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n tips & techniquesSection Editor: Steven F. Harwin, MD

Operative Treatment of Communited Olecranon Fractures Using Tension-band Wiring and Miniplate AugmentationHyoung Keun Oh, MD; Suk Kyu Choo, MD; Chang Soo Lee, MD; Jae Gwang Song, MD

Olecranon fractures are in-tra-articular injuries that

require anatomic restoration of the articular surface. To begin early range of motion (ROM) exercises and to prevent stiff-ness of the elbow joint, the fracture fixation must be se-curely fixed.1 Several methods of internal fixation are com-monly used, including tension band wiring, plate fixation,

intramedullary screw fixation, and fragment excision with tri-ceps advancement.2 No single treatment method is appropri-ate for all fractures because of the variability of fracture pat-terns and associated injuries. A direct blow to the olecranon will force it into the distal hu-merus, causing comminuted fractures with depressed ar-ticular surfaces, whereas an

indirect mechanism of injury can cause an avulsion-type fracture caused by the triceps pull, producing transverse or short oblique fractures.1,2

Tension-band wire fixa-tion can be effectively used for most simple noncommi-nuted transverse olecranon fractures.3,4 The tension band technique converts the ten-sile force of the triceps to a dynamic compressive force along the articular surface. To use tension band wiring, the anterior cortex must be intact and provide a buttress that will allow compression. If this does not occur, using tension band wiring in com-minuted fractures can cause a loss of fracture reduction in the sigmoid notch.3,4 Plate fix-ation has become the standard fixation method for commi-nuted olecranon fractures.5,6 However, concerns about dor-sal plating include the neces-sity of wider skin exposure and symptomatic plate irrita-tion on the skin.7 The current study reports the authors’ experiences of tension band wire fixation with miniplate

augmentation in 9 patients with comminuted olecranon fractures.

Materials and MethodsFrom September 2009 to

May 2010, nine comminuted olecranon fractures (Figure 1) treated by tension band wiring and miniplate augmentation were reviewed retrospectively. All patients were followed at regular intervals until osseous healing, defined as the pres-ence of crossing trabeculae on both anteroposterior and later-al radiographs. Fracture union was assessed by the 2 senior authors (H.K.O., S.K.C.). Pain was graded as none, mild, moderate, or severe. Elbow ROM was measured. The overall objective outcome was assessed with the joint-specif-ic Mayo Elbow Performance Score, which measures pain, motion, stability, and function; the results were graded as ex-cellent (.90), good (75-89), fair (60-74), or poor (,60).

surgical techniqueSurgery was performed

with the patient in the supine

The authors are from the Department of Orthopaedic Surgery (HKO, SKC, JGS), Ilsan Paik Hospital; and the Department of Orthopaedic Surgery (CSL), Ilsan Teun Teun Hospital, Go-yang, South Korea.

The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Hyoung Keun Oh, MD,

Department of Orthopaedic Surgery, Ilsan Paik Hospital, 2240, Daehwa-dong, Ilsan-Segu,-Koyang-si, Ilsan, Korea, 411-706 (osd11@paik.ac.kr).

doi: 10.3928/01477447-20130327-03

Abstract: Olecranon fractures are intra-articular injuries that require anatomic restoration of the articular surface. For most simple noncomminuted transverse olecranon fractures, tension band wire fixation can provide a stable construct to allow for early joint range of motion. However, in commi-nuted olecranon fractures, it is difficult to provide a sufficient buttress for impacted articular fragments using tension band wire fixation. Therefore, plate fixation is the standard fixa-tion method, but wide skin exposure and symptomatic plate irritation on the skin are common complications. The authors’ technique uses tension band wire fixation with miniplate aug-mentation for patients with comminuted olecranon fractures.

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poistion while under general anesthesia. Following limb ex-sanguination, a tourniquet was inflated and the arm was pre-pared, draped, and positioned across the patient’s chest to al-low for a full range of motion from extension to flexion. The fracture was exposed through a posterior midline incision with the proximal end curv-ing toward the lateral aspect of the olecranon. The ulnar nerve was not routinely exposed. After debridement of hemato-ma and interposed soft tissue, the impacted and comminuted articular fracture fragment was reduced. Precise articular re-construction was performed by lifting and repositioning the depressed articular frag-ment according to the contour of the trochlea.

After articular fragment re-duction, a 2.4- or 2.7-mm lock-ing plate was positioned on the medial or lateral ulnar border according to the fracture pat-terns and locking head screws were fixed in an anterior direc-

tion to buttress the impacted articular fragment. Cancellous chip bone grafting was per-formed when a metaphyseal bone defect developed after lifting the impacted articular fragment; thus, comminuted fractures were converted to simple transverse fractures (Figure 2). Then, separated transverse fracture fragments were reduced and mainte-nance of the reduction was performed using a reduction clamp. Two pararell 1.8-mm K-wires with 10 mm of sepa-ration were inserted from the olecranon into the distal frag-ment. The authors preferred to place the K-wire through the ulna anterior cortex to reduce the pullout strength.

After a drill hole was cre-ated 3 cm distal to the frac-ture site, the circlage wire was tightened in a figure-8 around the K-wires using a single knot. The K-wires were bent to 180° and cut, leaving 3 mm of wire. The wires were rotated in their longitudinal axis, tapped

down, and buried through the triceps tendon. Intraoperative fracture stability was checked with passive full flexion and extension of elbow joint.

Postoperatively, the elbow was immobilized in a remov-able posterior splint in 90° of elbow flexion. Passive and ac-tive elbow ROM were encour-aged as tolerated. Posterior splints were postoperatively removed within 2 weeks in all cases.

resultsNine comminuted olec-

ranon fractures treated us-ing tension band wiring and miniplate augmentation were reviewed retrospectively. Four male and 5 female patients with a mean age of 61 years (range, 31 to 81 years) were included in the study. The mechanism of injury was a simple fall in 7 patients, a fall from a height in 1 patient, and a motor vehicle accident in 1 patient. Three patients had as-sociated injuries: 1 each had a femoral shaft injury, an ipsi-lateral proximal humerus frac-ture, and and acetabular frac-ture. No open fractures were observed. According to AO/OTA classification, all frac-

tures were multifragmentary combined intra- and extra- articular ulnar (Type B1.3).

To buttress the impacted articular fragment, a mini-locking compression plate was used for all fractures de-pending on the fracture pat-terns and the size of the bone fragment. A 2.4-mm plate was used in 4 cases and a 2.7-mm plate was used in 5 cases. Cancellous chip bone grafts were used in 6 cases because of metaphyseal defects that developed after articular im-paction reduction.

Average follow-up was 13 months (range, 12-16 months) postoperatively. At the most recent follow-up, 8 patients reported no pain and 1 patient reported mild pain. All frac-tures united without a loss of fracture reduction, and average time to union was 10 weeks (Figure 3). According to the Mayo Elbow Performance Score, the results were con-sidered excellent 8 cases and good in 1 case. One patient reported skin irritation over the site of the k-wire (Figure 4). Full elbow ROM com-pared with the contralateral side could be obtained in all patients. No fixation failures,

1A 1BFigure 1: Anteroposterior (A) and lateral (B) radiographs of an 80-year-old woman with a comminuted olecranon fracture after a simple fall showing a complete olecranon fracture with an intra-articular impacted fragment (arrow).

2A 2BFigure 2: Intraoperative photographs of the patient in Figure 1 showing a 2.7-mm locking plate (A) and a bone graft (B) converting a comminuted fracture into a simple transverse fracture after supporting the impacted articular fragment.

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infection, or neurological le-sions were reported.

discussionThe purposes of opera-

tive treatment of commi-nuted intra-articular olecra-non fractures are to restore anatomic joint surface and provide a stable fixation to begin early range of motion exercise.1 Anatomic restora-tion of the articular surface of the olecranon with internal fixation that allows for early elbow ROM can be accom-plished through a variety of techniques. Several methods of internal fixation are com-monly used, including tension band wiring, plate fixation, intramedullary screw fixation, and fragment excision with triceps advancement.2

Tension-band wiring with K- wires is used in the surgical treatment of olecranon frac-tures, especially noncommi-nuted transverse fractures, and may provide a stable construct to allow for early joint ROM. A tension band construct is ad-vantageous because it theoreti-cally converts dorsal distrac-tion force to compression at the fracture site on the articu-lar surface.3,4 However, if the articular surface is comminut-ed and unstable, early motion after tension band wiring can cause compression failure.8 Thus, to be able to use a ten-sion band, the anterior cortex must not be comminuted and must provide a buttress to al-low for compression.

In comminuted olecranon fractures, it is difficult to pro-vide a sufficient buttress to the impacted articular fragment,

and in the cases of concomi-tant osteoporosis, bone defects in the metaphyseal area of the distal segment may develop because of severe impaction of the articular surface. For the application of effective tension bands in comminuted olecra-non fractures, the authors be-lieved that if it was possible to convert a comminuted fracture to a simple transverse fracture, then the tension band fixation would be the most simple and effective treatment method for the olecranon fractures. To support comminuted articular fragments to their anatomical position, posterior-to-anterior directed small locking head screws combined with locking plate were useful.

To avoid skin irritation, the authors positioned the plate on the medial or lateral border of the ulnar shaft, depending on the fracture patterns, instead of dorsal plating. They be-lieve that an additional bone graft for a metaphyseal defect may be useful to support the impacted articular fragments. The combination of a small mini-locking compression plate and a bone graft could enable tension band wiring to compress the fracture site and allow for early elbow ROM even in osteoporotic bones. In the current series, no re-duction loss of the articular fragment was observed at the last follow-up and all patients regained their preinjury func-

tional status without a limita-tion of elbow ROM.

Neurovascular injuries after placement of K-wires through anterior ulnar cor-tex have been reported.9,10 However, cadevaric studies have shown that K-wires that penetrate the anterior cortex require approximately dou-ble the force of intramedul-lary K-wires to pull out.11,12 The current authors placed K-wires though the anterior ulnar cortex under the tac-tile feedback in all cases so the neurovascular structures were not violated. The stable configuration of the tension band wiring was an important factor in their good operative results. The limitations of the

Figure 3: Immediate postoperative anteroposterior (A) and lateral (B) and final anteroposterior (C) and lateral (D) radiographs of the patient presented in Figure 1 showing stable bony union without articular reduction loss and K-wire migration.

3A 3B 3C 3D

Figure 4: Preoperative (A), immediate postoperative (B), and 3-month postoperative (C) lateral radiographs of a 79-year-old woman with symptomatic irritation caused by a migrated K-wire. However, stable bony union and full elbow range of motion were achieved.

4B4A 4C

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current study include its ret-rospective nature, the small number of patients, and non-comparison study of different fixation methods.

The combination of mini-locked compression plate and tension band wiring appears to be a simple and effective fixation method in commi-nuted olecranon fractures. Mini-locked compression plates with locking head screws can provide a stable buttress for the impacted ar-ticular fragment and allow early ROM without compli-cations, even for osteoporotic bones.

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