Overview
Anatomic reduction and stable internal fixation are essential for elbow function and for preventing arthrosis. An early range-of-motion program reduces the risk of posttraumatic arthrofibrosis, so the fixation must be stable enough to tolerate motion. Most olecranon fractures are displaced and need surgery.
Complications arise from the subcutaneous position of the olecranon, mainly wound problems and symptomatic implants. Distraction forces across the fracture during flexion or active extension can contribute to nonunion.
Treatment Options
Nondisplaced or minimally displaced fractures with active extension preserved: Nonoperative treatment. Splint the elbow at 90° of flexion for 2–3 weeks, then start gentle passive motion and progress to active-assisted and active motion.
Elderly, low-demand patients: Nonoperative treatment is acceptable. Poor bone quality, a poor soft-tissue envelope, and difficulty taking part in rehabilitation are the main challenges.
Fragment excision with triceps advancement: For low-demand or infirm patients, unreconstructable proximal comminution, or revision after failed fixation. Biomechanical data suggest that attaching the triceps posteriorly on the olecranon gives greater triceps strength than anterior attachment.
Preoperative assessment: Look for associated soft-tissue or bony injuries that indicate a more complex instability pattern.
Comparison of Fixation Methods
Method | Advantages | Disadvantages / notes |
|---|---|---|
Tension band wiring | Low cost; useful in simple transverse patterns; little bulk in patients with poor soft tissues | Symptomatic implants needing removal in about 80%; risk to forearm neurovascular structures (AIN and ulnar artery lie close to K-wire exit points through the volar cortex distal to the coronoid). Articular compression under elbow flexion has not been confirmed biomechanically. |
Plate fixation | Holds fixation in comminuted fractures, distal fractures, and complex fracture-dislocations; allows lag screws for the olecranon and coronoid to reconstruct the proximal ulna; gives enough stability for union and early motion | Symptomatic implants needing removal in about 10% with precontoured plates; wound complications. Precontoured plates are low profile, offer more proximal screw options and locking, give 80% favorable results, and produced more compression than tension bands in transverse fractures. Minifragment plates give enough stability with a lower profile. |
Large intramedullary screw (6.5 mm) | Significant compression if the screw is long enough; no surface metal except the head, which is buried under the triceps; low implant removal rate | Malreduction from translation if the starting point is wrong. Use a central or slightly lateral starting point. Good endosteal thread purchase is essential; use a calibrated tap to choose the length. |
Campbell rarely uses tension band wiring for displaced olecranon fractures, because of its high complication and reoperation rates.
Surgical Technique (Technique 62.13)
Positioning and Approach
Position the patient supine or lateral decubitus.
Make a posterior incision from the tip of the olecranon, extending distally as far as needed for fixation.
Clean the fracture edges carefully, keeping comminuted fragments attached to their periosteum and soft tissues.
Simple Fractures
Look at the joint surface and reduce the fracture using pointed reduction clamps.
A lateral capsulectomy can help confirm anatomic articular reduction (articular impaction sometimes occurs) and exclude intraarticular loose bodies.
Insert provisional K-wires outside the plane of the plate. Use a lag screw if possible.
Place the plate, ideally one precontoured for the olecranon, over the proximal fragment. Elevate the triceps tendon only as much as needed for the plate to sit flush on bone.
If possible, direct the most proximal screw intramedullary so that it crosses the fracture.
Fill the remaining holes with locking or cortical screws as needed.
Confirm reduction and screw paths on fluoroscopy.
Close in layers and splint the elbow in extension with an anterior plaster slab.
Comminuted or Complex Fractures
Reduce and fix one fragment at a time with minifragment lag screws or plates, generally working from central to peripheral:
First fix the coronoid fragment to the intact diaphysis.
Then fix or replace the radial head.
Then reduce the olecranon to the shaft–coronoid complex.
Finally, reduce and fix the medial and lateral blowout fragments.
Before reducing the olecranon, elevate any impacted subchondral segments and hold them with K-wires, with or without supporting graft.
Apply the main small-fragment precontoured plate. If bone size or quality makes fixation questionable, use locking screws.
Confirm reductions, screw positions and elbow stability on fluoroscopy.
Close in layers and splint in extension.
Olecranon Fracture-Dislocations
Anterior (transolecranon) fracture-dislocation: The distal humerus is driven through the olecranon. The ulnohumeral joint dislocates, but the proximal radioulnar joint and collateral ligaments remain intact. Comminution varies and may involve the coronoid, typically through its base.
Campbell routinely treats these with anatomic articular reconstruction and plate fixation.
Four main fragments need attention: coronoid, shaft, lateral wall, and olecranon.
Posterior fracture-dislocation: Both ulnohumeral and radioulnar, a variant of the Bado type II Monteggia injury. Coronoid and radial head fractures and LCL injury are common.
Associated radial head, coronoid or humeral condyle fractures, or ligament injury, lead to worse outcomes than simple transolecranon variants.
Postoperative Care
Remove the splint on the first postoperative day.
If the elbow is stable, start protected range-of-motion exercises and progress as tolerated.
Reference
Cosgrove CT. Fractures of the shoulder, arm, and forearm. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 62, Technique 62.13.