Peggers’ Super Summary of Tension band wiring for Olecranon & Patella Fractures

Indications:

  • Transverse fractures of the olecranon or patella with disruption of the extensor mechanism

Anatomy:

OLECRANON

  • Direct approach due to subcutaneous bony nature

PATELLA

  • Infra-patella saphenous nerve branches

Associated injuries

  • Examine hand, wrist joint and elbow thoroughly
  • n/v status specifically the ulnar nerve
  • Skin viability
  • Patella / Quadriceps tendon rupture patella length should = distal patella pole to tibial tuberosity AKA Insall index

NB bipartite patella is typically found on the proximal lateral junction with a sclerotic edge

Preoperative Planning:

  • Check extensor mechanism
  • Complex injuries or intra-articular compression of the elbow joint require CT imaging
  • Soft tissue injuries of the skin are required to heal, therefore delay the operation to reduce the risk of operation

Equipment

  • Olecranon
  • Tension band wiring set 18G stainless steel wire
  • 2x 2mm K wires
  • 3.5mm screw set for oblique fractures
  • Patella
  • 2mm k wires and 1.25mm stainless steel cerclage wires
  • Small fragment set with 3.5mm cortex wires
  • 4.0mm cancellous lag screws
  • 14G cannula
  • II
  • Tourniquet

Operative Room Planning

INTRODUCTION

  • Confirm Consent / Mark / WHO form / Abx at induction

POSITION

  • Olecranon
  • Supine with arm across body
  • Or lateral with arm draped over a bolster
  • Patella
  • Supine
  • Tourniquet
  • Tourniquet may affect reduction as the quadriceps is fixed in a shortened position

DRAPING

  • Antiseptic solution to whole of upper extremity hand in stockinet
  • Perforated or U drapes

Surgical Approach

OLECRANON

  • Make the medial and lateral sides of the olecranon if working in non anatomical position
  • A curvilinear incision is made going laterally around the tip / apex of the olecranon
  • Use a direct approach to the posterior surface of the ulna
  • Start distally and work up
  • Expose the fracture with minimal stripping using a No 15 blade
  • Inspect the articular surface and remove any osteochondral segments
  • Irrigate the joint thoroughly
  • Elevate depressed articular depression using a MacDonald’s or Watson-Cheyne elvators
  • Fill defect with bone of hydroxyapatite
  • Reduce fracture with reduction forceps and extend the elbow, if forceps do not grip need to make a drill hole for purchase
  • Oblique fracture need a 3.5mm lag screw

IMPLANT

  • Subchondral placement of 2x 2mm k wires through the triceps tendon until the anterior cortex of the ulna is breached.
  • Back out the k wires by 1.5cm
  • Bend the K wires to make a “v” shape
  • Using a 2mm drill piece drill a hole 3-4cm distal to the fracture from medial to lateral
  • Using a 14G cannula (orange) passed under the triceps and over the K wires as a guide to feed the 18G wire.
  • The second piece of wire is passed through the drill hole
  • The 2 wires are looped to create a figure of ‘8’
  • The 2 ends of the wire are pulled and twisted producing a helix
  • Stop tightening when the wires twist asymmetrically or change colour from fatigue
  • Enough tension is created when k wires bend towards each other and the fracture is stable in ROM
  • With a 15 blade spit the triceps and hammer home the sharp end of the K wires into the olecranon with a small punch and mallet
  • The twisted 18G wires are cut short and buried

PATELLA

  • Midline longitudinal incision over the patella
  • Beware of infra-patella branches of the saphenous nerve
  • Remove the bursa if open fracture is present or chronic bursitis
  • Incise superficial fascia
  • Avoid soft tissue stripping from the fracture and remove enough to see and reduced the fracture
  • Irrigate and wash out the fracture haematoma
  • Reduced using reduction forceps +/- hyperextension of the knee
  • Check the articulating surface of the patella for reduciton
  • 2 vertical 2mm k wires are drilled longitudinally through the patella
  • Fragmentation of fractures may need lag screw osteosynthesis via 4mm cancellous lag screws prior to or in addition to TBW
  • A 14G cannula may assist passing the wire through stiff ligaments
  • A figure of 8 pull and twist is performed on the anterior surface of the patella
  • Shorten and bend the tips into the patella and the 1.25mm stainless steel wire

Finishing off:

  • Check that the K wires are not in the humeral or PRUJ joint via II
  • Flex / extend & supinated / pronate the elbow to check implants are stable with movement
  • II AP / lateral elbow

Closure

  • Release tourniquet
  • Haemostasis
  • irrigate
  • 2 layer closure with 3/0 vicryl to subcutaneous and 3/0 PDS or caprosyn to subcuticular tissues. Nylon mattress or vicryl rapide to skin is under tension.

Post operative movement:

  • When wound dry and clean circa 48hrs
  • Continuous passive movement 900
  • Active assisted exercise to 900
  • Partial weight bearing ie toe touch 15Kg

NB osteoporotic bone or comminuted fractures delayed mobilisation but to avoid adhesions and retain quads tone for isometric quadriceps exercises

Operative Note

Preparation and Position:

Supine, block, light sedation, full sterile prep and drape, tourniquet 250mmHg, WHO checks , iv ANTIBIOTICS

Incision and Approach :

Longitudinal midline skin incision over olecranon, curving radial side over tip of olecranon

Findings :

3 part fracture – small butterfly fragment

Procedure :

All tissues divided in the line of incision, # identified, curettage of # ends

# reduced & held, hole drilled in ulna distal to fracture, 2 `K` wires passed parallel through tip of olecrtanon into ulnar medulla,

Loop of wire in figure of 8 manner applied behind the `K` wires through hole in ulna and passed under triceps tendon, preserving it. K wire ends bent and buried, tendon closed over wires with 3/0 vicryl

Good compression achieved

II check satisfactory

Closure :

Wound closed in layers , subcut vicryl 3/0

Dressings, wool, A/E slab applied and crepe

Post Op Instructions :

Monitor CSM,

Move fingers and hand actively

Analgesics

Wound inspection and removal plaster at clinic

Complications:

Early

  • Infection
  • Intra-articular placement of K wires

Late

  • Skin and wound complications
  • Wire backing out and loosening
  • Non mal-union
  • stiffness

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