Olecranon Fracture Fixation (ORIF) Info Evidence Consent
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
Why this operation has been suggested
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow and arrange imaging if it is needed. This tells us whether the broken bone at the point of your elbow has moved out of place.
If the pieces have barely moved, the break can often be managed without surgery, using a splint and check X-rays to make sure nothing shifts. This is usually the first option we discuss. Surgery is suggested when the break has moved enough that it will not heal in a useful position on its own. The aim of the operation is to hold the pieces back in their normal position while they join together, so the elbow surface stays smooth. A rough surface can lead to wear-and-tear arthritis in the joint over time. Holding the bone securely also lets you start moving the elbow early, which lowers the chance of lasting stiffness. Most people who have this operation keep their implants in place, and only 3% experience movement of the implant afterwards.
Before the operation
Once surgery is planned, we will give you clear instructions to follow. You will need to stop eating and drinking seven hours beforehand. We ask for seven hours rather than the usual six so your time can be brought forward if the theatre list runs early. Some medications can affect the operation, so bring a written list of everything you take and we will tell you which ones to pause. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing with sleeves that slide over your elbow easily. Imaging such as X-rays, MRI or ultrasound may be arranged beforehand to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, but most people do not.
On the day
You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who looks after your anaesthetic and pain relief. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home, depending on the procedure and how your recovery is going.
What the operation involves
The operation is called open reduction and internal fixation. Open means the surgeon reaches the break through one cut at the back of your elbow, over the point of the elbow itself. Reduction means the broken pieces are eased back into their normal position, and internal fixation means they are held there with metal implants while the bone joins together.
The surgeon chooses the implant that suits your fracture, because no single technique suits every break. For a simple break in two pieces, the pieces may be held with a wire loop that presses them together as you move, or with a screw placed down the middle of the bone. For breaks in several pieces, or in softer bone, a plate moulded along the back of the elbow and held with small screws is often used. Some breaks can be held with strong stitches anchored into the bone instead of metal. Whichever method is used, the aim is the same: a firm hold that lets you start moving the elbow early.
Once the pieces sit in their normal position and the implant is secure, the surgeon checks that the elbow surface is smooth and that the joint moves freely. The layers of tissue are stitched back together and the skin is closed with stitches, then covered with a dressing.
After the operation
When you wake up, your arm will rest in a simple sling for comfort. Nurses will check on you and give you pain relief if you need it. Someone should stay with you for the first 24 hours after you go home. Your team will tell you whether you go home the same day or stay one night in hospital. You can move around as soon as you feel steady, and the sling comes off for washing and for the exercises your team shows you. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Keep your hand and fingers moving from the first day, as this helps with swelling and comfort.
Recovery
For the first few days your elbow will be sore and swollen, and the skin around it may look bruised. This settles gradually. Keeping your hand and fingers moving from the first day helps, as does resting your arm up on pillows when you sit or sleep. Take the pain relief you have been given regularly at first rather than waiting for the pain to build.
Your arm rests in a simple sling for comfort in the early days. It comes off for washing and for your exercises. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will show you exercises that keep your elbow moving while the bone joins together, and she will make a splint if you need one. You will keep your fingers and hand moving from the start, and gentle elbow movement is added as the break settles. Everyday tasks take some planning at first: you will need help with meals, dressing and carrying things until your arm is steady again.
As the swelling settles and movement returns, you will notice the exercises become easier. Once your surgeon is happy the bone is joining well, the sling comes off for good and you start using the arm for light tasks around the home. Heavier lifting, sport and driving come later, once your therapist and surgeon agree the elbow is strong enough. If driving is on your list, see our guide to driving after upper-limb surgery for the rules that apply.
Everyone heals at a different pace, so your timeline may differ. Your surgeon and your hand therapist will guide you at each visit.
What can go wrong
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
The metal holding the bone can sometimes shift from where it was placed. You might notice a new sharp pain at the point of your elbow, a lump under the skin that was not there before, or the skin becoming sore or rubbed where the implant sits. If you feel this, call the clinic rather than waiting for your next visit.
The wires or implants can also press on or poke through the skin. This causes pain and skin irritation, and the wound can break down over the spot. Tell us promptly if you see this, as the implant may need to be taken out.
Infection is a risk with any operation. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the wound, fluid leaking from it, or a fever. If you notice any of these, contact the clinic the same day or go to the emergency department if you cannot reach us.
An infection can also slow down the joining of the bone. If healing seems to be taking much longer than your team expected, bring it up at your next review.
The nerve that runs behind the point of your elbow can become irritated. This can cause tingling, pins and needles or numbness down the outside of your forearm and into your little and ring fingers. Mention any of these feelings at your review, or call the clinic if they come on suddenly.
Some people notice a small loss of full straightening of the elbow, even when the break heals well. Others develop wear-and-tear arthritis in the joint over time, which can feel like aching, clicking or grinding. Both are worth raising at follow-up so your team can track them.
The bone can also fail to join, or join in the wrong position. If your elbow stays painful and unstable after several weeks of healing, we will check it with X-rays.
Smoking raises the chance of problems after this operation. If you smoke, talk to your GP about quitting before surgery.
The complications table on this page lists typical rates if you want the specifics.
When to call us
Most problems show up early, and we would rather hear about them straight away. Call us if you have a fever, if the wound becomes more red or starts leaking fluid, or if pain suddenly gets much worse. Go to emergency if you have swelling in your calf, shortness of breath, or chest pain. Call us as well if your fingers or hand go numb, feel cold, or you cannot move your arm. If you cannot reach us and something feels urgent, go to your nearest emergency department.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology
Bony Anatomy
- The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [3].
- The trochlea articulates with the ulna within the greater sigmoid notch to form the ulnohumeral, hinged, or trochoid portion of the elbow joint [3].
- The ulnohumeral articulation provides highly congruent anatomy through almost 180° of articular contact [3].
- The greater sigmoid notch of the ulna contains a bare area devoid of cartilage [3].
- The coronoid process has medial and lateral facets that buttress the trochlea anteriorly [3].
- The sublime tubercle is located just distal and medial to the coronoid and serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [3].
- The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle [3].
- The medial epicondyle forms the attachment site for the origins of the flexor pronator mass [3].
- The capitellum and radial head form the radiocapitellar joint [3].
- The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [3].
- The lesser sigmoid notch is the area of the ulna that articulates with the margin of the radial head at the proximal radioulnar joint [3].
- The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [3].
- The radial head articulates with both the capitellum and the lesser sigmoid notch [3].
- The lateral epicondyle is the origin of the lateral extensor musculature [3].
- The origin of the lateral ulnar collateral ligamentous complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [3].
- The distal humeral articulation is angled 30° from the longitudinal axis [3].
- The anterior humeral line should pass through the center of the axis of rotation [3].
- The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [3].
- The olecranon provides a broad attachment site for the triceps [3].
- The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [3].
- The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [3].
- There is a high correlation between the size of the radial head and capitellum on the left and right sides of the same individual [2, 3].
Ligaments and Soft Tissue
- Elbow stability is determined by primary stabilizers, which include the ulnohumeral articulation, the medial ulnar collateral ligament, and the lateral ulnar collateral ligament complex [1].
- Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [1].
- The medial ulnar collateral ligament is the primary valgus stabilizer of the elbow [4, 5].
- The anterior bundle of the medial ulnar collateral ligament is the most important component for stability [4, 5].
- The posterior bundle of the medial ulnar collateral ligament becomes taut at flexion beyond 120 degrees [4, 5].
- The lateral ulnar collateral ligament acts as a posterolateral stabilizer [4, 5].
- Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [4, 5].
- The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [4, 5].
- The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [4, 5].
- The joint capsule allows maximum distension at approximately 70 to 80 degrees of flexion [4, 5].
- Tensile forces are present at the medial elbow and compressive forces at the lateral elbow [4, 5].
- The triceps muscle has three distinct insertional areas to the olecranon: the posterior capsular insertion, the deep muscular portion, and the superficial tendinous portion [2].
- The deep muscular head of the triceps corresponds to the medial head of the triceps [2].
- The superficial tendinous portion of the triceps corresponds to the long and lateral heads [2].
- The width of the triceps insertion is 2.6 cm and is located 1.1 cm from the tip of the olecranon [2].
- The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [4, 5].
- The biceps brachii inserts at the ulnar margin of the radial tuberosity [4, 5].
- The primary elbow extensor, the triceps, inserts on the olecranon process [4, 5].
Biomechanics and Motion
- The normal elbow has a range of motion from 0° to 140° from extension to flexion [1].
- The normal elbow has a range of motion of 75° in pronation and 85° in supination [1].
- A functional arc for flexion and extension is 100° [1].
- A functional arc for forearm rotation is 100° [1].
- The angulation of the distal humeral articulation accounts for the change from a valgus carrying angle to a more varus position as the elbow is flexed [3].
Investigations
Physical Examination
- The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [1].
- Pathologic entities associated with these discrete compartments aid the examiner in detecting pathologic conditions [1].
- The soft tissue surrounding the elbow should be examined for previous skin incisions, grafts, eschar, or infection [9].
- Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [9].
- The contralateral elbow should be examined for comparison during range of motion assessment [9].
- If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [9].
- Pain should be assessed during the mid-arc or at the terminal ends of motion [9].
- Mid-arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [9].
- The ulnar nerve is of utmost importance during examination because of its anatomic proximity to the elbow [9].
- The posterior bundle of the medial collateral ligament forms the floor of the cubital tunnel along the course of the ulnar nerve [9].
- Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [9].
- An assessment for ulnar nerve subluxation should be performed [9].
- Subluxation of the ulnar nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [9].
- The presence of a prior ulnar nerve transposition should be verified if there is a history of prior surgical procedures [9].
Imaging
- Plain radiographs remain the hallmark and the best screening test for elbow evaluation [1].
- AP, lateral, and oblique radiographs are standard for elbow imaging [9].
- Serial radiography is used as follow-up when heterotopic ossification is present [9].
- Primary bony landmarks identified on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [9].
- CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [9].
- Three-dimensional CT is used to check for heterotopic ossification [9].
- CT is not necessary when the stiffness is entirely soft-tissue related [9].
- CT is beneficial if any joint incongruity or abnormal bony anatomy is present [9].
- MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [9].
- CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [11].
- MRI may be most helpful in evaluating associated injuries including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [11].
- Radiographic evaluations are essential when diagnosing an osteochondritis dissecans lesion of the elbow [12].
- Important aspects of osteochondritis dissecans lesions may be better seen with MRI [12].
- Standard AP and lateral radiographs typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa in elbow osteoarthritis [13].
- Joint spaces at the ulnohumeral joint are usually preserved in elbow osteoarthritis [13].
- Joint spaces at the radiocapitellar joint are mildly narrowed in elbow osteoarthritis [13].
- Loose bodies may be evident on radiographs, which typically underestimate the number present [13].
- CT may be useful for surgical planning in elbow osteoarthritis, allowing a detailed assessment of osteophytes and the presence of loose bodies [13].
References
[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Summary and Conclusions.
[2] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Annotated References.
[3] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Anatomy > Bony Anatomy.
[4] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > TABLE 2.3 Shoulder Spaces.
[5] Miller S Review Of Orthopaedics. Genetics of musculoskeletal conditions and abnormalities are summarized in Table 1.27 > TABLE 2.3 Shoulder Spaces.
[9] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.
[11] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.
[12] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.
[13] Aaos Comprehensive Orthopaedic Review 3. Arthritis and Arthroplasty of the Elbow > I. Osteoarthritis.
