Olecranon Fracture
Jacksonville, FL
A fall on a flexed elbow or a direct blow to the tip of the elbow — the olecranon is the most commonly fractured part of the elbow. Most displaced olecranon fractures require surgery. Dr. R. David Graham at JOI prefers plate fixation over tension band wiring for its more stable construct and lower hardware irritation rate.
- Olecranon = bony tip of the elbow, attachment of the triceps tendon
- Non-displaced fractures → long-arm cast, close X-ray follow-up
- Displaced fractures → surgery to restore elbow extension mechanism
- Dr. Graham's preference: plate fixation over tension band wiring
- Early motion after fixation — stiffness prevention is a priority
- Associated radial head fracture or coronoid fracture assessed every case
The olecranon is where the triceps attaches — it is the engine of elbow extension. A displaced fracture separates the triceps from the forearm, making active elbow extension impossible. Surgical fixation restores this mechanism and allows early protected motion.
Understanding the Fracture
The Olecranon — Elbow Extension Mechanism
The olecranon forms the posterior tip of the elbow and is the attachment site of the triceps tendon — the muscle responsible for elbow extension. Fractures disrupt this mechanism and require anatomic reduction to restore function.
Olecranon fractures occur by two main mechanisms. Direct blows to the posterior elbow — a fall onto a hard surface, a dashboard impact — fracture the olecranon in a transverse or comminuted pattern at the tip. Falls on an outstretched hand with the elbow flexed create an avulsion mechanism where the triceps pulls the olecranon fragment proximally — producing a more oblique fracture pattern at the triceps attachment.
Non-displaced fractures — confirmed by X-ray in multiple views, with no articular step-off and an intact extensor mechanism — can be treated with a long-arm cast in 60–90° of elbow flexion for 4–6 weeks with close X-ray follow-up to confirm no displacement occurs. Any displacement, articular step-off, or inability to actively extend the elbow against gravity is an indication for surgery.
In Dr. Graham's experience, plate fixation provides a more stable construct than traditional tension band wiring (TBW) — a wire technique that relies on the compressive forces of elbow motion to maintain reduction. TBW is biomechanically sound in simple transverse fractures but carries a significant hardware irritation rate (the wires sit directly under skin with minimal soft tissue coverage) and is less forgiving in oblique, comminuted, or osteoporotic bone. A contoured plate applied to the dorsal olecranon provides stable fixation that accommodates more complex fracture patterns and allows earlier, more confident range-of-motion therapy.
Unable to Extend Elbow
The cardinal sign of a displaced olecranon fracture — the patient cannot actively extend the elbow against gravity because the triceps is no longer attached to the forearm. Any patient with posterior elbow pain after trauma who cannot extend needs urgent X-rays.
Visible Deformity or Gap
Significant displacement may produce a palpable gap at the fracture site on the posterior elbow and visible swelling and ecchymosis. In thin patients, the fracture fragment may be visible or felt beneath the skin.
Associated Injuries
Olecranon fractures are rarely isolated in high-energy mechanisms. Radial head fractures, coronoid fractures, and ligamentous injuries (LUCL, MCL) coexist and are assessed on every olecranon fracture. The "terrible triad" — olecranon equivalent, radial head fracture, coronoid fracture — requires systematic evaluation.
Surgical Treatment
Plate Fixation — Dr. Graham's Preferred Technique
For most displaced olecranon fractures, Dr. Graham applies a contoured dorsal plate rather than tension band wiring. The rationale: more stable fixation, better management of comminuted patterns, and lower hardware irritation.
Why Plates Over Tension Band Wiring
Tension band wiring is the historically taught technique for olecranon fractures — two K-wires longitudinally across the fracture with a figure-of-eight wire looped around the proximal wires to create dynamic compression. It works well in simple transverse fractures in good bone. But it has real limitations: the hardware (wires and the prominent knot) sits immediately under skin with minimal soft tissue coverage, producing symptomatic hardware irritation that requires removal in a meaningful percentage of patients. It is also less reliable in comminuted patterns, oblique fractures, and osteoporotic bone where the wire technique cannot adequately control rotation.
Contoured dorsal plate fixation provides a rigid, anatomically contoured construct that spans the fracture and controls all displacement vectors. In Dr. Graham's experience, plates are more forgiving across a wider range of fracture patterns — including comminuted and more distal fractures — and allow earlier, more confident range-of-motion therapy because the stability of the construct is not dependent on the compressive forces of elbow motion in the way TBW is. Hardware prominence remains a consideration with plates as well, but modern low-profile implants have reduced this significantly.
Anesthesia & Setup
Outpatient procedure at Baptist Beaches Hospital or Horizon Surgery Center. Regional block with sedation. Prone or lateral position with the elbow over a bolster provides posterior elbow access. Tourniquet on the upper arm.
Posterior Approach
Longitudinal posterior incision over the tip of the olecranon. The fracture is exposed, hematoma evacuated, and the fracture surfaces debrided. Articular surface reduction is confirmed directly and under fluoroscopy — articular congruence is the priority reduction goal.
Fracture Reduction & Plate Application
The fracture is provisionally reduced with clamps and held with K-wires or provisional screws. A precontoured dorsal olecranon plate is applied. Proximal screws engage the olecranon fragment; distal screws engage the ulnar shaft. The plate is contoured to the dorsal ulna anatomy to minimize prominence. Final reduction and fixation confirmed under fluoroscopy including in full flexion and extension.
Stability Check & Associated Injury
Elbow is taken through full range of motion under fluoroscopy — fixation stability confirmed at extremes of motion. The radial head and coronoid process are assessed. Elbow varus-valgus stability is tested. Associated fractures or LUCL disruption are addressed before closure.
Closure & Splint
Meticulous closure in layers — the posterior skin has limited blood supply and must be handled carefully. Posterior splint at 60–70° of flexion. Motion begins within the first week under formal therapy supervision.
Recovery
After Olecranon Fracture Repair
Splint & Early Motion
Posterior splint for wound healing. Formal therapy begins at 1 week — active-assisted range of motion for elbow flexion-extension and forearm rotation. Preventing stiffness starts immediately.
Progressive Motion
Progressive range of motion under formal therapy. Most patients achieve functional motion (30–130°) within 6–8 weeks. Triceps strengthening deferred until fracture healing confirmed on X-ray.
Strengthening
Progressive strengthening including triceps resistance exercises. Return to light manual work. X-rays confirm fracture healing before advancing lifting and pushing activities.
Full Return
Full return to work and activity at 4–6 months. Hardware removal is not routinely performed but is offered if hardware becomes symptomatic — typically 12+ months post-op.
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Elbow fracture after a fall —
evaluated and treated promptly.
Displaced olecranon fractures need prompt surgical evaluation — delayed fixation makes the operation more difficult as swelling increases and the fracture fragments begin to contract. Walk-ins welcome via JOI Now, Monday–Friday, for acute elbow injuries.
Jacksonville Beach, FL 32250
Walk-ins welcome via JOI Now for acute elbow injuries.