Olecranon Fracture Fixation: An Intraoperative Masterclass in Open Reduction Techniques

Introduction to Olecranon Fracture Management

Alright, fellows, gather 'round. Welcome to the operating theater. Today, we're addressing a common yet critical injury: the olecranon fracture. These fractures, particularly when displaced, almost invariably require operative intervention to restore elbow function and stability. Our goal is to achieve a stable, anatomic reduction, especially of the articular surface, and provide robust fixation that allows for early mobilization.

Before we even consider the incision, a thorough understanding of the patient and the injury is paramount. Remember, the secondary survey is not just a checklist; it's a systematic search for other injuries, especially ipsilateral arm trauma, which can significantly impact our treatment strategy and alert us to potential compartment syndrome. Always assess pulses, capillary refill, and perform an Allen test if indicated. Peripheral nerve function – ulnar, median, and radial – must be meticulously documented preoperatively.

Fracture characteristics – displacement, comminution, and any associated subluxation or dislocation of the elbow – are crucial. We categorize these using systems like the Mayo classification, which helps guide our treatment decisions.

FIG 1 • The Mayo classification of olecranon fractures accounts for the factors that will influence treatment decisions: displacement, comminution, and dislocation or subluxation of the articulations.

Be vigilant for high-energy injuries, particularly those involving the ipsilateral wrist or forearm. These patients are at a heightened risk for compartment syndrome. If your clinical examination raises suspicion or is unreliable due to altered mental status, do not hesitate; compartment pressure monitoring is indicated. Open injuries, while unusual, demand immediate attention and appropriate debridement.

Comprehensive Surgical Anatomy of the Elbow

Let's review the critical anatomy we'll encounter. The elbow joint is a complex hinge, and the olecranon is a key component of its stability.

Osteology and Articular Surfaces

• The greater sigmoid notch of the ulna is formed by the olecranon and coronoid processes, articulating with the trochlea of the humerus. This forms a near 180-degree arc, providing significant inherent stability.
• The nonarticular transverse groove of the olecranon lies between the coronoid and olecranon articular facets. This is a common fracture location, and importantly, precise articular reduction here is not as critical as in the main articular surfaces. This is a key pearl when dealing with comminution in this specific area.
• The olecranon process itself is the most proximal part of the ulna, serving as the lever arm for elbow extension.

Muscular Attachments

• The triceps brachii muscle has a broad, thick insertion onto the olecranon, extending from just superior to the point of the olecranon and wrapping around the tip. This powerful muscle is a primary deforming force in olecranon fractures, pulling the proximal fragment proximally. Its robust insertion can also be strategically utilized to enhance fixation, especially in small, osteoporotic, or fragmented fractures. We can even split it longitudinally if needed for plate application.
• The anconeus muscle lies posterolaterally, originating from the lateral epicondyle and inserting onto the lateral surface of the olecranon and posterior ulna. It assists in elbow extension and stabilization.
• The flexor-pronator mass originates from the medial epicondyle and forms the bulk of the medial forearm musculature. Its deeper layers can be involved in complex coronoid fractures.

Neurovascular Structures: Critical for Protection

• Ulnar Nerve: This is our most significant neurovascular concern in olecranon surgery. It courses posterior to the medial epicondyle, within the cubital tunnel. During our dorsal approach, we must meticulously identify and protect it, especially when working medially or applying hardware. Any direct trauma, traction, or irritation from prominent hardware can lead to ulnar neuropathy.
• Radial Nerve: While less directly at risk with a purely dorsal approach, its deep branch (PIN) can be vulnerable during extensive lateral approaches to the radial head or if dissection extends too far anteriorly in the proximal forearm.
• Median Nerve and Brachial Artery: These structures are located anteriorly in the cubital fossa, well away from our primary dorsal dissection field. However, in fracture-dislocations, particularly anterior dislocations or severe comminution, their status must be confirmed pre- and postoperatively.

Preoperative Planning & Patient Positioning

Gentlemen, preoperative planning is where we win the battle before we even make an incision.

Imaging and Diagnosis

• Anteroposterior (AP) and Lateral Radiographs: These are our initial workhorse films for characterizing the injury. A true lateral view is indispensable for assessing displacement and articular involvement.
• Oblique Views: Can be incredibly helpful for delineating complex fracture patterns, especially comminution.
• Computed Tomography (CT) Scans: For fracture-dislocations and comminuted fractures, especially those involving the coronoid or radial head, a CT scan with 3D reconstructions is invaluable. It allows us to truly understand the fracture morphology, the relationship of fragments, and plan our approach. We're looking for coronoid involvement, radial head fractures, and lateral collateral ligament avulsions.

Templating and Equipment

• Templating: This is not optional for complex cases. Using tracings of radiographs, we'll "perform" the surgery on paper. This helps us anticipate challenges, select appropriate plate lengths and screw types, and ensure all necessary implants (tension band wires, K-wires, various plate systems – 3.5mm LC-DCPs, precontoured olecranon plates, locking plates) and instruments are available.
• Implants: For noncomminuted transverse fractures, tension band wiring is typically sufficient. For comminuted fractures and fracture-dislocations, dorsal contoured plate and screw fixation is the preferred method. Ensure you have a range of plates, including long ones (12-16 holes) for extensive comminution or poor bone quality.

Patient Positioning and Setup

• Lateral Decubitus Position: For most olecranon fractures, this is ideal. The patient is positioned laterally, with the injured arm draped over a well-padded arm bolster or a specialized elbow support. This allows for excellent access to the dorsal aspect of the elbow and facilitates fluoroscopy. Ensure the axilla is padded to prevent brachial plexus compression.
• Supine Position with Hand Table: For complex fracture-dislocations requiring both medial and lateral access (e.g., severe coronoid fractures requiring a medial approach, or radial head fractures needing a lateral approach), the supine position with the arm on a hand table can be more versatile. This allows for easier repositioning and access to all aspects of the elbow.
• Fluoroscopy Setup: The C-arm must be positioned to allow for immediate AP and true lateral views without repositioning the patient or the arm. This usually means the C-arm comes in from the opposite side of the table or is oriented parallel to the patient's body for lateral access.
• Sterile Pneumatic Tourniquet: A well-padded pneumatic tourniquet is applied to the upper arm. This provides a bloodless field, which is critical for precise identification of structures and accurate reduction. We'll inflate it to an appropriate pressure, typically 250-300 mmHg, after exsanguination.

Step-by-Step Intraoperative Execution: The Operating Surgeon's Viewpoint

Alright, fellows, let's get scrubbed in. We've got our patient positioned, draped, and the tourniquet is up.

Surgical Approach: Dorsal Longitudinal Incision

"Scalpel, please. We'll begin with a dorsal longitudinal skin incision centered directly over the olecranon process and extending proximally and distally to provide adequate exposure. Typically, this will be about 10-12 cm in length, but adjust as needed for the extent of the fracture.

• Incision: Make a clean, precise incision through the skin and subcutaneous tissue. Be mindful of the superficial sensory nerves, though they are less prominent dorsally than medially.
• Hemostasis: Use electrocautery meticulously to achieve excellent hemostasis. A bloodless field is crucial for visualizing the fracture and protecting vital structures.
• Subcutaneous Dissection: Elevate full-thickness skin flaps medially and laterally. This allows for retraction without excessive tension on the skin edges. Keep your dissection just superficial to the deep fascia.
• Identifying the Ulnar Nerve: As we proceed medially, remember the course of the ulnar nerve. It lies posterior to the medial epicondyle. While our primary incision is dorsal, any medial retraction or dissection needs to be cautious. We'll identify the deep fascia overlying the triceps.

Tension Band Wiring: For Transverse, Noncomminuted Fractures

"For our first case, we have a relatively simple, transverse, noncomminuted olecranon fracture, a perfect candidate for tension band wiring. This technique converts tensile forces on the olecranon into compressive forces across the fracture site."

1. Fracture Exposure and Provisional Reduction

"Let's expose the fracture site. I'm using a Metzenbaum scissors to incise the deep fascia and expose the triceps tendon. Now, carefully incise the periosteum longitudinally along the dorsal aspect of the ulna. We need to clear any hematoma and soft tissue interposition from the fracture site. Use a small curette or Cobb elevator to meticulously remove blood clot and periosteum, ensuring a clean bed for reduction. Remember, fellows, limited periosteal elevation is key here to preserve soft tissue attachments and vascularity."

"Now, let's get our reduction. I'm using a large tenaculum clamp. We'll apply this to secure the fracture in an anatomically reduced position. Sometimes, especially with a very oblique fracture line, making a small 2.0 mm drill hole in the dorsal cortex of the distal fragment can provide a secure purchase point for one jaw of the clamp, preventing it from slipping. Confirm your reduction visually, ensuring perfect restoration of the articular surface."

TECH FIG 1 • A. A lateral radiograph with the arm in plaster shows a transverse, noncomminuted fracture of the olecranon. B. An open reduction is held with a fracture reduction forceps.

2. Kirschner Wire Fixation

"Once we're happy with the reduction, we'll provisionally fix it with K-wires. I'm picking up two 1.0-mm smooth Kirschner wires. The trajectory is crucial here. We'll drill them obliquely from dorsal proximal to volar distal, aiming to exit the anterior ulnar cortex distal to the coronoid process. This provides a strong anchoring point in cortical bone and significantly limits the potential for pin migration."

• Drilling Technique: "Start drilling them parallel to each other, about 1-1.5 cm apart, crossing the fracture site. I'm using a low-speed drill to prevent thermal necrosis.
• Fluoroscopic Guidance: "Let's get a lateral fluoroscopy shot to confirm our K-wire trajectory and ensure they are not entering the joint and are indeed exiting the anterior ulnar cortex distal to the coronoid. This is a critical step, fellows. Intra-articular K-wires are a major pitfall and will lead to pain and arthrosis."

TECH FIG 1 • (continued) C. Two 1-mm Kirschner wires are drilled obliquely across the fracture site so that they exit the anterior ulnar cortex distal to the coronoid process. ( A,B: Copyright David Ring, MD.)
* Retraction: "Once both wires have breached the anterior ulnar cortex, we need to retract them slightly, about 5 to 10 mm. This is in anticipation of later impaction of their proximal ends, ensuring they don't protrude or irritate the soft tissues."

TECH FIG 1 • A. A lateral radiograph with the arm in plaster shows a transverse, noncomminuted fracture of the olecranon. B. An open reduction is held with a fracture reduction forceps. (continued)

3. Tension Band Wiring

"Now for the tension band wire itself. We'll create our distal anchoring point. I'm taking a 2.0-mm drill bit. We'll make a transverse drill hole through the ulnar diaphysis, just distal to the flat portion of the proximal ulna, at the apex of the ulnar diaphysis. If we're using two wires, I'll make a second drill hole about a centimeter more distal."

"My preference is to use two 22-gauge stainless steel wires to minimize implant prominence. If you prefer, a single 18-gauge wire can be used. I'm using a large-bore needle to facilitate passage of the wires through these drill holes. It makes it much easier and prevents kinking."

TECH FIG 2 • A. Two 22-gauge stainless steel tension wires are passed in a figure 8 fashion through drill holes in the ulnar shaft.

"Next, the wires are passed in a figure-of-eight fashion. They'll go over the dorsal ulna, around the Kirschner wires, and underneath the insertion of the triceps tendon. Again, a large-bore needle or a wire passer can help guide them smoothly beneath the triceps."

TECH FIG 2 • A. Two 22-gauge stainless steel tension wires are passed in a figure 8 fashion through drill holes in the ulnar shaft. B. They engage the triceps insertion proximally. C,D. The wires are tensioned on both sides. These do not need to be tight, but simply snug, with all slack taken up. Attempts to tighten these smaller 22gauge wires will break them. (continued)

"Now, the critical step of tensioning. Each wire is tensioned both medially and laterally by twisting the wire with a needle holder. This should be done only to take up slack, fellows. These smaller 22-gauge wires are strong enough for active exercises, but they will break if you try to firmly tighten them. We're aiming for snug, not overtightened. The goal is to convert the distraction force of the triceps into compression at the fracture site."

"Once tensioned, ensure the knots are placed in a position that will make them least prominent. Trim the excess wire, leaving about 5-7 mm, then bend the trimmed ends into the soft tissues to either side, burying them to minimize irritation."

4. K-wire Management

"Finally, let's address the proximal ends of our Kirschner wires. We'll bend them 180 degrees and then, using an osteotome or a small impactor, carefully impact them into the proximal olecranon, beneath the triceps insertion. This creates a low-profile construct, less likely to migrate or cause soft tissue irritation."

TECH FIG 2 • (continued) E. The proximal ends of the Kirschner wires are bent 180 degrees and impacted into the olecranon process, beneath the triceps insertion.

TECH FIG 2 • (continued) E. The proximal ends of the Kirschner wires are bent 180 degrees and impacted into the olecranon process, beneath the triceps insertion. F. The resulting fixation has a relatively low profile and is unlikely to migrate. G,H. Even these small wires are strong enough for active exercises to regain elbow motion. ( A,B,D,F–H: Copyright David Ring, MD.)

TECH FIG 2 • (continued) E. The proximal ends of the Kirschner wires are bent 180 degrees and impacted into the olecranon process, beneath the triceps insertion.

TECH FIG 2 • (continued) E. The proximal ends of the Kirschner wires are bent 180 degrees and impacted into the olecranon process, beneath the triceps insertion.

TECH FIG 2 • (continued) E. The proximal ends of the Kirschner wires are bent 180 degrees and impacted into the olecranon process, beneath the triceps insertion.

Surgical Warning: Always confirm with fluoroscopy that the K-wire tips are well-buried and not impinging on the triceps or skin. Prominent K-wires are a common cause of postoperative pain and require removal.

Plate and Screw Fixation of Olecranon Fractures

"Now, let's move on to a more complex scenario: a comminuted olecranon fracture, or one with a small, osteoporotic proximal fragment. These require the robust fixation provided by a plate and screws."

1. Exposure and Triceps Management

"Our dorsal longitudinal incision is already in place. We'll deepen our dissection to expose the fracture. For plate application, we have a choice regarding the triceps insertion. A precontoured olecranon plate is often designed to sit directly on top of the triceps insertion. This is often preferred as it maintains the integrity of the triceps."

"Alternatively, if we're using a standard plate or require direct bone contact for optimal contouring, we can incise the triceps insertion longitudinally and partially elevate it medially and laterally. This provides direct access to the bone. Remember, fellows, limit your periosteal elevation, especially distally, to preserve the blood supply to the ulna."

"Distally, the plate will lie directly on the apex of the ulnar diaphysis. We only need to split the muscle sufficiently to gain access to this apex; there's no need to elevate the muscle or periosteum off the medial or lateral flat aspects of the ulna."

2. Fracture Reduction and Provisional Fixation

"Similar to TBW, our first priority is to achieve anatomic reduction. Clear the fracture site of hematoma and debris. For comminuted fractures, we prioritize restoring the relationship of the coronoid and olecranon articular facets. Use a reduction clamp, such as a large tenaculum or point-to-point clamp, to hold the main fragments in reduction. We'll use fluoroscopy to confirm articular congruity."

TECH FIG 3 • A. A lateral radiograph illustrates a comminuted olecranon fracture with a small proximal olecranon fragment. B. An oblique view shows the fragmentation. C. A 3.5-mm limited-contact dynamic compression plate and screws contoured to wrap around the dorsal surface of the olecranon is used for fixation. (continued)

TECH FIG 3 • A. A lateral radiograph illustrates a comminuted olecranon fracture with a small proximal olecranon fragment. B. An oblique view shows the fragmentation. C. A 3.5-mm limited-contact dynamic compression plate and screws contoured to wrap around the dorsal surface of the olecranon is used for fixation. (continued)

"For intervening comminution, no attempt is made to precisely realign every small fragment. Once the main articular relationship is restored and overall alignment is achieved, we'll bridge the remaining fragments, leaving their soft tissue attachments intact. This preserves their vascularity and promotes healing."

3. Plate Application and Screw Insertion

"Now, let's select our plate. A 3.5-mm limited-contact dynamic compression plate (LC-DCP) or a precontoured olecranon plate is typically used. We need to contour the plate to wrap intimately around the proximal aspect of the olecranon. This anatomical contouring is vital for stable fixation."

• Proximal Fixation: "A straight plate will only allow for two or three screws in the metaphyseal bone proximal to the fracture. By bending the plate around the proximal aspect of the olecranon, we gain additional screw purchase in the proximal fragment. The most proximal screws can be quite long, crossing the fracture line into the distal fragment, achieving bicortical purchase. In some cases, these screws can be directed to engage the anterior ulnar cortex, providing excellent purchase."
• Distal Fixation: "Distally, we'll secure the plate to the ulnar diaphysis. Ensure at least 3-4 bicortical screws are placed distal to the fracture for adequate working length and stability."
• Screw Selection and Technique: "Use appropriate screw lengths, confirmed with depth gauge and fluoroscopy. For standard cortical screws, aim for bicortical purchase. If using locking plates, ensure the locking screws are fully engaged in the plate head and bone."

4. Augmenting Fixation for Challenging Cases

"If the proximal (olecranon) fragment is small, severely fragmented, or osteoporotic, plate and screws alone may not provide reliable fixation. In these situations, we can add a figure-of-eight tension wire to reinforce the construct. This wire engages the triceps insertion, passes over the top of the plate, and then wraps around one of the screws at the metaphyseal level."

TECH FIG 3 • (continued) D. A 22-gauge stainless steel wire engages the triceps insertion—this is useful when the olecranon fragment is small, fragmented, or osteopenic.

TECH FIG 3 • (continued) D. A 22-gauge stainless steel wire engages the triceps insertion—this is useful when the olecranon fragment is small, fragmented, or osteopenic.

TECH FIG 3 • (continued) D. A 22-gauge stainless steel wire engages the triceps insertion—this is useful when the olecranon fragment is small, fragmented, or osteopenic.

"This ancillary wire provides additional compression and helps ensure fixation even if screw purchase is compromised. Bone grafts are rarely necessary if we meticulously preserve soft tissue attachments during our dissection."

Plate and Screw Fixation of Fracture-Dislocations of the Olecranon

"Now, let's consider the most challenging scenario: a fracture-dislocation of the olecranon. These injuries often involve the coronoid process, radial head, and collateral ligaments. Our approach needs to be comprehensive."

TECH FIG 4 • A. A complex anterior fracture-dislocation of the elbow. A lateral radiograph shows extensive comminution of the trochlear notch of the ulna, including the coronoid, and anterior displacement of the forearm. B,C. The coronoid fragments are connected to the dorsal metaphyseal fragments in this patient, which facilitates reduction and fixation. ( A,C: Copyright David Ring, MD.)

1. Extended Exposure for Associated Injuries

"The existing olecranon fracture and our dorsal approach often provide surprisingly good exposure to evaluate and even definitively treat associated radial head and coronoid process fractures. We can mobilize the olecranon fragment proximally, much

Additional Intraoperative Imaging & Surgical Steps