Intrafocal K-Wire (Kapandji Technique)

What It Is

Mechanism: How It Works

• To correct dorsal angulation (restore volar tilt): A pin is inserted from the dorsal-ulnar aspect of the fracture site, levered in a volar direction (pressing against the dorsal cortex), then driven into the volar cortex of the proximal fragment.
• To correct radial shortening / lost radial inclination: A pin is inserted from the volar-radial side, levered distally and radially to restore radial length and inclination, then driven into the proximal fragment's radial cortex.

Indications

• Extra-articular distal radius fractures (e.g., Colles' fracture) with good bone stock
• Younger patients without significant osteoporosis
• Used as an isolated technique or as an adjunct to external fixation

Step-by-Step Technique (Summary)

1. Closed reduction is first attempted by manipulation.
2. Under fluoroscopy, K-wires are inserted into the fracture gap (not through intact bone).
3. The wire is used as a lever to restore volar tilt and/or radial inclination.
4. Once reduction is confirmed, the wire tip is advanced into the proximal fragment cortex to hold the position.
5. Typically 2-3 wires are used (one dorsal-ulnar for tilt, one radial for inclination, sometimes a third).
6. A supplemental plaster cast is applied for 4-6 weeks.

Advantages

• Simultaneous reduction AND fixation in one maneuver
• Minimally invasive (no open surgery)
• No need for traction or external fixation in many cases

Disadvantages / Limitations

• Does not provide rigid fixation on its own - often needs supplemental external fixation or cast
• Prone to loss of reduction in older patients, especially with metaphyseal comminution (fragments can slide along the pin)
• Less commonly used today with the widespread adoption of volar locking plates (ORIF), which provide more reliable fixation, especially in osteoporotic bone

Current Role

Reduction Criteria for Distal End Radius (DER) Fractures

Normal Anatomy - The Baseline ("11 : 22 : 11" Rule)

Acceptable Reduction Criteria

AAOS Guideline Benchmarks (Post-reduction)

• Radial shortening < 3 mm
• Dorsal tilt < 10°
• Intra-articular step-off < 2 mm

Criteria for Acceptable Healing (Graham's Criteria)

Why These Parameters Matter - Clinical Consequences of Malreduction

• Dorsal tilt > 10° - decreased wrist flexion, worse DASH scores, midcarpal instability
• Dorsal tilt > 20-30° - alters force distribution across radiocarpal joint; considered a prearthritic condition
• Radial shortening > 4-6 mm - DRUJ dysfunction, ulnar-sided wrist pain, reduced grip strength
• Radial inclination < 10° - reduced grip strength, higher DASH scores
• Intra-articular step-off > 2 mm - increased risk of post-traumatic arthritis

Malunion Definition (Rockwood & Green)

• Radial inclination < 10°
• Volar tilt > 20° or dorsal tilt > 20°
• Radial height < 10 mm
• Ulnar variance > +2 mm

Quick Summary Mnemonic

Normal = 11 : 22 : 11 (height : inclination : volar tilt) Accept = <3 mm short | >10° inclination | <10° dorsal tilt | <2 mm step-off

Post-Op X-Ray Assessment: Bipolar Hemiarthroplasty for NOF Fracture

Pre-op fracture (AP and lateral) and post-op cemented bipolar hemiarthroplasty in good position - Rockwood & Green, 10th Ed.

1. Femoral Stem Position

2. Leg Length

• Compare the lesser trochanter level bilaterally on AP pelvis
• Should be equal or within ~1 cm of the contralateral side
• Leg length inequality causes limp, hip instability, and patient dissatisfaction
• (Miller's Review of Orthopaedics, 9th Ed.): "Goal is to optimize limb length and femoral offset"

3. Femoral Offset

• Distance from femoral shaft axis to centre of the prosthetic head
• Adequate offset restores abductor tension and reduces dislocation risk
• Reduced offset → increased joint reaction force, abductor weakness, limp

4. Bipolar Head Position

• The outer metallic shell should sit concentrically within the acetabulum
• Head should be completely within the acetabular fossa - no subluxation
• The bipolar shell should not protrude into the pelvis (acetabular protrusion)
• Head size should match the anatomical femoral head size

5. Cement Mantle (Cemented Stems - Most Common in Elderly)

• Radiolucency between stem and cement at superolateral (Gruen zone 1) = debonding
• Radiolucency between cement mantle and bone = possible aseptic loosening
• Cement mantle fracture - most common near tip of stem (Gruen zone 4)
• Cement fragmentation at superomedial stem/neck junction (Gruen zone 7)
• Ideal: uniform 2-3 mm cement mantle all around, no radiolucent lines immediately post-op

6. Gruen Zones (for Systematic Radiolucency Assessment)

• Zones 1-7 on AP view (1 = proximal lateral, 7 = proximal medial, 4 = tip)
• Radiolucency in any zone is noted and followed serially

7. Greater and Lesser Trochanter

• Look for trochanteric fracture (intraoperative or postoperative complication)
• Trochanteric wires/cables intact if trochanteric osteotomy was used

8. Complications to Actively Exclude

9. Comparison with Contralateral Normal Hip

• Neck-shaft angle (normal ~130°)
• Leg length equality
• Trochanteric height
• Femoral offset

Summary Checklist (Post-Op Bipolar Hemiarthroplasty)

✅ Stem alignment (varus/valgus/anteversion) ✅ Leg length equality ✅ Femoral offset ✅ Bipolar head position in acetabulum (no dislocation, no protrusion) ✅ Cement mantle quality (Gruen zones - no early radiolucency) ✅ Trochanteric integrity ✅ No periprosthetic fracture ✅ No cortical breach ✅ Appropriate head size vs. native acetabulum

Post-Op X-Ray Assessment: Bipolar Hemiarthroplasty for NOF Fracture

1. Femoral Stem Position

2. Leg Length

• Compare lesser trochanter level on both sides on AP pelvis
• Should be equal or within ~1 cm of contralateral side
• Inequality → limp, instability, patient dissatisfaction

3. Femoral Offset

• Distance from femoral shaft axis to centre of prosthetic head
• Adequate offset restores abductor tension and prevents dislocation
• Reduced offset → weak abductors, Trendelenburg gait

4. Bipolar Head / Acetabular Relationship

• Head sits concentrically within the acetabular fossa
• No subluxation or dislocation
• No acetabular protrusion (shell pushing through acetabular floor medially)
• Outer shell diameter matches native femoral head size

5. Cement Mantle (Gruen Zones - for Cemented Stems)

• Definite - migration of stem/cement
• Probable - complete radiolucency around cement mantle
• Possible - radiolucency around >50% of cement

6. Trochanteric Region

• Greater trochanter intact (no intraoperative fracture)
• If trochanteric osteotomy was done - check wires/cables intact and trochanter well-seated

7. Complications to Actively Exclude

8. Comparison with Contralateral Side

• Neck-shaft angle (normal ~130°)
• Leg length
• Offset
• Trochanteric height

Quick Summary Checklist

✅ Stem alignment (varus/valgus, anteversion) ✅ Leg length equality ✅ Femoral offset ✅ Head concentric in acetabulum (no dislocation, no protrusion) ✅ Cement mantle (Gruen zones, no radiolucency) ✅ Trochanteric integrity ✅ No periprosthetic fracture ✅ No cortical breach ✅ Appropriate head size

Olecranon Fracture - Tension Band Wiring: Procedure

Principle

Equipment Required

• Two 0.062-inch (1.6 mm) K-wires
• 20-gauge stainless steel cerclage wire
• Pointed reduction clamps
• Power drill, Angiocatch catheter
• Radiolucent table + C-arm fluoroscopy

Patient Positioning

• Lateral or prone position on radiolucent table
• Radiolucent arm board under the arm (allows full elbow flexion/extension)
• C-arm brought in from the head of the table
• Sterile tourniquet available

Surgical Approach

• Posterior midline incision, placed just radial to the tip of the olecranon (not directly over it - reduces wound complication risk)
• Full-thickness medial and lateral fasciocutaneous flaps raised
• Identify and protect the ulnar nerve (do not fully release from cubital tunnel)
• Develop interval between ECU and FCU
• Elevate FCU from olecranon (ulnar side) to visualize joint
• Incise anconeus fascia (radial side) if further visualization needed

Step-by-Step Technique

• Expose fracture edges and clean the fracture hematoma
• Inspect joint for trochlear damage or loose bodies
• Extend the elbow to reduce the fracture

• Drill holes on both radial and ulnar sides of the ulnar shaft
• Apply a pointed reduction clamp with tines in the drill holes to hold and compress the reduction
• A shoulder hook or dental pick helps hold small fragments

• Drive two parallel 0.062-inch K-wires from the tip of the olecranon (superior aspect), crossing the fracture site, exiting the anteromedial cortex of the ulna
• Back out the wires slightly to allow for later impaction
• ⚠️ Avoid lateral placement - K-wires exiting laterally can irritate the bicipital tuberosity → heterotopic ossification and radioulnar synostosis
• ⚠️ Avoid excessive length of the medial K-wire → ulnar or median nerve injury

• Drill a hole in the dorsal cortex of the ulnar shaft, distal to the coronoid (approximately 2-4 cm distal to the fracture line, 5 mm from posterior cortex)
• This is the anchor point for the figure-of-8 wire

• Pass a 20-gauge stainless steel wire using an Angiocatch catheter:
  • Deep to the triceps tendon around the proximal K-wire ends
  • Through the transosseous drill hole distally
  • Creating a figure-of-8 configuration
• One or two figure-of-8 wire loops may be used

• Tension the wire simultaneously on both the radial and ulnar sides
• Equal bilateral tightening ensures uniform compression across the fracture
• Confirm anatomic reduction under fluoroscopy

• Bend K-wire tips 180°
• Impact/bury the bent wire tips underneath the triceps tendon into the olecranon tip through small incisions in the triceps
• This reduces hardware prominence

• Take elbow through full range of motion - especially full flexion
• Confirm fixation is secure under fluoroscopy
• No hardware should impinge on the radioulnar joint

• Layered closure so early range of motion can begin while sutures are still in place

Postoperative Protocol

• Long-arm splint in semi-extended position for 48 hours
• At 48 hours: start active and active-assisted flexion + gravity-assisted extension
• 6 weeks: active exercises against gravity
• 3 months (or when united): full resistive exercises

Pitfalls and Prevention

Key Points Summary

• Principle: distraction → compression by posterior wire loop
• Two parallel K-wires from olecranon tip → anteromedial cortex
• Figure-of-8 wire through transosseous drill hole + around K-wire ends
• Tension wire simultaneously on both sides
• Bend and bury K-wire tips under triceps
• Compression increases with elbow flexion (dynamic fixation)
• Best for simple transverse fractures proximal to coronoid only
• Most common complication: hardware prominence requiring removal

Comminuted Olecranon Fracture: Treatment and the Role of TBW

⚠️ Critical Point: TBW is Contraindicated in Comminuted Fractures

"Simple olecranon fractures without comminution or instability may be managed with tension band wiring... Comminuted fractures or those associated with elbow instability should be managed with plate fixation." — Rockwood & Green's Fractures in Adults, 10th Ed.

"We infrequently use the tension-band technique for displaced olecranon fractures because of the high complication and reoperation rates compared with other techniques. Plate fixation has the advantage of maintaining fixation in fractures with comminution." — Campbell's Operative Orthopaedics, 15th Ed.

• The figure-of-8 wire relies on two solid cortical surfaces to compress against each other
• With comminuted fragments, there is no stable fulcrum - the wire cannot maintain reduction
• Fragments slide along the K-wires causing loss of reduction
• Hardware complications (wire migration, prominence) are extremely high (~80% require removal)

Mayo Classification - Treatment Guide

Correct Treatment for Comminuted Olecranon Fracture: Plate Fixation

Indications for Plating

• Comminuted fractures (Mayo IIB, IIIB)
• Fractures with elbow instability (transolecranon fracture-dislocation)
• Fractures extending distal to the coronoid
• Posterior Monteggia injuries (shaft extension)

Plate Fixation: Step-by-Step Procedure

• Precontoured proximal ulna plates (locking or non-locking)
• 3.5-mm reconstruction plates or 2.7-mm plates
• Small fragment set, pointed reduction clamps, provisional K-wires

• Lateral, prone, or supine with arm over chest
• Radiolucent table, C-arm from the head

• Posterior midline incision, just radial to olecranon tip
• Full-thickness fasciocutaneous flaps
• Identify and protect ulnar nerve
• FCU elevated from olecranon (ulnar side); anconeus elevated (radial side)

• Expose and clean fracture ends
• Reduce fragments with pointed reduction clamp + provisional K-wires
• For comminuted patterns - indirect reduction techniques to preserve biology

• Split triceps longitudinally in the midline to accommodate proximal plate end
• Precontoured or manually contoured plate placed around olecranon tip and distally along ulnar border (between ECU and FCU)
• Check plate position with fluoroscopy before screw insertion
• Plate contouring adjusted to ensure flush bone contact

• Short screw at the plate tip (away from lag hole) to draw plate to bone
• Lag screw across fracture for non-comminuted components (interfragmentary compression)
• For comminution - bridging/neutralisation mode rather than lag screw
• Remaining screws placed to secure both proximal and distal fragments
• Locking screws preferred in osteoporotic bone

• For short proximal fragments with tenuous fixation: place a Krackow (triceps interlocking) suture through the triceps tendon and secure to the plate as backup
• This protects against proximal fragment pullout

• Full elbow range of motion under fluoroscopy
• Confirm articular reduction
• No hardware in radioulnar joint

• Layered closure; fascia over plate distally where possible
• Incision radial to olecranon tip reduces wound complication risk

Fixation Types Compared (Campbell's Table 62.12)

Special Situation: Elderly / Osteoporotic + Severe Comminution

• Excise all comminuted fragments (safe if < 75% of the articular surface)
• Advance triceps tendon to remaining ulna with non-absorbable sutures (No. 2 FiberWire/Ticon) through 2-mm transosseous drill holes
• Reserved for low-demand elderly patients only
• Not suitable for young/active patients (loses elbow extension strength)

Summary

✅ Comminuted olecranon fracture = Plate fixation (NOT TBW) ✅ TBW is only for simple transverse, non-comminuted, stable fractures (Mayo IIA) ✅ Plate provides stable bridging/neutralisation regardless of comminution ✅ Supplement with Krackow triceps suture for short proximal fragments ✅ Elderly with unreconstructable comminution = excision + triceps advancement