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
Loss of Active Extension Test
Procedure
Patient is positioned supine or seated with the elbow flexed. Ask the patient to actively extend the elbow against gravity and resistance. Observe for inability or severe weakness in elbow extension.
Positive Finding
Inability to actively extend the elbow or maintain extension against gravity, indicating disruption of the triceps mechanism or fracture displacement
Sensitivity / Specificity
Unknown / Unknown
Interpretation
A positive finding strongly suggests olecranon fracture, especially if combined with clinical deformity, swelling, and pain. Loss of extension indicates either significant fracture displacement or triceps avulsion.
Clinical Deformity and Palpation Test
Procedure
Palpate the olecranon process with the elbow flexed at 90 degrees. Assess for step-off, crepitus, swelling, ecchymosis, and bony discontinuity along the posterior elbow.
Positive Finding
Presence of a palpable step-off, crepitus, gap in the olecranon outline, or gross deformity of the posterior elbow
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Physical deformity and step-off are highly suggestive of olecranon fracture. Crepitus indicates fracture surfaces in contact. These findings warrant immediate imaging confirmation.
Swelling and Effusion Assessment
Procedure
Inspect and palpate the posterior and lateral elbow for joint effusion. Assess the degree of swelling and fluctuance around the olecranon bursa and joint capsule.
Positive Finding
Marked swelling, bulging of the posterior joint capsule, or fluid wave suggesting hemarthrosis
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Rapid swelling with hemarthrosis is consistent with intra-articular fracture. However, this finding is non-specific and requires imaging to confirm fracture and assess fracture pattern.
Posterior Elbow Tenderness Test
Procedure
Palpate directly over the olecranon process and the surrounding posterior and lateral aspects of the elbow. Grade severity of point tenderness.
Positive Finding
Severe, well-localized tenderness directly over the olecranon with reproduction of pain on palpation
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Focal tenderness over the olecranon is suggestive but not diagnostic. Must be correlated with mechanism of injury, loss of extension, and imaging findings to confirm fracture.
Elbow Range of Motion Assessment
Procedure
Passively and actively measure elbow flexion and extension. Note any pain-limited range, guarding, or mechanical block to motion.
Positive Finding
Severe limitation of flexion and/or extension with pain and guarding; mechanical block to full extension in displaced fractures
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Marked loss of extension and guarding on motion are consistent with fracture. Passive range of motion may reveal mechanical block from fracture fragment displacement, supporting fracture diagnosis.
Neurovascular Status Screening
Procedure
Assess distal pulses (radial and ulnar), capillary refill, hand colour, and sensation in the radial, median, and ulnar nerve distributions. Test motor function of intrinsic hand muscles.
Positive Finding
Diminished or absent distal pulses, delayed capillary refill, neurosensory deficit, or motor weakness suggesting vascular compromise or nerve injury
Sensitivity / Specificity
Unknown / Unknown
Interpretation
While neurovascular injury is relatively uncommon in simple olecranon fractures, it is critical to screen preoperatively and postoperatively. Positive findings suggest displaced fracture with vascular compromise or nerve traction injury requiring urgent intervention.
⚠ 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
Region
Cervical spine and shoulder girdle
Technique
Soft Tissue
Rationale
Release tension in upper trapezius, levator scapulae, and paraspinal muscles to improve postural support and reduce compensatory strain during immobilization period; addresses proximal kinetic chain dysfunction that may develop from guarding.
Region
Shoulder complex (glenohumeral, acromioclavicular, scapulothoracic joints)
Technique
Articulation
Rationale
Maintain shoulder girdle mobility and prevent adhesions during the immobilization phase of fracture healing; gentle active-assisted mobilization of the shoulder reduces risk of adhesive capsulitis and maintains proprioceptive input.
Region
Wrist and hand
Technique
Soft Tissue
Rationale
Address intrinsic and extrinsic hand muscle tension and maintain lymphatic drainage to reduce distal swelling; supports circulation in immobilized limb and reduces stiffness in non-affected joints.
Region
Thoracic spine and ribcage
Technique
Soft Tissue
Rationale
Release compensatory tension in thoracic muscles and improve ribcage mobility to optimize respiratory function and postural control during recovery; supports overall kinetic chain function.
Region
Elbow and surrounding tissues (post-immobilization, physician clearance required)
Technique
Soft Tissue
Rationale
Following medical clearance and fracture union confirmation, gentle soft tissue mobilization addresses muscular guarding, adhesions, and scar tissue to facilitate progressive restoration of mobility and function.
Region
Lymphatic system (upper limb)
Technique
Lymphatic
Rationale
Enhance lymphatic drainage from the immobilized limb to reduce swelling and edema that may limit recovery; supports cardiovascular return and tissue healing during the acute and subacute phases.
Add-On Approaches
Chinese Medicine
Acupuncture points LI-10 (Quchi) and LI-11 (Pool at the Bend) may be useful post-immobilization to promote Qi circulation and reduce pain; moxibustion may support healing phase; herbal formulas such as Du Zhong (Eucommia) may support bone union.
Chiropractic
Gentle mobilization of the cervical and thoracic spine to maintain alignment and reduce compensatory strain; once fracture union is confirmed, controlled articular mobilizations of the elbow joint may aid restoration of extension.
Physiotherapy
Progressive resistance exercises, proprioceptive retraining, functional movement patterns; eccentrical strengthening of triceps post-union; ultrasound therapy may aid soft tissue healing in post-immobilization phase.
Remedial Massage
Soft tissue therapy to upper trapezius, levator scapulae, and rotator cuff during immobilization; post-immobilization cross-friction massage to address scar tissue and myofascial restrictions around the fracture site and elbow joint.
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