Radiographs of the same visit showed healing of the fracture with a stable hardware position (Figures 3A, 3B). The sling was then discontinued to allow active extension and begin isometric strengthening exercises followed by graduated resistance training as tolerated. At three months, she demonstrated 10-to-130-degrees of active elbow motion with no pain at the fracture site. Outpatient physical therapy (PT) was initiated allowing active elbow flexion and gravity-assisted extension along with a weight-bearing restriction for up to six weeks postoperatively. The sutures were removed on the 10th postoperative day and the arm was placed in a sling. A well-padded long-arm posterior splint was applied over sterile dressings keeping the elbow in 70-degrees of flexion. The ulnar nerve was found to be stable in the cubital tunnel and therefore no transposition was attempted. The triceps split was meticulously repaired, followed by standard wound closure in a layered fashion. The ROM was tested to check for any hardware impingement. Anatomic reduction, stability, and hardware position were verified by fluoroscopy (Figure 2C). Plate fixation was achieved with two 3.5-mm cortical screws into the ulnar shaft while three 2.7-mm (two cortical and one locking) screws were utilized proximally across the fracture line. The triceps attachment was split in the midline to accommodate the head of the plate close to the bone (Figure 2B). A pre-contoured low-profile proximal olecranon locking compression plate (DePuy Synthes, PA, USA) was placed along the dorsal surface. The fracture reduction and articular congruity were verified by multiplanar fluoroscopic images. One of them was utilized as a joystick to anatomically reduce the butterfly fragment. Multiple 0.045-inch Kirschner wires (K-wires) were utilized for provisional fracture fixation. The intraarticular butterfly fragment was found to be partially attached to the distal fragment. Direct reduction of the main fracture fragments was achieved by a pointed reduction clamp. Subtle comminution of articular and dorsal cortical margins was noted. The hematoma was evacuated, and fracture fragments were freshened (Figure 2A). The ulnar nerve was identified and protected throughout the operation. Full-thickness flaps were created on either side. After sterile preparation and draping, a 10-cm midline posterior incision was made centering the fracture site with a smooth lateral curve around the tip of the elbow. A pneumatic arm tourniquet was applied but not inflated. A single dose of 2 g of cefazolin was given intravenously as surgical prophylaxis. Being medically well and active, she was recommended ORIF, which was performed as an outpatient procedure on day six post-injury.Īfter successful general anesthesia, she was placed in a semi-lateral position using a beanbag on a standard operating table with her left upper extremity resting over the body. Her medical problems were hypothyroidism and type II diabetes mellitus, controlled on regular oral medications. The patient was a non-smoker and an active community ambulator. We describe a case of displaced olecranon fracture in an older adult managed by open reduction and internal fixation (ORIF) by a low-profile locking plate, which led to satisfactory clinical and radiological outcomes. Therefore, recent attention has been directed towards surgical fixation in select elderly populations using newer generation osteosynthesis implants. However, healthy and active geriatric patients may have suboptimal outcomes with nonoperative treatment because of loss of elbow extension strength. Nonsurgical treatment in low-demand elderly patients has been shown to have acceptable outcomes while avoiding potential surgical complications. Despite fracture displacement, controversy exists between conservative and operative management among geriatric patients. Typically, the fracture tends to displace (Mayo type II) due to the pull of triceps insertion resulting in a large fracture gap. Olecranon fractures in the elderly, unlike in young individuals, occur after a ground-level fall from standing height.
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