No generally accepted classification of olecranon fractures has been presented in the orthopaedic literature.

A simple classification of fractures of adult olecranon is proposed by C. L. Colton and used as a basis for making recommendations about treatment

1. Non-displaced or displacement less than 2mm.

2. Displaced fractures

a. Avulsion Fractures.

b. Oblique Fractures.

c. Comminuted Fractures

d. Fracture –Discolations.

3. Major classification systems, [1, 2, 3, 4]

1. The AO classification system

2. The Mayo Classification System, and

3. The Schatzker-Schmeling Classification System, have dominated the published data, with each system having both advantages and disadvantages.

The Schatzker-Schmeling classification system for olecranon fractures focuses specifically on fracture morphology and the biomechanical concerns related to each type of internal fixation (Table 2).

Fractures of the olecranon are usually caused by three main types of injuries

Direct violence, such as falling on the tip of the elbow.

Classification of olecranon fractures taken for study,

I. Undisplaced and stable fractures

To be considered un displaced and stable, the fractures must be displaced <2 mm, exhibit no change in position with gentle flexion to 900 with extension against gravity.

II. Displaced fractures

A. Avulsion fractures

A transverse fracture line separates a small proximal fragment of the olecranon process from the rest of the ulna.

B. Oblique and transverse fractures

The fracture line runs obliquely, starting near the deepest part of the semilunar notch and running dorsally and distally to emerge on the subcutaneous crest of the proximal part of the ulna. This fracture may be a single oblique line or it may have an element of comminution caused by a fracture in the sagittal plane or a central area of depression in the articular surface.

C. Comminuted fractures

This group includes all the severely comminuted fractures of the olecranon, which usually result from direct trauma to the posterior aspect of the elbow. There are multiple fracture planes, often with severe crushing of many fragments. There may be associated fractures of the distal end of the humerus, the shafts of the forearm bones, or the head of the radius.

D. Fracture-dislocations

The olecranon fracture is at or near the level of the tip of the coronoid process, so that a plane of instability is located through the fracture site and the radiob humeral joint as well, resulting in an anterior dislocation of the ulna and radius (Fig. 1).

Later, the practitioners slowly began to use the position of mid-flexion but, this frequently led to non-union because of wide separation of fracture fragments, resulting in decreased power of the triceps mechanism [3].

The dilemma for nonunion and stiffness led Lister to choose the fracture of olecranon to be the first fracture treated by open reduction and internal fixation using his method of asepsis with a wire loop 2. Modifications of this technique, which was the forerunner of the tension band technique advocated by the AO group are now in use.

Multiple methods of internal fixation have been proposed for olecranon fractures and the commonly used are

Open reduction and fixation with a figure- of-eight wire loop.

The choice of the method of internal fixation depends on the nature and location of the fracture, the amount of comminution and the age of the patient.

The advantages of open reduction and internal fixation include –

This method provides an anatomical reduction of the fracture and a congruous articular surface.

Immediately on arrival of the patient, if he/she was in shock, the level of shock was noted and managed accordingly. X-ray of the part was taken and the elbow was immobilized in whatever the position patients presence in a A/E POP posterior slab. The affected limb was kept elevated. Analgesics and antibiotics were given if necessary. Patient was then prepared for surgery and anesthesia after the pre-anesthetic checkup.

Following points were considered – (a) Age of the patient, (b) extent of damage to the articular surface, and (c) degree of comminution. The patients of extremes of age and the patients in whom operative risk was great were not taken up for surgery.

(a) Anesthesia – The operation was performed under general anesthesia or brachial block. (b) Position and Tourniquet – Mid arm tourniquet was applied with patient in supine or lateral position. Site of the surgery was thoroughly painted with iodine and spirit and draped. (c) Exposure – Exposure of the olecranon was done by Campbell’s posterolateral approach. A vertical incision was taken over the posterior aspect of the elbow about 2.5 cms proximal to olecranon, curving distally along the lateral aspect of olecranon reaching the subcutaneous border of the ulna and extending distally for about 7.5 cm distal to olecranon. Fascia was incised along the line of skin incision and fracture site was exposed. Fracture hematoma was cleared off and the fracture site was gently curettage. Accurate anatomical hairline reduction was achieved and held with either reduction clamp or long towel clip. Two K-wires are introduced parallel from the tip of the olecranon, that is, the proximal fragment across the fracture site to the distal fragment. Periosteum was stripped from the shaft of ulna distal to fracture site and a transverse hole was drilled approximately 3–5 cm distal to fracture site. A No.18 stainless steel malleable wire was passed through this transverse hole and crossed over the posterior surface of olecranon in a figure-of-eight manner and then passed around the protruding Kirschner wires and tightened using AO tensioner and then secured with a twist. Bend the proximal ends of the Krishner wires 1800 and tap the cut ends back into the proximal fragment. Accuracy of reduction was that stability was tested by moving the joint. Wound closed in layers and sterile dressing and compression bandage given. For communited olecranon fracture, exposure of the olecranon was done by Campbell’s posterolateral approach. A vertical incision was taken over the posterior aspect of the elbow about 2.5 cm proximal to olecranon, curving distally along the lateral aspect of olecranon reaching the subcutaneous border of the ulna and extending distally for about 7.5 cm distal to olecranon. Fascia was incised along the line of skin incision and fracture site was exposed. Fracture hematoma was cleared off and the fracture site was gently curettage. Accurate anatomical hairline reduction was achieved and held with either reduction clamp olecranon hook plate was applied on the posterior surface with cortical screws after drilling and tapping, through wash was given, wound closed in layers and sterile dressing was applied [5, 6].

Post-operative Management

All the patients were treated with Inj. Cefotaxime 1gm twice daily for 5 days followed by Tab Cefixime 200 mg daily for 5 days. Some cases were treated with Inj. Amikacin 500 mg daily for 3 days.

This part of the study should be done very carefully and meticulously. In our study, the patients on discharge were advised to report for follow-up after 6 weeks and 12 weeks and thereafter every 3 months. The result is assessed 3 months after the procedure. At follow-up, a detailed clinical examination was done and patient was assessed subjectively for the symptoms such as pain, swelling, and restriction of joint motion. On clinical examination, swelling of the joint, tenderness, movements of the elbow joint, prominence of head of cancellous screw, nutrition, and power of the muscles acting on the joint were noted (Table 3).

Patients were instructed to carry out physiotherapy in the form of, active flexion-extension, and pronation-supination without loading (Table 4).

Patients were instructed to carry out physiotherapy in the form of active flexion extension and pronation supination without loading (Table 5).

Check X-ray was taken and when final X-ray showed union, implant was removed. In all patients duration after which they returned to job was noted (Table 2).

Although there are many methods of evaluation of results given by many authors, the treated olecranon fractures by Tension band wiring and olecranon hook plate were evaluated in our study with Mayo Elbow Performance score (MEPS) (According to Morrey BF, An KN. Functional evaluation of the elbow) [7, 8]. for functional outcome and standard radiographs for radiological outcome (Fig. 2 and 3).