How to perform a olecranon fracture tension band fixation

Expose the Fracture Site

1. Advance through the olecranon bursa.

2. Create full thickness skin and subcutaneous tissue flaps.

3. Place retractors proximally and distally between the bone and soft tissue, or temporarily suture the skin flaps laterally and medially in order to maintain optimal visibility.

4. Remove hematoma and soft tissue debris from the fracture site. For additional visibility, elevate 1-2 mm of the periosteum from the edges of the fracture. However, keep the periosteum detachment minimal.

Fracture Reduction

1. Drill a 2.0 mm transverse hole approximately 4 cm distal to the fracture line at the center of the bone. Use a sharp drill guide to avoid the drill sliding on the bone surface. This is the distal anchor hole for the tension band and you can, if necessary, also use it during fracture reduction for attaching the reduction clamp. Alternatively, you can drill an additional small hole in the posterior cortex for the clamp placement.

2. Next, extend the elbow to assist reduction and place a reduction clamp over the fracture. Place one end of the clamp in the drilled hole in the ulna and firmly attach the other end to the tip of the olecranon. Then close clamp to achieve reduction. Additional reduction clamps can be used if necessary; however, make sure not to block possible K-wire entry points.

Fracture Fixation With the Tension Band Technique

1. Make sure to have adequate exposure of the tip of the olecranon for inserting two parallel K-wires. The objective of this step is to set the tension band wire (1.0-1.2 mm) in a figure-eight pattern over the fracture site with the proximal end anchored around two K-wires and beneath the triceps tendon, and the distal end anchored to the drill hole in the ulna.

2. Insert the two K-wires (1.6-2.0 mm) at the proximal side of the fracture, through the proximal end of olecranon.
   
   Use a drill guide to direct the first K-wire towards the anterior cortex. Position the K-wire as close to the joint surface as possible without affecting the joint, and drill through both cortices.
   
   To avoid damage to the anterior interosseous nerve and the ulnar artery, be careful not to drill too deep through the anterior cortex. Placing the wire at a 20-30-degree angle with respect to the ulnar shaft should minimize this risk.
   
   Piercing the anterior cortex too radially may also block the movement of the radius during pro-supination.
   
   Introduce the first K-wire medially, in order to leave room for the second K-wire. Then, use a drill guide to similarly introduce the second K-wire laterally, parallel to the first one. Having two parallel K-wires prevents fragment rotation.
   
   

3. Check the K-wire position using the C-arm. If the fracture reduction remains adequate and the position of the wires is satisfactory, retract the K-wires to approximately 1 cm from the anterior cortex, in order to have a margin for advancing the K-wires deeper into the bone again after securing adequate tension. Transcortical fixation of the K-wires through the anterior cortex should reduce the risk of wires backing out and thus loss of tension.

4. If satisfied with the positioning of the K-wires, remove the reduction forceps.

5. Pass approximately two thirds of the tension band wire beneath the triceps tendon in a medial-to-lateral (ulnar-to-radial) direction. Use a needle to assist guiding the wire if necessary; however, make sure not to damage the ulnar nerve.
   
   When the tension band wire is passed under the tendon, make a loop on the longer side of the band. Then pull the longer end of the band back to the medial side and pass it through the distal drill hole in ulna, again in a medial-to-lateral direction.
   
   Finally, pull the longer end to meet the shorter end and unite the ends by twisting them. The wire should now have a figure-of-eight pattern.
   
   

6. Verify that the ulnar loop and the radial twisting point of the wire ends are not positioned over the hole drilled in the ulna. This is to avoid excessive tension over the hole and also having the loops more proximally will require smaller incisions should the hardware have to be removed in the future.

7. Tighten the wire first loosely with pliers by twisting the loop and then twisting the wire ends together. Make sure the wires spiral equally around each other. If one wire is spiraling around a straight wire, the twist will give way under force.

8. Shorten the wires, and further tighten the wires until you have achieved satisfactory tension. The tension should be firm, but not excessive. Especially osteoporotic bone may break if the wires are too tight. It is important to tighten the twists on both sides of the hole simultaneously in order to have equal tension on both sides.

9. To minimize soft tissue irritation, twist the sharp tips of the wires to face the bone.

10. Finally, bend the proximal ends of the K-wires by 180 degrees and cut away the excess part, leaving approximately 5 mm. Then sink in the curved ends into the bone, through small cuts in the triceps, in order to prevent the K-wires from backing out. You can additionally close the holes in the triceps to further prevent the wires backing out.

Verify Accomplishment of Goal, Check for Potential Damage and Ensure Hemostasis

1. Check for adequate reduction and fixation using the C-arm. Make sure to also assess the reduction looking at the joint line from a lateral view.

2. Verify that the elbow has free motion in extension-flexion and pro-supination. Pay special attention to the pro-supination movement. If pins are placed so that they penetrate the lateral/radial ulnar cortex, they may block the movement of radius.

3. Release tourniquet, if used, and coagulate any bleeding vessels.

Wound Closure

1. The wound closure should be done in layers if possible: use e.g. 0 Vicryl for deep closure, 2-0 Vicryl for the subcutis, and 3-0 nylon thread or staples for the skin.

2. Apply a non-bulky surgical dressing and place the arm in a sling.