Operative Treatment of Communited Olecranon Fractures Using Tension-Band Wiring and Miniplate Augmentation

n tips & techniques Section Editor: Steven F. Harwin, MD

Operative Treatment of Communited Olecranon Fractures Using Tension-band Wiring and Miniplate Augmentation

Hyoung Keun Oh, MD; Suk Kyu Choo, MD; Chang Soo Lee, MD; Jae Gwang Song, MD

indirect mechanism of injury augmentation in 9 patients Abstract: Olecranon fractures are intra-articular injuries can cause an avulsion-type with comminuted olecranon that require anatomic restoration of the articular surface. For fracture caused by the triceps fractures. most simple noncomminuted transverse olecranon fractures, pull, producing transverse or tension band wire fixation can provide a stable construct to 1,2 allow for early joint range of motion. However, in commi- short oblique fractures. Materials and Methods nuted olecranon fractures, it is difficult to provide a sufficient Tension-band wire fixa- From September 2009 to buttress for impacted articular fragments using tension band tion can be effectively used May 2010, nine comminuted wire fixation. Therefore, plate fixation is the standard fixa- for most simple noncommi- olecranon fractures (Figure 1) tion method, but wide skin exposure and symptomatic plate nuted transverse olecranon treated by tension band wiring irritation on the skin are common complications. The authors’ fractures.3,4 The tension band and miniplate augmentation technique uses tension band wire fixation with miniplate aug- technique converts the ten- were reviewed retrospectively. mentation for patients with comminuted olecranon fractures. sile force of the triceps to a All patients were followed at dynamic compressive force regular intervals until osseous along the articular surface. healing, defined as the pres- lecranon fractures are in- intramedullary screw fixation, To use tension band wiring, ence of crossing trabeculae on Otra-articular injuries that and fragment excision with tri- the anterior cortex must be both anteroposterior and later- require anatomic restoration of ceps advancement.2 No single intact and provide a buttress al radiographs. Fracture union the articular surface. To begin treatment method is appropri- that will allow compression. was assessed by the 2 senior early range of motion (ROM) ate for all fractures because of If this does not occur, using authors (H.K.O., S.K.C.). Pain exercises and to prevent stiff- the variability of fracture pat- tension band wiring in com- was graded as none, mild, ness of the elbow joint, the terns and associated injuries. minuted fractures can cause moderate, or severe. Elbow fracture fixation must be se- A direct blow to the olecranon a loss of fracture reduction in ROM was measured. The curely fixed.1 Several methods will force it into the distal hu- the sigmoid notch.3,4 Plate fix- overall objective outcome was of internal fixation are com- merus, causing comminuted ation has become the standard assessed with the joint-specif- monly used, including tension fractures with depressed ar- fixation method for commi- ic Mayo Elbow Performance band wiring, plate fixation, ticular surfaces, whereas an nuted olecranon fractures.5,6 Score, which measures pain, However, concerns about dor- motion, stability, and function; sal plating include the neces- the results were graded as ex- The authors are from the Department of Orthopaedic Surgery (HKO, sity of wider skin exposure cellent (.90), good (75-89), SKC, JGS), Ilsan Paik Hospital; and the Department of Orthopaedic Surgery (CSL), Ilsan Teun Teun Hospital, Go-yang, South Korea. and symptomatic plate irrita- fair (60-74), or poor (,60). The authors have no relevant financial relationships to disclose. tion on the skin.7 The current Correspondence should be addressed to: Hyoung Keun Oh, MD, study reports the authors’ Surgical Technique Department of Orthopaedic Surgery, Ilsan Paik Hospital, 2240, Daehwa- experiences of tension band Surgery was performed dong, Ilsan-Segu,-Koyang-si, Ilsan, Korea, 411-706 ([email protected]). doi: 10.3928/01477447-20130327-03 wire fixation with miniplate with the patient in the supine

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2A 2B Figure 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.

down, and buried through the tures were multifragmentary 1A 1B triceps tendon. Intraoperative combined intra- and extra- Figure 1: Anteroposterior (A) and lateral (B) radiographs of an 80-year-old woman with a comminuted olecranon fracture after a simple fall showing a fracture stability was checked articular ulnar (Type B1.3). complete olecranon fracture with an intra-articular impacted fragment (arrow). with passive full flexion and To buttress the impacted extension of elbow joint. articular fragment, a mini- Postoperatively, the elbow locking compression plate poistion while under general tion to buttress the impacted was immobilized in a remov- was used for all fractures de- anesthesia. Following limb ex- articular fragment. Cancellous able posterior splint in 90° of pending on the fracture pat- sanguination, a tourniquet was chip bone grafting was per- elbow flexion. Passive and ac- terns and the size of the bone inflated and the arm was pre- formed when a metaphyseal tive elbow ROM were encour- fragment. A 2.4-mm plate was pared, draped, and positioned bone defect developed after aged as tolerated. Posterior used in 4 cases and a 2.7-mm across the patient’s chest to al- lifting the impacted articular splints were postoperatively plate was used in 5 cases. low for a full range of motion fragment; thus, comminuted removed within 2 weeks in all Cancellous chip bone grafts from extension to flexion. The fractures were converted to cases. were used in 6 cases because fracture was exposed through simple transverse fractures of metaphyseal defects that a posterior midline incision (Figure 2). Then, separated Results developed after articular im- with the proximal end curv- transverse fracture fragments Nine comminuted olec- paction reduction. ing toward the lateral aspect of were reduced and mainte- ranon fractures treated us- Average follow-up was 13 the olecranon. The ulnar nerve nance of the reduction was ing tension band wiring and months (range, 12-16 months) was not routinely exposed. performed using a reduction miniplate augmentation were postoperatively. At the most After debridement of hemato- clamp. Two pararell 1.8-mm reviewed retrospectively. Four recent follow-up, 8 patients ma and interposed soft tissue, K-wires with 10 mm of sepa- male and 5 female patients reported no pain and 1 patient the impacted and comminuted ration were inserted from the with a mean age of 61 years reported mild pain. All frac- articular fracture fragment was olecranon into the distal frag- (range, 31 to 81 years) were tures united without a loss of reduced. Precise articular re- ment. The authors preferred to included in the study. The fracture reduction, and average construction was performed place the K-wire through the mechanism of injury was a time to union was 10 weeks by lifting and repositioning ulna anterior cortex to reduce simple fall in 7 patients, a fall (Figure 3). According to the the depressed articular frag- the pullout strength. from a height in 1 patient, and Mayo Elbow Performance ment according to the contour After a drill hole was cre- a motor vehicle accident in 1 Score, the results were con- of the trochlea. ated 3 cm distal to the frac- patient. Three patients had as- sidered excellent 8 cases and After articular fragment re- ture site, the circlage wire was sociated injuries: 1 each had a good in 1 case. One patient duction, a 2.4- or 2.7-mm lock- tightened in a figure-8 around femoral shaft injury, an ipsi- reported skin irritation over ing plate was positioned on the the K-wires using a single lateral proximal humerus frac- the site of the k-wire (Figure medial or lateral ulnar border knot. The K-wires were bent to ture, and and acetabular frac- 4). Full elbow ROM com- according to the fracture pat- 180° and cut, leaving 3 mm of ture. No open fractures were pared with the contralateral terns and locking head screws wire. The wires were rotated in observed. According to AO/ side could be obtained in all were fixed in an anterior direc- their longitudinal axis, tapped OTA classification, all frac- patients. No fixation failures,

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infection, or neurological le- sions were reported.

Discussion The purposes of operative treatment of comminuted intra-articular olecranon fractures are to restore anatomic joint surface and provide a stable fixation to begin early range of motion exercise.1 Anatomic restoration of the articular surface of the olecranon with internal 3A 3B 3C 3D fixation that allows for early Figure 3: Immediate postoperative anteroposterior (A) and lateral (B) and final anteroposterior (C) and lateral (D) elbow ROM can be accom- radiographs of the patient presented in Figure 1 showing stable bony union without articular reduction loss and K-wire migration. 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 4A 4B 4C 2 triceps advancement. Figure 4: Preoperative (A), immediate postoperative (B), and 3-month postoperative (C) lateral radiographs of a Tension-band wiring with 79-year-old woman with symptomatic irritation caused by a migrated K-wire. However, stable bony union and full K- wires is used in the surgical elbow range of motion were achieved. treatment of olecranon fractures, especially noncomminuted transverse fractures, and and in the cases of concomi- To avoid skin irritation, the tional status without a limita- may provide a stable construct tant osteoporosis, bone defects authors positioned the plate on tion of elbow ROM. to allow for early joint ROM. in the metaphyseal area of the the medial or lateral border of Neurovascular injuries A tension band construct is ad- distal segment may develop the ulnar shaft, depending on after placement of K-wires vantageous because it theoreti- because of severe impaction the fracture patterns, instead through anterior ulnar cor- cally converts dorsal distrac- of the articular surface. For the of dorsal plating. They be- tex have been reported.9,10 tion force to compression at application of effective tension lieve that an additional bone However, cadevaric studies the fracture site on the articu- bands in comminuted olecra- graft for a metaphyseal defect have shown that K-wires that lar surface.3,4 However, if the non fractures, the authors be- may be useful to support the penetrate the anterior cortex articular surface is comminut- lieved that if it was possible to impacted articular fragments. require approximately dou- ed and unstable, early motion convert a comminuted fracture The combination of a small ble the force of intramedul- after tension band wiring can to a simple transverse fracture, mini-locking compression lary K-wires to pull out.11,12 cause compression failure.8 then the tension band fixation plate and a bone graft could The current authors placed Thus, to be able to use a ten- would be the most simple and enable tension band wiring to K-wires though the anterior sion band, the anterior cortex effective treatment method for compress the fracture site and ulnar cortex under the tac- must not be comminuted and the olecranon fractures. To allow for early elbow ROM tile feedback in all cases so must provide a buttress to al- support comminuted articular even in osteoporotic bones. the neurovascular structures low for compression. fragments to their anatomical In the current series, no re- were not violated. The stable In comminuted olecranon position, posterior-to-anterior duction loss of the articular configuration of the tension fractures, it is difficult to pro- directed small locking head fragment was observed at the band wiring was an important vide a sufficient buttress to the screws combined with locking last follow-up and all patients factor in their good operative impacted articular fragment, plate were useful. regained their preinjury func- results. The limitations of the

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