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Olecranon Fracture

- See:
      - Surgical Approach:
      - Tension Band Theory:

- 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;
            - see: properties of 6.5 mm cancellous 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


Complications of tension-band wiring of olecranon fractures.

Surgical treatment of displaced olecranon fractures by tension band wiring technique.

Tension band wiring of olecranon fractures. A modification of the AO technique.

Elbow function following tension band fixation of displaced fractures of the olecranon.                                                              

Tension-band fixation of olecranon fractures. A cadaver study of elbow extension.

Cyclic Loading of Olecranon Fracture Fixation Constructs.

Comparison of tension-band and figure-of-eight wiring techniques for treatment of olecranon fractures.

Transcortical screw fixation of the olecranon shows equivalent strength and improved stability compared with tension band fixation.