Several methods have been used to classify fractures of the olecranon. One classification classifies the fractures based on the area of the articular involvement, dividing the articular surface into thirds. While simple, this kind of classification does not provide any guidance to the treatment. A classification method by Colton groups factures on basis of displacement and the anatomy of the fracture. It therefore, provides guidance to the treatment.

Colton’s classification divides the olecranon fracture into following types

Nondisplaced/Stable

Undisplaced or Displacement less than 2 mm

Displacement does not increase with elbow flexion. Elbow extensor mechanism remains intact.

Displaced fractures

A. Avulsion fractures

B. Transverse/oblique fractures

C. Isolated comminuted fractures

D. Fracture/dislocations

Treatment of Fractures of Olecranon

Nondisplaced and Stable

In this category, following fractures are included the fracture is

• Displaced less than 2 mm,
• Exhibit no change in position with gentle flexion to 90 degrees or with extension against gravity.

These fractures are treated by immobilization in a above elbow cast. Traditionally, the elbow was positioned in 30 degrees of flexion for fear of displacement of the fracture fragments.  But long arm long arm cast with the elbow in 90 degrees of flexion for 3 to 4 weeks works well too and is more comfortable to the patients.

The cast is kept for 3-4 weeks and after that  protected range of motion exercises are begun. Special care is taken not to move elbow beyond 90 degrees of flexion. This is continued for anothre 4 weeks.

In case of an elderly patient, the range of motion may be initiated earlier than 3 weeks depending upon the tolerance of the patient.

To avoid surprises,  a follow-up x-ray should be obtained within 5 to 7 days after cast application to ascertain the position of the fragmets.

Displaced Fractures

These fractures must be treated by open reduction and internal fixation. Nonoperative treatment in these fractures may cause decrease in power of extension, loss of articular incongruity sand elbow stiffness.

The treatment of displaced olecranon aims at maintaining power of elbow extension, restore congruity of the articular surface, restore stability of the elbow and prevent stiffness of the joint.

Avulsion Fractures

In an avulsion fracture a transverse fracture line separates a small proximal fragment of the olecranon process from the rest of the ulna. This fracture is most common in elderly patients  and  is usually caused by an avulsion force

If the fragment is small, excision is the best treatment with repair of the triceps back to the bone. If the fragment is large then tension band wiring surgery should be done.

Transverse Fractures
Transverse Fractures without Comminution

• Tension band wiring.

Transverse Fractures with Comminution

• Tension band technique

• plate fixation with or without bone grafting

Oblique Fractures

The fracture line runs obliquely, starting near the deepest part of the semilunar notch and running dorsally and distally to emerge on the subcutaneous crest of the proximal part of the ulna. It may be having an element of comminution.

A plate with lag screw fixation is preferable over the tension band in these fractures. In case of comminution this is even truer

Isolated Comminuted Fractures
This includes all the severely comminuted fractures of the olecranon usually resulting from direct trauma . There are multiple fracture planes, and many fragments.

Associated fractures of the lower humerus, the radius/ulna, and the radial head may accompany.

These fractures are difficult to treat and pose quite a challenge. If there is no other associated injury, these fractures are best treated by excision of the olecranon and reattachment of the triceps tendon to the remaining bone, flush with the articular surface. Early ebow mobilisation should be started.

If  excision is not possible, possible surgical stabilization by TBW or plating can be attempted.

Fracture-Dislocation

• Severe injuries
• Restoration of alignment and stability  is primary goal