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Olecranon Fracture

Fracture of the elbow tip caused by direct impact or triceps traction, often requiring tension band wiring or plate fixation. Restoring active extension is the primary rehabilitation goal.

Characteristics

Olecranon fractures account for approximately 10% of upper limb fractures in adults [1]. The olecranon forms the proximal end of the ulna and serves as the insertion point for the triceps brachii muscle. The injury mechanism is either direct (fall on the flexed elbow tip) or indirect through sudden triceps traction during eccentric contraction in hyperflexion. The fracture disrupts the elbow extensor mechanism, causing loss of active extension against gravity, a pathognomonic clinical sign. Incidence is bimodal: young subjects (sports injuries, accidents) and elderly patients (fall from standing height on osteoporotic bone) [2].

Treatment is surgical in 85-90% of cases because triceps traction systematically displaces the proximal fragment. Techniques include tension band wiring with figure-of-eight cerclage (gold standard for simple transverse fractures), posterior anatomical plate fixation (comminuted or oblique fractures), and interfragmentary screw fixation [3]. Only stable non-displaced fractures (Mayo Type I) may be treated conservatively.

The main risk is post-operative stiffness, as the elbow is the joint most prone to post-traumatic stiffening due to its thick capsule and tendency for heterotopic ossification.

  • The olecranon is the tip of the greater sigmoid cavity of the ulna (trochlear notch), forming with the humeral trochlea the humeroulnar joint. It receives the terminal insertion of the triceps brachii and anconeus. Its subcutaneous position makes it vulnerable to direct trauma.
  • Direct mechanism: fall on the flexed elbow tip (60% of cases). Indirect mechanism: violent eccentric contraction of the triceps against a forcefully flexed elbow (40%). In elderly patients, low-energy trauma is sufficient on osteoporotic bone.
  • Risk factors: osteoporosis, contact sports (rugby, judo), working at height, history of elbow fracture. Advanced age and female sex increase the risk on osteoporotic bone.
  • Complications: joint stiffness (most frequent complication, 10-30%), hardware irritation requiring removal (20-80% depending on series), heterotopic ossification, nonunion (rare, 5%), long-term post-traumatic arthritis.

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  1. Type I – Non-displaced, stable

    Non-displaced fracture or displacement less than 2 mm, with intact extensor mechanism. Stable joint. Conservative treatment possible with brachioantebrachial splint for 3-4 weeks. Excellent prognosis with early mobilization.

  2. Type II – Displaced, stable

    Fracture displaced more than 2 mm with disruption of the extensor mechanism, but stable humeroulnar joint. Surgical treatment by tension band wiring or plate fixation. Subtypes: IIA (non-comminuted) and IIB (comminuted). Represents the majority of operated fractures.

  3. Type III – Unstable

    Fracture with humeroulnar joint instability, often comminuted with articular surface involvement. Subtypes: IIIA (non-comminuted) and IIIB (comminuted). Mandatory surgical treatment by anatomical plate fixation. More guarded prognosis with increased risk of stiffness and arthritis.

Medical and Surgical Management

  • Tension band wiring with figure-of-eight cerclage and Kirschner wires: gold standard for simple transverse fractures (Mayo Type II). Biomechanical principle of converting traction forces into compression. Hardware often bothersome under the skin requiring secondary removal.
  • Posterior anatomical pre-contoured plate fixation: indicated for comminuted, oblique, or Mayo Type III fractures. Provides more rigid fixation and allows early active mobilization from day 3. Healing rate above 95%.
  • Conservative treatment with brachioantebrachial splint at 90° flexion: reserved exclusively for stable non-displaced fractures (Mayo Type I). Immobilization for 3-4 weeks with weekly radiographic follow-up to monitor potential secondary displacement.

Physiotherapy treatment

  • Early mobilization upon surgical clearance (day 3-7 if stable fixation). Progressive active flexion within pain-free range, active extension against gravity. Avoid forced passive extension which may compromise the fixation construct.
  • Prioritize flexion recovery through active-assisted exercises and gentle sustained stretching. Extension returns spontaneously under gravity. Cryotherapy and retrograde massage for post-operative edema drainage.
  • Forearm rotation: early active work from day 3 as not limited by the olecranon fracture. Exercises with dowel rod, active rotations with elbow at side. Mobilization of proximal and distal radioulnar joints.
  • Progressive triceps strengthening from week 6-8: isometric then concentric exercises with increasing resistance. Functional reintegration through closed-chain exercises. Return to sports from week 12-16 based on radiographic healing.

After the session

You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.

Questions About Elbow Rehabilitation

When should I start physiotherapy after elbow surgery?

Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.

What are the goals of elbow rehabilitation?

Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.

Is elbow rehabilitation painful?

The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.

Scientific sources

Average duration

8 to 16 weeks after fixation, up to 6 months for complete recovery

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