Implants. Pointed and serrated reduction clamps, Kirschner wire (K-wire) set, small and mini fragment screw and plate set, proximal ulna periatricular locking plates, 18-gauge stainless steel cerclage wire, 6.5-mm cancellous screws

Patient position. Lateral decubitus position with operative side up and axillary roll is placed. Patient is supported by a bean bag and patient straps or tape. Affected extremity is placed over blanket roll bolster or radiolucent padded post. Tourniquet is applied as proximal on arm as possible. All bony prominences are padded. Sequential compression devices are applied to legs. Supine position for simple fracture patterns or polytrauma patients with the arm brought over the chest padded with a stack of blankets can be utilized. Prone position has also been described, which keeps the unaffected upper extremity out of the field and improves the ease of obtaining C-arm images. ¹

Table and room setup. Table is turned 90 degrees. Utilize the C-arm prior to prepping and draping to assure that unobscured images of the elbow can be obtained (▶Fig. 7.1).

Exsanguinate the extremity and inflate the tourniquet.

Perform a direct posterior approach to the proximal ulna centered over the subcutaneous border of the ulna distally with a slight curve of the incision radially around the prominent tip of the olecranon. Return to the midline proximal to the tip of the olecranon for several centimeters. Develop full thickness flaps radially and ulnarly.

Split the fascia between the flexor carpi ulnaris (FCU) and anconeus. If more distal exposure is needed, which is often seen in Monteggia fractures, split the fascia between the extensor carpi ulnaris and FCU.

Identify and protect the ulnar nerve if visualization is needed of the medial proximal ulna. If the ulnar nerve is not exposed, know its location by palpation.

At the fracture site, sharply remove 2 mm of periosteum from the fracture edges to allow cortical reads to improve the accuracy of reduction. Remove fracture hematoma and thoroughly irrigate the fracture site. For intraarticular fractures, expose the elbow joint and assure that there are no intra-articular loose bodies or debris that require removal (▶Fig. 7.2). Excessive dissection of soft tissue attachments to fracture fragments should be avoided to preserve vascularity.

Fracture reduction is aided with elbow extension to relax the triceps pull on the proximally displaced olecranon. Utilize pointed reduction clamps to align the olecranon with the intact proximal ulna. This step can be aided by placing unicortical drill holes distal to the fracture to help anchor the clamps.

After reduction is obtained, place two 1.6 mm smooth K-wires, one ulnarly and one radially, across the fracture site to hold reduction. Place these wires outside of the footprint of the plate or definitive fixation construct. Confirm anatomic reduction with fluoroscopic images.

Additional reduction clamps and K-wires may be needed for the reduction and provisional fixation of additional fracture fragments.

Mini or small fragment lag and positional screws or plates can be placed for the sequential fracture reduction of smaller fracture fragments and areas of comminution.