Olecranon Fractures

The elbow is a complex hinge joint. The major stabilizers to valgus stress (ie, bending away from the body) are the medial (ulnar) collateral ligament and the radial head. The major stabilizer to varus stress (ie, toward the body) is the lateral collateral ligament complex. The coronoid process stabilizes the humerus against the distal ulna.

The olecranon (the proximal bony projection of the ulna at the elbow; see the image below) also prevents anterior translation of the ulna with respect to the distal humerus. The anterior surface of the olecranon is covered with articular cartilage. Therefore, all fractures (except the rare tip fractures) are intra-articular fractures. The olecranon articulates with the trochlea of the humerus. The triceps inserts into the posterior third of the olecranon and proximal ulna. The periosteum of the olecranon blends with the triceps.

The ulnar nerve lies on the posterior aspect of the elbow, posterior to the medial collateral ligament. The ulnar nerve sweeps anteriorly to join the ulnar artery. The ulnar neurovascular bundle may be at risk during Kirschner wire (K-wire) fixation.

Fracture displacement is largely due to the pull of the triceps, which tends to pull a separated fragment upward but is resisted by the strong fibrous covering on the olecranon. This fibrous covering is formed by the blending of fibers in the lateral ligaments, the elbow capsule, and some triceps fibers that blend with the periosteum.

If the fracture force does not tear the fibrous sheath, little or no tendency toward displacement exists, even in the presence of comminution. Usually, wide separation of fragments indicates an extensive tearing of the fibrous sheath in which the unopposed triceps is contracted, drawing the separated fragment upward.

The most common mechanism of an olecranon fracture is a fall on the semiflexed supinated forearm. As the hand strikes the ground, muscles are tensed to break the fall, and the powerful triceps snaps the olecranon over the lower end of the humerus, which acts as a fulcrum. The next most frequent cause of this injury is direct trauma, as in falls on or blows to the point of the elbow.[5]

Occasionally, the olecranon may be fractured by hyperextension injuries, such as those resulting in elbow dislocation in adults or supracondylar fractures in children. Very rarely is the olecranon broken by muscular violence, as in throwing. Stress fractures can occur in baseball players and other throwing athletes.[6]

Even though the olecranon is a very heavy, strong process of bone, it is fractured frequently in adults. This is partly because of its exposed position on the point of the elbow, where most direct injuries to the elbow occur, and partly because of the tremendous cross-strain put on the olecranon during falls on the flexed forearm.

The olecranon process is rarely broken in children, because in early life, it is short, thick, and relatively much stronger than the lower end of the humerus. Usually, children sustain supracondylar fractures of the humerus instead. Nevertheless, the clinician should have a high index of suspicion in children because olecranon fractures do occur, often associated with radial head subluxation or dislocation; failure to diagnose the fracture can have long-term negative consequences.

Open fractures occur in 2-31% of cases. Neurologic injuries to median, radial, or ulnar nerves may occasionally occur. Ulnar neurapraxia has been reported in 2-5% of cases. Generally, symptoms resolve with conservative treatment, but late neurolysis or transposition may occasionally be required.

Approximately 95% of patients with olecranon fractures are expected to have near-normal function; 20-25% of patients will develop radiographic evidence of arthrosis at 15- to 20-year follow-up, but these patients are usually asymptomatic.

Age is the most important factor influencing outcome: Younger patients generally do better than older ones.[7]

One study retrospectively reviewed the outcome of 18 patients who underwent locking-plate osteosynthesis after open reduction for comminuted olecranon fractures.[8] In all cases, complete union was achieved. The findings indicated that whereas the risk of limited elbow motion is high in cases with concomitant injuries, locking plates are an additional and often successful option for olecranon fracture fixation.

Buijze et al compared stiffness and strength with contoured locking compression plate fixation (combined with an intramedullary screw) and one-third tubular plate fixation (combined with bicortical screws) in a cadaveric comminuted olecranon fracture model with a standardized osteotomy.[9] Stiffness was measured by subjecting the specimens to cyclic loading while measuring gapping at the osteotomy site, and strength was measured by subjecting specimens to ramp load until failure. The two fixation methods did not differ significantly with regard to construct stiffness and strength, and all failures consisted of failure of the bone, not of hardware.

In a study by Buijze and Kloen, 19 patients with an acute comminuted olecranon fracture were managed with a contoured locking compression plate and intramedullary screw fixation, 16 of whom were available for follow-up at a minimum of 12 months after fixation.[10] The authors noted that in patients managed with plate fixation for olecranon fractures, placement of an axial intramedullary screw may obstruct the placement of bicortical screws in the ulnar shaft. As a solution, they assessed the effectiveness of unicortical screws with a contoured locking compression plate.

In this study, all 19 fractures healed, and the mean time to fracture union was 4 months.[10] The mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 13. According to the Mayo Elbow Performance Index and the Broberg and Morrey grading system, 15 of the 16 patients followed had a good or excellent outcome. In nine patients, hardware removal was necessary; after removal, the mean elbow extension deficit improved from 34º to 10º, and mean flexion improved from 118º to 138º.

According to Iannuzzi et al, in comminuted fractures of the olecranon (Mayo type IIB), it may be difficult or even impossible to preserve the olecranon's normal articulation with the trochlea of the humerus.[11] The authors therefore described a modified technique for reconstructing these fractures when stable anatomic reduction and fixation cannot be achieved. In this technique, the comminuted fragments are excised, and the proximal olecranon fragment is advanced past the resulting defect and fixed to the distal ulna. The authors presented two cases with clinical follow-up and noted that satisfactory preservation of range of motion (ROM) and elbow stability were achieved in each case.

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.

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.

Standard anteroposterior (AP) and lateral radiographs of the elbow are sufficient for evaluation of isolated olecranon fractures. Direct supervision of the x-ray process may be necessary to ensure that true AP and lateral radiographs are obtained. The radiocapitellar view may be helpful for delineation of the radial head and capitellar fractures. (See the images below.)

MRI may be necessary to diagnose an olecranon stress fracture that may not be seen on plain radiographs.[6]

Classification helps decide treatment options. Both acute fractures and stress fractures occur. Several classification systems have been suggested for acute fractures.

The Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Association for the Study of Internal Fixation (ASIF) classification, used by the Orthopaedic Trauma Association (OTA), divided these fractures into three broad categories, as follows[12] :

• Type A - Extra-articular fractures
• Type B - Intra-articular fractures
• Type C - Intra-articular fractures of both the radial head and the olecranon

Schatzker developed a classification with six types, as follows (types A, B, and C are intra-articular fractures)[13] :

• Type A - Simple transverse fracture
• Type B - Transverse impacted fracture
• Type C - Oblique fracture
• Type D - Comminuted fracture
• Type E - More distal fracture, which actually is extra-articular
• Type F - Fracture dislocation

Colton developed a classification with four fracture types, as follows:

• Type I - Avulsion
• Type II - Oblique
• Type III - Associated dislocation of the elbow
• Type IV - Multisegmented

The Mayo Clinic classification specified three fracture types, as follows[14] :

• Type I - Nondisplaced (12%)
• Type II - Displaced but stable (82%)
• Type III - Associated instability of the elbow (6%)

Benetton et al studied these four systems of classifying olecranon fractures with a view to determing their intraobserver and interobserver reliability.[15]  They noted the following findings:

• Colton classification - Substantial intraobserver and interobserver agreement for specialists and nonspecialists
• Schatzker classification - Fair agreement for both specialists and nonspecialists
• Mayo classification - Fair concordance for both specialists and nonspecialists
• AO-ASIF classification - Moderate agreement for specialists; slight intraobserver agreement for nonspecialists

The goals of olecranon fracture treatment must be individualized to the needs of the patient. In young active individuals, restoration of the articular surface, preservation of motor power, restoration of stability, and prevention of joint stiffness are important. In older patients, minimization of morbidity is the most important goal. An understanding of the extent of associated injuries is critical before treatment is initiated. Additional fractures or disruptions of collateral ligaments render the elbow unstable.

Nondisplaced olecranon fractures with intact extensor mechanisms (as demonstrated by the ability to actively extend the elbow) are generally treated nonoperatively. Nonoperative treatment is often desirable in patients with significant associated medical conditions and in low-demand elderly patients.[5] Stable (Mayo type 1 fractures) are treated nonoperatively.[16]  (See Nonoperative Therapy.)

Surgical treatment is indicated for the following:

• Fractures with significant displacement (>1-2 mm)
• All patients lacking active extension of the elbow
• Most fractures associated with elbow instability
• Cases in which nonoperative treatment has failed

Controversy exists regarding the amount of acceptable articular displacement for closed treatment. Certainly, several millimeters of displacement is usually well tolerated. Degenerative changes occur in fewer than 20% of these patients.

The method chosen for open treatment of olecranon fractures is also controversial. Decisions regarding fragment excision versus internal fixation often are based on the percentage of joint-space involvement.

In 1947, McKeever and Buck stated that as much as 80% of the trochlear notch can be excised without compromise of elbow stability, provided that the coronoid and the distal trochlea are preserved. One patient developed anterior instability after excision of 75% of the articular surface. The consensus suggests that at least 50%, but likely less than 80%, of the articular surface can be excised, and a good result can still be obtained.[17]

Future treatment of olecranon fractures may very well involve percutaneous fixation accompanied by arthroscopic assistance. 

In patients with significant associated medical conditions, nonoperative treatment is often desirable. Healing of contused soft tissue is of paramount importance. Nonoperative treatment of even significantly displaced olecranon fractures is reasonable in patients with severe medical illness, steroid use, or dementia. Skillful neglect is the treatment of choice for these patients. An Ace wrap with sufficient padding to protect the elbow is the only requirement.

Patients with wide separation of fracture fragments lose much, but not all, of their elbow extension power. Late pain from a nonunited displaced olecranon fracture generally is not a problem, but the extensor power is compromised. Approximately 70% of the extensor power is estimated to be lost when the fracture is displaced more than 1.5 cm.

Gallucci et al evaluated 28 patients older than 70 years who had displaced olecranon fractures that were treated by early mobilization.[18] Of these patients, 22 developed minimally symptomatic nonunion, which did not warrant operative intervention in any cases. Patients had 15-140º of range of motion (ROM) with an average pain score of 1/10. The authors concluded that nonsurgical functional treatment was reasonable for elderly patients.

Similarly, Duckworth et al reported satisfactory long-term outcomes following nonoperative management of isolated displaced olecranon fractures in elderly low-demand patients.[19] In this study, 91% of patients were satisfied with their outcome.

Nondisplaced fractures (< 1-2 mm displacement) with intact extensor mechanisms may be treated nonoperatively. The patient must be able to actively extend the elbow. In such cases, 7-10 days of casting usually suffices. The elbow can be placed at any degree of flexion. Displacement generally can be reduced by placing the elbow in more extension. Patients can be comfortable with the elbow extended 135°. However, it is often more convenient to immobilize the elbow at 90°.

Regaining both flexion and extension can be difficult. At first, patients are cautioned to limit flexion to 90°, at least until evidence of radiographic healing is satisfactory. Repeat x-rays should be obtained to be sure the fracture does not displace. The paient can usually be allowed to lift at 6-8 weeks.

As noted (see Nonoperative Therapy), nonoperative care is usually successful in managing nondisplaced stable fractures with an intact extensor mechanism. However, surgical intervention is usually required for fractures with significant displacement (>1-2 mm) or comminution.

Excision and triceps advancement may be indicated for severely comminuted fractures or for patients with osteoporotic bone. Open reduction with internal fixation (ORIF) is preferred for displaced intra-articular fractures. Intramedullary screw fixation, with or without a wire or cable, is secure. Tension-band wiring is especially useful for transverse fractures.

Plate fixation with a lag screw provides excellent stability for oblique fractures. Plate fixation is especially recommended for extensive comminuted or unstable oblique fractures not amenable to other types of treatment. Plate fixation also may be preferable in the face of an associated coronoid fracture.[9, 11, 14, 20, 21, 22, 23]  Intramedullary rod techniques have also been suggested.

In determining the appropriate surgical approach, it is important to consider the following:

• Patient age
• Patient health
• Bone quality
• Fracture pattern
• Ligamentous stability

In general, tension-band wiring is preferred for transverse fractures in older patients, whereas plate fixation is preferred for multifragmented fractures in younger patients.[24]  

Careful evaluation of the dorsal cortex on preoperative x-rays assists in preoperative planning to choose the surgical technique. The tension-band techniques convert dorsal distraction forces to compressive forces at the articular surface and fracture site. If the dorsal cortex is comminuted, mechanical stability is lost. Therefore, if there is an intact dorsal cortex, tension-band wiring is an excellent choice for fixation, but if the dorsal cortex is comminuted, the surgeon should consider a plate or an intramedullary device instead.

The surgeon should also evaluate the fracture-line orientation: If the fracture is transverse, then a tension-band wire is effective; if it is oblique, a lag screw technique should be considered; and if it is comminuted, then usually a plate is the best option.[25]

A 2014 Cochrane review of trials of surgical interventions for treating olecranon fractures in adults did not find sufficient evidence to indicate that any particular surgical approach was clearly superior to any of the others.[26]

A midline posterior surgical incision is used curved radially to avoid the subcutaneous tip of the olecranon.

Excision of the fracture fragment and reattachment of the triceps tendon may be indicated in a select group of elderly patients with osteoporotic bone with low functional demands in whom the olecranon fracture involves less than 50% of the joint surface or when the fragment is too small or comminuted for successful internal fixation.[20, 23, 27, 17]  Excision of more than 50% of the olecranon leads to instability of the elbow joint.[20]

Integrity of the collateral ligaments, the intraosseous membrane, and the distal radioulnar joint (DRUJ) must be established before excision is considered; otherwise, instability can result. The triceps is reattached with nonabsorbable sutures that are passed through drill holes in the proximal ulna. The drill holes are placed so that the triceps will insert anteriorly just off the articular margin of the olecranon articular surface, in essence extending the articular margin. More posterior reattachment of the triceps tendon leads to elbow weakness.[20]

Weakening of the extensor mechanism is a drawback of excision and triceps advancement. However, comparison of the isometric strength of patients treated by excision with those who had internal fixation showed no differences. Excision and triceps advancement may be followed by immediate motion if the suture repair of the triceps is secure.

An example of olecranon excision in a 79-year-old man that went on to nonunion despite excellent tension-band wiring is shown in the images below.

A tension-band wire is the most common fixation technique for noncomminuted fractures. The goal is to convert the extensor force of the triceps to a dynamic compression force along the articular surface. Tension-band wiring is indicated for displaced fractures proximal to the coronoid process that are not at risk of compressing the olecranon fossa. Tension-band wiring is contraindicated if the articular surface is comminuted and unstable.[23, 28, 29, 30, 31]  Takada et al described a minimally invasive technique for tension-band wiring.[32]

The fracture is usually reduced with a pointed reduction forceps. The surgeon may drill a dorsal cortical hole distally for purchase of the reduction prong.

Next, two smooth Kirschner wires (K-wires) are drilled obliquely through the triceps tendon into the olecranon into the anterior cortex, with great care taken to bury the wires beneath the tendon and firmly impact them into the bone; otherwise, the wires certainly will migrate posteriorly and can become an irritant or possibly a source of infection. (See the image below.) The best mechanical stability is achieved with a configuation in which the K-wires engage both cortices (the tip of the olecranon proximally and the anterior cortex distally). Intramedullary configurations have worse mechanical stability.[33, 34, 24]

Migration of K-wires can occur in as many as 71% of patients. The wires are three times more likely to back out if they are not anchored in the anterior cortex.

K-wires help to hold the tension-band wire in place as it loops around the tip of the olecranon. Placing the pins under the tendon also minimizes strangulation of the tendon. A transverse bicortical drill hole through the ulna at 1-2 cm distal to the articular surface provides the distal fixation point. (A unicortical drill hole increases the risk of stress fracture through the hole.)

Next, a 18- or 20-gauge wire (or a braided cable) is looped under the K-wires and through the distal transverse hole in a figure-eight pattern. An IV cannula can be used to guide the wire. Tightening the wire creates interfragmentary compression. Using two knots results in more rigid fixation than using a single knot and provides symmetric tension at the fracture site. The key is to place the tension-band wire as dorsally as possible on the surface of the olecranon.[35]  An example of a tension-band technique is shown in the images below.

Another example of tension-band wiring technique is shown in the images below.

Tension-band wiring is best for transverse fractures, but if it is used for an oblique fracture, a lag screw placed across the fracture site can provide additional compression and stabilization.[12]

The challenges associated with appropriate technical placement of the hardware are frequently underestimated. Despite good functional results, Schneider et al found technical imperfections to be common.[36]

Plate fixation is most commonly recommended for treatment of comminuted fractures for which tension-band wire fixation is not feasible. It also is indicated for treatment of fractures that involve the coronoid process or extend distal to the coronoid process, including those extending into the shaft and for those associated with Monteggia fracture-dislocations of the elbow. Additionally, plates are sometimes indicated for oblique fractures when tension-band wiring may not provide ideal compression across the fracture site.

An example of a plate used for fixation of an olecranon fracture extending distal to the coronoid process is shown in the images below.

An example of a plate used for fixation of a comminuted olecranon fracture is shown in the images below.

The surgeon should first anatomically reduce and provisionally fix the intra-articular fragments and then attach the articular construct to the shaft. Indirect reduction techniques preserving soft-tissue attachments should be used when possible.[25]  The surgeon should not narrow the olecranon-to-coronoid distance (the trochlear/semilunar notch). It should be restored to within a few millimeters of the correct anatomic distance. In comminuted fractures, the ulnar nerve is at risk and should be isolated and avoided.

Some authors have used one-third tubular 3.5-mm dynamic compression or pelvic reconstruction plates for comminuted fractures. Minifragment 2.7-mm plates can be used for smaller patients. Specialized olecranon plates are also available (see the image below).

The proximal end of the one-third tubular plate can be modified to make a hook-plate that provides additional fixation for small fragments. The last hole in the plate, where it has been bent to make a hook, provides a good location for an intramedullary screw. Bone grafting sometimes is necessary in comminuted fractures. Bridge plating is recommended in highly comminuted fractures where interfragmentary compression will not be possible. Periosteal attachments should be preserved.

An example of bridge plating for a comminuted fracture resulting from a gunshot wound is shown in the images below.

Plates may be placed either posteriorly or laterally. The subcutaneous location of posterior hardware raises concerns about prominence necessitating subsequent removal of fixation.[37, 10]  Lateral plating is less prominent and may cause less implant pain and require late removal less often. Lateral plates also allow bicortical screw fixation proximally.

To avoid intra-articular placement of hardware, the surgeon can only use unicortical screws proximally with posterior plating. Posterior plates act as tension bands. Lag screws through either position of the plate provide interfragmentary compression, but the posterior plate usually has a more advantageous position for oblique fractures, allowing a coronoid screw, an intramedullary screw, and olecranon tip screws. There is no mechanical difference between posterior and lateral placement.[38]  (See the images below.)

Classically, the Monteggia fracture-dislocation is a fracture of the proximal third of the ulnar shaft with dislocation of the radial head. The Monteggia variant in which the olecranon is fractured (instead of the proximal diaphysis) usually requires ORIF with plate fixation. Usually, with an anatomic reduction, the radial head will reduce. The most common cause of an irreducible radial head is malreduction of the ulna.

Another Monteggia variant includes fracture of the olecranon with fracture of the radial head. Treatment of the ulna is again with ORIF. Treatment of the radial head depends on the fracture pattern and could include ORIF, replacement with a prosthesis, or excision. Repair is preferred.

An example of a Monteggia variant treated with radial head repair is shown in the images below.

An example of a Monteggia variant treated with radial head replacement is shown in the images below.

A raft technique using K-wires to support the articular surface adds additional stability in comminuted fractures treated with plate fixation.[39]

A screw was used in the same way to raft or support the articular surface in this example below.

Use of a single large-diameter cancellous screw for repair of olecranon fractures has been advocated for a long time. The Rush brothers wrote that intramedullary insertion of a Steinmann pin was the beginning of the Rush pin technique of fracture fixation in 1936. They claimed this to be the first American case of intramedullary pinning. They found that Steinmann pins were difficult to use and designed their own pins. When 6.5-mm AO/ASIF screws became available, they were used more commonly.[22]

In the frontal plane, there is 4° of valgus angulation in the ulnar shaft with respect to the sigmoid notch (see the image below). When intramedullary screws are used, they must be properly placed along the intramedullary shaft axis to avoid displacement of the fracture. With the advent of cannulated screws, it is much easier to correctly place the screw in the medullary canal of the ulna simultaneously, accommodating the bow in the ulna and achieving anatomic reduction. If the screw is too long, it can cause a medial shift of the tip of the olecranon, leading to malunion or nonunion.[40]

The 7.3-mm cannulated AO screws are the most secure. In placing the screws, it is important to keep in mind that if the screw diameter is large, there will be increased torque forces instead of compression as the screw is tightened, but if the canal diameter is too large, the screw will also have poor purchase and therefore inadequate compression. A screw that is too large can also split or crack the distal olecranon or proximal shaft, causing increased comminution of the fracture site or extending the fracture distally. Screw fixation is a technically demanding technique.

Biomechanically, screw fixation (see the image below) does not provide as secure a fixation as tension-band wiring, and it carries a higher rate of fixation failure.

However, by adding a tension band around the screw, improved fixation can be obtained. The most secure technique is placement of a large-diameter cannulated screw with a braided cable (see the images below). A 1.6-mm cable is adequate and much stronger than an 18-gauge wire.[31]

Nondisplaced stress fractures of the olecranon are rare injuries that occur with valgus extension overload in baseball players. ORIF with cannulated screws has been shown to be an effective treatment for refractory nonunion of these fractures, resulting in healing in 94% of patients and allowing return to competitive play in an average of 29 weeks.[41]

Although intramedullary rod systems are usually used for olecranon osteotomies, they are also an option for fixation of stable olecranon fractures. These systems minimize articular stepoff after osteotomy, and the connection between the nail and its end cap provides compression across transverse fractures. Because the nail is buried in the medullary canal below the surface of the bone, there is less soft-tissue hardware irritation than there is with other techniques. Fixation is more stable than with intramedullary screws because the distal locking screw of the implant prevents toggling of the bone, regardless of the size of the canal.

The entry portal is established with a drill by using minimally invasive techniques over a guide pin placed percutaneously. (Alternatively, an awl may be used to open up the proximal olecranon.) Details of insertion vary by manufacturer.[42]

Nowak et al found that fixation with intramedullary nails (see the image below) was more rigid than fixation with precontoured locking compression plates.[43]

Historically, cerclage fixation of olecranon fractures has yielded poorer results than tension-band wiring, plate fixation, or intramedullary fixation.  Cerclage does not provide interfragmentary compression and does not solidly hold comminuted fragments in position. However, two relatively recent studies implied that there remain indications for cerclage.

Phadnis et al compared the rates of reoperation in 138 consecutive Mayo type 1 and 2 olecranon fractures (stable) and 30 olecranon osteotomies, using tension-band wiring (89 patients), plating (38 patients), and suture fixation (without any metal) (41 patients).[5] They found the reoperation rate to be significantly higher for tension-band wiring (36%) than for plating (11%) or suturing (2%). Revision fixation was required in both the tension band wiring group and the suture group.

The outcome measures in this study were number of reoperations and radiographic evidence of union.[5] The authors did not assess adequacy of reduction (malunion or malalignment), including failure to assess stepoff at the articular surface, nor did they assess shortening of the olecranon.  The authors also did not evaluate functional clinical results (eg, strength, stiffness, crepitus, or the development of later arthritis).

Wenger et al compared cerclage wire fixation with tension-band wiring in elderly patients with stable displaced olecranon fractures (Mayo type 2) and found the former to yield lower reoperation rates.[16] Unfortunately, a significant proportion of their elderly, medically fragile patient population died before follow-up, and as a result, the authors were unable to assess functional outcomes.[16]

Operative management of olecranon fractures should provide sufficient fixation for immediate motion. Typically, patients are immobilized for only a brief time to assist wound healing and are then started on ROM exercises at 10 days. However, muscle strengthening is not emphasized until bone healing is visualized radiographically. Patients may return to work involving vigorous use of the extremity at 3-4 months postoperatively.

Symptomatic hardware requiring removal is the most frequent complication after internal fixation, occuring in 22-80% of patients. Hardware problems have occurred in as many as 80% of patients with Kirschner tension-band wires. Wire migration occurs with soft-tissue irritation, wire breakage, or fracture displacement.[34]

Patients must be counseled about the possibility of symptomatic hardware when internal fixation is offered.[25, 24]  

Secondary surgery is performed in 41% of patients after olecranon fracture fixation. Symptomatic painful hardware is the most frequently reported indication for such surgery. Secondary surgery after olecranon fracture fixation is required more frequently after tension-band wiring than after plate fixation. There is a 13% incidence of major complications, distributed equally among techniques. Younger patients require more reoperations.[24]

Pins can migrate and protrude through the skin.[16] Although anchoring the pins in the anterior cortex during tension-band wiring helps prevent pin migration, pins that are too long can impinge on the radial neck and causing motion loss or pain, or they can damage the biceps tendon or the supinator muscle, thereby also causing pain.[32]

Hardware complications generally occur less frequently with intramedullary screw fixation. Plate and screw fixation carries a moderate risk of subsequent need for hardware removal.

An example of an olecranon fracture treated with plate fixation that required eventual hardware removal after healing is shown in the images below. Because of comminution, this specialized olecranon plate was placed more proximally than usual to obtain better stabilization of the fragments.

Loss of motion is a common problem following fractures of the elbow but is usually not a significant issue for olecranon fractures. Generally, patients lose 15° of extension and, occasionally, a small amount of supination. Motion tends to improve progressively with time for up to 2 years.

Heterotopic ossification occurs in 13-14% of patients. Reported rates of infection following operative treatment are in the range of 0-6%. Reflex sympathetic dystrophy occurs on rare occasions. Ulnar neuritis occurs in 2-12%.

Generally, nonunion occurs in fewer than 5% of patients. When nonunions are treated by internal fixation with or without bone grafting, good-to-excellent results are obtained in approximately two thirds of cases. Nonunion can occur even in patients treated nonoperatively.

An example of nonunion after closed treatment of an olecranon fracture is shown in the images below. The nonunion was successfully treated by means of double plating (for rotational stabilization).

An example of nonunion after tension-band wiring of an elderly patient is shown in the images below. Successful treatment was accomplished with olecranon fragment excision.

An example of a nonunion following intramedullary fixation of an oblique olecranon fracture is shown in the image below. The screw did not have adequate purchase in the distal medullary canal.