Simple olecranon fractures (without instability) are very common injuries in all age groups. Fractures either result from a trauma forcing the proximal ulna into the distal humerus or a forceful contraction of the triceps. Olecranon fractures can be classified into stable (transverse, oblique, or comminuted) or unstable (fracture-dislocation) patterns (Figure 21.1). Most olecranon fractures require surgical fixation; however, nondisplaced, stable, noncomminuted fractures can be considered for nonoperative treatment. Displaced transverse fractures can be treated using a variety of surgical constructs, including tension-band, intramedullary screw, or plate and screw fixation with the goals of restoring appropriate ulnar length and anatomic articular congruity (Figure 21.2, A and B). Comminuted or oblique fractures require dorsal plate fixation often with possible addition of interfragmentary screws outside the plate. The primary goal of surgery is to provide stable, rigid fixation, allowing immediate protected motion in order to optimize final range of motion (ROM) and strength.

Transolecranon fracture-dislocations typically occur as a result of a blow to the dorsum of the forearm. These injuries occur in the young with good bone quality as a result of a high-energy injury. Typically, a highly comminuted fracture of the olecranon process occurs with subluxation or dislocation of the radial head anteriorly on the distal humerus (Figure 21.3, A and B). The proximal radioulnar joint is not injured in this pattern, which is an important difference between transolecranon fracture-dislocations and posterior Monteggia fracture-dislocations. Both the radial shaft and the ulnar shaft translate anteriorly and in the same direction; in a Monteggia injury, the radius and ulna translate in opposite directions. Radial head and neck fractures are uncommon with transolecranon fracture-dislocations, and if coronoid fractures occur, they are typically basal injuries. The medial collateral ligaments (MCLs) and LCLs are typically spared in this injury compared to a typical elbow dislocation or a
Monteggia fracture-dislocation. The primary lesion in a transolecranon fracture-dislocation is disruption of the ulnohumeral joint. The key to treatment of these injuries is restoration of the trochlea notch with stable fixation (Figure 21.4, A and B). A dorsally applied 3.5-mm reconstruction, precontoured, or compression plate is the implant of choice for these injuries with a higher failure rate if a tension-band device or one-third tubular plate is utilized. In general, outcomes of these injuries are very good, with a low level of posttraumatic arthritis as long as the contour and dimensions of the trochlea notch are restored independent of comminution. As long as stable fixation is achieved, very aggressive postoperative therapy can be performed with limited protection since there is no reliance on soft-tissue ligamentous healing. Early stretching will optimize clinical outcomes.

Fractures of the ulna with a dislocation of the proximal radioulnar joint are known as Monteggia fractures. The traditional classification of Monteggia fractures is according to the direction of the radial head dislocation (anterior, lateral, or posterior). In the adult, posterior Monteggia fracture-dislocations are the most common injury classified as a Bado type 2. In this injury pattern, the proximal radioulnar joint is disrupted, with the radial head dislocating posteriorly and the apex of the proximal ulna fracture directed anteriorly. Jupiter has further classified the Bado type 2 injuries by location of the ulna fracture: A—the distal olecranon and coranoid process, B—at the metaphyseal–diaphyseal junction, C—diaphyseal, D—extending along the proximal third to half of the ulna. These injuries typically occur in the elderly and osteoporosis is often present, which can compromise stable internal fixation. A low-energy fall onto an outstretched arm is the most common injury mechanism. A comminuted fracture of the olecranon typically occurs and is commonly associated with fractures of the coronoid process (frequent) and the radial head (almost always) (Figure 21.5, A and B). Associated LCL complex injuries occur in up to
two-thirds of patients and associated ulnohumeral instability can occur as well. Surgical treatment typically involves treating all of the pathologic structures, including the anatomic axial alignment of the ulna fracture (primary goal), repair or replacement of radial head and coronoid fractures, and repair of the injured LCL complex (Figure 21.6, A and B). Ulna fractures should be treated with a dorsally applied 3.5 reconstruction, precontoured, or compression plate. Overall results are slightly worse than the results of transolecranon fracture-dislocations due to increased risk for complications, including proximal radioulnar synostosis, ulnar malunion, posterolateral rotatory instability, and fixation failure due to
osteoporotic bone. Associated radial head and coronoid fractures negatively affect the surgical outcomes of these injuries. Postoperative rehabilitation therapists need to practice more cautious with these injuries compared to transolecranon fracture-dislocations due to less stable fixation associated with osteoporosis and the protection required for a repaired LCL complex. Despite these limitations, reasonable outcomes can still be achieved with a structured rehabilitation program.

The indications for operative fixation of an olecranon fracture—simple stable patterns with or without comminution,
transolecranon fracture-dislocation, and a posterior Monteggia fracture-dislocation—are fairly straightforward. In general, displaced fractures of the olecranon generally require surgical fixation and nonoperative management has a minimal role except for nondisplaced stable injuries or in patients who are not surgical candidates due to other comorbid conditions.

In general, there are few contraindications to surgical repair for these injuries. If a patient is medically unfit and cannot tolerate an anesthetic, that may be considered a contraindication. Open fractures will require definitive fixation, but initial fixation may be deferred until adequate debridement and wound management has been performed.

The setup, patient positioning, and superficial approach are identical for surgical procedures to treat all variants of olecranon and proximal ulna fractures. The deep approach and aspects of the fixation differ depending on the specific injury pattern. The patient can be positioned “lazy lateral” with soft padding behind the ipsilateral chest and thorax and the arm draped across the chest, or full lateral decubitus. Either setting provides access to the posterior and lateral aspects of the elbow and forearm while still allowing medial access if required. A mini C-arm or full-sized image intensifier is used throughout the case and brought in from the same side as the operative arm. A sterile tourniquet is used for bleeding control throughout the case.

It is important to have a full complement of plates and screws available. For simple stable fractures, tension band and intramedullary screw fixation are options and having appropriately sized Kirschner wires (K-wires; 1.6 or 2 mm), wire (18- or 20-gauge), and intramedullary screws (7.3-mm partially threaded cancellous) available is recommended (Figure 21.2, A and B). For more comminuted stable fractures as well as the dislocation patterns, plate-and-screw fixation is recommended. Current precontoured locking olecranon plates provide advantages over traditional reconstruction and compression plates. Additionally, smaller screws of various lengths may be needed to fix small fracture fragments. Long K-wires and reduction clamps are required to gain provisional fixation. If a displaced radial head fracture is part of the injury pattern, radial head and neck plates, headless screws, and radial head arthroplasty implants should be available. Finally, small screws and plates are used to fix coronoid fractures.