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Management of Fractures of the
Proximal Ulna
Abstract
Proximal ulna fractures can be difficult to manage because of the
elbow’s complex anatomy. Advances in understanding elbow
anatomy and biomechanics, however, have led to new insights.
Careful preoperative evaluation is critical because failure to restore
normal anatomy of the proximal ulna could have a detrimental
effect on postoperative elbow function. Management options
include anatomic plates, intramedullary devices, and strong tension
band materials. Determining the most appropriate option for an
individual fracture is based on analysis of radiographs and CT
scans, including three-dimensional reconstruction. Coronoid
fractures, olecranon fractures, and associated elbow instability
influence the indications for any given fixation device. Appreciating
the subtleties of proximal ulna anatomy and biomechanics can lead
to improved clinical outcomes. Recent concepts affecting fracture
management include proximal ulna dorsal angulation, the
importance of the anteromedial facet of the coronoid, and
intermediate fragments of the olecranon.
Elbow fractures and dislocations
present a particular challenge
due to the elbow’s complex anatomy
and the presence of local neurovas-
cular structures. Also, the modest
soft-tissue envelope requires careful
intraoperative manipulation and
postoperative attention. Malreduced
proximal ulna fractures may result in
complications such as contracture,
instability, posttraumatic arthrosis,
and functional deficits.
1-4
Many frac-
tures require surgical stabilization to
allow 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 that
consists of three articulations: the
proximal radioulnar, the radiocapi-
tellar, and the ulnotrochlear joints.
Elbow stability is provided by osse-
ous congruity and the surrounding
soft tissues. The coronoid process is
a primary stabilizer and acts as a
buttress to prevent posterior axial
ulna translations.
6,7
The medial col-
lateral ligament, particularly the an-
terior bundle, is a primary constraint
to 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 defined
as a secondary stabilizer against val-
gus and posterolateral rotational
forces.
8,9
The olecranon and the cor-
onoid compose the greater sigmoid
notch, which articulates with the
trochlea. The lesser sigmoid notch,
on the lateral aspect of the proximal
ulna, articulates with the radial head
to 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 de
Montréal, University of Montreal,
Montreal, Canada (Dr. Rouleau and
Dr. Sandman), the Monica Hospital
and Monica Orthopaedic Research
(MoRe) Foundation, Antwerp,
Belgium, and Erasme University
Hospital, Brussels, Belgium (Dr. van
Riet), and Washington University
Orthopedics, Barnes-Jewish
Hospital, 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 American
Academy of Orthopaedic Surgeons.
JAAOS Plus Webinar
Join Dr. Galatz, Dr. Sandman, and
Dr. van Riet for our first JAAOS
interactive webinar, discussing
“Management of Fractures of the
Proximal Ulna,” on Wednesday, April
3, 2013, at 9 PM EST. The moderator
will be William Levine, MD, the
Journal’s Deputy Editor for Shoulder
and Elbow topics.
To join and to submit questions in
advance, please visit the
OrthoPortal website: http://
orthoportal.aaos.org/jaaos/
default.aspx#tab1
Review Article
March 2013, Vol 21, No 3 149
joint. The articular surface of the
greater sigmoid notch is covered
with hyaline cartilage, except for a
transverse “bare area” that divides
the olecranon from the coronoid
process.
10
Proximal ulna morphology is
highly variable, especially relative to
its volar and varus angulation. A
physiologic sagittal plane bowing
has been described as the proximal
ulna dorsal angulation (PUDA).
11,12
A PUDA is present in 96% of the
population, with a strong correlation
between right and left elbows for
each individual (r = 0.86).
11
The av-
erage PUDA is approximately 6° and
is located nearly 5 cm distal to the
tip of the olecranon. An interaction
between the PUDA and overall el-
bow range of motion (ROM) has
been observed, with greater dorsal
angles associated with a decrease in
terminal elbow extension.
12
Puch-
wein et al
13
described a mean varus
angulation of the proximal ulna; the
angle formed by the axis of the olec-
ranon and the axis of the ulnar mid-
shaft is 14° ± 4°. These authors also
found a mean anterior angulation of
6° ± 3°. To guide surgical manage-
ment, contralateral radiographs of
the uninjured elbow may be useful to
determine the normal proximal ulna
anatomy, which is unique for each
individual.
11,14,15
The olecranon prevents anterior
displacement of the ulna relative to
the distal humerus.
16,17
The triceps
tendon inserts on the posterior sur-
face of the olecranon with a more di-
rect muscular insertion deep to the
superficial tendon.
18
The net vector
of 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 varus
stress.
19
The coronoid process is di-
vided into a tip, body, anteromedial
and anterolateral facets, and the sub-
lime tubercle.
3
The anterior band of
the medial collateral ligament inserts
on the sublime tubercle. The brachia-
lis muscle and the anterior capsule
attach to the coronoid distal to the
tip, leaving a small amount of bone
and generous cartilaginous cap visi-
ble from within the joint.
20
The lateral ulnar collateral liga-
ment also attaches to the proximal
ulna. It inserts on the crista supinato-
ris on the lateral proximal ulna at
the point where the supinator crest
blends 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 all
proximal forearm fractures.
21
A cor-
onoid tip fracture occurs following a
progressive valgus stress that forces
the coronoid under the trochlea, im-
Illustration demonstrating dorsal net vector muscle forces at the elbow
(arrow). The olecranon provides a buttress against anterior displacement of
the ulna (red line). The coronoid resists posterior displacement of the ulna
and 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 has
received 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 from
Zimmer and serves as a board member, owner, officer, or committee member of the European Society for Surgery of the Shoulder
and 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 American
Academy of Orthopaedic Surgeons. Neither Dr. Sandman nor any immediate family member has received anything of value from or
has 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 coronoid
tip fracture seen on an otherwise
normal radiograph is suggestive of a
dislocation or subluxation injury
that spontaneously reduced. The ter-
rible triad injury results from a val-
gus with additional posterolateral
force.
22,23
The triad refers to the com-
bination of a coronoid fracture, ra-
dial head fracture, and dislocation of
the elbow, resulting in collateral liga-
ment injury. Alternatively, an antero-
medial coronoid facet fracture results
from 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 supination
force progresses to a terrible triad,
whereas a pronation force results in
a varus, posteromedial type of injury.
Direct trauma to the olecranon
typically causes comminuted frac-
tures, whereas indirect avulsion inju-
ries from the contraction of the tri-
ceps muscle result in transverse or
oblique fracture patterns.
16
Commi-
nuted olecranon fractures can gener-
ate intermediate fragments from the
articular surface, which are often dif-
ficult to detect. Recognition of the
intermediate fragment, however, is
essential to restore the congruity of
the ulnohumeral joint and to avoid
impingement by iatrogenic narrow-
ing of the greater sigmoid notch.
Diagnostic Evaluation
A complete history and physical ex-
amination are fundamental for any
patient presenting with upper ex-
tremity trauma. Patients with a prox-
imal ulna fracture present with local
pain, swelling, and frequently a pal-
pable gap or visible deformation of
the elbow. ROM is often decreased.
Olecranon fractures are often associ-
ated with an extension lag. Careful
neurovascular evaluation may detect
associated injuries. Increased suspi-
cion of soft-tissue and/or neurovas-
cular injury is warranted in the pres-
ence of high-energy trauma or
fracture-dislocation injuries. Inspec-
tion of the skin and soft tissues can
provide clues to the status of deeper
structures. The condition of the soft-
tissue envelope is an important con-
sideration with regard to the timing
of surgery. Although compartment
syndromes are rarely seen with these
types of injuries, a combined proxi-
mal ulna and more distal forearm
fracture can be associated with ex-
cessive swelling.
AP and lateral radiographs of the
elbow are usually sufficient to char-
acterize simple, noncomminuted
fracture patterns. It is important to
evaluate any ulnohumeral or radio-
capitellar incongruity and to identify
all possible fragments. Radial head
alignment is measured with the ra-
diocapitellar ratio (RCR) on a lateral
view (Figure 2). The RCR measure-
ment is the minimal distance be-
tween the axis of the radial head and
the center of the capitellum, divided
by the diameter of the capitellum.
The RCR is a valid measurement to
assess radial head translation about
the capitellum. Malalignment is an
RCR value outside the normal range
of −5% to 13%.
24
The PUDA and the RCR are
closely related. In an unpublished
biomechanical study, we found that
a 5° malreduction at the PUDA al-
ready leads to radial head sublux-
ation at the radiocapitellar joint.
25
Thus, in complex fracture patterns, a
contralateral elbow radiograph can
be important to assess the patient’s
native 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 the
diameter of the capitellum. A, A perpendicular line is drawn to the articular surface of the radial head at its mid
distance. B, A circle is drawn on the capitellum and its diameter measured. C, The center of the capitellum (+) is
identified. 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, or
anteromedial coronoid facet frac-
tures are suspected. The threshold
for obtaining CT is very low. We be-
lieve that CT scans with three-
dimensional reconstruction offer
greater understanding of fracture
patterns and fragment displacement
for preoperative and surgical plan-
ning.
Classification Systems
Many classifications have been pro-
posed to describe proximal ulna frac-
tures. Accurate fracture classification
can greatly influence management
recommendations and ultimate prog-
nosis.
16
Olecranon Fractures
Morrey
26
described the Mayo classi-
fication for olecranon fractures
based on elbow stability, fracture
displacement, and degree of commi-
nution. Type I is a nondisplaced or
minimally displaced fracture. Type II
is displaced but with preserved el-
bow stability. Type III involves a
greater surface area of the olecranon
and is associated with elbow joint in-
stability. Each type is further subclas-
sified into subtypes A and B, which
are described, respectively, as non-
comminuted and comminuted frac-
ture patterns.
16,27
The Schatzker classification divides
olecranon fractures into six types
16,28
(Figure 3). Intermediate fragments
are accounted for in a few classifica-
tion schemes, including Mayo
26
type
II and III fractures, as well as in
Schatzker
28
type B and D fractures.
Coronoid Fractures
Two classification systems describe
coronoid process fractures. In 1989,
Regan and Morrey
29
described three
types of coronoid fracture patterns,
identified on lateral radiographs.
Type I implied an “avulsion” of the
tip of the coronoid process; type II
involved ≤50% of the process; and
type III, >50% of the coronoid. The
type III fracture pattern was addi-
tionally classified into type A, repre-
senting an absence of elbow disloca-
tion, and type B, representing the
presence of elbow dislocation.
O’Driscoll et al
23
later proposed a
second, more descriptive classifica-
tion, based on the anatomic location
of the coronoid fracture, determined
by CT. This anatomic classification
system refers to three main portions
of the coronoid—the tip, the antero-
medial facet, and the base. Fractures
of the tip of the coronoid are de-
scribed as two subtypes: ≤2mmand
>2 mm fragments. Anteromedial
facet fractures are divided into three
subtypes: a subtype 1 fracture in-
volves the anteromedial rim; subtype
2 involves the anteromedial rim and
the coronoid tip; and a subtype 3
fracture is a subtype 2 pattern with a
fracture of the sublime tubercle. Cor-
onoid base fractures are divided into
two subclassifications: subtype 1,
comprising the coronoid body at its
base, 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 of
olecranon 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
Management of Fractures of the Proximal Ulna
152 Journal of the American Academy of Orthopaedic Surgeons
transolecranon basal coronoid frac-
ture (Figure 4).
There is a paucity of literature em-
phasizing the importance of identify-
ing the presence of olecranon and
coronoid fracture combinations.
O’Driscoll et al
23
briefly describe this
fracture pattern combination in its
type 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 Fractures
Monteggia-type injuries were initially
described in 1814 as fractures of the
proximal ulna associated with a radial
head dislocation.
30
Monteggia-type
injuries lead to a disruption of the
proximal radioulnar joint (PRUJ),
which enables the radial head to dis-
locate from the capitellum as well as
from the ulna. In 1967, Bado
31
devel-
oped a Monteggia fracture classifica-
tion based on the direction of radial
head dislocation. Type I is an ante-
rior dislocation of the radial head as-
sociated with an anterior angulation
of the proximal ulna fracture. Type
II is a posterior dislocation of the ra-
dial head with a posterior angulation
of the proximal ulna fracture. Type
III is a lateral or anterolateral radial
head dislocation associated with a
proximal ulna fracture. Type IV is an
anterior dislocation of the radial
head with fractures of the proximal
ulna and radius.
3
Jupiter et al
32
modi-
fied Bado’s Monteggia fracture clas-
sification by subdividing type II inju-
ries and further describing the
pattern of proximal ulna fractures.
Type IIA are fractures at the greater
sigmoid notch; type IIB represents
fractures distal to the coronoid and
at the proximal metaphysis; type IIC
are diaphyseal fractures; and type
IID are comminuted proximal ulna
fractures.
33
Management
As described in the AO principles of
fracture management, the main goals
of fracture fixation are anatomic re-
duction, stable fracture fixation,
soft-tissue preservation, and early ar-
ticular motion to prevent associated
morbidities.
34
Nonsurgical
Nonsurgical management of coro-
noid fractures should be offered for
isolated tip fractures ≤2 mm or small
Illustrations of the coronoid fracture according to the classification of
O’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, Type
3. Type 3 subtype 1 (coronoid base) and 2 (coronoid base and olecranon).
Panels A and B illustrate axial views of the proximal elbow demonstrating the
radial neck and radial head (inset, dotted line) and the first distal view after
the joint surface. This view provides visibility of the three areas of the coro-
noid (tip, AM facet, and sublime tubercle).
Figure 4
Dominique M. Rouleau, MD, MSc, FRCS
March 2013, Vol 21, No 3 153
fractures <15% in height associated
with a stable elbow.
19
A limited pe-
riod of immobilization is followed by
early ROM. Isolated coronoid frac-
tures are often associated with liga-
ment injuries; thus, congruent reduc-
tion of the elbow should be assessed
regularly in the early recovery period
to detect intervening instability.
Olecranon fractures are rarely
treated conservatively, but nonsurgi-
cal management may be appropriate
when the patient is inoperable or in
low-demand patients with nondis-
placed fractures with an intact exten-
sor mechanism.
16
Close monitoring is
important in these patients to assure
proper bone healing and mainte-
nance of anatomic reduction. The el-
bow is immobilized in the maximal
amount 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 prevented
until complete bone union is docu-
mented. In a compliant patient, auto-
assisted active ROM exercises in a
standing position may be started at 2
weeks postoperatively, four times per
day. However, use of a long arm re-
movable splint is indicated until ra-
diologic bone union.
Surgical
In adults, most olecranon and Monteg-
gia fracture-dislocations are treated
with anatomic reduction and fixation.
The global surgical approach for prox-
imal ulna fractures is presented in Fig-
ures 6 and 7.
Olecranon Fractures
Isolated, simple noncomminuted
transverse olecranon fractures are
typically managed with tension band
wiring (TBW) through a posterior
approach. TBW creates a dynamic
compressive force across the frac-
ture.
35
TBW is contraindicated, how-
ever, in comminuted fractures and
some oblique fractures. Olecranon
fractures distal to the bare area in-
volving the base of the coronoid are
also poor candidates for TBW. Two
smooth Kirschner wires (1.6 mm or
2 mm) inserted from the proximal
olecranon traverse the fracture line
and engage the anterior ulna cor-
tex.
16,36
After engaging the second
cortex, the wires are slightly backed
out to prevent injury to surrounding
soft tissues. A figure-of-8 is formed
with one or two 18-gauge wires,
passing deep to the triceps tendon
and through a predrilled, 2-mm
transverse hole on the dorsal aspect
of the proximal ulna, at least 2 cm
distal to the fracture line. The pins
are bent over the tension band and
impacted to bury the ends in the tri-
ceps tendon. Alternatively, an in-
tramedullary screw can be used for
longitudinal fixation.
Combined fractures of coronoid, olecranon, and radial head. A, Sagittal CT
scan demonstrating a combined fracture of the olecranon and coronoid. This
represents an O’Driscoll type 3–subtype 2 fracture. B, Lateral radiograph of
the fracture shown in panel A managed with anatomic reduction and fixation
with 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 ratio
a
Plate should be adapted to the contralateral proximal ulna dorsal
angulation.
Figure 6
Management of Fractures of the Proximal Ulna
154 Journal of the American Academy of Orthopaedic Surgeons
Wilson et al
37
recently challenged
this treatment method and suggested
that precontoured plates provide
greater compressive force at the frac-
ture site for transverse olecranon
fractures. In addition, in comparing
TBW to plate fixation, there is a
greater risk of secondary displace-
ment, and removal of instrumenta-
tion is more often necessary with
TBW.
In comminuted or oblique olecra-
non fractures, a tension band can
overcompress the greater sigmoid
notch, thereby narrowing the articu-
lar surface. More importantly, a ten-
sion band does not provide sufficient
stability in complex fracture pat-
terns. In these specific cases, ana-
tomic reduction and rigid fixation
with interfragmentary screws and
plate fixation is mandatory. Plate fix-
ation is performed through a straight
posterior approach. In the setting of
complex elbow fractures, the authors
place the patient in a lateral decubi-
tus or prone position. The triceps in-
sertion must be protected, and plate
devices can be positioned superficial
to the tendon.
Alternatively, a small longitudinal
incision can be made in the tendon
to bury wires or a plate. Suture fixa-
tion with a Krackow or similar
tendon-grasping stitch may be used
to reinforce the triceps insertion in
cases of small and comminuted prox-
imal fragments. Comminuted articu-
lar fragments should be anatomically
reduced 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 and
grafting for complex comminuted
fractures. A thorough washout of the
joint is necessary before fixation to
remove any fracture debris from the
articulation. A “home run screw” for
intermediate olecranon fragments
has been shown to stabilize and opti-
mize the anatomically reduced artic-
ular surface
38
(Figure 8). Visualiza-
tion of the joint is necessary with
articular comminution. A lateral ap-
proach to the joint can be used as an
alternative to a straight posterior ap-
Algorithm of the management of coronoid fractures based on the O’Driscoll
classification. LCL = lateral collateral ligament, ORIF = open reduction and
internal 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
Dominique M. Rouleau, MD, MSc, FRCS
March 2013, Vol 21, No 3 155
proach. The collateral ligaments
must be protected to preserve joint
stability. The proximal fragment can
be reflected during identification and
fixation of the smaller, impacted or
displaced intra-articular fragments.
Fragments are reduced and fixed,
building from the distal to proximal
direction using interfragmentary
screws as much as possible.
On rare occasions, anatomic fixa-
tion of an olecranon fracture may
not be possible. Severely commi-
nuted fractures (ie, Schatzker type D)
and open fractures associated with
bone loss can preclude use of the
usual fixation techniques. The proxi-
mal bone fragment attached to the
triceps should be preserved as much
as possible. In some instances, the
distal and proximal bone can be
sculpted with a rongeur to create a
congruent contact surface.
39
The
fragments are then fixed with a plate
and screws. Some bone loss can be
accepted in the bare area. Bone graft
should be used to bring the proximal
ulna out to length at the posterior
cortex. A gap in the nonarticulating
bare area will fill with fibrous tissue
as long as the posterior cortex is rig-
idly fixed. To secure the repair,
tendon-grasping sutures are placed
in the triceps tendon and passed
through bone tunnels in the distal
fragment. Management of bone in-
sufficiency of the olecranon is based
in large part on biomechanical stud-
ies on the amount of bone required
to maintain stability. An et al
17
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 study
demonstrated 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 that
up 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 reattached
as dorsally as possible to maximize
triceps strength; however, even in the
optimal position, 24% of strength is
lost.
41
It is important to note that all
of these biomechanical studies as-
sume that the elbow is otherwise sta-
ble. For obvious reasons, olecranon
excision should be reserved only for
cases of nonreconstructable frac-
tures.
Coronoid Fractures
Fractures of the coronoid can be ap-
proached and fixed through a poste-
rior, medial, or lateral surgical ap-
proach. A posterior skin incision
with a lateral skin flap is preferred
when the lateral collateral ligament
is already ruptured and surgical
treatment of the radial head is
planned.
42
The coronoid process can
be approached anterior to the radial
head or when the radial head is re-
sected but before replacing it with a
prosthesis. During surgery, the fore-
arm should be pronated to protect
the posterior interosseous nerve.
Large coronoid tip fragments are re-
duced and fixed with compression
screws or threaded pins, which can
be placed anterograde or retrograde
under fluoroscopic or arthroscopic
visualization. For comminuted frac-
tures or smaller fragments not large
enough for screw placement, suture
fixation through the anterior capsule
adjacent to the coronoid fragments
encompassing the bone can provide
some stability. The suture is passed
through bone tunnels created from
the dorsal ulnar cortex into the frac-
ture bed. Two tunnels are created,
and the sutures are tied over the
bone bridge. Tunnels directed from
the more medial or lateral aspect of
the dorsal cortex prevent soft-tissue
irritation from suture material. The
ulnar nerve must be protected if
more medial tunnels are used.
Anteromedial facet fractures of the
coronoid are addressed through a
medial approach to the joint, but the
skin incision can be either medial or
posterior.
43
Initially, the ulnar nerve
is identified in the cubital tunnel and
can be released in situ for posterior
retraction to avoid postoperative
neuropathies. The flexor-pronator
muscle group is detached from the
medial epicondyle using an L-shaped
distal-to-proximal incision, preserv-
ing the medial collateral ligament at-
tachment. An opening of the joint
capsule permits excellent visibility
for anatomic fixation with screws
and, when possible, a buttress
plate
3,44
(Figure 9). Alternatively, a
flexor-pronator split, anterior to the
ulnar nerve, can be used.
The coronoid is critical to elbow
stability, and even small fractures
can have a significant impact on el-
bow biomechanics. Rigid fixation
techniques should be employed for
larger fragments to provide stability
and maximize the opportunity for
bone healing.
Combined Fractures
Combined coronoid and olecranon
fractures pose a challenge for proxi-
mal ulna fracture management. The
patient is positioned in a lateral de-
cubitus or prone position, and the
procedure is performed through a
posterior incision. The proximal
fragment of the olecranon is reflected
with the attached triceps to expose
the coronoid fragments. A useful
strategy employs fixation of the frag-
ments from distal to proximal. The
coronoid fragment is reduced with
the elbow in flexion. Anatomic re-
duction can be confirmed by elevat-
ing some soft tissue from the medial
and lateral aspects of the olecranon.
The collateral ligaments must be pre-
served or reinserted at the end of the
procedure to maintain stability. The
sublime tubercle is often fractured
and can be lifted to provide access to
Management of Fractures of the Proximal Ulna
156 Journal of the American Academy of Orthopaedic Surgeons
the other coronoid fragments. The
ulnar nerve must be protected during
any medial fracture exposure. Intra-
articular fragments are stabilized
with small screws or threaded wires.
Finally, the olecranon is reduced and
a posterior plate is applied to the
posterior ulna and olecranon (Figure
5). If malalignment at the radiocapi-
tellar joint is suspected, a contralat-
eral radiologic measurement of the
PUDA should be done to reproduce
the native proximal ulna angulation.
Postoperative
Management
Postoperative rehabilitation for olec-
ranon fractures depends on the soft-
tissue status and fixation stability.
For cooperative patients presenting
in whom solid fixation was achieved,
early active ROM exercises may be
started typically after 1 week of im-
mobilization for wound healing and
control of swelling. Passive ROM,
strengthening exercises, and weight
bearing are permitted after con-
firmed radiologic bone union. In
cases of compromised soft tissues
and thin skin, a dynamic splint
blocked in extension may be used
until the wound has healed. Flexion
can progressively be allowed at a
controlled rate (eg, increments of 15°
per week), depending on the quality
of the soft tissue. ROM exercises
may be delayed and the elbow may
be immobilized for 2 weeks or more
if strong fixation was not possible.
Pearls and Pitfalls
Preoperative planning is critical
when approaching proximal ulna
fractures (Table 1). Stable anatomic
fixation of all fragments is necessary
to restore normal articular anatomy
of the elbow. Simple fractures can be
fixed with a tension band or plate
and screws; more complex fractures
require plate-and-screw fixation. The
coronoid process can be approached
from a medial, posterior (through
the olecranon fracture site), or lateral
approach. Intermediate fragments
Table 1
Pearls and Pitfalls in the
Management of Proximal Ulna
Fracture
Pearls
Preoperative planning
Stable fixation of all fragments
Simple fractures: tension band or plate
Complex fractures: plate and screws
Coronoid process can be approached
from medial, posterior, or lateral
Radial head can be approached from
lateral or posterior
Fix intermediate fragments first, fix cor-
onoid fragments distal to proximal
Intraoperative fluoroscopy
Test the elbow through a full range of
motion for stability, range, and con-
gruence
Pitfalls
Failure to identify and fix all fragments
leads to loss of reduction or instability
Nonanatomic reduction of the proximal
ulna leads to radial head subluxation,
bony impingement, and decreased
motion
Poorly placed hardware or screws and
pins 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, Postoperative
lateral radiograph demonstrating reduction and fixation done using the medial approach and a mini fragment plate and
screws. Medial and lateral ligaments were repaired with bone anchors.
Figure 9
Dominique M. Rouleau, MD, MSc, FRCS
March 2013, Vol 21, No 3 157
need to be fixed first in order to cre-
ate larger fragments that are subse-
quently reduced to more proximal
fragments as well as to facilitate an
anatomic articular reduction.
Nonanatomic reconstruction of the
proximal ulna can cause radiocapi-
tellar malalignment or dislocation.
Narrowing the greater sigmoid notch
by fixing the proximal fragment in
flexion limits motion. Poorly posi-
tioned instrumentation can limit mo-
tion or cause ulnar nerve symptoms.
Incorrectly placed screws or pins can
affect motion or damage articular
cartilage. Intraoperative fluoroscopy
is helpful to evaluate the final reduc-
tion of the fracture and the position
of instrumentation. Stability of the
fixation, impingement of hardware,
and articular incongruity should be
evaluated by taking the elbow
through a full ROM. Elbow move-
ment should be smooth, without
scraping, grating, or clicking.
Outcome
Clinical results after olecranon frac-
ture fixation are available for small
series reported in the literature (Ta-
ble 2). On average, patients lost 30°
of ulnohumeral ROM after plate and
combined plate-and-screw fixation,
although there was improvement in
ROM after late instrumentation
removal.
45-47,49,50
Device removal was
required for 18% to 62% of the
cases and is the most frequent com-
plication after olecranon fixation.
Functional outcome expressed by the
Mayo Elbow Performance Score is
good to excellent in the great major-
ity of patients.
45-47,49
Disabilities of
the Arm, Shoulder, and Hand
(DASH) and QuickDASH scores are
reported as being between 9 and 17
for olecranon fractures managed
with plate fixation.
45-47,49
Posttrau-
matic arthritis occurs in 21% to
48% of patients in long-term
follow-up studies.
49,50
Anderson
et al
48
summarized the orthopaedic
literature and illustrated the higher
rate of device removal following
olecranon 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 facet
of the coronoid susceptible to in-
jury.
51
Doornberg and Ring
52
demon-
strated the importance of secure fixa-
tion of anteromedial facet fractures
of the coronoid; limited treatment
may compromise elbow stability,
leading to varus subluxation, early
arthrosis, and poor to fair results in
the Broberg-Morrey score.
Summary
Proximal ulna fractures challenge
even the most experienced surgeon.
Recognition and restoration of each
patient’s unique proximal ulna anat-
omy is essential for adequate ana-
tomic restoration. Thorough evalua-
tion of the injured extremity and
interpretation of radiologic images
are essential for adequate diagnosis,
preoperative planning, and optimiza-
tion of treatment outcomes. Clinical
outcome studies reveal high rates of
postoperative complications, includ-
ing symptomatic instrumentation
and posttraumatic arthritis. A me-
thodical approach to surgical deci-
sion making maximizes the opportu-
nity for successful reconstruction of
elbow anatomy and biomechanics.
Further research and innovation in
terms of surgical technique and de-
vices will be useful to help improve
outcomes in these complex fractures.
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Table 2 (continued)
Outcomes Following Plating of Olecranon Fracture
Mean ROM
(Flexion-extension/
Pronation-
supination
[degrees])
Mean MEPS
Score
Mean DASH
Score
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Broberg-
Morrey Score
OA
(%)
Hardware
Removal
(No.)
Nonunion
(No.)
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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
Dominique M. Rouleau, MD, MSc, FRCS
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Management of Fractures of the Proximal Ulna
160 Journal of the American Academy of Orthopaedic Surgeons