Proximal radio-ulnar synostosis and nonunion after olecranon fracture tension-band wiring: a case report

Conservative versus surgical treatment for displaced olecranon fractures in the elderly: a retrospective study and a review of the literature

BACKGROUND

Surgery is the gold standard treatment of displaced olecranon fracture, but it presents a high rate of complications, especially in the elderly, including wound breakdown and fixation failure. Conservative treatment of these fractures has recently been proposed with good functional outcomes. The aim of this retrospective study was to compare the functional results and level of satisfaction of displaced olecranon fractures which were managed surgically or conservatively in geriatric patients. The rate of implant removal and reoperation in the surgical group were also calculated.

MATERIALS AND METHODS

Sixteen and eleven patients aged ≥ 75 years (mean 83 and 86.2, respectively) with isolated Mayo IIA or IIB olecranon fracture were surgically and conservatively treated, respectively. All but 1 were females. Due to coronavirus pandemic, they were contacted by phone to validated clinical scores (QuickDASH, PREE and VAS), which were used to assess the outcome.

RESULTS

At an average follow-up of 26.5 months in the conservative group and 53.1 in the surgical group (range 4-82), the mean Quick DASH was 11.67 and 11.2, respectively, while the mean PREE was 11.36 and 12.67, respectively. There was no significant difference in functional outcomes between the two groups, and all patients were satisfied. Seven complications occurred in the surgical cohort (33.3%), requiring reoperation in 4 cases (19%).

CONCLUSIONS

Displaced olecranon fractures can successfully be treated conservatively in low-demand geriatric patients with good functional results and high satisfaction rate.

Double-Bending Tension Band Wire for Olecranon Fractures: A Novel Technique

Purpose

This retrospective study aimed to compare the clinical outcomes and complications of conventional tension band wire (TBW), TBW with penetrating technique, and double-bending technique.

Methods

A total of 40 patients (17 men and 23 women; mean age: 64.0 ± 19.0 years) who underwent surgery for displaced olecranon fractures between January 2018 and December 2021 were included and divided into three groups based on the surgical method used (group A, conventional TBW; group B, TBW with penetrating technique; and group C, double-bending technique). Thirteen patients were assigned to group A, 17 to group B, and 10 to group C, including 2 Mayo type IB, 30 Mayo type IIA, and 8 Mayo type IIB fractures. Postoperative outcomes (elbow extension and flexion arc) and complications, such as backing out of the Kirschner wire (K-wire), were retrospectively evaluated.

Results

No significant difference was found in the general characteristics of the patients and fracture type among the three groups. The mean elbow extension arc values were 6.2°, 10.9°, and 0° in groups A, B, and C, respectively; it was significantly better in group C than in group B (P = .001). The rates of backing out of the K-wire were 84.6% (11/13) in group A, 41.2% (7/17) in group B, and 0% (0/10) in group C; the rate was significantly lower in group C than in group A (P < .001).

Conclusions

The double-bending technique may be the best procedure for preventing the backing out of the K-wire and postoperative complications, such as range of motion restriction, for treating olecranon fractures that are treatable by TBW.

Type of study/level of evidence

Therapeutic IV.

Olecranon fractures : current treatment concepts

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.

Comparison of the efficacy of the tension band wiring with eyelet wire versus anatomical locking plate fixation for the treatment of displaced olecranon fractures

BACKGROUND

This retrospective study was conducted to assess the clinical outcome and complications between tension band wiring (TBW) with eyelet wire and locking plate fixation used for the treatment of displaced olecranon fractures.

METHODS

A total of 58 patients (36 males and 22 females; mean age: 63 years) were reviewed between April 2014 and September 2020. TBW with Ring Pin (RP group) was applied in 24 patients, including 15 Mayo type ⅡA and 9 Mayo type ⅡB patients. Anatomical locking plate (ALP group) was used in 34 patients, including 22 Mayo type ⅡA and 12 Mayo type ⅡB patients. Clinical outcome was evaluated using the Mayo Elbow Performance Score (MEPS), and active range of motion of the elbow and forearm and postoperative complications were reviewed.

RESULTS

General characteristic of the patients and the fracture type were similar in the two groups. The mean MEPS values were 96.5 ± 7.3 in the RP group and 94.9 ± 9.4 in the ALP group. The mean elbow flexion arc was 127°±11 in the RP group. The mean elbow flexion arc was 122°±18 in the ALP group. No significant differences in clinical outcomes were observed between the two groups. Complication rates were significantly higher in the ALP group (19/34: 56%) than in the RP group (6/24: 25%).

CONCLUSION

Although there were no statistically significant differences in clinical outcomes between the two groups, the ALP group had a higher proportion of any complication than the RP group.

Tension-band wiring of displaced stable olecranon fractures with Eyelet-pins in the elderly: A series of 17 cases

BACKGROUND

Tension-band wiring (TBW) and plate fixation are commonly used to fix displaced olecranon fractures. However, the high incidence of complications in the elderly, such as wound breakdown, infection, and loss of reduction, remain a concern for orthopaedic surgeons. Furthermore, patients frequently suffer from removal of the hardware. Even so, the operation seems to be indicated for independent elderly patients to return to their former activities of daily living.

HYPOTHESIS

TBW of displaced stable olecranon fractures with Eyelet-pins in the independent elderly reduce the incidence of complications and allow early elbow joint exercise to keep their former activities.

PATIENTS AND METHODS

We operated on the displaced stable olecranon fractures of 17 independent patients aged ≥ 70 using TBW with two Eyelet-pins. Eyelet-pins have an eyelet at the trailing end to prevent pin migration by passing a soft wire through it. The patients were reviewed clinically and radiologically at 2, 6, 12, and 24 weeks, and clinically at 1 year after the surgery.

RESULTS

All fractures were united within 12 weeks, and the anatomic reduction was maintained. Mean radiographic proximal migration of the Eyelet-pins was 0.4mm (0.1 ∼ 1.2mm). Mean active elbow flexion was 136° (115° ∼ 145°) and extension 6.2° (0° ∼ 30°). Two patients had mild local pain and pain on motion at the tip of the eyelet. No patient required removal of the hardware. Other complications, such as superficial or deep wound infections, and neurological symptoms or signs, were not seen. All patients were able to maintain their former activities of daily living.

CONCLUSION

TBW with Eyelet-pins for displaced stable olecranon fractures is useful for independent elderly patients to reduce the incidence of complications and to maintain their former activities of daily living without removal of the hardware.

LEVEL OF EVIDENCE

IV; single-centre retrospective study.

Displaced olecranon fractures in the elderly: outcomes after non-operative treatment - a narrative review

Operative treatment with tension band wiring or plate is the gold standard of care for displaced olecranon fractures.

In elderly patients, multiple comorbidities combine with increased intraoperative risks, and postoperative complications may yield poor results.

There are small series in the literature that show promising results with non-operative treatment.

Non-operative treatment may provide reasonable function and satisfaction in the elderly population and could be considered as a treatment option in this group, especially for those with comorbidities, to avoid postoperative complications and the need for re-operation.

Cite this article: EFORT Open Rev 2020;5:391-397. DOI: 10.1302/2058-5241.5.190041

Results of non-operative treatment of olecranon fracture in over 75-year-olds

INTRODUCTION

Surgery is the gold-standard treatment of displaced olecranon fracture, but is associated with numerous complications, especially in the elderly. Functional results of non-operative treatment in this population have never been analyzed in a prospective study.

STUDY HYPOTHESIS

Non-operative treatment of isolated olecranon fracture with stable elbow-joint in over 75-year-olds gives functional results comparable to those of surgery as reported in the literature, with fewer complications.

MATERIAL AND METHODS

A prospective study analyzed functional results of non-operative treatment of isolated closed Mayo I and II olecranon fracture with stable elbow, in patients aged ≥75 years. The principal assessment criterion was functional recovery on the Mayo Elbow Performance Score (MEPS) and QuickDASH at 6 months.

RESULTS

Twenty-two fractures in 21 patients were included. Mean MEPS was 95.26/100 (range, 85-100), and mean QuickDASH 4.3 (range, 0-29.55). Eighteen fractures showed osteoarthritis of the olecranon. There were no cases of elbow instability. There were no complications.

DISCUSSION

Non-operative treatment of olecranon fracture in patients aged ≥75 years provided excellent functional results at 6 months, without associated complications.

TYPE OF STUDY

Single-center prospective observation cohort study.

LEVEL OF EVIDENCE

4.

Malpositioned olecranon fracture tension-band wiring results in proximal radioulnar synostosis

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.

[Treatment of isolated fractures of the olecranon: percutaneous double-screw fixation versus conventional tension band wiring]

BACKGROUND

Isolated fractures of the olecranon account for 7-10% of all osseous injuries in adults. These fractures are usually treated surgically by conventional tension band wiring. The percutaneous double-screw fixation is an optional treatment in patients with two fragment olecranon fractures with some postoperative advantages.

PATIENTS AND METHODS

A total of 13 patients with isolated fractures of the olecranon (Schatzker-Schmelling type A) treated by percutaneous double-screw fixation were included in this prospective study. The mean age of patients was 43.6 ± 11.0 years. Intraoperative and postoperative complications were recorded. Functional results were assessed after a mean follow-up of 38.2 ± 11.5 months using the Quick-DASH score. The results were compared with those obtained in the control group including 26 patients treated by conventional tension band wiring.

RESULTS

No intraoperative complications were observed in both groups. In the group with percutaneous double-screw fixation the scar length was significantly shorter (2.4 ± 0.4 cm vs. 11.0 ± 1.8 cm, p < 0.001) and the hardware removal was substantially less frequent that in the group with conventional tension band wiring with 38.5 % and 73.1 %, respectively. At the minimum follow-up of 2 years comparable functional results were obtained in both groups (Quick-DASH score 2.3 vs. 0.0 points, respectively, p = 0.155); however, the range of elbow motion was significantly higher in the group with percutaneous double-screw fixation (extension/flexion 145° vs. 130°, p < 0.001; pronation/supination 165° vs. 155°, p < 0.001).

CONCLUSIONS

The percutaneous double-screw fixation is a safe and viable treatment option in patients with isolated fractures of the olecranon (Schatzker-Schmelling type A). The functional results regarding DASH scores obtained using this technique were comparable with those observed in patients with conventional tension band wiring; however, range of elbow motion and cosmetic results were significantly better in the patient group with percutaneous double-screw fixation.

Treatment of olecranon fractures with 2.4- and 2.7-mm plating techniques

OBJECTIVES

To evaluate the outcomes of olecranon fractures treated with 2.4- and 2.7-mm plate constructs.

DESIGN

Retrospective Case Series.

SETTING

One-level 1 trauma center and 1 tertiary care hospital.

PATIENTS

Thirty-five consecutive patients meeting inclusion criteria.

INTERVENTION

A 2.7- or 2.4-mm reconstruction plate was placed on the dorsal ulnar cortex and contoured to allow passage of either a 2.7- or 3.5-mm intramedullary screw. In 9 patients, additional plates were required to control comminution. Available computed tomographic (CT) scans were evaluated for the presence of comminution.

MAIN OUTCOME MEASUREMENTS

Average Disabilities of the Arm, Shoulder, and Hand (DASH) and Mayo Elbow Performance Score (MEPS).

RESULTS

All fractures were united. Average extension deficit was 4.2 degrees, and average flexion angle was 137.4 degrees. Outcome scores were completed by 94% (33/35) of study patients. Average DASH score was 6.6, and average MEPS score was 94.5. Implants were removed in 18 patients. In the cohort of patients with CT scans, 6 of the 7 fractures thought to be simple on plain film analysis were found to have occult comminution on CT scan.

CONCLUSIONS

Comminution should be considered in all olecranon fractures, even when plain films display simple patterns; although this did not affect treatment in this series of plated patients, it may be important if selecting tension band wiring. Fixation with 2.4- and 2.7-mm plates addresses comminution in olecranon fractures, avoiding the pitfalls of tension band wiring. In patients with completed outcome scores, 97% (32/33) reported their outcomes as good or excellent according to the MEPS.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Simple and comminuted displaced olecranon fractures: a clinical comparison between tension band wiring and plate fixation techniques

INTRODUCTION

The purpose of this retrospective study is to compare the clinical, functional outcome and complications occurrence between tension band wiring (TBW) and plate fixation both for simple and comminuted displaced olecranon fractures.

MATERIALS AND METHODS

Between January 2005 and June 2012 (minimum 1-year follow-up), 78 consecutive patients with Mayo type IIA and IIB fractures were treated with the following methods: tension band wire or plate and screws fixation. The primary outcome of this study was the functional outcome, assessed by the following self-administered evaluation scales: the disabilities of the arm, shoulder and hand, and the Mayo Elbow Performance Score. Secondary outcome measures included the assessment of pain level, analysis of passive range of motion, and the occurrence of any early or late complications.

RESULTS

Comparing the clinical results between the two groups, at mean 33 months follow-up, no significant differences in the functional and clinical outcome were observed. Complications were reported in 48 and 17 % of cases, following TBW and plate fixation in patients treated for type IIA fractures, and similarly in 40 and 23 % of cases in type IIB fractures, respectively. Hardware removal was more frequently performed in TBW group: 38 versus 17 % for type IIA fractures and 20 versus 6 % for type IIB fractures.

CONCLUSIONS

The findings of this study indicate that both with the use of TBW and plate fixation excellent/good clinical outcomes with minimal loss of physical capacity, little pain and disability can be obtained in the majority of patients with simple and comminuted displaced olecranon fractures. Hardware removal was most frequently observed after TBW.

Management of heterotopic ossification and restricted forearm rotation after tension band wiring for olecranon fracture

A 32-year-old lady presented to our clinic with persistent painful restriction of her dominant forearm movements for three months after tension band wiring of olecranon. She had full elbow flexion and extension; however, her forearm rotations were restricted and painful. Investigations revealed prominent tips of the wire, eroding the radial tuberosity with heterotopic ossification between the radius and ulna. As there was no synostosis, the patient had implant exit. During surgery, before implant removal, examination under anaesthesia revealed a mechanical block of the rotation beyond 30° on pronation and supination from neutral. However, after the removal of implant, the mechanical block eased off and with gentle manipulation, full pronation and supination were achieved. At the final follow-up at 6 months, the patient had full pain-free forearm rotation with regression of heterotopic ossification. Our case report highlights the importance of intra-operative assessment of wire tips at full supination and pronation, and in patients with restricted forearm rotation, CT scan may be needed to assess the position of the hardware is essential as it can progress to synostosis. In cases with prominent hardware, removal of the implant may suffice if performed before the development of synostosis.

Tension band wiring in olecranon fractures: the myth of technical simplicity and osteosynthetical perfection

PURPOSE

The tension band wiring (TBW) technique is a common treatment for the fixation of olecranon fractures with up to three fragments. The literature and surgeons describe TBW as an uncomplicated, always available and convenient operation producing excellent results. The purpose of this study was to determine whether TBW is more ambitious than believed or the procedure provides an increased level of tolerance concerning the surgical technique.

METHODS

This study reviewed 239 TBW cases in patients with olecranon fractures or osteotomies. We reviewed a total of 2,252 X-rays for ten operative imperfections: (1) nonparallel K-wires, (2) long K-wires, (3) K-wires extending radially outwards, (4) insufficient fixation of the proximal ends of the K-wires, (5) intramedullary K-wires, (6) perforation of the joint surface, (7) single wire knot, (8) jutting wire knot(s), (9) loose figure-of-eight configuration, and (10) incorrect repositioning.

RESULTS

On average, there were 4.24 imperfections per intervention in the cases reviewed. A total of 1,014 of 2,390 possible imperfections were detected. The most frequent imperfections were insufficient fixation of the proximal ends of the K-wires (91% of all cases), the use of a single wire knot (78%) and nonparallel K-wires (72%). Mayo IIa (n = 188) was the most common fracture type.

CONCLUSIONS

Our results and the number of complications described by the literature together support the conclusion that TBW is not as easy as surgeons and the literature suggest. Although bone healing and the functional results of TBW are excellent in most cases, the challenges associated with this operation are underestimated.

LEVEL OF EVIDENCE

IV, treatment study.

Design and application of nickel-titanium olecranon memory connector in treatment of olecranon fractures: a prospective randomized controlled trial

PURPOSE

We carried out this study to test the efficacy of the olecranon memory connector (OMC) in olecranon fractures.

METHODS

We designed a prospective randomised controlled trial involving 40 cases of olecranon fractures. From May 2004 to December 2009, 40 patients with olecranon fractures were randomly assigned into two groups. Twenty patients were treated with OMC, while another 20 patients were fixed with locking plates in our hospital. The DASH score, MEP score, range of motion and radiographs were used to evaluate the postoperative elbow function and complications.

RESULTS

For MEP score, OMC was better than the locking plate; for DASH score, complication rate, and range of elbow motion, the two methods presented no significant difference.

CONCLUSION

The study showed that OMC could be an effective alternative to treat olecranon fractures.

Successful treatment of a radioulnar synostosis in a Mississippi kite (Ictinia mississippiensis)

A Mississippi kite (Ictinia mississippiensis) was presented to the Wildlife Hospital of Louisiana, School of Veterinary Medicine, Louisiana State University, for an inability to fly and was subsequently diagnosed with a minimally displaced, closed, simple, short oblique, diaphyseal fracture of the distal third of the right ulna. A figure-8 bandage was initially applied to the wing to stabilize the fracture. Over a 5-week period, the kite developed progressive reduction in wing extension, and serial radiographs revealed a bridging callus at the ulnar fracture site, as well as development of a radioulnar synostosis. To restore wing function and extension, surgical excision of the bony union between the radius and the ulna was performed, after which a polypropylene mesh implant was interposed between the 2 bones. Within 2 weeks after the surgical procedure, the kite had recovered normal wing extension and was able to fly without noticeable impairment. The bird was released 2 weeks after surgery. This case illustrates a common complication of external coaptation used as sole means of managing fractures of the avian ulna, radius, or both, which results from lack of interosseous soft tissue in the antebrachial area. On the basis of the successful outcome in this case, surgical excision of the interdiaphyseal callus and interposition of a polypropylene mesh could be a viable option for management of posttraumatic radioulnar synostosis in birds of prey.

Potential dangers of tension band wiring of olecranon fractures: an anatomic study

PURPOSE

Displaced olecranon fractures are often amenable to treatment with open reduction and tension-band wiring. The purpose of this study is to examine the relationships of the tips of K-wires used in a tension-band construct to volar neurovascular structures in the proximal forearm and the proximal radioulnar joint.

METHODS

We performed simulated percutaneous pinnings of the proximal ulna under fluoroscopic guidance on 15 cadavers with intact proximal ulnas. The K-wires were drilled obliquely through the tip of the olecranon process and directed to engage the anterior ulnar cortex, distal to the coronoid. Using calipers, we measured the distance from the tip of each pin to the anterior interosseous nerve (AIN), ulnar artery, proximal radioulnar joint (PRUJ), and volar cortex of the ulna, as well as the distance from the volar cortex of the ulna to the AIN and ulnar artery. The angle created by the K-wires and the longitudinal axis of the ulna was measured on both anteroposterior and lateral radiographs.

RESULTS

The distance from pin tip to the AIN and ulnar artery measured a mean of 16 mm with a standard deviation of 6 mm and 14 mm with a standard deviation of 5 mm, respectively, with 1 pin abutting the artery. The shortest distance from both the AIN (11 ± 5 mm) and the ulnar artery (8 ± 6 mm) was measured with the shallowest angle of insertion, ranging from 10° to 14.9° on lateral radiographs. The mean distance between the pin tip and the PRUJ measured 7 mm with a standard deviation of 4 mm, with 3 pins penetrating the PRUJ.

CONCLUSIONS

The impaction of K-wires under the triceps is often approximately 1 cm, which is similar to the distance of the K-wire tips to the AIN and ulnar artery. Our findings suggest that larger insertion angles might help avoid neurovascular injury when the insertion point of the K-wires is at or just proximal to the tip of the olecranon. In this study, the safe zone for pin insertion on the anteroposterior view is 0° to 10°, and on the lateral view it is 20° to 30°.

CLINICAL RELEVANCE

This anatomic study was done to diminish the chance of complications resulting from K-wire placement during tension-band wiring for olecranon fractures.