Injury to the olecranon is relatively frequent. Although much less common in minors, it accounts for 5–7% of elbow fractures in adults ^[1]. Its subcutaneous location makes it susceptible to direct trauma, which typically results from a direct impact to the elbow’s point or a fall onto an extended arm ^[2]. Strong biceps contractions against a fixed ulna can also result in olecranon fractures. Simple non-displaced fractures or complicated fractures involving elbow joint dislocation are both possible. Intact ligamentous structures, especially the anterior part of the medial collateral ligament, are indicated by the displacement of Mayo Type II fractures with a stable ulnohumeral joint ^[3,4]. Plain radiographs are typically adequate to confirm the diagnosis and formulate a management strategy. In some circumstances, a computed tomography (CT) scan may be necessary to evaluate the injury’s seriousness and determine a fixation strategy. The gold standard of care for comminuted fractures, Monteggia fractures, fractures accompanied by dislocations, and oblique fractures with distal extension impacting the coronoid is fixation with plates and screws ^[5]. With surgical fixation, a good recovery is expected, though the final result may be influenced by the extent of the soft-tissue damage, the presence of multiple fracture fragments, and the intra-articular nature of the injury. In our case report, we have treated a Mayo type IIB olecranon fracture with open reduction internal fixation with fragment-specific plates.

Case presentation

A male in his 20’s complained of right elbow pain and movement restrictions for 1 day when he visited the outpatient department. Before going to the hospital, he appeared to be in good health. However, the day before, he fell off his bike, and as a result, he experienced an acute onset, continuous, aching, moderately severe elbow pain that was exacerbated by movement and alleviated by immobilization, rest, and analgesics. On examination of the right elbow, there was tenderness, swelling, and restriction of movements. Active flexion was possible up to 30°.

Investigations

The right elbow’s displaced comminuted olecranon fracture was identified by a normal radiograph as shown in (Fig. 1).

A 3D CT scan was done for better delineation of the fracture fragments as shown in (Fig. 2).

Treatment

The surgical procedure was done after routine laboratory investigations and pre-anesthesia checkup under general anesthesia with the patient in the left lateral position. After exsanguination, the upper limb tourniquet was inflated to 220 mm of Hg. A 15 cm incision was made over the posterior aspect of the right elbow via the lateral paraolecranon approach as shown in (Fig. 3). The ulnar nerve was identified and protected throughout the surgery. After elevating the triceps, the fracture site and post-erolateral and post-eromedial fragments were identified. The fracture was reduced using pointed reduction forceps and two 2.7 mm L plates were used to fix the post-eromedial and post-erolateral fragments using locking and cortical screws as shown in (Fig. 4). Final reduction was checked using fluoroscopic guidance and closure was done in layers.

Outcome and follow-up

An acceptable fracture reduction was visible on a post-operative radiograph as shown in (Fig. 5). Elbow range of motion was started on post-operative day 2 as per patient tolerance.

On follow-up at 2 months, the patient had full range of motion of the elbow with no complaints.

Olecranon fractures frequently affect the elbow’s articular surface. In 20% of instances, post-traumatic arthritis develops, and this result is linked to chronic malreduction of >2 mm of the articular surface ^[6]. Accidental malreduction by reducing the larger sigmoid notch in fractures with considerable comminution may increase the patient’s risk for developing arthritis ^[7]. For unstable fracture patterns with significant comminution, a fracture line exiting distal to the semilunar notch (Mayo type IIB), and fracture-dislocations (Mayo type III), plate and screw fixation is advised ^[8]. Fragment plate fixation is designed to minimize subcutaneous plate prominence without sacrificing stability, thus decreasing the rate of symptomatic implants and potentially the need for implant removal. Mini-fragment fixation has also been found to be a viable alternative in clavicle, talar neck, and tibial plafond fractures ^[9,10]. Fracture stabilization with mini-fragment plates in comminuted fractures involving multiple fragments is linked to a decreased incidence of symptomatic implants, whereas there is no discernible difference in terms of post-operative complications or reoperations ^[8].

In order to effectively categorize olecranon fractures according to displacement, comminution, and stability, the Mayo classification was developed. With appropriate CT scan imaging and pre-operative planning, individual fragments of these comminuted fractures can be delineated, and fragment specific implants can be used, producing a favourable radiological and clinical result with minimal complications.

Fragment specific implants can be used in comminuted olecranon fracrures for favourable radiological and clinical result with minimal complications. In case of comminuted fracture, fixation using plates helps to maintain ulnar length and provides good stability as compared to tension band wiring.