with double-plate technique.
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MRI showing olecranon stress fracture.
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Use of pins to raft joint surface of comminuted olecranon fracture with plate fixation of fracture as well.
