Right shoulder and arm, posterior view

Posterior view of right elbow

Blood supply and anastomosis around the right elbow. Anterior view

The triangular structure of distal humerus at elbow joint provides structural strength.

Olecranon fractures are fractures of the proximal Ulnar bone that forms the elbow joint. This area is superficial and can easily fracture when falling onto it or with a direct blow to the area (comminuted fracture type) or it can be fractured indirectly by falling with an outstretched arm (transverse/oblique fracture type).

Exclude elbow dislocation/instability

Proximal fragment excision and triceps advancement is optional for comminuted olecranon fractures. As much as 50% of the olecranon is effective in managing comminuted proximal olecranon fractures not amenable to surgical fixation. Limit olecranon excision <60%  articular involvement preventing poor functional outcome. Triceps power is reduced after surgical procedure.

Total joint replacement a consideration for elderly patients with significant comminuted proximal olecranon fractures with > 60% articular involvement.

Posterior approach to right distal humerus, Radial nerve at risk

Radial nerve is responsible for motor elbow and wrist extension. Sensory distribution shown on pic.

Deep posterior approach to distal humerus/elbow:

Fascia release or olecranon osteotomy

• Ulnar nerve exploration along medial intermuscular septum and followed to the cubital tunnel, isolate and retract with latex loop
• Retract triceps laterally
• Medial attachment of triceps along olecranon is partially released

• Free triceps on lateral side
• Split triceps fascia & mobilize from lateral intermuscular septum &
• Partially release triceps tendon on lateral side of olecranon with 1mm sliver of cartilage
• Retract triceps medially
• Distally partially release anconeus

• Split triceps tendon in midline to to upper limit of olecranon fossa to proximal triceps muscle area with caution to Radial nerve for more proximal muscle splitting
• Medial incision along medial ulnar border ± cartilage/periosteum sleeve
• Retract the split triceps

Indications:

• Fracture nonunion
• Extensive comminuted proximal ulnar fractures
• Elderly patients with osteoporotic bone
• Note: procedure require elbow ligament stability

Surgery approach: directly over ulnar. Reattach triceps tendon close to the articular surface thereby improving stability as triceps acts as a sling for the trochlea.

2 Tunnels are drilled using a 2mm bit, drilling from proximal to distal:

• Dorsal superficial
• Volar deep
• Start at the volar corners of footprint & drill the deep tunnels in a crossing pattern so that the tunnels exit 1.5 to 2.5 cm distal to olecranon tip and 8 to 10mm to the side of dorsal ulnar ridge
• The superficial (dorsal) tunnels drilled similarly crossing corners of the footprint starting from dorsal ulnar ridge 10 to 12mm proximal to deep tunnels
• Triceps sutured with Krackow technique with 4 exiting strands exiting deep surface of triceps
• Unattached free sutures are passed, crossing retrograde through superficial tunnels exiting the dorsal corners of footprint. These sutures are passed through the triceps using a free needle from deep to superficial and tied across four corners after the Krakow sutures are tied
• Modified technique used with excision of proximal olecranon

• Rigid fixation: arm sling for 7-10 days then elbow range of motion, non-weight bearing
• Suboptimal fixation may require splintage or elbow hinge brace
• Strengthening exercises after fracture union

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