Management of Fractures of the Proximal Ulna

Management of Fractures of theProximal Ulna

Abstract

Proximal ulna fractures can be difficult to manage because of theelbow’s complex anatomy. Advances in understanding elbowanatomy and biomechanics, however, have led to new insights.Careful preoperative evaluation is critical because failure to restorenormal anatomy of the proximal ulna could have a detrimentaleffect on postoperative elbow function. Management optionsinclude anatomic plates, intramedullary devices, and strong tensionband materials. Determining the most appropriate option for anindividual fracture is based on analysis of radiographs and CTscans, including three-dimensional reconstruction. Coronoidfractures, olecranon fractures, and associated elbow instabilityinfluence the indications for any given fixation device. Appreciatingthe subtleties of proximal ulna anatomy and biomechanics can leadto improved clinical outcomes. Recent concepts affecting fracturemanagement include proximal ulna dorsal angulation, theimportance of the anteromedial facet of the coronoid, andintermediate fragments of the olecranon.

Elbow fractures and dislocationspresent a particular challenge

due to the elbow’s complex anatomyand the presence of local neurovas-cular structures. Also, the modestsoft-tissue envelope requires carefulintraoperative manipulation andpostoperative attention. Malreducedproximal ulna fractures may result incomplications such as contracture,instability, posttraumatic arthrosis,and functional deficits.1-4 Many frac-tures require surgical stabilization toallow early motion and to limit com-plications such as stiffness, elbow in-stability, and posttraumatic arthri-tis.5

Anatomy

The elbow is a trochoid joint thatconsists of three articulations: the

proximal radioulnar, the radiocapi-tellar, and the ulnotrochlear joints.Elbow stability is provided by osse-ous congruity and the surroundingsoft tissues. The coronoid process isa primary stabilizer and acts as abuttress to prevent posterior axialulna translations.6,7 The medial col-lateral ligament, particularly the an-terior bundle, is a primary constraintto valgus stress at the elbow joint,and the lateral ulnar collateral liga-ment acts to prevent rotatory trans-lation.3,8 The radial head is definedas a secondary stabilizer against val-gus and posterolateral rotationalforces.8,9 The olecranon and the cor-onoid compose the greater sigmoidnotch, which articulates with thetrochlea. The lesser sigmoid notch,on the lateral aspect of the proximalulna, articulates with the radial headto form the proximal radioulnar

Dominique M. Rouleau, MD,MSc, FRCS

Emilie Sandman, MD

Roger van Riet, MD, PhD

Leesa M. Galatz, MD

From the Hôpital du Sacré Coeur deMontréal, University of Montreal,Montreal, Canada (Dr. Rouleau andDr. Sandman), the Monica Hospitaland Monica Orthopaedic Research(MoRe) Foundation, Antwerp,Belgium, and Erasme UniversityHospital, Brussels, Belgium (Dr. vanRiet), and Washington UniversityOrthopedics, Barnes-JewishHospital, St. Louis, MO (Dr. Galatz).

J Am Acad Orthop Surg 2013;21:149-160

http://dx.doi.org/10.5435/JAAOS-21-03-149

Copyright 2013 by the AmericanAcademy of Orthopaedic Surgeons.

JAAOS Plus Webinar

Join Dr. Galatz, Dr. Sandman, andDr. van Riet for our first JAAOSinteractive webinar, discussing“Management of Fractures of theProximal Ulna,” on Wednesday, April3, 2013, at 9 PM EST. The moderatorwill be William Levine, MD, theJournal’s Deputy Editor for Shoulderand Elbow topics.

To join and to submit questions inadvance, please visit theOrthoPortal website: http://orthoportal.aaos.org/jaaos/default.aspx#tab1

Review Article

March 2013, Vol 21, No 3 149

joint. The articular surface of thegreater sigmoid notch is coveredwith hyaline cartilage, except for atransverse “bare area” that dividesthe olecranon from the coronoidprocess.10

Proximal ulna morphology ishighly variable, especially relative toits volar and varus angulation. Aphysiologic sagittal plane bowinghas been described as the proximalulna dorsal angulation (PUDA).11,12

A PUDA is present in 96% of thepopulation, with a strong correlationbetween right and left elbows foreach individual (r = 0.86).11 The av-erage PUDA is approximately 6° and

is located nearly 5 cm distal to thetip of the olecranon. An interactionbetween the PUDA and overall el-bow range of motion (ROM) hasbeen observed, with greater dorsalangles associated with a decrease interminal elbow extension.12 Puch-wein et al13 described a mean varusangulation of the proximal ulna; theangle formed by the axis of the olec-ranon and the axis of the ulnar mid-shaft is 14° ± 4°. These authors alsofound a mean anterior angulation of6° ± 3°. To guide surgical manage-ment, contralateral radiographs ofthe uninjured elbow may be useful todetermine the normal proximal ulna

anatomy, which is unique for eachindividual.11,14,15

The olecranon prevents anteriordisplacement of the ulna relative tothe distal humerus.16,17 The tricepstendon inserts on the posterior sur-face of the olecranon with a more di-rect muscular insertion deep to thesuperficial tendon.18 The net vectorof the major muscle forces at the el-bow, primarily the triceps, biceps,and brachialis, is directed dorsally(Figure 1). The intact coronoid re-sists posterior translation and varusstress.19 The coronoid process is di-vided into a tip, body, anteromedialand anterolateral facets, and the sub-lime tubercle.3 The anterior band ofthe medial collateral ligament insertson the sublime tubercle. The brachia-lis muscle and the anterior capsuleattach to the coronoid distal to thetip, leaving a small amount of boneand generous cartilaginous cap visi-ble from within the joint.20

The lateral ulnar collateral liga-ment also attaches to the proximalulna. It inserts on the crista supinato-ris on the lateral proximal ulna atthe point where the supinator crestblends with the radial notch.

Mechanisms of Injury

Proximal ulna fractures most com-monly occur from a low-velocity, di-rect or indirect trauma to the elbow.Overall prevalence is 21% of allproximal forearm fractures.21 A cor-onoid tip fracture occurs following aprogressive valgus stress that forcesthe coronoid under the trochlea, im-

Illustration demonstrating dorsal net vector muscle forces at the elbow(arrow). The olecranon provides a buttress against anterior displacement ofthe ulna (red line). The coronoid resists posterior displacement of the ulnaand serves as a buttress against varus stress (blue line).

Figure 1

Dr. Rouleau or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith& Nephew; has received research or institutional support from DePuy, KCI, Smith & Nephew, Stryker, Synthes, and Zimmer; and hasreceived nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding(such as paid travel) from Arthrex. Dr. van Riet or an immediate family member has received research or institutional support fromZimmer and serves as a board member, owner, officer, or committee member of the European Society for Surgery of the Shoulderand Elbow. Dr. Galatz or an immediate family member serves as an unpaid consultant to Tornier and as a board member, owner,officer, or committee member of American Shoulder and Elbow Surgeons, the American Orthopaedic Association, and the AmericanAcademy of Orthopaedic Surgeons. Neither Dr. Sandman nor any immediate family member has received anything of value from orhas stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Management of Fractures of the Proximal Ulna

150 Journal of the American Academy of Orthopaedic Surgeons

pacting it there. An isolated coronoidtip fracture seen on an otherwisenormal radiograph is suggestive of adislocation or subluxation injurythat spontaneously reduced. The ter-rible triad injury results from a val-gus with additional posterolateralforce.22,23 The triad refers to the com-bination of a coronoid fracture, ra-dial head fracture, and dislocation ofthe elbow, resulting in collateral liga-ment injury. Alternatively, an antero-medial coronoid facet fracture resultsfrom a varus and posteromedial ro-tational force on the elbow.19 The na-ture of the injury depends on the di-rection of rotation; a supinationforce progresses to a terrible triad,whereas a pronation force results ina varus, posteromedial type of injury.

Direct trauma to the olecranontypically causes comminuted frac-tures, whereas indirect avulsion inju-ries from the contraction of the tri-ceps muscle result in transverse oroblique fracture patterns.16 Commi-nuted olecranon fractures can gener-ate intermediate fragments from thearticular surface, which are often dif-ficult to detect. Recognition of theintermediate fragment, however, isessential to restore the congruity of

the ulnohumeral joint and to avoidimpingement by iatrogenic narrow-ing of the greater sigmoid notch.

Diagnostic Evaluation

A complete history and physical ex-amination are fundamental for anypatient presenting with upper ex-tremity trauma. Patients with a prox-imal ulna fracture present with localpain, swelling, and frequently a pal-pable gap or visible deformation ofthe elbow. ROM is often decreased.Olecranon fractures are often associ-ated with an extension lag. Carefulneurovascular evaluation may detectassociated injuries. Increased suspi-cion of soft-tissue and/or neurovas-cular injury is warranted in the pres-ence of high-energy trauma orfracture-dislocation injuries. Inspec-tion of the skin and soft tissues canprovide clues to the status of deeperstructures. The condition of the soft-tissue envelope is an important con-sideration with regard to the timingof surgery. Although compartmentsyndromes are rarely seen with thesetypes of injuries, a combined proxi-mal ulna and more distal forearm

fracture can be associated with ex-cessive swelling.

AP and lateral radiographs of theelbow are usually sufficient to char-acterize simple, noncomminutedfracture patterns. It is important toevaluate any ulnohumeral or radio-capitellar incongruity and to identifyall possible fragments. Radial headalignment is measured with the ra-diocapitellar ratio (RCR) on a lateralview (Figure 2). The RCR measure-ment is the minimal distance be-tween the axis of the radial head andthe center of the capitellum, dividedby the diameter of the capitellum.The RCR is a valid measurement toassess radial head translation aboutthe capitellum. Malalignment is anRCR value outside the normal rangeof −5% to 13%.24

The PUDA and the RCR areclosely related. In an unpublishedbiomechanical study, we found thata 5° malreduction at the PUDA al-ready leads to radial head sublux-ation at the radiocapitellar joint.25

Thus, in complex fracture patterns, acontralateral elbow radiograph canbe important to assess the patient’snative PUDA because a straight lock-ing plate may alter the normal anat-

Lateral radiographs demonstrating measurement of radial head alignment by means of the radiocapitellar ratio (RCR).The RCR is the minimal distance between the axis of the radial head and the center of the capitellum divided by thediameter of the capitellum. A, A perpendicular line is drawn to the articular surface of the radial head at its middistance. B, A circle is drawn on the capitellum and its diameter measured. C, The center of the capitellum (+) isidentified. D, The minimal distance between the right bisector and the center of the capitellum is assessed.

Figure 2

Dominique M. Rouleau, MD, MSc, FRCS

March 2013, Vol 21, No 3 151

omy and thus preclude successful ra-diocapitellar joint reduction.

CT should be ordered when com-minution, intermediate fragments, oranteromedial coronoid facet frac-tures are suspected. The thresholdfor obtaining CT is very low. We be-lieve that CT scans with three-dimensional reconstruction offergreater understanding of fracturepatterns and fragment displacementfor preoperative and surgical plan-ning.

Classification Systems

Many classifications have been pro-posed to describe proximal ulna frac-tures. Accurate fracture classificationcan greatly influence managementrecommendations and ultimate prog-nosis.16

Olecranon FracturesMorrey26 described the Mayo classi-fication for olecranon fracturesbased on elbow stability, fracturedisplacement, and degree of commi-

nution. Type I is a nondisplaced orminimally displaced fracture. Type IIis displaced but with preserved el-bow stability. Type III involves agreater surface area of the olecranonand is associated with elbow joint in-stability. Each type is further subclas-sified into subtypes A and B, whichare described, respectively, as non-comminuted and comminuted frac-ture patterns.16,27

The Schatzker classification dividesolecranon fractures into six types16,28

(Figure 3). Intermediate fragmentsare accounted for in a few classifica-tion schemes, including Mayo26 typeII and III fractures, as well as inSchatzker28 type B and D fractures.

Coronoid FracturesTwo classification systems describecoronoid process fractures. In 1989,Regan and Morrey29 described threetypes of coronoid fracture patterns,identified on lateral radiographs.Type I implied an “avulsion” of thetip of the coronoid process; type IIinvolved ≤50% of the process; and

type III, >50% of the coronoid. Thetype III fracture pattern was addi-tionally classified into type A, repre-senting an absence of elbow disloca-tion, and type B, representing thepresence of elbow dislocation.

O’Driscoll et al23 later proposed asecond, more descriptive classifica-tion, based on the anatomic locationof the coronoid fracture, determinedby CT. This anatomic classificationsystem refers to three main portionsof the coronoid—the tip, the antero-medial facet, and the base. Fracturesof the tip of the coronoid are de-scribed as two subtypes: ≤2 mm and>2 mm fragments. Anteromedialfacet fractures are divided into threesubtypes: a subtype 1 fracture in-volves the anteromedial rim; subtype2 involves the anteromedial rim andthe coronoid tip; and a subtype 3fracture is a subtype 2 pattern with afracture of the sublime tubercle. Cor-onoid base fractures are divided intotwo subclassifications: subtype 1,comprising the coronoid body at itsbase, and subtype 2, described as a

Illustrations of the Schatzker classification of olecranon fractures. A, Type A, simple transverse fracture. B, Type B,transverse fracture with a central articular surface impaction. C, Type C, simple oblique fracture. D, Type D,comminuted olecranon fracture. E, Type E, oblique fractures distal to the mid-trochlear notch. F, Type F, combination ofolecranon and radial head fractures, often associated with medial collateral ligament tear. (Reproduced from Hak DJ,Golladay GJ: Olecranon fractures: Treatment options. J Am Acad Orthop Surg 2000;8[4]:266-275.)

Figure 3



transolecranon basal coronoid frac-ture (Figure 4).

There is a paucity of literature em-phasizing the importance of identify-ing the presence of olecranon andcoronoid fracture combinations.O’Driscoll et al23 briefly describe this

fracture pattern combination in itstype 3–subtype 2 subclassification.The treatment of this type of com-plex elbow injury relies on meticu-lously planning the surgical interven-tion to optimize final outcomes(Figure 5).

Monteggia FracturesMonteggia-type injuries were initiallydescribed in 1814 as fractures of theproximal ulna associated with a radialhead dislocation.30 Monteggia-typeinjuries lead to a disruption of theproximal radioulnar joint (PRUJ),which enables the radial head to dis-locate from the capitellum as well asfrom the ulna. In 1967, Bado31 devel-oped a Monteggia fracture classifica-tion based on the direction of radialhead dislocation. Type I is an ante-rior dislocation of the radial head as-sociated with an anterior angulationof the proximal ulna fracture. TypeII is a posterior dislocation of the ra-dial head with a posterior angulationof the proximal ulna fracture. TypeIII is a lateral or anterolateral radialhead dislocation associated with aproximal ulna fracture. Type IV is ananterior dislocation of the radialhead with fractures of the proximalulna and radius.3 Jupiter et al32 modi-fied Bado’s Monteggia fracture clas-sification by subdividing type II inju-ries and further describing thepattern of proximal ulna fractures.Type IIA are fractures at the greatersigmoid notch; type IIB representsfractures distal to the coronoid andat the proximal metaphysis; type IICare diaphyseal fractures; and typeIID are comminuted proximal ulnafractures.33

Management

As described in the AO principles offracture management, the main goalsof fracture fixation are anatomic re-duction, stable fracture fixation,soft-tissue preservation, and early ar-ticular motion to prevent associatedmorbidities.34

NonsurgicalNonsurgical management of coro-noid fractures should be offered forisolated tip fractures ≤2 mm or small

Illustrations of the coronoid fracture according to the classification ofO’Driscoll et al.23 A, Type 1. B, Type 2. Type 2 subtypes 1, 2, and 3 corre-spond to progressive severity of anteromedial (AM) facet fractures. C, Type3. Type 3 subtype 1 (coronoid base) and 2 (coronoid base and olecranon).Panels A and B illustrate axial views of the proximal elbow demonstrating theradial neck and radial head (inset, dotted line) and the first distal view afterthe joint surface. This view provides visibility of the three areas of the coro-noid (tip, AM facet, and sublime tubercle).

Figure 4


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fractures <15% in height associatedwith a stable elbow.19 A limited pe-riod of immobilization is followed byearly ROM. Isolated coronoid frac-tures are often associated with liga-ment injuries; thus, congruent reduc-tion of the elbow should be assessedregularly in the early recovery periodto detect intervening instability.

Olecranon fractures are rarelytreated conservatively, but nonsurgi-

cal management may be appropriatewhen the patient is inoperable or inlow-demand patients with nondis-placed fractures with an intact exten-sor mechanism.16 Close monitoring isimportant in these patients to assureproper bone healing and mainte-nance of anatomic reduction. The el-bow is immobilized in the maximalamount of flexion that prevents frac-ture gapping, which typically occurs

between 45° and 90°. Any upper ex-tremity weight bearing and active el-bow extension must be preventeduntil complete bone union is docu-mented. In a compliant patient, auto-assisted active ROM exercises in astanding position may be started at 2weeks postoperatively, four times perday. However, use of a long arm re-movable splint is indicated until ra-diologic bone union.

SurgicalIn adults, most olecranon and Monteg-gia fracture-dislocations are treatedwith anatomic reduction and fixation.The global surgical approach for prox-imal ulna fractures is presented in Fig-ures 6 and 7.

Olecranon FracturesIsolated, simple noncomminutedtransverse olecranon fractures aretypically managed with tension bandwiring (TBW) through a posteriorapproach. TBW creates a dynamiccompressive force across the frac-ture.35 TBW is contraindicated, how-ever, in comminuted fractures andsome oblique fractures. Olecranonfractures distal to the bare area in-volving the base of the coronoid arealso poor candidates for TBW. Twosmooth Kirschner wires (1.6 mm or2 mm) inserted from the proximalolecranon traverse the fracture lineand engage the anterior ulna cor-tex.16,36 After engaging the secondcortex, the wires are slightly backedout to prevent injury to surroundingsoft tissues. A figure-of-8 is formedwith one or two 18-gauge wires,passing deep to the triceps tendonand through a predrilled, 2-mmtransverse hole on the dorsal aspectof the proximal ulna, at least 2 cmdistal to the fracture line. The pinsare bent over the tension band andimpacted to bury the ends in the tri-ceps tendon. Alternatively, an in-tramedullary screw can be used forlongitudinal fixation.

Combined fractures of coronoid, olecranon, and radial head. A, Sagittal CTscan demonstrating a combined fracture of the olecranon and coronoid. Thisrepresents an O’Driscoll type 3–subtype 2 fracture. B, Lateral radiograph ofthe fracture shown in panel A managed with anatomic reduction and fixationwith a locking plate.

Figure 5

Algorithm of the management of olecranon fractures. C-arm = fluoroscopy,IF = interfragmental screw, ORIF = open reduction and internal fixation,RCR = radiocapitellar ratioa Plate should be adapted to the contralateral proximal ulna dorsalangulation.

Figure 6



Wilson et al37 recently challengedthis treatment method and suggestedthat precontoured plates providegreater compressive force at the frac-ture site for transverse olecranonfractures. In addition, in comparingTBW to plate fixation, there is agreater risk of secondary displace-ment, and removal of instrumenta-tion is more often necessary withTBW.

In comminuted or oblique olecra-non fractures, a tension band canovercompress the greater sigmoidnotch, thereby narrowing the articu-lar surface. More importantly, a ten-sion band does not provide sufficientstability in complex fracture pat-terns. In these specific cases, ana-tomic reduction and rigid fixationwith interfragmentary screws andplate fixation is mandatory. Plate fix-ation is performed through a straightposterior approach. In the setting ofcomplex elbow fractures, the authorsplace the patient in a lateral decubi-tus or prone position. The triceps in-sertion must be protected, and platedevices can be positioned superficialto the tendon.

Alternatively, a small longitudinalincision can be made in the tendonto bury wires or a plate. Suture fixa-tion with a Krackow or similartendon-grasping stitch may be usedto reinforce the triceps insertion in

cases of small and comminuted prox-imal fragments. Comminuted articu-lar fragments should be anatomicallyreduced whenever possible to mini-mize articular incongruence, narrow-ing of the greater sigmoid notch,and—possibly—the risk of progres-sive early arthrosis.

We strongly advocate fixation andgrafting for complex comminutedfractures. A thorough washout of the

joint is necessary before fixation toremove any fracture debris from thearticulation. A “home run screw” forintermediate olecranon fragmentshas been shown to stabilize and opti-mize the anatomically reduced artic-ular surface38 (Figure 8). Visualiza-tion of the joint is necessary witharticular comminution. A lateral ap-proach to the joint can be used as analternative to a straight posterior ap-

Algorithm of the management of coronoid fractures based on the O’Driscollclassification. LCL = lateral collateral ligament, ORIF = open reduction andinternal fixation, PUDA = proximal ulna dorsal angulation, ST = subtype

Figure 7

Lateral radiograph (A) and sagittal CT scan (B) demonstrating intermediate fragment in an olecranon fracture.C, Lateral radiograph demonstrating postoperative fixation. The intermediate fragment is visible in the sagittal CT scan(panel B) but was difficult to visualize radiographically (panel A).

Figure 8


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proach. The collateral ligamentsmust be protected to preserve jointstability. The proximal fragment canbe reflected during identification andfixation of the smaller, impacted ordisplaced intra-articular fragments.Fragments are reduced and fixed,building from the distal to proximaldirection using interfragmentaryscrews as much as possible.

On rare occasions, anatomic fixa-tion of an olecranon fracture maynot be possible. Severely commi-nuted fractures (ie, Schatzker type D)and open fractures associated withbone loss can preclude use of theusual fixation techniques. The proxi-mal bone fragment attached to thetriceps should be preserved as muchas possible. In some instances, thedistal and proximal bone can besculpted with a rongeur to create acongruent contact surface.39 Thefragments are then fixed with a plateand screws. Some bone loss can beaccepted in the bare area. Bone graftshould be used to bring the proximalulna out to length at the posteriorcortex. A gap in the nonarticulatingbare area will fill with fibrous tissueas long as the posterior cortex is rig-idly fixed. To secure the repair,tendon-grasping sutures are placedin the triceps tendon and passedthrough bone tunnels in the distalfragment. Management of bone in-sufficiency of the olecranon is basedin large part on biomechanical stud-ies on the amount of bone requiredto maintain stability. An et al17 sug-gested that up to 50% of the olecra-non can be removed without render-ing the elbow completely unstable.

More recently, new information,based on more complex biomechani-cal models, has enhanced our under-standing of this problem. One studydemonstrated that removal of as lit-tle as 12.5% of the olecranon is suf-ficient to alter joint stability.40 How-ever, it has also been reported thatup to 75% of the olecranon can be

removed without creating gross in-stability.40 When triceps is directly re-paired to bone, it must be reattachedas dorsally as possible to maximizetriceps strength; however, even in theoptimal position, 24% of strength islost.41 It is important to note that allof these biomechanical studies as-sume that the elbow is otherwise sta-ble. For obvious reasons, olecranonexcision should be reserved only forcases of nonreconstructable frac-tures.

Coronoid FracturesFractures of the coronoid can be ap-proached and fixed through a poste-rior, medial, or lateral surgical ap-proach. A posterior skin incisionwith a lateral skin flap is preferredwhen the lateral collateral ligamentis already ruptured and surgicaltreatment of the radial head isplanned.42 The coronoid process canbe approached anterior to the radialhead or when the radial head is re-sected but before replacing it with aprosthesis. During surgery, the fore-arm should be pronated to protectthe posterior interosseous nerve.Large coronoid tip fragments are re-duced and fixed with compressionscrews or threaded pins, which canbe placed anterograde or retrogradeunder fluoroscopic or arthroscopicvisualization. For comminuted frac-tures or smaller fragments not largeenough for screw placement, suturefixation through the anterior capsuleadjacent to the coronoid fragmentsencompassing the bone can providesome stability. The suture is passedthrough bone tunnels created fromthe dorsal ulnar cortex into the frac-ture bed. Two tunnels are created,and the sutures are tied over thebone bridge. Tunnels directed fromthe more medial or lateral aspect ofthe dorsal cortex prevent soft-tissueirritation from suture material. Theulnar nerve must be protected ifmore medial tunnels are used.

Anteromedial facet fractures of thecoronoid are addressed through amedial approach to the joint, but theskin incision can be either medial orposterior.43 Initially, the ulnar nerveis identified in the cubital tunnel andcan be released in situ for posteriorretraction to avoid postoperativeneuropathies. The flexor-pronatormuscle group is detached from themedial epicondyle using an L-shapeddistal-to-proximal incision, preserv-ing the medial collateral ligament at-tachment. An opening of the jointcapsule permits excellent visibilityfor anatomic fixation with screwsand, when possible, a buttressplate3,44 (Figure 9). Alternatively, aflexor-pronator split, anterior to theulnar nerve, can be used.

The coronoid is critical to elbowstability, and even small fracturescan have a significant impact on el-bow biomechanics. Rigid fixationtechniques should be employed forlarger fragments to provide stabilityand maximize the opportunity forbone healing.

Combined FracturesCombined coronoid and olecranonfractures pose a challenge for proxi-mal ulna fracture management. Thepatient is positioned in a lateral de-cubitus or prone position, and theprocedure is performed through aposterior incision. The proximalfragment of the olecranon is reflectedwith the attached triceps to exposethe coronoid fragments. A usefulstrategy employs fixation of the frag-ments from distal to proximal. Thecoronoid fragment is reduced withthe elbow in flexion. Anatomic re-duction can be confirmed by elevat-ing some soft tissue from the medialand lateral aspects of the olecranon.The collateral ligaments must be pre-served or reinserted at the end of theprocedure to maintain stability. Thesublime tubercle is often fracturedand can be lifted to provide access to



the other coronoid fragments. Theulnar nerve must be protected duringany medial fracture exposure. Intra-articular fragments are stabilizedwith small screws or threaded wires.Finally, the olecranon is reduced anda posterior plate is applied to theposterior ulna and olecranon (Figure5). If malalignment at the radiocapi-tellar joint is suspected, a contralat-eral radiologic measurement of thePUDA should be done to reproducethe native proximal ulna angulation.

PostoperativeManagement

Postoperative rehabilitation for olec-ranon fractures depends on the soft-tissue status and fixation stability.For cooperative patients presentingin whom solid fixation was achieved,early active ROM exercises may bestarted typically after 1 week of im-mobilization for wound healing andcontrol of swelling. Passive ROM,strengthening exercises, and weightbearing are permitted after con-

firmed radiologic bone union. Incases of compromised soft tissuesand thin skin, a dynamic splintblocked in extension may be useduntil the wound has healed. Flexioncan progressively be allowed at acontrolled rate (eg, increments of 15°per week), depending on the qualityof the soft tissue. ROM exercisesmay be delayed and the elbow maybe immobilized for 2 weeks or moreif strong fixation was not possible.

Pearls and Pitfalls

Preoperative planning is criticalwhen approaching proximal ulnafractures (Table 1). Stable anatomicfixation of all fragments is necessaryto restore normal articular anatomyof the elbow. Simple fractures can befixed with a tension band or plateand screws; more complex fracturesrequire plate-and-screw fixation. Thecoronoid process can be approachedfrom a medial, posterior (throughthe olecranon fracture site), or lateralapproach. Intermediate fragments

Table 1

Pearls and Pitfalls in theManagement of Proximal UlnaFracture

PearlsPreoperative planningStable fixation of all fragmentsSimple fractures: tension band or plateComplex fractures: plate and screwsCoronoid process can be approached

from medial, posterior, or lateralRadial head can be approached from

lateral or posteriorFix intermediate fragments first, fix cor-

onoid fragments distal to proximalIntraoperative fluoroscopyTest the elbow through a full range of

motion for stability, range, and con-gruence

PitfallsFailure to identify and fix all fragments

leads to loss of reduction or instabilityNonanatomic reduction of the proximal

ulna leads to radial head subluxation,bony impingement, and decreasedmotion

Poorly placed hardware or screws andpins lead to ulnar nerve problems,decreased motion, or articular degen-eration

A, AP radiograph of the elbow demonstrating a large anteromedial facet fracture (arrow) that could easily be missed.B, Lateral radiograph demonstrating associated instability and an abnormal radiocapitellar ratio. C, Postoperativelateral radiograph demonstrating reduction and fixation done using the medial approach and a mini fragment plate andscrews. Medial and lateral ligaments were repaired with bone anchors.

Figure 9


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need to be fixed first in order to cre-ate larger fragments that are subse-quently reduced to more proximalfragments as well as to facilitate ananatomic articular reduction.

Nonanatomic reconstruction of theproximal ulna can cause radiocapi-tellar malalignment or dislocation.Narrowing the greater sigmoid notchby fixing the proximal fragment inflexion limits motion. Poorly posi-tioned instrumentation can limit mo-tion or cause ulnar nerve symptoms.Incorrectly placed screws or pins canaffect motion or damage articularcartilage. Intraoperative fluoroscopyis helpful to evaluate the final reduc-tion of the fracture and the positionof instrumentation. Stability of thefixation, impingement of hardware,and articular incongruity should beevaluated by taking the elbowthrough a full ROM. Elbow move-ment should be smooth, withoutscraping, grating, or clicking.

Outcome

Clinical results after olecranon frac-ture fixation are available for smallseries reported in the literature (Ta-ble 2). On average, patients lost 30°of ulnohumeral ROM after plate andcombined plate-and-screw fixation,although there was improvement inROM after late instrumentationremoval.45-47,49,50 Device removal wasrequired for 18% to 62% of thecases and is the most frequent com-plication after olecranon fixation.Functional outcome expressed by theMayo Elbow Performance Score isgood to excellent in the great major-ity of patients.45-47,49 Disabilities ofthe Arm, Shoulder, and Hand(DASH) and QuickDASH scores arereported as being between 9 and 17for olecranon fractures managedwith plate fixation.45-47,49 Posttrau-matic arthritis occurs in 21% to48% of patients in long-term

follow-up studies.49,50 Andersonet al48 summarized the orthopaedicliterature and illustrated the higherrate of device removal followingolecranon fractures for TBW (11%to 82%) compared with plating sys-tems (zero to 20%).

Approximately 58% of the antero-medial facet of the coronoid pro-trudes from the proximal ulna shaft,which makes the anteromedial facetof the coronoid susceptible to in-jury.51 Doornberg and Ring52 demon-strated the importance of secure fixa-tion of anteromedial facet fracturesof the coronoid; limited treatmentmay compromise elbow stability,leading to varus subluxation, earlyarthrosis, and poor to fair results inthe Broberg-Morrey score.

Summary

Proximal ulna fractures challengeeven the most experienced surgeon.Recognition and restoration of eachpatient’s unique proximal ulna anat-omy is essential for adequate ana-tomic restoration. Thorough evalua-tion of the injured extremity andinterpretation of radiologic images

are essential for adequate diagnosis,preoperative planning, and optimiza-tion of treatment outcomes. Clinicaloutcome studies reveal high rates ofpostoperative complications, includ-ing symptomatic instrumentationand posttraumatic arthritis. A me-thodical approach to surgical deci-sion making maximizes the opportu-nity for successful reconstruction ofelbow anatomy and biomechanics.Further research and innovation interms of surgical technique and de-vices will be useful to help improveoutcomes in these complex fractures.

References

References printed in bold type arethose published within the past 5years.

1. Ring D, Tavakolian J, Kloen P, Helfet D,Jupiter JB: Loss of alignment aftersurgical treatment of posteriorMonteggia fractures: Salvage with dorsalcontoured plating. J Hand Surg Am2004;29(4):694-702.

2. Ring D, Jupiter JB, Gulotta L: Atrophicnonunions of the proximal ulna. ClinOrthop Relat Res 2003;409:268-274.

3. Athwal GS, Ramsey ML, Steinmann SP,Moriatis Wolf J: Fractures and

Table 2

Outcomes Following Plating of Olecranon Fracture

StudyNo. of

Patients

AverageFollow-up(Range) Fixation

Anderson et al48 32 2.2 yr(0.7–5.1)

Mayo congruent elbowplate system

Buijze and Kloen47 19 22 mo(12–48)

Contoured LCP andintramedullary screwfixation

Erturer et al45 18 22.6 mo(7–42)

Locking-plate osteosyn-thesis

Siebenlist et al46 15 16 mo(8–29)

3.5-mm LCP olecranonplate

DASH = Disabilities of the Arm, Shoulder, and Hand; LCP = locking compression plate;MEPS = Mayo Elbow Performance Score; OA = osteoarthritis; ROM = range of motion



dislocations of the elbow: A return to thebasics. Instr Course Lect 2011;60:199-214.

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Course Lect 2009;58:481-493.

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29. Regan W, Morrey B: Fractures of the

Table 2 (continued)

Outcomes Following Plating of Olecranon Fracture

Mean ROM(Flexion-extension/Pronation-supination[degrees])

Mean MEPSScore

Mean DASHScore

AverageBroberg-

Morrey ScoreOA(%)

HardwareRemoval

(No.)Nonunion

(No.)

120/158 89 32 — — 4 2

123/145 93 13 93 44 9 0

116/126 — 17 81 — 2 0

129/171 97 13 — — 4 1

DASH = Disabilities of the Arm, Shoulder, and Hand; LCP = locking compression plate; MEPS = Mayo Elbow Performance Score;OA = osteoarthritis; ROM = range of motion


March 2013, Vol 21, No 3 159

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41. Ferreira LM, Bell TH, Johnson JA, KingGJ: The effect of triceps repairtechniques following olecranon excisionon elbow stability and extensionstrength: An in vitro biomechanicalstudy. J Orthop Trauma 2011;25(7):420-424.

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46. Siebenlist S, Torsiglieri T, Kraus T,

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Management of Fractures of the Proximal Ulna