Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered. Cite this article: Bone Joint J 2023;105-B(2):112–123

Aims. The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years. Patients and Methods. Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year. Results. A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05). . Conclusion. These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964–72

Aims. Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon. Methods. SOFFT is a multicentre, pragmatic, two-arm parallel-group, non-inferiority, randomized controlled trial. Participants will be assigned 1:1 to receive either tension suture fixation or tension band wiring. 280 adult participants will be recruited. The primary outcome will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at four months post-randomization. Secondary outcome measures include DASH (at 12, 18, and 24 months), pain, Net Promotor Score (patient satisfaction), EuroQol five-dimension five-level score (EQ-5D-5L), radiological union, complications, elbow range of motion, and re-operations related to the injury or to remove metalwork. An economic evaluation will assess the cost-effectiveness of treatments. Discussion. There is currently no high-quality evidence comparing the clinical and cost effectiveness of the tension suture repair to the traditional tension band wiring currently offered for the internal fixation of displaced fractures of the olecranon. The Simple Olecranon Fracture Fixation Trial (SOFFT) is a randomized controlled trial with sufficient power and design rigour to provide this evidence for the subtype of Mayo grade IIA fractures. Cite this article: Bone Jt Open 2023;4(1):27–37

Aims. The aim of this study is to report the results of a case series of olecranon fractures and olecranon osteotomies treated with two bicortical screws. Methods. Data was collected retrospectively for all olecranon fractures and osteotomies fixed with two bicortical screws between January 2008 and December 2019 at our institution. The following outcome measures were assessed; re-operation, complications, radiological loss of reduction, and elbow range of flexion-extension. Results. Bicortical screw fixation was used to treat 17 olecranon fractures and ten osteotomies. The mean age of patients being treated for olecranon fracture and osteotomy were 48.6 years and 52.7 years respectively. Overall, 18% of olecranon fractures were classified as Mayo type I, 71% type II, and 12% type III. No cases of fracture or osteotomy required operative re-intervention. There were two cases of loss of fracture reduction which occurred in female patients ≥ 75 years of age with osteoporotic bone. In both cases, active extension and a functional range of movement was maintained and so the loss of reduction was managed non-operatively. For the fracture fixation cohort, at final follow-up mean elbow extension and flexion were -5. °. ± 5. °. and 136. °. ± 7. °. , with a mean arc of motion of 131. °. ± 11. °. . Conclusion. This series has shown that patients regain near full range of elbow flexion-extension and complication rates are low following bicortical screw fixation of olecranon fractures and osteotomy. Cite this article: Bone Joint Open 2020;1-7:376–382

Olecranon plates used for the internal fixation of complex olecranon fractures are applied directly over the triceps tendon on the posterior aspect of the olecranon. The aim of the study is to describe the relationship of the plates and screws to the triceps tendon at the level of the olecranon. Eight cadaveric elbows were used. Dimensions of the triceps tendon at the insertion and 1cm proximal were measured. A long or a short olecranon plate was then applied over the olecranon and the most proximal screw applied. The length of the plate impinging on the tendon and the level of the screw tract on the tendon and bone were measured. The mean olecranon height was 24.3cm (22.4-26.9cm) with a tip-to-tendon distance of 14.5cm (11.9-16.2cm). The triceps tendon footprint averaged 13.3cm (11.7-14.9cm) and 8.8cm (7.6-10.2cm) in width and length, respectively. The mean width of the central tendon 1 cm proximal to the footprint was 6.8 cm. The long olecranon plate overlay over more movable tendon length than did the short plate and consequently the superior screw pierced the triceps tendon more proximally with the long plate. Using the Mann-Whitney U test, the differences were significant. The long olecranon plates encroach on more triceps tendon than short plates. This may be an important consideration for olecranon fractures with regards implant loosening or triceps tendon injury

Fixation of comminuted olecranon and proximal ulna fractures can be a challenge. The goal of surgery is for stable fixation to encourage union and allow early elbow movement. Over a 3 year period, a low profile titanium, precon-toured olecranon plate (Acumed LLC, Hillsboro, Portland, Oregon) was used in 16 patients with comminuted olecranon and proximal ulna fractures, using a standard universal posterior approach to the olecranon with the patient in a lateral position and active flexion/extension of the elbow was started 48 hours postoperatively. Functional outcomes were measured during follow-up (FU), including range of movement (ROM), Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS). There were 9 isolated olecranon fractures, including one open fracture in a multiple injured patient and one an infected non-union and 7 with associated ipsilateral upper limb injuries. Mean age was 52 years (13 to 84) and mean FU was 12.8 months (3 to 33). All had achieved radiological union at 3 months. Overall mean ROM for both groups was 19.3 to 130.7 degrees flexion, 71.8 degrees pronation and 72.1 degrees supination. DASH was 19.1 and MEPS was 87.7. When comparing the 2 groups, there was no significant difference in supination or pronation but all other mean outcomes measurements showed statistical significance in favour of isolated, comminuted olecranon fractures. Extension 9.4 versus 35.0 degrees (p< 0.005), Flexion 140.6 versus 117.5 (p< 0.05), DASH 7.5 versus 34.7 (p=0.0007) and MEPS 96.3 (excellent) versus 78.3 (good) (p< 0.05). There were no infections or failure of metalwork, but two patients had the metalwork removed after union as they required further surgery to their elbows. We demonstrate this is a safe and reliable method of fixation and can expect excellent results when treating isolated comminuted olecranon/proximal ulna fractures and good results when there are associated ipsilateral injuries

Abstract. Introduction. Displaced olecranon fractures in the elderly are challenging due to associated comorbidities, poor tissue quality, high risk of complications, and the possible need for implant removal. Treatment options with such fractures range from non-operative management to internal fixation with various types of implants. Currently, there is no consensus on the treatment of olecranon fractures in the elderly with relatively low functional demand. Aim. The aim of this systematic review was to analyse the clinical outcomes of various treatment modalities for olecranon fracture in the elderly. Methods. We systematically reviewed the literature covering the treatment of olecranon fractures in the elderly according to PRISMA guidelines. We used search tools of Medline, Embase, Wiley online library, Cochrane and Scopus. Keywords used in the search were Olecranon fracture and Elderly OR Geriatric in all fields. Studies involving patients older than 60 years of age and all modalities of treatment were included. Results. 14 papers studying 270 patients were identified of which, 112 were treated non-operatively, 25 with limited fixation, 98 with tension band wire fixation, 34 with plate fixation, and 1 patient was treated with excision. Conclusions. Nonoperative as well as limited fixation were shown to provide satisfactory results in the elderly. Treatment decisions in this age group should be individualised to factors such as fracture stability, quality of bone & soft tissues, and patient's functional demand. We recommend a treatment protocol for treating olecranon fracture in the elderly based on the above factors

Olecranon fractures are common injuries representing roughly 5% of pediatric elbow fractures. The traditional surgical management is open reduction and internal fixation with a tension band technique where the pins are buried under the skin and tamped into the triceps. We have used a modification of this technique, where the pins have been left out of the skin to be removed in clinic. The purpose of the current study is to compare the outcomes of surgically treated olecranon fractures using a tension-band technique with buried k-wires (PINS IN) versus percutaneous k-wires (PINS OUT). We performed a retrospective chart review on all pediatric patients (18 years of age or less) with olecranon fractures that were surgically treated at a pediatric academic center between 2015 to present. Fractures were identified using ICD-10 codes and manually identified for those with an isolated olecranon fracture. Patients were excluded if they had polytrauma, metabolic bone disease, were treated non-op or if a non-tension band technique was used (ex: plate/screws). Patients were then divided into 2 groups, olecranon fractures using a tension-band technique with buried k-wires (PINS IN) and with percutaneous k-wires (PINS OUT). In the PINS OUT group, the k-wires were removed in clinic at the surgeon's discretion once adequate fracture healing was identified. The 2 groups were then compared for demographics, time to mobilization, fracture healing, complications and return to OR. A total of 35 patients met inclusion criteria. There were 28 patients in the PINS IN group with an average age of 12.8 years, of which 82% male and 43% fractured their right olecranon. There were 7 patients in the PINS OUT group with an average age of 12.6 years, of which 57% were male and 43% fractured their right olecranon. All patients in both groups were treated with open reduction internal fixation with a tension band-technique. In the PINS IN group, 64% were treated with 2.0 k-wires and various materials for the tension band (82% suture, 18% cerclage wire). In the PINS OUT group, 71% were treated with 2.0 k-wires and all were treated with sutures for the tension band. The PINS IN group were faster to mobilize (3.4 weeks (range 2-5 weeks) vs 5 weeks (range 4-7 weeks) p=0.01) but had a significantly higher complications rate compared to the PINS OUT group (6 vs 0, p =0.0001) and a significantly higher return to OR (71% vs 0%, p=0.0001), mainly for hardware irritation or limited range of motion. All fractures healed in both groups within 7 weeks. Pediatric olecranon fractures treated with a suture tension-band technique and k-wires left percutaneously is a safe and alternative technique compared to the traditional buried k-wires technique. The PINS OUT technique, although needing longer immobilization, could lead to less complications and decreased return to the OR due to irritation and limited ROM

The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Olecranon Osteotomy is a common approach used in the management of intraarticular distal humerus fractures. Significant complication rates have been associated with this procedure, including non-union rates of 0–13% and implant removal rates between 12–86%. This study is a multicentre retrospective study involving the largest cohort of olecranon osteotomies in the literature, examining implant fixation types, removal rates and associated complications. Patients were identified between 2007 and 2017 (minimum one year follow-up) via Canadian Classification of Health Interventions (CCI) coding and ICD9/10 codes by our health region's data information service. CCI intervention codes were used to identify patients who underwent surgery for their fracture with an olecranon osteotomy. Reasons for implant removal were identified from a chart review. Our primary outcome was implant removal rates. Categorical data was assessed using Chi square test and Fischer's Exact test. Ninety-nine patients were identified to have undergone an olecranon osteotomy for treatment of a distal humerus fracture. Twenty patients had their osteotomy fixed with a plate and screws and 67 patients were fixed with a tension band wire. Eleven patients underwent “screw fixation”, consisting of a single screw with or without the addition of a wire. One patient had placement of a cable-pin system. Of patients who underwent olecranon osteotomy fixation, 34.3% required implant removal. Removal rates were: 28/67 for TBW (41.8%), 6/20 plates (30%), 0/1 cable-pin and 0/11 for osteotomies fixed with screw fixation. Screw fixation was removed less frequently than TBW p<.006. TBW were more commonly removed than all other fixation types p<.043. Screws were less commonly removed than all other fixation types p<.015. TBW were more likely to be removed for implant irritation than plates, p<.007, and all other implants p<.007. The average time to removal was 361 days (80–1503 days). A second surgeon was the surgeon responsible for the removal in 10/34 cases (29%). TBWs requiring removal were further off the olecranon tip than those not removed p=.006. TBWs were associated with an OR of 3.29 (CI 1.10–9.84) for implant removal if implanted further than 1mm off bone. Nonunion of the osteotomy occurred in three out of 99 patients (3%). K-wires through the anterior ulnar cortex did not result in decreased need for TBW removal. There was no relation between plate prominence and the need for implant removal. There was no association between age and implant removal. The implant removal rate was 34% overall. Single screw fixation was the best option for osteotomy fixation, as 0/11 required hardware removal, which was statistically less frequent than TBW at 28/67. Screw fixation was removed less frequently than TBW and screw fixation was less commonly removed than all other fixation types. Only 6/20 (30%) plates required removal, which is lower than previously published rates. Overall, TBW were more commonly removed than all other fixation types and this was also the case if hardware irritation was used as the indication for removal. Nonunion rates of olecranon osteotomy were 3%

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications. . Cite this article: Bone Joint J 2014;96-B:1252–7

Introduction. In oblique olecranon fracture, fracture line begins in the trochlear notch and proceeds distally to the dorsal cortex of the ulna. We have experienced a nonunion of reverse oblique fracture. Hypothesis. Reverse oblique olecranon fracture has instability. Materials & Methods. 130 patients with an olecranon fracture were retrospectively evaluated. Inclusion criteria are that fracture line begins at the base of the coronoid process, distal portion of the trochlear notch, and proceeds proximally to the dorsal cortex of the ulna on the lateral radiograph. Fractures with articular comminution were excluded. Results. Seven patients met the criteria. They were associated with local injuries: anterior translation of the proximal radius and ulna, fracture of the medial epicondyle or the lateral condyle of the humerus. One out of five patients treated with tension band wiring (TBW) was revised with screw fixation because of nonunion. Discussion. The associated injuries suggested the anterior and valgus instability. A nonunion case suggests a requirement of more secure fixation. However, these findings are common in distal olecranon fracture. Therefore, the instability in our series is due to the distal location of fracture on the trochlear notch rather than reverse obliquity. The reverse obliquity attributes to small proximal fragment. Conclusion. Reverse oblique olecranon fracture has instability because of its distal location. It should be distinguished from simple, stable fracture

Osteotomy through the bare area of olecranon minimises the damage to articular cartilage in the trans-olecranon approach to the distal humerus. In this study we have identified a reliable and easily reproducible anatomical land mark to make sure that the osteotomy passes through the bare area. Two methods were used to determine the line for the osteotomy, in the first a line from the lateral epicondyle perpendicular to the olecranon and in the second an intra-articular marker was used to determine the osteotomy. In 5 cadavers the osteotomy with lateral epicondylar line as a marker went 2 mm proximal to the bare area. Of the 5 cadavers dissected with a marker passed to the angle of olecranon the osteotomy went through the bare area of olecranon in three specimens and just proximal in the other two. In conclusion a cheveron osteotomy with the base of the chevron on the lateral epicondylar line will be the ideal site to make sure that the osteotomy passes through the bare area of the olecranon

Purpose: We undertook a primarily cadaveric study of trabecular architecture of olecranon to link theory of biomechanics and morphological trabecular patterns of olecranon and secondly compare with real-life trabecular pattern in CT scans. Methods & Results: Eight pairs of ulnae (fresh-frozen bones) were obtained from cadavers following road traffic accidents, aged 25 to 60 (mean 34 years). None suffered from previous pathology of elbow. Half of the ulnae were sliced longitudinally, each slice 2–3 mm thick (Group I), and the other half vertically (Group II). After they were radiographed, orientation of trabeculae was studied. CT scans of 8 patients (Group III), originally performed for investigation of fractures of radial head, were studied for comparison of real life trabecular pattern of olecranon. In Group I, two main sets of trabeculae were observed. The first set consists of three bundles, which arise from anterior cortex and support subchondral area – the posterior third bundle curves and spreads to posterior cortex of olecranon. The second set arises from posterior cortex and terminates under subchondral area. In Group II, trabeculae subtend a 900 angle to articular surface. CT scans of 8 patients (Group III), originally performed for investigation of fractures of radial head, ascertained real-life trabecular pattern of olecranon and confirmed cadaveric observations. Conclusion: Trabeculae of olecranon comprise a set to resist compressive loading and a further set to resist tensile stresses. Thicker trabeculae coincide with maximal loading. Prosthetic design of elbow should take into account the trabecular pattern to facilitate stress absorption

Reconstruction of deficient bone stock during total elbow arthroplasty in rheumatoid arthritis represents a challenge for the surgeon. Fracture and osteolysis of the olecranon process is a very rare condition in rheumatoid arthritis. The consequence of a deficient olecranon is an instable and painful elbow. We report a case of successful olecranon reconstruction with bone graft associated to total elbow arthroplasty with a 8 years follow up and discuss surgical aspects. This case concerns a 44 years old woman with a very severe rheumatoid arthritis. She complains of pain and instability of her right elbow. X-rays show fracture and major osteolysis of the olecranon process with only some persistent bone at the insertion of the triceps tendon. The humeral condyles were subluxated posteriorly. We performed a total elbow replacement with a GSB3 implant and reconstruction of the olecranon with two cancellous iliac bone strut fixed by 2.7 diameter screws to the proximal ulna. The triceps tendon with remnant olecranon bone chips was secured to the bone graft by tension band wiring. Postoperatively, the elbow was immobilized for 3 weeks. With a follow up of more than 8 years the elbow is pain free with excellent function. The active range of motion of flexion – extension is 140° / −20°. The elbow is stable and triceps function is very satisfying authorizing the use of crutches. X-rays show good bony integration of the reconstructed olecranon process and no signs of loosening of the GSB3 implant. The literature concerning olecranon reconstruction during total elbow arthroplasty in rheumatoid patients is very poor. Kamineni and Morrey reported on one case of olecranon reconstruction with strut allograft in revision total elbow arthroplasty with an unsatisfying result. Their fixation technique was different. We prefer an autograft whenever it is possible and we recommend our fixation technique using screws and tension band wiring

Background. The pattern of appearance of secondary ossification centers in the elbow has been based on historical studies and is popularly referred to with the mnemonic CRITOL. However the six secondary ossification centers can be variable in their presentation and pose a challenge in assessment of children with elbow injuries. Furthermore limited studies available in the current literature have reported an aberration to the sequence of appearance especially with the ossification centers of trochlea and olecranon. Aims. The aim of the study was to evaluate the relative sequence of appearance of secondary ossification centers for the trochlea and olecranon. Methods. Children between 8 and 10 years of age who had radiographs of elbow following trivial trauma between July 2013 and Feb 2015 were identified using the hospital PACS database. Cases with radiographic markers of significant trauma ie. fat pad sign, displaced fracture were excluded. Anteroposterior and lateral views of elbow were reviewed for the presence of the six ossification centers. Results. A total of 114 radiographs were reviewed of which 51 were boys and 63 were girls with a mean age of 9.03 years (±0.59). 60 radiographs were of right elbow and 54 were of the left elbow. The capitulum, radial head and medial epicondyle ossification centers were present in all patients. Both trochlea and olecranon ossification centers were noted in 51/114 (44.7%) children. 12/114 (10.5%) of the children were noted to have trochlea ossification center with no olecranon ossification center. Of these 12 children 7 were boys and 5 were girls. On the other hand 19/114 (16.7%) of the children had an olecranon ossification center but without a trochlea ossification center. Amongst these 7 were boys and 12 were girls. Discussion and Conclusions. The results of this limited cross sectional study demonstrate that the CRITOL sequence may not followed in 16.7% of cases and more so in girls. Historical studies were based on conventional radiographs. However the current digital radiographs with image enhancement tools help in accurate identification of relatively small ossification centers which may not be apparent on conventional radiographs. The current study has helped to quantify the violators to CRITOL sequence. Level of Evidence. Level III (Cross-sectional study among non-consecutive patients)

Compression and absolute stability are important in the management of intra-articular fractures. We compared tension band wiring with plate fixation for the treatment of fractures of the olecranon by measuring compression within the fracture. Identical transverse fractures were created in models of the ulna. Tension band wires were applied to ten fractures and ten were fixed with Acumed plates. Compression was measured using a Tekscan force transducer within the fracture gap. Dynamic testing was carried out by reproducing cyclical contraction of the triceps of 20 N and of the brachialis of 10 N. Both methods were tested on each sample. Paired t-tests compared overall compression and compression at the articular side of the fracture. The mean compression for plating was 819 N (. sd. 602, 95% confidence interval (CI)) and for tension band wiring was 77 N (. sd. 19, 95% CI) (p = 0.039). The mean compression on the articular side of the fracture for plating was 343 N (. sd. 276, 95% CI) and for tension band wiring was 1 N (. sd. 2, 95% CI) (p = 0.038). During simulated movements, the mean compression was reduced in both groups, with tension band wiring at −14 N (. sd. 7) and for plating −173 N (. sd. 32). No increase in compression on the articular side was detected in the tension band wiring group. Pre-contoured plates provide significantly greater compression than tension bands in the treatment of transverse fractures of the olecranon, both over the whole fracture and specifically at the articular side of the fracture. In tension band wiring the overall compression was reduced and articular compression remained negligible during simulated contraction of the triceps, challenging the tension band principle

Purpose: The purpose of this study was to determine the effect of serial olecranon resections on elbow stability. Method: Eight fresh, previously frozen cadaveric arms underwent CT scanning. The specimens were mounted in an in-vitro motion simulator, and kinematic data was obtained using an electromagnetic tracking system. Simulated active and passive flexion was produced with servo-motors and pneumatic pistons attached to specific muscles. Flexion was studied in the dependent, horizontal, varus, and valgus positions. Custom computer navigation software was utilized to guide serial resection of the olecranon in 12.5% increments. A triceps advancement repair was performed following each resection. Results: Serial olecranon resections resulted in a significant increase in valgus-varus (V-V) laxity for both passive (p< 0.001) and active (p=0.04) flexion. For passive motion this increase reached statistical significance following the 12.5% resection. This corresponded to an increase in V-V laxity of 1.4 ± 0.1o and a total laxity of 7.5 ± 1.0o. For active flexion this increase reached significance following the 62.5% resection. This corresponded to an increase in V-V laxity of 5.6 ± 1.1o and a total laxity of 11.2 ± 1.5. There was no significant effect of sequential olecranon excision on elbow kinematics or stability with the elbow in the vertical or horizontal positions. The elbows became grossly unstable after resection of greater than 75% of the olecranon. Conclusion: A progressive increase in the varus-valgus laxity of the elbow was seen with sequential excision of the olecranon. Laxity of the elbow was increased with excision of 75% of the olecranon, likely due to the loss of the bony congruity and attachment site of the posterior band of the medial collateral ligament. Gross instability resulted when 87.5% or greater was removed, likely due to damage to the anterior band of the medial collateral ligament as it inserts on the sublime tubercle of the ulna. Rehabilitation of the elbow with the arm in the dependant position should be considered following excision of the olecranon; varus and valgus orientations should be avoided. The contribution of the olecranon to elbow stability may be even more important in patients with associated ligament injuries or fractures of the elbow

The aim of this study was to document both the short and long term outcome of isolated displaced olecranon fractures treated with primary non-operative intervention. We identified from our prospective trauma database all patients who were managed non-operatively for a displaced olecranon fracture over a 13-year period. Inclusion criteria included all isolated fractures of the olecranon with >2 mm displacement of the articular surface. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary short-term outcome measure was the Broberg and Morrey Elbow score. The primary long-term outcome measure was the DASH score. There were 43 patients in the study cohort with a mean age of 76 yrs (40–98). A low energy fall from standing height accounted for 84% of all injuries, with ≥1 co-morbidities documented in 38 (88%) patients. At a mean of 4 months (range, 1.5–10) following injury the mean Broberg and Morrey score was 83 (48–100), with 72% achieving an excellent or good short-term outcome. Long-term follow-up was available in 53% (n=21) patients, with the remainder deceased. At a mean of six years (2–15) post injury, the mean DASH score was 2.9 (0–33.9), the mean Oxford Elbow Score was 47 (42–48) and overall patient satisfaction was 91% (n=21). We have reported satisfactory short-term and longer-term outcomes following the non-operative management of isolated displaced olecranon fractures in older lower demand patients. Further work is needed to directly compare operative and non-operative management in this patient group

Non-operative management of displaced olecranon fractures in elderly low demand patients is reported to result in a satisfactory outcome despite routinely producing a nonunion. The aim of this study was to assess whether there is evidence of dynamic movement of the fracture fragment during the elbow arc of movement. Five consecutive patients (≥70 years of age) with a displaced olecranon fracture (Mayo 2A) that were managed with non-operative intervention were recruited. All underwent ultrasound evaluation at six weeks and follow-up questionnaires at six months including the DASH and Oxford Elbow Score (OES). There were three women and two men with a mean age of 79yrs (range 70–88). All injuries were sustained following a fall from standing height. The mean fracture gap in extension was 22.5mm (95% CI 13.0–31.9), midflexion 21.8mm (11.6–32.0) and in deep flexion 21.8mm (10.9–32.8). Although the amount of fracture displacement varied between patients, it remained static in each patient with no significant differences observed throughout the arc of motion (ANOVA p=0.99). The six-month median DASH score was 7.5 (IQR range, 4.2–39.3) and the OES was 44.0 (29.0–47.5). Four out of the five patients were satisfied with their function. Ultrasound evaluation of displaced olecranon fractures following non-operative management suggests the proximal fragment may function as a sesamoid type bone within the triceps sleeve. This could explain how a functional arc of movement with a minimum level of discomfort can usually be expected with non-operative management in select patients