Overview
The elbow is a hinge with very little tolerance: a fracture that steps the joint surface by a couple of millimeters produces a stiff, painful joint. The two fractures treated here are a distal humerus fracture, at the bottom of the upper arm bone, and an olecranon fracture, at the tip of the elbow. Open reduction and internal fixation (ORIF) puts the pieces back in position and holds them with plates, screws or a tension band rigidly enough that the elbow can move within days.
Early motion is the main goal. An elbow left in a cast for six weeks stiffens in a way that is hard to reverse, so the goal is fixation stable enough to bend on day one while the bone heals. Most are outpatient procedures at Bayside Surgery Center in Coconut Grove.
Who It's For
Dr. O'Donnell recommends fixation for most displaced olecranon fractures in adults, because the triceps pulls on the fragment and the fracture runs into the joint; a gap over about 2 mm on X-ray, or inability to straighten the elbow against gravity on exam, is the usual criterion. Distal humerus fractures are fixed when the joint surface is stepped, the fragments are displaced, or the fracture is unstable, which is most of them.
Undisplaced olecranon cracks with an intact extensor mechanism can be treated in a splint briefly, then early motion, with X-rays to confirm nothing moves. In elderly, low-demand patients with a shattered distal humerus and poor bone, plates may not hold, and Dr. O'Donnell discusses elbow replacement instead.
A fracture on the X-ray is not by itself the reason to operate. Dr. O'Donnell fixes an elbow when the displacement or joint step on X-ray or CT matches the exam, including whether the elbow can be straightened against gravity, and the pattern is one that does not hold in a splint. The olecranon fracture and distal humerus fracture pages describe how each is measured.
What the Procedure Involves
Surgery is performed under a regional nerve block with general anesthesia and takes one to two hours for an olecranon, two to three for a complex distal humerus, through an incision along the back of the elbow. The ulnar nerve is identified early and protected, and in distal humerus fractures often moved forward at the end so it does not lie against the plate.
For the olecranon the joint surface is reduced under direct vision and the fixation depends on the pattern. A simple transverse fracture is held with a tension band: two pins down the ulna and a figure-of-eight wire that turns the triceps pull into compression across the fracture. Comminuted or oblique fractures, and osteoporotic bone, get a contoured plate along the back of the ulna, which holds better.
For the distal humerus the joint surface is rebuilt first, fragment by fragment, then the block is fixed to the shaft with two plates on the inner and outer columns, set at 90° to each other or parallel. Locking screws are used in poor bone. When the joint is hard to see, the olecranon is deliberately cut, folded back for access and fixed at the end. X-rays in the operating room confirm alignment before closure. The elbow goes into a padded splint and you go home the same day or the next morning.
Risks & How They Are Minimized
Stiffness is the risk that matters most, and rigid fixation with motion in the first two weeks is the main safeguard; end-range stretching and, rarely, a later release are added if motion stalls. Ulnar nerve irritation, felt as numbness in the ring and little fingers, is common after distal humerus fixation because the nerve lies against the inner plate; identifying it early and transposing it when needed keeps most cases temporary.
Hardware prominence is the most frequent reason for a second operation after olecranon fixation, because the skin over the point is thin. Low-profile plates and buried wire ends reduce it, and hardware is removed after healing if it bothers you. Nonunion is uncommon at the olecranon but a real risk in the distal humerus, particularly in smokers, and is minimized by two-column fixation and no loading until X-rays show union. Heterotopic ossification is reduced by gentle tissue handling and early motion. Infection is covered by antibiotics before the incision and careful wound care. Blood clots after arm surgery are rare.
Recovery & Rehabilitation
Both protocols follow one principle: motion first, strength only after the bone has healed. Active-assisted bending starts in the first days; lifting, pushing and resisted exercise wait for radiographic union, typically six to twelve weeks. After olecranon fixation, resisted extension is avoided for about six weeks because the triceps pulls directly on the fixation.
| Phase | Timing | What happens |
|---|---|---|
| Early protected motion | Weeks 0–2 | Splint between exercises. Active-assisted elbow flexion, extension and forearm rotation within set limits; active shoulder, wrist and hand motion. No weight bearing or resisted motion. |
| Active motion | Weeks 2–6 | Active elbow and forearm motion progressed toward full; scar management. No lifting or strengthening; X-rays checked for healing. |
| Strengthening | Weeks 6–12 | Begins once Dr. O'Donnell confirms healing. Progressive resisted elbow, forearm and grip strengthening; gentle end-range stretching. |
| Return to activity | Months 3–6 | Progressive strengthening, sport- or job-specific tasks. Full loading once radiographs show union and strength and motion are functional. |
Desk work is possible within one to two weeks; driving at three to four weeks, once you are off narcotic pain medication and out of the splint with enough motion to steer. Manual work and sport wait for union and strengthening, generally three to six months.
Protocol summary
Both protocols call for a posterior splint initially with motion progressed according to fixation stability, no lifting, pushing or weight bearing through the arm until union is confirmed, and no resisted elbow exercise early. The olecranon protocol adds no resisted extension for about six weeks and limited end-range passive flexion early; the distal humerus protocol expects union at six to twelve weeks.
Phases advance on criteria: wound healing and improving motion to leave Phase I, radiographs showing healing to leave Phase II, radiographic union and improving strength to leave Phase III, and functional motion and strength with surgeon clearance for full loading to finish. Dr. O'Donnell sets the pace from the fixation achieved at surgery and the healing seen on follow-up X-rays.
Physical Therapy Protocols
Distal Humerus Fracture — Open Reduction & Internal PDF ↗Olecranon Fracture — Open Reduction & Internal PDF ↗Frequently Asked Questions
Do I need surgery for an olecranon fracture?
Most displaced olecranon fractures are fixed, because the triceps pulls the fragment apart and the fracture runs into the joint; the decision rests on the gap on X-ray and whether you can straighten the elbow against gravity. A crack that has not separated and lets you straighten the elbow against gravity can be treated in a splint with early motion and repeat X-rays. Fixation lets the elbow move within days, the best protection against stiffness.
How long does it take an elbow fracture to heal after surgery?
The bone usually unites in six to twelve weeks, confirmed on X-rays, and that is when strengthening and lifting begin. Motion starts within the first week. Full return to sport and heavy work takes three to six months per the distal humerus and olecranon protocols.
Will my elbow be stiff after fracture surgery?
Losing the last few degrees of straightening is common after any elbow fracture, and most patients do not notice it. Meaningful stiffness is avoided by early motion, which is why the splint comes off for exercises in the first days. If motion plateaus, end-range stretching and a hinged brace are added; a surgical release is rarely needed.
Will the plate or wires need to come out?
Not usually for the distal humerus. At the olecranon the skin is thin and pins or a plate can be felt when leaning on the elbow, so hardware removal is the most common second operation. It is a short outpatient procedure done once the bone has fully healed, typically after a year, and only if the hardware bothers you.
When can I drive after elbow fracture fixation?
Usually three to four weeks, once you are off narcotic pain medication, out of the splint, and able to bend and straighten the elbow enough to steer comfortably. Get in and out of the car without pushing through the operated arm until the bone has healed.
This page is for general education and is not a substitute for a medical evaluation. The right procedure depends on your individual diagnosis, anatomy, and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.