What is the step-by-step management of an olecranon fracture?

Management of Olecranon Fractures: Step-by-Step Approach

For displaced olecranon fractures with a stable ulnohumeral joint, surgical fixation using tension band wiring or plate osteosynthesis is the standard treatment, while undisplaced fractures can be managed with immobilization in an above-elbow cast for 4 weeks. 1, 2

Initial Assessment and Diagnosis

Clinical Evaluation

• Obtain mechanism of injury: low-energy falls in older patients or direct blows/high-energy trauma in younger patients 1
• Perform neurovascular examination of the affected limb to identify any nerve or vascular compromise 1
• Assess for open fracture by examining the skin overlying the olecranon, as its superficial location makes it vulnerable to open injury 1
• Palpate for displacement and assess active elbow extension ability (inability suggests complete fracture with triceps disruption) 1

Imaging Protocol

• Order anteroposterior and lateral radiographs of the elbow as first-line imaging to confirm diagnosis and assess displacement, comminution, and joint involvement 3, 1
• Look for joint effusion on radiographs (posterior and anterior fat pad elevation) which may indicate occult fracture 3
• Obtain CT without contrast when radiographs are normal or indeterminate but clinical suspicion remains high, as CT identifies occult fractures and clarifies fracture morphology 3

Fracture Classification (Mayo System)

• Type 1: Undisplaced fractures (displacement <2mm) 2
• Type 2: Displaced fractures with stable ulnohumeral joint 2
  • Type 2A: Without significant articular fragmentation 2
  • Type 2B: With articular comminution 2
• Type 3: Displaced fractures with ulnohumeral instability 2

Immediate Management

All Fractures

• Immobilize in above-elbow backslab with elbow at 90 degrees flexion 1
• Apply sling for comfort 1
• Provide adequate analgesia 1

Definitive Treatment Algorithm

Nonoperative Management

Indications:

• Undisplaced fractures (Mayo type 1) with <2mm displacement 2, 4
• Displaced fractures in frail elderly patients with low functional demands who are not medically fit for surgery 2

Protocol:

• Apply above-elbow cast with elbow at 90 degrees flexion for 4 weeks 1
• Obtain repeat radiographs at 1 week to confirm no displacement has occurred 1
• Begin gradual range of motion exercises after 4 weeks 4

Operative Management

Indications for Surgery:

• Displaced fractures (>2mm displacement) in patients fit for surgery 1, 2
• Fractures with inability to actively extend the elbow 1
• Open fractures 1
• Fractures associated with elbow instability 2

Surgical Technique Selection

Tension Band Wiring:

• Best for: Simple transverse fractures (Mayo type 2A) without significant comminution 2, 4
• Use figure-of-eight configuration with two knots to produce symmetric tension and more rigid fixation than single knot 4
• Position tension-band wire and proximal Kirschner wire ends deep to triceps fibers to prevent wire migration 4
• Avoid overpenetration of wires into anterior soft tissues if anterior cortex is engaged 4
• Caveat: Requires removal in 13 of 54 patients due to hardware prominence or migration 5

Plate Osteosynthesis:

• Best for: 2, 4
  • Multifragmentary fractures with significant comminution
  • Fractures associated with ulnohumeral instability (Mayo type 3)
  • Oblique fractures distal to midpoint of trochlear notch
  • Monteggia fracture-dislocations
  • Nonunions
• Use dorsally applied limited-contact dynamic-compression plate with supplemental bone graft for comminuted fractures 4
• Consider one-third tubular hook-plate for fractures with small proximal fragment requiring additional fixation of olecranon tip 4
• Advantage: Lower complication rate (13 complications in 54 fixation cases, but includes all fixation types) 5

Intramedullary Fixation:

• Alternative option for Mayo type 2A fractures 2

Suture Repair:

• Emerging option for Mayo type 2A fractures 2

Fragment Excision with Triceps Advancement:

• Reserved for: Severely comminuted fractures in osteoporotic elderly patients where open reduction unlikely to succeed 4
• Results in similar pain, function, range of motion, and elbow stability compared to fixation 5
• Advantage: Only 2 complications in 53 excision cases versus 13 in 54 fixation cases 5
• No significant difference in elbow extensor strength compared to internal fixation 5

Postoperative Management

Early Mobilization Protocol

• Begin gentle active range of motion exercises within first week after stable internal fixation 4
• Avoid heavy lifting or resistance exercises for 6-8 weeks until fracture healing confirmed 1
• Obtain radiographs at 2,6, and 12 weeks to assess healing 1

Expected Outcomes

• Good results expected overall after surgical management 6
• Similar functional outcomes between excision and fixation groups for pain, function, range of motion, and elbow stability 5

Common Pitfalls to Avoid

• Hardware prominence: Position all wires and tension bands deep to triceps to prevent migration and need for removal 4
• Loss of reduction: Confirm stability intraoperatively and obtain early follow-up radiographs in nonoperative cases 1
• Elbow stiffness: Begin early range of motion after stable fixation to minimize stiffness 4
• Overlooking instability: Assess ulnohumeral stability intraoperatively, as this changes fixation strategy from tension band to plate 2