What is the appropriate urgent care management of a comminuted, moderately displaced olecranon fracture with displacement of both the anterior and posterior olecranon fat pads, moderate swelling, and intact Common Sensory Motor (CSM) function distally?

From the Guidelines

The urgent care management of a comminuted, moderately distracted olecranon fracture with displacement of both anterior and posterior fat pads and moderate swelling should focus on stabilization and prompt orthopedic referral, with immediate immobilization in a long arm posterior splint and adequate pain control. The management approach is based on the principles outlined in the American College of Radiology's appropriateness criteria for acute elbow and forearm pain 1. Given the presence of a comminuted and moderately distracted olecranon fracture, the risk of further displacement and the need for surgical intervention to restore articular congruity and elbow function are significant concerns. Key steps in management include:

• Immobilizing the elbow in a long arm posterior splint at approximately 60-90 degrees of flexion to prevent further displacement, as full extension could exacerbate the injury.
• Providing adequate pain control with a combination of acetaminophen and ibuprofen, supplemented with oxycodone as needed for breakthrough pain, ensuring that the patient's pain is managed effectively without over-reliance on opioid medications.
• Applying ice for 20 minutes every 2 hours and elevating the arm above heart level to reduce swelling, which is crucial in the initial management of such injuries.
• Ensuring urgent orthopedic consultation, ideally within 24-48 hours, as the fracture's characteristics suggest a high likelihood of requiring surgical intervention. The presence of displaced fat pads (sail sign) indicates intra-articular effusion and significant injury, underscoring the need for prompt and appropriate management to prevent long-term morbidity and mortality related to elbow dysfunction and potential complications such as infection, nerve damage, or chronic pain. Despite intact compartment, sensation, and motor function (CSM), it is essential to provide clear return precautions, including monitoring for increasing pain unresponsive to medication, numbness, tingling, color changes, or increased swelling, which could indicate compartment syndrome or neurovascular compromise requiring immediate reevaluation 1.

From the Research

Urgent Care Management

• The management of a comminuted, moderately distracted olecranon fracture with displacement of both the anterior and posterior olecranon fat pads and moderate swelling requires careful consideration of the fracture characteristics and patient factors 2, 3.
• Initial management includes immobilisation in an above elbow backslab, a sling, and analgesia to reduce pain and prevent further injury 2.
• A thorough history and clinical examination, including neurovascular assessment, should be completed to rule out any other injuries or complications 2.

Surgical Intervention

• Surgical intervention is often required for displaced olecranon fractures, especially those with comminution, to achieve stable fixation and promote healing 2, 3.
• Tension band wiring, open reduction internal fixation with a pre-contoured locking plate, and tension band suture fixation are common surgical techniques used to manage olecranon fractures 2, 3.
• Plate fixation is typically employed for comminuted fractures, as tension-band wiring constructs can compress through fragments, leading to shortening of the articular segment 4.

Fixation Options

• Locked versus minifragment non-locked plate fixation has been compared in biomechanical studies, with no significant differences detected in fracture rotation or gapping between 2.7 mm and 3.5 mm plates 4.
• The choice of fixation technique depends on the fracture pattern, patient factors, and surgeon preference, with the goal of achieving stable fixation and promoting optimal outcomes 3, 5.

Conservative Management

• Nonoperative management can be considered for undisplaced fractures or displaced fractures in older patients with lower functional demands, using an above elbow cast for 4 weeks 2, 3.
• However, displaced fractures with significant comminution or instability may require surgical intervention to achieve optimal outcomes 3, 4.