A comparative study of tension band wiring and reconstruction ...

Original Article
A comparative study of tension band wiring and
reconstruction plating in olecranon fractures
Gagan Khanna # , H S Sohal*, R S Boparai**, Devinderpal Singh***
# Assistant Professor
Department of Orthopedics, Sri Guru Ram Das Institute of Medical Sciences, Amritsar
*Professor & Head Orthopaedics, ** Professor
Department of Orthopaedics, GMC, Amritsar
*** Orthopaedic Specialist Officer
Department of Orthopaedics, Civil Hospital, Amritsar
ABSTRACT
Olecranon fractures occupy a special role in orthopedic management asthey require accurate reduction of
fracture and a short period of immobilization.We present a prospective study of 30 cases of Olecranon
fractures which were divided in two groups. One group was managed by open reduction and internal fixation
(ORIF) with tension band wiring (TBW) while the second was treated by ORIF with 3.5 mm reconstruction
plate. Patients of each group were graded during their followup for clinical and radiological results as per
criteria laid by Rogers et al. The cost effectiveness of tension band wiring is better to 3.5 mm reconstruction
plate but comparing the clinical and radiological results of both the groups the 3.5 mm reconstruction plate
shows better clinical and radiological statistics than TBW.
Keywords: Olecranon fracture,Tension band wiring, Reconstruction plate
INTRODUCTION
The fracture involving the joint surfaces have always occupied
a special role in orthopedic management since they require an
accurate reduction.Fracture of olecranon occurs either as a
direct trauma by theforceful impact at the posterior surface of
the elbow, or as an indirect trauma due to falling on partially
flexed elbow resulting in avulsion of proximal fragment of the
olecranondue to the pull of triceps muscle. 1
Tension band wiring is a technique developed by AO Group
which is based upon the principle of counteracting the tensile
forces acting across the fracture site and then converting them
into compressive forces. Two parallel Kirschner wires (K-wires)
across the fracture site before applying the tension band wire
Corresponding Author :
Dr. Gagan Khanna
Department of Orthopedics,
Sri Guru Ram Das Institute of Medical Sciences,
Vallah, Amritsar-143001.
Email: drgk75@gmail.com
(TBW) improves alignment, prevents rotation and
provides greater stability. Figure of eight wire placed on
posterior surface across the fracture site will produce
compression 2 .Problems of wire protrusion and pain after TBW
have been reported even without proximal migration of the
pins 3,4 .Reconstruction plate is very useful in comminuted or
oblique longitudinal fractures. Tension band wiring in these
fractures results in shortening of the olecranon which effects
the articulation with loss of motion or impingement. Plate
provides adequate rigidity and can be contoured according to
the specific needs of fracture configuration which provides
greater strength and rigid fixation across the fracture site
permitting early motion of joint 5 .
MATERIAL AND METHODS
In this prospective study, 30 skeletally mature patients with
closed olecranon fractures were taken who were distributed
alternatively to two groups as
Group A; treated by ORIF with tension band wiring.
Group B; treated by ORIF with 3.5 mm reconstruction
plate.
Pb Journal of Orthopaedics Vol-XIII, No.1, 2012
57

Khanna et al
Severely comminuted fractures were given preference for
internal fixation with plate. Cases were classified as per Horne
and Tanzer’s Classification 6 (Table-1)
Type-1
Type-2
Type-3
Table 1
Showing the classification of Olecranon
Transverse intra-articular fractures on the proximal third
of the articular surface of the olecranon fossa or oblique
extra-articular fracture of the olecranon
Oblique or transverse fractures on the middle third of the
articular surface of the olecranon fossa.
Oblique or transverse fractures on the middle thirdof the
articular surface of the olecranon fossa.
Transverse or oblique fractures on the distal third ofthe
olecranon fossa.
3 rd generation cephalosporins plus aminoglycosides were given
for 72 hours.X-rays were taken on 1 st post-operative dayto
confirm the fixation and reduction. Wound site was checked
on 3 rd post-op day. Stitches were removed on 12th post-op
day.
The patients were examined on 3rd, 6th, 9th, 12th week
and at six weekly intervals after that. On every visit patients
were examined clinically and X-rays of the elbow taken in
anteroposterior and lateral view. Movements of elbow were
recorded. During the period of follow up, only active exercises
in physiotherapy centre or at home were advocated.
Every patient of each group then is graded during his
follow-up for clinical and radiological results as per criteria laid
by Rogers et al 8 . (Table-2)
Surgical steps:
Exposure: General Anesthesia or brachial block was preferred
and tourniquet was used in all cases. Posterior midline incision,
extending 2.5 cm proximal and 10 cm distal to the olecranon
was usedfor both groups and fracture site was exposed 7 .
ORIF with TBW: A hole was drilled transversely in the ulna
about 5-7 cm distal to fracture site. A Stainless steel wire No.20
was passed through this hole. Two parallel 2.00 mm K-wires
were drilled from the tip of the olecranon through the proximal
fragment in slight oblique anterior direction to engage the
anterior cortex of the distal fragment of ulna. The loop of wire
was crossed over the posterior surface of the olecranon in
figure of eight fashion and passed around the protruded K-
wires under the triceps tendon. The wire was tightened and
secured with a twist. Range of movements checked. K-wires
were cut and bended end was rotated posteriorly and impacted
in the olecranon under the triceps. Wound was stitched in
layers and was sealed and compression bandage applied.
ORIF with 3.5 mm Reconstruction plate: After reduction
of fragments, the fracture was temporarily fixed and aligned
with 2.00 mm K-wire passed from the tip into the medullary
canal of distal ulna. After necessary contouring of the plate, it
was applied subperiosteally on the posterior or posteromedial
surface of ulna, using 3.5mm cortical and 4.0mm cancellous
screws. K-wire was not removed in some cases so as to maintain
the fixation and alignment. Wound was closed in layers and
dressing was applied.
POSTOPERATIVE MANAGEMENT & FOLLOW UP
The operated limb was kept elevated for 48 hours. Intravenous
RESULTS
Table 2
SHOWING BASIS OF GRADING
Grade Loss of Loss of Union
movement supination and
at elbow pronation
Excellent

A comparative study of tension band wiring and
reconstruction plating in olecranon fractures
Fig 1. Showing results of Group B
Table 3
Showing Complications
Complications Group A Group B
No. of cases %age No. of cases %age
Superficial infection 2 13.3 1 6.7 3 10.0
Deep infection 1 6.7 - - 1 3.4
Delayed union - - 1 6.7 1 3.4
Non union - - - - - -
Symptomatic metal skin impingement 5 33.3 1 6.7 6 20.0
Implant loosening (plate loosening/ proximal migration) 2 13.3 - - 2 6.7
Implant exposure - - - - - -
Implant failure - - - - - -
Pb Journal of Orthopaedics Vol-XIII, No.1, 2012
59

Khanna et al
In group A 2(13.3%) cases had superficial infection as
compare to one (6.6%) case in group B. Group A had 1(6.6%)
deep infection which resulted in loosening of K-wires and its
proximal migration. This patient was treated with implant removal
after the bone healed, along with I/V antibiotics resulting in
resolution of infection. Proximal migration of K-wires was
present in two patients, both of them belonged to group A.
(Fig 2).
In the present study 13 cases (86%) showed excellent and
good results while 2 cases (13.3%) had unsatisfactory outcome
in group A with TBW as compare to 14 cases (93.3%) showed
excellent and good results while only 1 case (6.7%) had
unsatisfactory outcome in with 3.5 mm reconstruction plate
fixation (group B). In both the groups, none of the patient
showed poor outcome (Table-4).Doursounian et al 13 in 1994
reported 87% cases had good functional results and 13% fair
functional results after tension band wiring of the olecranon
fractures. Hume and Wiss 11 showed 79% good and fair
results with TBW and 91% good and fair results with plate
fixation.
Bailey in 2001 reported 88% excellent or good results
after plate fixation of displaced fracture of the olecranon 14 .
Other studies reported results similar to the present
study 15,16,17 .
Fig 2. Showing results in Group A
CONCLUSION
In this comparative study, radiographic union occurred within
9 to 26 weeks of follow-up with no statistical difference in the
average union time in the groups treated with TBW and 3.5 mm
reconstruction plate at the final follow-up.
Ten patients incurred 13 complications. Patients were
significantly more likely to develop symptomatic metal
prominence after tension band wiring then after plate fixation.
Superficial and deepinfection was also more common in tension
Table 4
Showing clinical results according to roger's criteria
Results Group A Group B
No. of cases %age No. of cases %age
Excellent 8 53.3 10 66.6 19 63.3
Good 5 33.3 4 26.7 9 30.0
Unsatisfactory 2 13.3 1 6.7 2 6.7
Failure - - - -
Total 15 100.0 15 100.0 30 100.0
Pb Journal of Orthopaedics Vol-XIII, No.1, 2012
60

A comparative study of tension band wiring and
reconstruction plating in olecranon fractures
band wiring then plate fixation. Pin loosening and proximal
migration of K-wire was also more common with tension band
wiring. There was no case of non-union or failure of fixation in
the present study in either group. The cost effectiveness of
tension band wiring is better to 3.5 mm reconstruction plate
but comparing the clinical and radiological results of both the
groups the 3.5 mm reconstruction plate shows better clinical
and radiological statistics than TBW.
REFERENCES
1. Canale ST andBeaty JH: Fracture of olecranon; Campbell’s
Operative Orthopaedics, 11th editon, 2007;Ch.54.
2. Muller ME, Allgower M, Schneider R and Willenegger H. Manual of
internal fixation, 2 nd Ed., New York, Springer-Verlag, 1970.
3. Wolfgang G, Burke F, Bush D, Parenti J, Perry J and LaFolleHe B.
Surgical treatment of displaced olecranon fractures by tension band
wiring technique. J Clin Ortho 1987; 2245, 192-204.
4. Romero JM, Miran A, Jensen CH. Complications and re-operation
rate after tension-band wiring of olecranon fractures. J OrthopSci
2000; 5(4):318-20.
5. King GJ, Lammens HN, Milne AD, Roth JH, Johnson JA. Plate
fixation of comminuted olecranon fractures: an invitro
biomechanical study. J Shoulder Elbow Surg 1996; 5 (6): 437-41.
6. Horne JG and Tanzer TL. Olecranon fractures: A review of 100
cases. J Trauma 1981; 21: 469-72.
7. Taylor TKF and Scham SM. A posteromedial approach to the
proximal end of the ulna for the internal fixation of olecranon
fractures. J Trauma 1969; 9: 594-602.
8. Rogers JS, Bennett JB and Tullos, HS. Management of concomitant
ipsilateral fractures of the humerus and forearm. J Bone and Joint
Surg 1984; 66-A (4): 552.
9. Ring D, Jupiter JB, Sanders RW, Mast J, Simpson NS. Transolecranon
fracture-dislocation of the elbow. J Orthop Trauma 1997;
11(8):545-50.
10. Baruha RK. Displaced olecranon fractures results of TBW without
K-wires. IndOrthop J 1998; 32 (4): 263-65.
11. Hume MC, Wiss DA. Olecranon fractures. A clinical and radiographic
comparison of tension band wiring and plate fixation. ClinOrthop
1992; (285):229-35.
12. Fan GF, Wu CC, Shin CH. Olecranon fractures treated with tension
band wiring techniques—comparisons among three different
configurations. Changgeng Yi XueZaZhi 1993; 16(4):231-8.
13. Doursounian L, Prenot O, Touzard RC. Osteosynthesis by tension
band wiring of displaced fracture of the olecranon. Ann Chir 1994;
48 (2): 169-77.
14. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate
fixation of olecranon fractures. J Orthop Trauma 2001; 15(8):
542-8.
15. Konig S, Kilga M, Kwasny O. Results of plate osteosynthesis in
comminuted fracture of the olecranon Unfallchirurg 1990;
93(5):216-20.
16. Akman S, Erturer RE, Tezer M, Tekesin M, Kuzgun U. Long term
results of olecranon fracture treated with tension band wiring
technique. ActaOrthopTraumatolTurc 2002; 36 (5): 401-7.
17. Karlsson MK, Hasserius R, Besjakov J, Karlsson C, Josefsson PO.
Fracture of the olecranon: 15-25 years followup of 73 patients.
ClinOrthop 2002; 403: 205-12
Pb Journal of Orthopaedics Vol-XIII, No.1, 2012
61