summary Olecranon Fractures are common fractures of the elbow that lead to loss of extensor mechanism. Diagnosis can be made with plain radiographs of the elbow. Treatment may be nonoperative for nondisplaced fractures with an intact extensor mechanism. Surgical management is indicated for displaced fractures or fractures associated with loss of extensor mechanism. Epidemiology Incidence 12 per 100,000 per year account for approximately 10% of upper extremity fractures Age mean age is ~57 years Bimodal distribution high energy injuries in the young low energy falls in the elderly Etiology Pathophysiology mechanism direct blow usually results in comminuted fracture indirect blow fall onto outstretched upper extremity usually results in transverse or oblique fracture Associated conditions Transolecranon fracture/dislocation severe axial load leading to potential instability of the ulnohumeral joint due to severe intra-articular comminution of the olecranon fracture considered an anterior dislocation of the elbow (distal humerus is driven through the olecranon) there is no disruption of the proximal radioulnar joint Anatomy Osteology together with coronoid process, forms the greater sigmoid (semilunar) notch greater sigmoid notch articulates with trochlea provides flexion-extension movement adds to stability of elbow joint Muscles triceps inserts onto posterior, proximal ulna blends with periosteum innervated by radial nerve (C7) anconeus inserts on lateral aspect of olecranon innervate by radial nerve (C7) Classification Mayo Classification Based on comminution, displacement, fracture-dislocation Colton Classification Nondisplaced - Displacement does not increase with elbow flexion Avulsion (displaced) Oblique and Transverse (displaced) Comminuted (displaced) Fracture-dislocation (Transolecranon) Schatzker Classification Type A Simple transverse fracture Type B Transverse impacted fracture Type C Oblique fracture Type D Comminuted fracture Type E More distal fracture, extra-articular Type F Fracture-dislocation AO Classification Type A Extra-articular Type B Intra-articular Type C Intra-articular fractures of both the radial head and olecranon Presentation Symptoms pain well localized to posterior elbow Physical exam palpable defect indicates displaced fracture or severe comminution inability to extend elbow indicates discontinuity of triceps (extensor) mechanism Imaging Radiographs recommended views AP/lateral radiographs true lateral essential for determination of fracture pattern additional views radiocapitellar may be helpful for radial head fracture capitellar shear fracture CT indications may be useful for preoperative planning in comminuted fractures Treatment Nonoperative cast immobilization indications nondisplaced fractures with intact extensor mechanism displaced fracture in low demand, elderly individuals technique immobilization in 45-90 degrees of flexion initially begin motion at 1 week Operative open reduction internal fixation (ORIF) fixation techniques tension band technique indications transverse fracture with no comminution outcomes excellent results with appropriate indications intramedullary fixation (IMN) indications transverse fracture with no comminution (same as tension band technique) plate fixation indications comminuted fractures Monteggia fractures fracture-dislocations oblique fractures that extend distal to coronoid fragment excision and triceps advancement indications elderly patients with osteoporotic bone fracture must involve <50% of joint surface nonunions outcomes salvage procedure that leads to decreased extension strength may result in instability if ligamentous injury is not diagnosed before operation Techniques Open reduction internal fixation (ORIF) techniques tension band fixation technique converts distraction force of triceps into a compressive force engaging anterior cortex of ulna with Kirschner wires may prevent wire migration avoid overpenetration of wires through anterior cortex may injury anterior interosseous nerve (AIN) may lead to decreased forearm rotation use 18-gauge wire or non-absorbable thick suture in figure-of-eight fashion through drill holes in ulna cons high % of second surgeries for hardware removal (40-80%) does not provide axial stability in comminuted fractures plate fixation technique place plate on dorsal (tension) side oblique fractures benefit from lag screws in addition to plate fixation one-third tubular plates may not provide sufficient strength in comminuted fractures may advance distal triceps tendon over plate to avoid hardware prominence pros more stable than tension band technique cons 20% need second surgery for plate removal intramedullary fixation (IMN) technique can be combined with tension banding intramedullary screw must engage distal intramedullary canal Excision and triceps advancement technique triceps tendon reattached with nonabsorbable sutures passed through drill holes in proximal ulna Complications Symptomatic hardware most frequent reported complication Stiffness occurs in ~50% of patients usually doesn't alter functional capabilities Heterotopic ossification more common with associated head injury Posttraumatic arthritis Nonunion rare Ulnar nerve symptoms Anterior interosseous nerve injury Loss of extension strength