Management of Olecranon Fractures in Pediatric Patients
For pediatric olecranon fractures, conservative management with immobilization is the primary treatment for minimally displaced fractures (<2mm displacement), while surgical fixation is reserved for displaced fractures (>2-3mm) or those with associated injuries, with both approaches yielding excellent long-term outcomes in children.
Initial Assessment and Imaging
- Obtain anteroposterior and lateral radiographs to confirm the diagnosis and assess fracture displacement 1
- Perform complete neurovascular examination of the affected extremity 2
- Examine for associated injuries, as approximately 45% of pediatric olecranon fractures have associated lesions or complications that significantly impact outcomes 3
- Consider skeletal survey in children <12 months with fractures to screen for non-accidental trauma 2
Fracture Classification and Treatment Algorithm
Minimally Displaced Fractures (<2mm displacement)
- Conservative management is indicated for fractures with <2mm interfragmentary displacement 4
- Immobilize in an above-elbow cast or posterior splint for 4 weeks 1, 5
- Posterior splints provide superior pain relief during the first two weeks compared to other immobilization methods 6
- These minimally displaced fractures account for approximately 80% of all pediatric olecranon fractures and rarely require hospital admission 5
Displaced Fractures (>2-3mm displacement)
- Surgical intervention is required for fractures with >2-3mm displacement due to triceps muscle pull causing progressive displacement 1, 4
- Tension band wiring is the most commonly used technique for oblique metaphyseal fractures 5
- Open reduction and internal fixation with pre-contoured locking plates may be necessary for complex fracture patterns 1
- Tension band suture fixation represents a newer alternative technique 1
Special Considerations
Associated Injuries
- The presence of associated lesions is a negative prognostic factor and requires more aggressive management 4
- Multifragmental fractures or fracture-dislocations typically require surgical stabilization 5
Pediatric Remodeling Potential
- Children have exceptional remodeling potential that mitigates residual deformity risk even when some initial deformity is accepted 2, 6
- This allows for more conservative initial management compared to adult fractures 2
Follow-Up and Imaging Strategy
- Minimize follow-up radiographs unless clinically indicated, as routine postoperative imaging identifies complications in only 0.22% of cases 2
- Perform imaging only if it will change the treatment plan 2, 6
- Immobilization duration is typically 4-6 weeks 6
Expected Outcomes
- Long-term prognosis is excellent, with 87% achieving good results even though 85% involve intraarticular fractures 4
- At mean 19-year follow-up, 91% of patients have no subjective complaints 7
- Non-union and elbow osteoarthritis are rare complications in pediatric patients 7
- Most patients (>50%) achieve satisfactory return to normal function within 12 weeks 3
Critical Pitfalls to Avoid
- Do not miss associated injuries or complications, which occur in approximately 45% of cases and significantly impact outcomes 3
- Avoid underestimating displacement—fractures with >2mm displacement require surgical management to prevent poor outcomes 4
- Do not perform unnecessary follow-up imaging that will not change management 2, 6
- Screen appropriately for non-accidental trauma in young children, particularly those <12 months 2