Olecranon - Tension band wiring

Indication

Displaced fracture of olecranon

See Olecranon fractures

Anatomy

Remember ulnar nerve medially

Considerations

Consider:

• Non operative in elderly

• Fragment excision if small and or comminuted and proximal followed by re-attachment of triceps

• If the fracture has an oblique component, consider 1 or 2 inter-fragmentary screws

• Plate fixation in distal fractures of the olecranon process or proximal ulnar fractures with dislocation of the radial head (Monteggia fracture-dislocation).

Consider tourniquet

Positioning

Supine with arm in gutter, or over "L" bar

Skin Incision

Direct posterior, consider curving laterally around point of elbow

Superficial dissection

Be mindful of ulnar nerve, expose the fracture and reduce.

To expose the ulna nerve is open to personal preference.

Deep dissection

Drill hole for wire in ulnar first, thread wire through.

Reduce fracture

Insert 2 k-wires or 6.5 mm cancellous screw into ulna (remember ulna not straight bone)

Several configurations of k wire exist (K wire configurations)

Thread tension band wire in figure of 8 around k wires/ screw and UNDER triceps aponeurosis posteriorly. Use 18 Gauge wire (1 - 1.2 mm) in thickness

Biomechanical studies have shown 6.5mm screw and figure of 8 tension band wire construct stronger than K wires and figure of 8 tension band wire.

BUT no clinical studies to show improved outcome.

Current standard is 2 K wires.

Try bury the k wires under the triceps to prevent them backing out postoperatively.

Exposure extension

Closure

Post operatively

Consider splint for two weeks to allow wound healing

Then early movement (Active flexion, passive extension) 6 weeks

Fragment excision and re-atachment

Most displaced olecranon fractures are treated by ORIF using either tension-band wiring or plate fixation.

The proposed advantages include preservation of motor power of elbow extension, joint stability, and joint mobility. However, these techniques are associated with problems such as an increased rate of infection, loss of fixation, and noticeable, sometimes painful, hardware.

Olecranon excision causes a decrease in the surface area of the articular cartilage of the ulna and a loss of the mechanical advantage of the olecranon. Theoretically, this decreased surface area and decreased moment arm should increase the resultant stresses on the remaining olecranon articular cartilage.

However, Gartsman et al., reviewed 107 patients and compared the functional results between excision and ORIF, they noted similar ratings for pain, function, elbow stability, and incidence of degenerative joint disease.

Therefore, excision is supported as the treatment of choice because of the similar results and lower complication rate. However, the patient follow-up averaged only 3.6 years, with a 2-year minimum.

Mild to moderate elevations in the joint stresses in the upper extremity may take several years to become clinically detectable.

This time frame may be inadequate for evaluating the incidence of osteoarthrosis.

K wire configurations

Several variations of tension band wiring have been advocated.

The original AO tension band wiring technique

• Place two Kirschner wires into the ulnar marrow cavity only.

• The length of the Kirschner wires is not especially emphasized, and in most cases, they are only placed proximal to the ulnar shaft.

AO modified this technique due to a high complication rate, notably proximal migration of Kirschner wires

• In the modified AO technique, Kirschner wires are inserted through the anterior ulnar cortex.

• Biomechanical studies have reported that stability is increased significantly.

References

Wu, Chi-Chuan MD; Tai, Ching-Lung MS; Shih, Chun-Hsiung MD Biomechanical Comparison for Different Configurations of Tension Band Wiring Techniques in Treating an Olecranon Fracture. Journal of Trauma-Injury Infection & Critical Care. 48(6):1063-1067, June 2000

Moed, Berton R. MD; Ede, David E. MD, BSE; Brown, Thomas D. PhD Fractures of the Olecranon: An In Vitro Study of Elbow Joint Stresses after Tension-Band Wire Fixation versus Proximal Fracture Fragment Excision. Journal of Trauma-Injury Infection & Critical Care. 53(6):1088-1093, December 2002.

Page created by: Lee Van Rensburg

Last updated 11/09/2015