Technique Spotlight: ORIF with Intramedullary Screw Fixation

Olecranon fractures have historically been treated with tension band wires and recently plates. Plate and tension band hardware have been associated with soft tissue irritation from hardware prominence and migration due to improper seating at the time of surgery. Another treatment option is intramedullary (IM) screws. The goals of proximal ulna fracture fixation are joint reduction, rigid fixation, and early range of motion. IM screw fixation for proximal ulna or olecranon fractures provides rigid fixation, excellent compression, and minimal soft tissue irritation. The IM screw provides excellent compression perpendicular to the typical fracture lines of the proximal ulna. It also has a long working length that increases stability and allows for early range of motion. Additionally, the cost of an IM screw is 20 times lower than that of a proximal ulnar plate system.

Indications

Operative indications for fixation with an IM screw are based on the proximal fragment size. If the fragment size is large enough to accept a 6.5- or 7.3-mm partially threaded screw, the fixation can be performed. Comminution is not a contraindication for IM screw usage. Augmenting the IM screw fixation with miniplates using both bicortical and unicortical locking screws allows for fracture-specific fixation around the IM screw in setting of comminution. Fractures occurring at the coronoid flair can still be treated with the IM screw as long as there is enough cortical contact of the proximal and distal fragments to provide length stability. Proximal shaft screws are also feasible as the length of fixation and compressive effect by the IM screw is limited by the screw length and purchase distal to the shaft fracture.

Contraindications for surgical management by the IM screw involve any fractures in which there is a coronal or sagittal split in the proximal fragment. Further, small-comminuted subchondral bone fragments with articular cartilage attached will not be secured by the IM screw and would be an indication for fragment-specific minifragment plate fixation or rafting K-wires to augment the length stabilizing effect of the IM screw.

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