The theoretical basis for tension band fixation of the olecranon is that it converts tensile forces on the posterior side of the olecranon into compression forces at the joint line during flexion. The fixation is simple and inexpensive and works well if executed properly.
A tension band can only be used if the anterior (far) cortex is not comminuted and provides a buttress to allow for compression. Therefore, multifragmentary fractures cannot be fixed with a tension band.
Choose a wire of sufficient strength to withstand the tensile forces generated in the figure-of-eight loop. Positioning the K-wires close to the joint while also penetrating the volar cortex is paramount.
2. Instruments and implants
The following equipment is needed:
K-wires of appropriate sizes
Wire of appropriate strength
Drill or a T-handle for manual insertion
Two pliers for wire twisting
Wire cutting instruments
Standard orthopedic instrument set
Alternative: Use a high-strength, braided composite suture or tape instead of figure-of-eight wire.
There is almost always a small spike on one of the fragment sides that exactly fits into a gap on the opposite fragment.
Reduce and hold the reduction of the transverse olecranon fracture with a small pointed reduction forceps.
Pearl: Drill a small unicortical hole in the distal fragment to secure the reduction forceps.
5. Prepare wire insertion
Drill a hole through the ulna approximately 2-4 cm distal to the fracture line and 5 mm from the posterior cortex.
Wire preparation and insertion
Prepare the wire by making a loop approximately one third along its length.
Insert the shorter segment of the wire through the drilled hole from medial to lateral. As the ulnar nerve is medial it is safer to introduce the wire from this side.
6. Insertion of K-wires
Using the drill guide, introduce the first K-wire medially through the olecranon apophysis.
Aim the drill towards the anterior cortex, passing as close as possible to the joint. Leave enough space on the lateral side for the second K-wire.
Drill the K-wire through both cortices.
Insert a second parallel K-wire.
Check the position of both K-wires with image intensification.
7. Wire fixation
Remove the small pointed reduction forceps.
Pass the long segment of the wire (bearing the loop) in a figure-of-eight configuration beneath the triceps tendon around the protruding ends of the K-wires.
Twist the two wires ends together.
Note: Make sure that the loop and wire twist do not lie too close to the wire hole to avoid unnecessary tension at the wire hole.
Placing the loops more proximally will allow a smaller incision when removing them after healing.
Some surgeons find it easier to use two separate pieces of wire instead of one loop to create the tension band.
Tightening the wire
Ensure that each end of the wire spirals equally - the twist should not comprise one spiral around a straight wire.
Cut the wire ends short.
The slack is then taken up by further twisting. Repeat this until the desired tension is achieved. Both loops must be tightened at the same time and in the same direction, to achieve equal tension on both arms of the wire.
By tightening the twist and the loop with two pliers simultaneously, the two fragments are drawn together such that the fracture is placed under compression.
Note: Avoid excessive tensioning.
Prevention of later soft-tissue irritation
Trim the twisted wire and turn both ends towards the ulna/olecranon to minimize soft-tissue irritation.
Sinking the K-wires
Bend the proximal end of the K-wires 180° with pliers, bending irons or forceps and cut the K-wires.
Sink the curved ends into the olecranon or triceps tendon to prevent backing out and skin irritation.
8. Final assessment
Confirm fracture stability and range of motion, including supination-pronation.
Exclude K-wire penetration into the humeroulnar or radioulnar joint.
Final x-rays or image intensifier views should show good reduction and correct hardware position.
9. Aftercare following tension band wiring
Immediate postoperative care
Whilst the child remains in bed, the elbow and forearm should be elevated on pillows to reduce swelling and pain.
Cast or splint immobilization
Fixation of olecranon fractures with tension band wiring is intrinsically stable and supplementary casting or splinting is therefore not required.
Ibuprofen and paracetamol should be administered regularly during the first 24-48 hours after surgery, with opiate analgesia for breakthrough pain.
Opiates should not be necessary after 48 hours and regular ibuprofen and paracetamol should be sufficient until 4-5 after injury or surgery.
The child should be examined if the level of pain is increasing or prolonged analgesia is needed.
The child should be examined regularly, to ensure finger range of motion is comfortable and adequate.
Neurological and vascular examination should also be performed.
Compartment syndrome should be considered in the presence of increasing pain, especially pain on passive stretching of muscles, decreasing range of active finger motion or deteriorating neurovascular signs, which is a late phenomenon.
Tension band wire removal is delayed until function has fully recovered and can be performed as a day case, under general anesthesia.
Usually the incision is smaller than for open reduction if the twisted wire ends lay close to the olecranon tip. Sometimes for cosmetic reasons, it is best to resect the whole scar and use cosmetic wound closure.
Make a small incision over the olecranon tip extract the two K-wires with pliers.
Unwind or cut the twisted wire and pull it out of the bony track.