Plating has taken over from tension band wiring in most displaced olecranon fractures, and for clear reasons: comminution, oblique fracture lines and extension into the proximal ulnar shaft all defeat the simple mechanics of a wire loop, while a contoured dorsal plate controls the fracture and lets the elbow move early. The operation rewards precision — the plate sits on the tension side of the bone, the joint surface of the sigmoid notch must be restored exactly, and prominent hardware is the price paid for that stability. This guide walks through the technique using the elbow plating systems we supply at BoneCraft as the hardware reference. The operating surgeon makes every final decision for the individual fracture.
Plating or tension band: the selection question
Tension band wiring still works well for simple transverse fractures through the bare area of the sigmoid notch, in good bone, with two fragments and no comminution. Plating is the better choice for everything else: oblique fractures, comminuted fractures, fractures that extend distal to the coronoid, Monteggia-type injuries, osteoporotic bone, and any case where the triceps would saw through a wire loop. A dorsal plate resists the deforming pull of the triceps directly and captures intermediate fragments that a wire loop would simply squeeze out of place.
| Factor | Tension band wiring | Dorsal plate |
|---|---|---|
| Best pattern | Transverse, two fragments | Oblique, comminuted, shaft extension |
| Mechanism | Converts triceps pull to compression | Neutralizes triceps pull directly |
| Coronoid capture | Not possible | Long proximal screws into the coronoid |
| Hardware prominence | K-wire ends, frequent irritation | Plate under the triceps insertion |
| Early motion | Limited by fixation strength | Usually tolerated early |
Preoperative planning
Lateral and AP radiographs of the elbow classify the fracture and show how far the comminution runs into the proximal shaft. A CT scan is added when the articular surface of the sigmoid notch is involved, because intermediate fragments hidden between the olecranon and the coronoid change the reduction sequence. Planning settles the plate family, the screw lengths needed to reach the coronoid, and whether the ulnar nerve must be identified during the approach — decisions made on the images rather than improvised at the table.
Positioning and exposure
The patient is placed in lateral decubitus with the arm over a padded bolster, or prone with the arm abducted; supine with the arm across the chest works when an assistant holds the limb. A sterile tourniquet is optional. The incision runs along the posterior midline of the elbow but curves slightly to the lateral side of the olecranon tip, so the suture line does not rest directly on the bone or on the hardware beneath it. Full-thickness flaps are raised medially and laterally without hunting for the ulnar nerve unless the fracture pattern or the planned medial screws require it — in comminuted proximal fractures, identifying the nerve before plating is the safer habit. The fracture hematoma is cleared, and the joint surface of the sigmoid notch is inspected directly or through the fracture gap.
Reduction
The olecranon fragment is small and held by the triceps, so a pointed reduction clamp placed through a small stab in the triceps tendon, or a K-wire joystick in the fragment, controls it. Reduction restores the smooth curve of the sigmoid notch; the coronoid and any intermediate articular fragments are reduced first and held provisionally with fine K-wires, then the main olecranon fragment is brought down over them. Articular congruity is confirmed under fluoroscopy and, where the fracture gap allows, by direct vision through the fracture itself. Provisional K-wires keep the reduction while the plate is applied.
Plate placement on the tension side
The plate sits on the dorsal surface of the ulna, the tension side, where the triceps pull tries to open the fracture. Anatomic plates for the proximal ulna wrap over the olecranon tip, and the proximal end of the plate is tucked beneath the triceps insertion after the tendon fibers are split longitudinally over the bone. Screw strategy matters more than screw count: the most proximal screws are directed from the olecranon tip down into the coronoid region, creating long, interlocking fixation across the whole fragment, while distal screws fix the plate to the ulnar shaft. In osteoporotic bone, locking screws improve purchase; in good bone, conventional screws allow compression through the plate. BoneCraft stocks the olecranon plate for tip-level fractures, the proximal ulna locking plate for comminuted and osteoporotic patterns, and the proximal ulna plate for shaft-level extension — the full elbow range sits in the elbow collection.
Final checks and closure
With the plate fixed, the elbow is taken through a full arc of flexion and extension under fluoroscopy. The checks are concrete: no screw tip inside the joint, the sigmoid notch smooth on the lateral view, and no gapping of the fracture under triceps tension. The triceps split is repaired over the proximal end of the plate to cushion the hardware, and the skin is closed in layers over a drain where swelling demands one. A posterior splint for a few days protects the wound, then motion begins.
Aftercare and the hardware prominence question
Early active motion within the first two weeks is the norm for a stable construct, and it is the main argument for plating in the first place; the exact protocol is set by the operating surgeon. The honest downside of dorsal plating is hardware prominence at the olecranon tip, and a meaningful share of patients eventually ask for plate removal after union. Repairing the triceps over the plate and keeping the proximal plate end low reduce irritation, and low-profile anatomic designs help further. Removal, when requested, waits for confirmed radiographic union.
Sourcing elbow plating systems
BoneCraft is an independent distributor of genuine Zimmer Biomet trauma implants, including the elbow plating families referenced in this guide. Hospitals and distributors who need olecranon plates, proximal ulna plates and locking screws from stock can contact our team for availability and lot documentation.
Frequently asked questions
When is plating preferred over tension band wiring?
For oblique or comminuted fractures, fractures extending into the ulnar shaft, Monteggia-type injuries, and osteoporotic bone. Tension band wiring remains reasonable for simple transverse two-fragment fractures in good bone.
Why is the plate placed on the dorsal side of the ulna?
The dorsal surface is the tension side. The triceps pulls the olecranon fragment away from the shaft, and a plate on that surface resists the force directly instead of relying on the bone to convert it into compression.
Where should the skin incision go?
Along the posterior elbow but curved slightly lateral to the olecranon tip, so the scar does not sit on the bone or the plate edge. This small offset lowers wound problems over the most prominent point of the elbow.
How is the coronoid fragment captured?
With long proximal screws directed from the olecranon tip region of the plate down toward the coronoid. Capturing the coronoid restores the anterior buttress of the sigmoid notch and the stability of the joint.
Is hardware removal common after olecranon plating?
Yes. The olecranon tip has little soft tissue cover, so dorsal plates are felt more than plates elsewhere. Removal is elective and waits for solid radiographic union; low-profile anatomic plates and triceps repair over the hardware reduce how often it is needed.
When can the elbow move after plating?
Stable constructs generally allow active motion within the first two weeks, which is one of the main reasons to plate. The surgeon sets the schedule from the fixation quality and the fracture pattern.
Does the ulnar nerve need to be exposed?
Not routinely. It is identified and protected when medial screws are planned near its course or when the fracture pattern puts it at risk, but routine exposure adds dissection without proven benefit in simple cases.
Zimmer Biomet, ZPLP and ALPS are trademarks of their respective owner. BoneCraft is an independent distributor of genuine Zimmer Biomet products and is not affiliated with, sponsored by, or endorsed by the trademark owner.
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