What is the treatment for an olecranon process fracture at the elbow?

Treatment of Olecranon Process Fractures

Surgical fixation is the treatment of choice for displaced olecranon fractures, while non-displaced fractures can be managed conservatively with short-term immobilization followed by early mobilization. 1, 2

Initial Assessment and Imaging

• Radiographs are the first-line imaging modality for suspected olecranon fractures to assess displacement, comminution, and joint involvement 3
• CT without contrast is indicated when radiographs are normal or indeterminate but clinical suspicion for fracture remains high, as it can identify occult fractures of the olecranon and clarify fracture morphology 3
• Joint effusion on radiographs, indicated by posterior and anterior fat pad elevation, may suggest an occult elbow fracture in the context of trauma 3

Treatment Algorithm

Non-displaced Fractures (Mayo Type 1)

• Conservative treatment with short-term immobilization (2-3 weeks) followed by gradually increasing range of motion 1, 2
• A posterior long-arm splint is typically used during the immobilization period 4
• Early mobilization is crucial to prevent joint stiffness 1, 5

Displaced Fractures (Mayo Type 2)

1. Simple Transverse or Oblique Fractures:

   • Tension-band wiring technique is the standard treatment 2, 5
   • Two Kirschner wires with figure-of-eight tension-band wire provides symmetric tension at the fracture site 2
   • Position wires deep to triceps fibers to prevent migration 2
   • Alternatively, intramedullary screw fixation can be used, which may reduce complication rates compared to traditional techniques 4

2. Comminuted Fractures (Mayo Type 2A with fragmentation):

   • Plate fixation is recommended for better stability 2, 6
   • Options include dorsally applied limited-contact dynamic-compression plate with supplemental bone graft 2
   • One-third tubular hook-plate can be used for fractures with a small proximal fragment 2, 5

3. Fractures with Special Considerations:

   • Plate fixation is appropriate for:
     • Distal fractures involving the coronoid process
     • Oblique fractures distal to the midpoint of the trochlear notch
     • Monteggia fracture-dislocations of the elbow
     • Nonunions 2

4. Elderly or Frail Patients with Lower Functional Demands:

   • Conservative management may be considered even for displaced fractures 6
   • Fragment excision and triceps advancement is appropriate in selected cases with severe comminution and osteoporosis where open reduction is unlikely to be successful 2

Post-Treatment Management

• After surgical fixation, the arm is typically splinted for 2 weeks to allow for soft-tissue healing 4
• Following this period, early active range of motion exercises should be initiated to minimize stiffness 2, 5
• Regular radiographic follow-up is essential to monitor fracture healing and hardware position 5

Potential Complications

• Surgical treatment complications include hardware prominence requiring removal, wound issues, and infection 1, 4
• Tension-band wiring has a reoperation rate of approximately 24%, primarily due to symptomatic hardware 4
• Plate fixation has a reoperation rate of about 13% 4
• Intramedullary screw fixation has shown promising results with lower complication rates (18% reoperation rate) 4
• Prolonged immobilization can lead to joint stiffness and contractures 1, 4

Key Considerations

• The anatomical reduction of the articular surface is critical for maintaining elbow function 5, 6
• Early mobilization after appropriate fixation is essential to prevent stiffness 1, 5
• The choice between tension-band wiring, plate fixation, or intramedullary screw fixation should be based on fracture pattern, bone quality, and patient factors 2, 6