Olecranon Fracture
Upper LimbOverview
Olecranon fractures are breaks in the proximal ulna at the elbow joint, typically resulting from direct trauma or falls onto a flexed elbow. These fractures range from simple non-displaced breaks to complex comminuted injuries and require careful assessment to determine operative versus conservative management. Early recognition and appropriate referral are essential to prevent complications such as loss of extension, malunion, and functional impairment.
Pathophysiology
The olecranon is the bony prominence at the back of the elbow and serves as the insertion point for the triceps muscle, which provides elbow extension. Fractures typically occur from direct impact to the posterior elbow or from a fall on an outstretched hand with the elbow flexed. The fracture line may be simple (non-comminuted) or complex (comminuted), and displacement depends on the force and direction of injury. Non-displaced fractures remain stable due to intact soft tissue attachments, while displaced fractures often require surgical fixation because the triceps pull disrupts alignment and prevents healing in proper anatomical position.
Patient Education
Olecranon fractures require urgent medical imaging and specialist assessment; many will need surgery to restore the ability to straighten your elbow properly and regain full function.
Typical Presentation
Site
Posterior elbow over the olecranon prominence; may extend into the elbow joint
Quality
Sharp, localized pain; swelling and bruising over the fracture site
Intensity
Severe pain (7-9/10) immediately after injury; pain increases with attempted elbow extension or weight-bearing through the arm
Aggravating
Attempted elbow extension, lifting or carrying objects, pressure over the olecranon, flexion beyond 90 degrees in some cases
Relieving
Rest, immobilization in flexion, ice application, elevation, anti-inflammatory medication
Associated
Significant swelling and ecchymosis, visible deformity or step-off at fracture site, loss of active elbow extension, elbow held in flexed position, possible crepitus on palpation, inability to perform triceps resistance testing
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Elbow Extension Test (Fracture Rule-Out)
Procedure
Patient seated with the arms by the sides, palms up. Ask the patient to straighten both elbows fully, locking them out, and compare the two sides.
Positive Finding
Unable to straighten the injured elbow fully compared with the other side.
Sensitivity / Specificity
Reference: Appelboam A, Reuben AD, Benger JR, Beech F, Dutson J, Haig S, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ. 2008;337:a2428.
Interpretation
Anyone who cannot fully straighten the elbow after an injury needs an X-ray. Full extension makes a fracture much less likely, but an olecranon fracture can still be present, so check the olecranon for tenderness and review in 7–10 days if pain persists. From 1,740 adults and children with an acute elbow injury in five emergency departments (Appelboam 2008). The figures are for ANY elbow fracture, not olecranon fractures alone. Being able to fully straighten the elbow made a fracture unlikely, but two olecranon fractures were missed in patients who could extend fully, so check the olecranon carefully. Anyone who cannot fully straighten the elbow after an injury needs an X-ray: about half have a fracture.
Active Elbow Extension Against Gravity (Triceps Mechanism)
Procedure
Patient seated, shoulder raised forward with the elbow bent (or lying face down with the arm over the edge). Ask the patient to straighten the elbow against gravity.
Positive Finding
Unable to straighten the elbow against gravity.
Interpretation
Inability suggests the triceps mechanism is disrupted: a displaced olecranon fracture or a triceps tendon rupture. These usually need surgery; refer urgently with the arm in a sling.
Olecranon Palpation
Procedure
Gently palpate the olecranon and the back of the elbow, feeling for a gap, step or grating, and check the skin over it.
Positive Finding
A palpable gap or step in the olecranon, crepitus, or marked focal bony tenderness.
Interpretation
Strongly suggests an olecranon fracture; immobilise and refer for an X-ray. A wound over the olecranon may mean an open fracture, which is an emergency.
Swelling and Effusion Assessment
Procedure
Look at and feel the elbow for swelling. Check the soft spot on the outside of the elbow (between the radial head, lateral epicondyle and olecranon) for fullness.
Positive Finding
Rapid swelling, fullness in the lateral soft spot, or bruising.
Interpretation
A tense joint effusion after injury suggests a fracture inside the joint. Swelling limited to the back of the elbow may be a traumatic olecranon bursitis. Either way, after a fall, imaging is needed if the elbow cannot be fully straightened.
Bony Tenderness Screen
Procedure
Palpate the olecranon, radial head, and medial and lateral epicondyles in turn.
Positive Finding
Focal tenderness over one of the bony points.
Interpretation
Locates a possible fracture. Radial head tenderness after a fall on the outstretched hand is common and often means a radial head fracture. Focal bony tenderness with loss of full extension needs an X-ray.
Neurovascular Status Screening
Procedure
Check the radial pulse and capillary refill, then sensation and power in the radial, median and ulnar nerve areas of the hand. Record findings before and after any immobilisation.
Positive Finding
Reduced pulse, slow capillary refill, or a sensory or motor deficit.
Interpretation
Nerve or vessel injury is uncommon with olecranon fractures but must be checked and recorded. The ulnar nerve runs just behind the medial epicondyle and is the most at risk. A cold, pale hand or increasing pain with passive finger stretch is an emergency.
⚠ Red Flags
- •Severe deformity or angulation of the elbow suggesting displaced fracture
- •Neurovascular compromise (pale, pulseless limb; pins and needles; inability to move fingers)
- •Open fracture with skin breach or visible bone
- •Associated injuries to the forearm, wrist, or hand from high-energy trauma
- •Intra-articular involvement with joint effusion visible on imaging
- •Fracture with dislocation of the elbow joint
⚡ Yellow Flags
- •High-energy mechanism suggesting polytrauma requiring comprehensive assessment
- •Delay in seeking care beyond 48 hours from injury
- •Anxiety about loss of elbow function affecting compliance with treatment
- •Substance use or intoxication at time of injury affecting reliability of history
- •Cognitive impairment limiting ability to comply with immobilization or rehabilitation protocols
- •Previous ipsilateral upper limb injury affecting rehabilitation tolerance
Osteopathic Techniques
Refer first
A suspected olecranon fracture needs orthopaedic review and imaging. Non-displaced fractures are splinted, then started on early active movement while avoiding active extension, with serial X-rays to check the fracture does not displace; displaced (type II–III) fractures generally need surgery. Refer before using manual techniques on the arm.
- Reference bookSullivan et al. · StatPearls 2023
Rehabilitation Exercises
Pendulum Elbow Swings (Codman's Pendulum Modification)
Supine Elbow Flexion and Extension with Gravity Eliminated
Triceps Stretch (Hands Behind Head, Gentle Pull)
Elbow Extension Stretch (Supinated Forearm, Gentle Overpressure)
Triceps Isometric Contractions (Arm Flexed at 90 Degrees)
Triceps Dips (Chair Supported, Partial Range)
Resistance Band Elbow Extension (Seated, Supinated)
Dumbbell Triceps Extension (Supine or Seated)
Scapular Stabilization (Prone Y-T-W Raises)
Single-Arm Balance and Reach (Standing, Post-Healing Phase)
Walking with Arm Movement (Unrestricted Limb Emphasis)
Pronation and Supination Active Range of Motion (90 Degrees Elbow Flexion)
Referral Criteria
- •Any suspected olecranon fracture requires immediate referral to emergency department for X-ray imaging and specialist orthopaedic assessment
- •Displaced fractures (>2mm displacement) typically require surgical fixation and orthopedic surgery consultation
- •Open fractures require emergency orthopedic surgery and possible infectious disease consultation
- •Fractures with neurovascular compromise require immediate emergency referral
- •Comminuted fractures involving >25% of the articular surface require orthopedic specialist evaluation
- •Any fracture with associated elbow dislocation requires emergency orthopedic assessment
- •Post-surgical olecranon fractures with complications (infection, non-union, loss of motion) require return to orthopedic surgeon
- •Patients with loss of triceps function or persistent extension deficit despite appropriate treatment require physiotherapy and possible specialist reassessment
- •Any concern for compartment syndrome (pain out of proportion, paresthesia, pallor) requires emergency vascular surgery consultation