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Olecranon Fracture

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;
  • 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