The crushing force of the distal humerus impacting the greater sigmoid notch can cause impaction and comminution of the articular surface. This can occur in high energy and low energy injuries. While small areas of comminution and minor incongruities in the transverse groove are well tolerated due to limited load transmission, anatomic reduction of the contour of the greater sigmoid notch and the anterior cortex of the coronoid results in restoration of the ulnohumeral articulation, allowing for a stable elbow joint, and is critical for a successful outcome [5]. While completely displaced and free fragments are obvious, direct exposure and visualization of the greater sigmoid notch is the best means of confirming the presence of articular injury and restoring the anatomy.

Impacted articular fragments should be carefully elevated to avoid creating a free fragment. A small osteotome is placed between the impacted fragment and the underlying stable bone to elevate and reduce the fragment. This creates a cavity that can be filled with bone graft or bone graft substitute to support the reduction. Displaced free osteochondral fragments also need to be reduced and fixed to larger and more stable aspects of the ulna. Fixation can be achieved with small K-wires, absorbable pins, fibrin glue, or cyanoacrylate. Very small chondral and osteochondral fragments can be discarded.

A splint is used after surgery for comfort and to protect the elbow during early soft tissue healing. An anteriorly placed extension splint can be utilized to relax posterior soft tissues. Patients should not be splinted longer than 7 days, unless there is a significant soft tissue concern. Stable osseous fixation should allow for early motion of the elbow joint. However, in the case of severely comminuted fractures and poor quality bone, elbow motion may be delayed. Once the initial splint has been removed, assisted passive elbow and forearm motion is initiated. A compressive sleeve that extends from the hand to the upper arm is placed to control edema. A compressive glove can also be worn at night to control hand swelling and frequent wrist, hand, and finger range of motion is encouraged. A hinged elbow brace is utilized for added protection during early stages of healing, as well as also to limit flexion if there is concern about the posterior soft-tissues.

Active motion is progressed after 6 weeks, and carefully controlled passive stretching is initiated to overcome stiffness. Osseous healing is monitored radiographically. Isometric elbow extension and flexion, wrist extension and flexion, and forearm pronation and supination strengthening can be started after 6 weeks. Once motion is recovered, resistive strengthening is begun (typically 10–12 weeks). Patients are generally allowed to return to unrestricted activities at 4–6 months if motion and strength have recovered and there is osseous union.

Osseous healing is monitored with serial plain radiographs. In addition, heterotopic ossification (HO) is a concern for these patients and oral indomethacin can be used for 3–6 weeks to reduce the risk of HO. Radiation therapy should be avoided secondary to risk of fracture nonunion [12].

It is not uncommon for these patients to have limitations of elbow motion at final outcome. If patients are slow at regaining motion, static progressive braces can be used. Late stiffness can be addressed with capsular release and excision of heterotopic bone.

Good or excellent outcomes can be achieved following management of transolecranon fracture-dislocations [4, 6, 8]. Mortazavi et al. [8] followed patients an average of 37.4 months (range, 10–50 months) after injury. Seven patients were managed with plate fixation and one with tension band. The mean range of flexion was 115° (range, 85–140°), with a mean flexion contracture of 22° (range, 0–45°). There is average arc of rotation measured 157.5° (range, 120–173°), with a mean pronation of 75° (range, 40–90°) and a mean supination of 83° (range, 80–85°). The mean score on the system of Broberg and Morrey was 88 points (range, 71–100 points). There were two excellent, five good, and one fair result. The average score on the American Shoulder and Elbow Surgeons (ASES) system was 89 points.

In a retrospective review of 17 transolecranon fracture-dislocation cases by Ring et al. [4], 15 cases had good or excellent results according to the scale of Broberg and Morrey. The average elbow flexion was 127° (range, 100–140°), with an average elbow flexion contracture of 14° (range, 0–40°). Forearm pronation and supination were normal in all but four patients. Doornberg et al. [5] reported satisfactory results in 9 of 10 patients. In a study by Rommens et al. [13], 65 % of the patients treated with a tension band required removal of hardware after an average of 12 months. Moushine et al. [6] retrospectively evaluated 14 transolecranon fracture-dislocations comparing seven treated with a tension band and seven treated with a plate. In the tension band group, three patients had early complications and had to be revised with a plate and supplemented with bone graft. Two of these patients had comminuted fracture patterns. Consequently, tension band fixation of these injuries should be avoided. Even simple transverse or oblique fractures in the setting of a transolecranon fracture-dislocation should be repaired using a dorsally applied plate.

Poor outcomes are often associated with hardware failure, nonunion, or inadequate postoperative immobilization. Several studies have shown that one-third of tubular plates fail to provide sufficient strength and rigidity for stabilizing more comminuted fractures of the olecranon [3, 4, 10, 14]. Consequently, 3.5 mm reconstruction or dynamic compression plates or precontoured olecranon plate s should be used. In cases involving a large type 3 coronoid fracture, a poor outcome is inevitable if the fracture is not recognized and treated [4, 5]. Therefore, anatomic coronoid fixation providing stability to allow early motion is critical for success. Coronoid injuries with severe comminution or poor fixation due to bone quality should be considered for reconstruction utilizing an auto- or allograft with or without the addition of an external fixator. As the olecranon is a subcutaneous bone, hardware may be more prominent and can be painful to patients. In a multicenter study, the need for hardware removal of both plate and screw and tension band constructs was reported as high as 65 % by 18 months after surgery [7].

A long-term outcome study (18 ± 5 years after surgery) by Lindenhovius et al. [14] demonstrated that secure anatomical restoration of the greater sigmoid notch led to durable results. Final flexion arc was 124 ± 30° and final arc of forearm rotation was 133 ± 54°. Outcomes according to the ASES score were 85 ± 19, the Disability of Arm Shoulder and Hand questionnaire (DASH) were 14 ± 17, and Broberg and Morrey were 87 ± 18. The categorical ratings based on the Mayo Elbow Performance Index (MEPI) score were five excellent results, three good results, one fair result, and one poor result. 50 % (5 of 10 patients) developed some degree of ulnar neuropathy and arthrosis. Pain, final flexion arc, and ulnar neuropathy were the most important predictors of poor functional results and outcome. Furthermore, arthrosis did not correlate with final flexion arc and did not affect their evaluation scores. Therefore, despite the complexity of the injury, if stable anatomic reconstruction is achieved, one can be optimistic about the functional result.