Olecranon Fracture

- See:
      - Surgical Approach:
      - Tension Band Theory:

- Discussion:
      - transverse frx involving less than 50% of proximal sigmoid notch are suited to stable internal fixation by tension band;
      - Weber modification provides improved frx rigidity;
      - may also use T.B.W. along with a 6.5 mm cancellous screw, 7.0 mm screws, or 7.3 mm screw;
      - surgical consent: patient should understand, the the hardware can causeolecranon bursitis, which will require future hardware removal;

- Surgical Approach:

- Frx Reduction:
    - performed w/ elbow in extension which relaxes pull of triceps muscle;
    - begin by drilling a superficial hole in the distal fragment to allow introduction of the tip of the pointed reduction forceps;
    - other tip of forceps catches proximal fragment & reduces fracture;
    - lag screw: stabilization of oblique frx w/ lag screw before tension band wiring will improves stability;

- Tension Band Wiring:
    - wire for the tension band should be 1.0 to 1.2 mm in diameter (or 18 gauge);
    - distally, wire for tension band is inserted thru 2.0 mm drill hole which is distally located, approximately same distance
            from frx as tip of olecranon (which is usually 3-4 cm distal to frx site);
            - some authors advocate placement of the distal hole ulnar to the central longitudinal axis, noting that this helps to compress the 
                   articular surface;
            - this distance is necessary to maximize tension band effect;
            - drill hole must be deep to the subQ cortex of the ulna (at least 3 mm), since it may cut out if it is placed too superficially;
    - proximally, tension band wire must pass deep to triceps tendon (on periosteum of the olecranon) & be just proximal
            to the 6.5 mm screw (or K wires);
            - use 14 gauge angiocath to facilitates passage beneath triceps;
            - if the wire is run deep to the triceps tendon without the support of the K wires, there is a risk of triceps tendon necrosis & rupture

- K wire Technique:

- Screw Technique:
    - depending on the size of the patient, may use 6.5 mm screw, 7.0 mm screw, or 7.3 mm screw;
            - see: properties of 6.5 mm cancellous screw;
    - cancellous screw plus tension band wire in combination provides greater strength of fixation than K wire and 
            tension band technique;
    - preop planning:
            - select partially threaded screw w/ 32 mm of distal threads;
            - in small ulna, the screw thread may not pass into meduallary cavity of shaft and a long 6.5 mm screw may jam before it achieves a
                     good bite;
    - 1 cm longitudinal incision is made in the midline of the triceps;
    - 4.5 mm drill is used to make glide hole in proximal frx fragment;
    - be sure that frx reduction has not been lost;  
    - golf tee is inserted, and 3.2 mm drill is inserted across distal fragment;
    - 6.5 mm tap is inserted across the frx site;
            - some authors recommend stopping the tap once it meets firm torsional resistance (which marks the 
                   appropriate screw length);
            - other authors recommend inserting the screw 8-10 cm, but excessively long screws can bend, making 
                   retrieval difficult;
    - 6.5 mm screw is inserted over washer, and incompletely tightened (to allow of tensioned wire);

- Technique of Wire Tightening:
    - before tightening the figure of eight wire, two loops should be made, which allows more even tightening on both sides of fracture;
    - prior to tightening, make sure that wires are straightened out & pulled very tight before it is placed under tension by twisting;
          - consider using the "Jet" or "Harris" wire tightener;
    - tension band should be tightened in full extension to cause slight overreduction of frx, which disappears as elbow is flexed;
    - ensure that frx site does not collapse or shift;
    - wire loops are tightened by pulling, and the slack taken by twisting;
    - trying to tighten wire by twisting results in an asymmetrical spiral with the danger of wire breakage;
    - wires must be straightened first and then pulled and twisted at the same time to avoid failure;
    - after the wires have been tightened, the ends are cut off slightly long, and are bent into the bone w/ needle nose pliers;

- Complications:
    - loss of fixation and nonunion;
          - occurs most often in olecranon fractures which occur along the distal half of the sigmoid notch;
          - in this case, an olecranon nonunion was treated w/ a one third tubular hook plate


Complications of tension-band wiring of olecranon fractures.

Surgical treatment of displaced olecranon fractures by tension band wiring technique.

Tension band wiring of olecranon fractures. A modification of the AO technique.

Elbow function following tension band fixation of displaced fractures of the olecranon.                                                              

Tension-band fixation of olecranon fractures. A cadaver study of elbow extension.

Cyclic Loading of Olecranon Fracture Fixation Constructs.

Comparison of tension-band and figure-of-eight wiring techniques for treatment of olecranon fractures.

Transcortical screw fixation of the olecranon shows equivalent strength and improved stability compared with tension band fixation.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, March 18, 2015 1:41 pm