Management of Combined Olecranon and Radial Head Fractures
Combined olecranon and radial head fractures require operative fixation with open reduction and internal fixation (ORIF) of both fractures, using contoured plating for the olecranon and either mini-screw fixation or radial head replacement for the radial head, followed by early active range of motion exercises. 1, 2
Initial Diagnostic Workup
Obtain CT imaging without contrast to fully characterize the injury pattern, identify the extent of comminution, assess coronoid process involvement (which indicates severe instability), and evaluate for the "terrible triad" constellation (radial head fracture, coronoid fracture, and elbow dislocation). 3, 4
Look specifically for coronoid fractures on CT, as these are commonly missed on plain radiographs but critically affect treatment planning and prognosis—coronoid involvement occurred in 3 of 28 patients in one surgical series. 2, 3
Assess joint effusion on lateral radiographs (posterior and anterior fat pad elevation), which may indicate occult fractures even when displacement appears minimal. 4
Surgical Management Approach
The operative strategy must address both fractures with stable fixation to allow early mobilization:
For the olecranon fracture: Use a contoured locking plate and screw system, which provides superior stability in comminuted fracture patterns compared to tension band wiring. 2, 5
For the radial head fracture: Perform open reduction and internal fixation with mini-screws if the fracture is reconstructable, or proceed with radial head replacement if the fracture is severely comminuted or unreconstructable. 1, 2
Consider primary bone grafting in severely comminuted olecranon fractures—this was performed in 12 of 28 patients (43%) in one series with favorable outcomes. 2
Repair the lateral collateral ligament complex if disrupted, as ligamentous injury commonly accompanies these combined fracture patterns. 6
Postoperative Rehabilitation
Initiate active finger motion exercises immediately postoperatively to prevent hand stiffness, which is a functionally disabling complication. 3
Begin early active range of motion of the elbow as soon as stable fixation is achieved—this approach was used successfully in all cases in the landmark series by Ring et al. 1
Expected Outcomes and Prognostic Factors
Patients should be counseled that functional outcomes are generally good but not perfect:
Expect an average loss of 18° of elbow extension and 56° of forearm rotation at 12-48 months follow-up, with maintenance of approximately 132° of flexion. 1
Combined injuries involving both the radial head and coronoid have significantly worse rotational outcomes (73° pronation-supination arc) compared to isolated olecranon fractures, though ulnohumeral motion remains similar. 6
Union rates are excellent (100% in multiple series) with mean time to union of 15 weeks, and no elbow instability or wrist pain should occur with proper fixation. 1, 2
Overall functional outcomes using the Broberg and Morrey scale show 78.6% excellent or good results in complex comminuted patterns. 2
Critical Pitfalls to Avoid
Do not miss coronoid fractures—they indicate severe instability and require CT imaging for identification, as they are frequently occult on plain radiographs. 3, 2
Do not attempt nonoperative management of these combined injuries—the pull of the triceps muscle on the olecranon combined with radial head instability makes displacement inevitable without surgical stabilization. 5
Do not delay surgery—early stable fixation is essential to permit the early active motion that prevents the devastating complication of elbow stiffness. 1
Do not underestimate the complexity—these injuries represent high-energy trauma patterns that require meticulous surgical technique and realistic patient counseling about expected functional limitations, particularly in forearm rotation. 6