Willinger et al. Eur J Med Res (2015) 20:87 DOI 10.1186/s40001-015-0184-7 CASE REPORT Open Access Malpositioned olecranon fracture tension‑band wiring results in proximal radioulnar synostosis Lukas Willinger†, Martin Lucke†, Moritz Crönlein, Gunther H. Sandmann, Peter Biberthaler and Sebastian Siebenlist* Abstract Background: Tension-band wiring (TBW) is a well-established fixation technique for two-part, transverse fracture types of the olecranon. However, complication rates up to 80 % are reported. By reporting on the enormous impact on the patient if failed the aim of the present report was to emphasize the importance of correct K wire positioning in TBW. Case presentation: We present the case of a 49-year-old woman who suffered from a radioulnar synostosis of the forearm due to malpositioned K wires after TBW treatment. The patient was treated by heterotopic bone resection supported by ossification prophylaxis (radiotherapy and Indomethacin). At follow-up of 12 months after revision surgery, elbow motion was unrestricted with a strength grade 5/5. The patient was free of pain and reported no restrictions in daily as well as sporting activities. Radiologic assessment showed no recurrence of heterotopic bone tissue. Conclusion: Intraoperative radiographic and clinical examination of the elbow is highly recommended to identify incorrect hardware positioning and, therefore, to avoid serious postoperative complications in TBW. Keywords: Olecranon fracture, Tension-band wiring, Radioulnar synostosis, Complication, Radiotherapy Background hardware removal is the most frequent complication in Isolated olecranon fractures are the most common frac- case K wires are inserted into the medullary canal of the tures of the proximal ulna and account for 10 % of upper distal ulna fragment [5]. To avoid this complication, the extremity fractures. The direct fall onto the elbow is the modified technique involving the transcortical K wire main injury pattern [1, 2]. Surgical treatment depends on placement through the anterior cortex of the ulna has the grade of fracture dislocation and the number of bony been introduced [9, 10]. Nevertheless, extensive hard- fragments [3]. Tension-band wiring (TBW) is a well- ware protrusion through the anterior ulnar cortex may established fixation technique for two-part, transverse result in nerve and/or vascular injuries, impaired range of fracture types of the olecranon with sufficient bone qual- elbow motion and heterotopic ossification (HO) [11–15]. ity [3, 4]. Even though TBW is often considered as an easy In the following case, we refer a proximal radioulnar and convenient surgical procedure, several imperfections synostosis (RUS) following TBW of a simple transverse are described in the current literature and complication olecranon fracture. To our research of the literature, rates up to 80 % are reported [5–8]. Proximal migration there are just two articles on this topic, and only one of of Kirschner (K) wires followed by the necessity of early them reported about the therapeutic management of this severe complication [15, 16]. The purpose of the pre- *Correspondence: [email protected] sent article is, therefore, to emphasize the importance †Lukas Willinger and Martin Lucke contributed equally to this work of correct K wire insertion during the TBW procedure Department of Trauma Surgery, Klinikum rechts der Isar, Technical by reporting on the enormous impact on the patient if University Munich, Ismaningerstr. 22, 81675 Munich, Germany © 2015 Willinger et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Willinger et al. Eur J Med Res (2015) 20:87 Page 2 of 6 failed. The surgical approach including pre- and postop- Two hours before revision surgery, a prophylactic radi- erative measures is described in detail and discussed with otherapy (with a dosage of 7 Gy) focused on the proxi- reference to the current literature. mal aspect of the forearm was performed to minimize the risk of synostotic recurrence [18, 19]. The previously Case presentation used dorsal approach was reopened and the remaining A 49-year-old woman sustained a two-part olecranon cerclage wire was removed a priori. Next, the approach fracture (AO 21-B1, Mayo type IIA [17]) in her left elbow. was extended distally and the supinator muscle was sub- She was consequently treated by open reduction and periosteally detached en bloc from the proximal ulna internal fixation using the transcortical TBW technique. to expose the heterotopic bone formation (Fig. 3). We Immediately after surgery the patient complained about decided for that approach to protect the posterior inter- persistent pain in her elbow, wrist and shoulder as well osseous nerve (PIN) running through the supinator mass. as strong difficulties to rotate the forearm during physi- The synostotic bone was first exposed from its proxi- otherapy. Despite the reported complaints the patient mal to its distal extent. Second, by subperiosteal prepa- was advised to intensify physiotherapy. Follow-up radio- ration the heterotopic bone formation was dissected graphs 6 weeks postoperatively revealed not only union step-by-step to its radial extent at the radial tuberos- of the olecranon fracture, but also extensive protrusion of ity. This preparation was mainly performed by chiseling the K wires through the anterior ulnar cortex scratching along well attached to the bone. Thereby, it was carefully the radial tuberosity (Fig. 1). Both K wires were conse- observed not to damage the distal biceps tendon that was quently removed in a second operation, but the tension- immured by heterotopic bone. The synostosis was finally band cerclage remained at its position. After K wires removed all in one. Subsequent intraoperative examina- removal, the patient was encouraged again to enforce tion revealed full pronation and supination movements physiotherapy. before closure. For rehabilitation, active and passive Three months after trauma, the patient was presented elbow exercises including immediate free forearm rota- to our outpatient clinic due to a total block of supination tion started under physiotherapist’s supervision the day and pronation with the forearm fixed in neutral position. after surgery. No splint or cast was applied. Indometha- The extension–flexion arc of the elbow was 0°–5°–110°. cin (50 mg 1–0–1 per day) was prescribed for 2 weeks for Wrist and shoulder examinations showed a free range of prophylaxis of ossification [20]. motion (ROM); pain or sensomotoric restrictions did not Ten weeks postoperatively the ROM of the elbow was exist. Radiographs showed a massive synostosis between 0°–10°–140° for extension–flexion arc and 75°–0°–90° for the radial tuberosity and the proximal ulna where previ- pronation–supination arc. At final follow-up 12 months ously the K wires had penetrated the anterior radial cor- after surgery, the ROM was unrestricted when compared tex of the ulna (Fig. 2). Based on clinical and radiographic to the uninjured arm side (Fig. 4). Supination strength findings the resection of the synostotic bone was indi- was also unlimited presenting grade 5/5 on both arms. cated to restore forearm motion. The patient was free of pain and reported no restrictions in daily as well as sporting activities (swimming three times per week). Radiologic assessment showed no recur- rence of heterotopic bone tissue. Discussion and conclusion TBW is often considered an easy-to-use operation tech- nique to treat isolated simple olecranon fractures. Many authors showed good-to-excellent short- to long-term clinical outcomes [21–25], however, different complica- tion rates were observed in the literature [1, 7, 11–16, 26, 27]. However, the development of an RUS due to hardware protrusion was—to the best of our knowledge—reported in only two articles so far [15, 16]. Velkes et al. [15] pre- sented two cases of RUS following the transcortical technique within 3 months after surgery. The authors Fig. 1 Malpositioned K wires after olecranon TBW. 3D computed supposed as mechanism that the RUS was induced by tomography scans show the K wire placement within the radioulnar soft tissue trauma and bleeding resulting from the K space at the radial tuberosity 6 weeks after initial surgery wire protrusion into the interosseous membrane and Willinger et al. Eur J Med Res (2015) 20:87 Page 3 of 6 Fig. 2 Proximal radioulnar synostosis. a Massive radioulnar synostosis (white arrows) at the level of the radial tuberosity 3 months after initial sur- gery. The olecranon fracture is healed while the cerclage wire remained in situ. b CT scans show the heterotopic ossification starting from the distal biceps tendon (white star) insertion to the ulnar cortex its surroundings. Consequently, secondary haematoma indicative for that suggestion. And additionally, soft tis- calcification was assumed for RUS development [28, sue trauma during physiotherapy (e.g., of the supinator 29]. Because both fractures showed bony healing within muscle) might have played a role in HO synthesis