Olecranon Fracture: Open Reduction and Internal Fixation with Tension Band Wiring

Preoperative Planning

• Implants required: Two 0.062-inch (1.6 mm) Kirschner wires (K-wires), 20-gauge stainless steel cerclage wire, pointed reduction clamps
• Table: Radiolucent
• Fluoroscopy: C-arm positioned from the head of the table
• Tourniquet: Sterile tourniquet available; used at surgeon's discretion
• Review radiographs to confirm fracture morphology - transverse, proximal to the coronoid, no comminution, stable elbow

Patient Positioning

• Lateral decubitus or prone on a radiolucent table (lateral is preferred to minimize risk of eye injury vs. prone)
• A radiolucent arm positioner is placed under the arm so the elbow can be flexed and extended freely during the procedure
• Supine with a bump under the ipsilateral shoulder and arm across the chest is an acceptable alternative (requires an assistant to hold the arm; C-arm comes in from the side)
• Obtain test fluoroscopic images before draping to confirm adequate visualization

Anesthesia

• General or regional (brachial plexus block)
• Inflate tourniquet to 250 mmHg (or 100 mmHg above systolic) after exsanguination if used

Surgical Approach

1. Mark the posterior midline of the elbow, placing the incision just radial to the tip of the olecranon (this provides better soft-tissue coverage over the hardware)
2. Make a longitudinal posterior midline incision from approximately 5 cm proximal to the tip of the olecranon to an adequate distance distally for fixation
3. Raise full-thickness medial and lateral fasciocutaneous flaps
4. Identify and protect the ulnar nerve - palpate it in the cubital tunnel; formal transposition is usually not required but the nerve must be kept in view throughout
5. Develop the interval between the ECU (extensor carpi ulnaris) and FCU (flexor carpi ulnaris) to expose the subcutaneous border of the ulna
6. On the ulnar side, elevate the FCU from the olecranon to visualize the ulnohumeral joint
7. On the radial side, incise the anconeus fascia and elevate the muscle from the olecranon fragment for further visualization as needed

Procedure Steps

Step 1 - Fracture Exposure and Joint Inspection

• Expose and thoroughly debride the fracture edges; preserve periosteum and soft-tissue attachments on any comminuted fragments
• Inspect the articular surface of the trochlear notch for damage to the trochlea and for any intra-articular loose bodies
• If needed, a lateral capsulectomy may be performed to confirm anatomic articular reduction, particularly if impaction of the joint surface is suspected

Step 2 - Fracture Reduction

• Extend the elbow to reduce the fracture
• Place drill holes on the ulnar shaft - one radially and one ulnarly - just distal to the fracture, so that a pointed reduction clamp can be used with one tine in the drill hole and the other tine at the tip of the olecranon, providing compression from both sides
• A shoulder hook or dental pick can assist in reducing smaller articular fragments
• Confirm anatomic articular reduction visually and under fluoroscopy

Step 3 - K-Wire Insertion (Intramedullary Fixation)

• Insert two 0.062-inch (1.6 mm) K-wires from the superior aspect (tip) of the olecranon, directed distally in an intramedullary fashion
• The K-wires should exit the anteromedial ulnar cortex (not lateral, to avoid irritating the radial tuberosity which predisposes to rotational stiffness and proximal radioulnar synostosis)
• After seating, back out the wires approximately 1 cm (they will be impacted flush at the end of the procedure)
• Confirm K-wire position with fluoroscopy: both wires should cross the fracture site, be parallel, and exit the anteromedial cortex
• Caution: Avoid excessive medial K-wire protrusion - the ulnar artery and anterior interosseous nerve (and median nerve) are in close proximity to the K-wire exit points distal to the coronoid

Step 4 - Transverse Drill Hole for the Tension Band Wire

• Place a transverse drill hole through both cortices of the dorsal ulnar cortex, approximately 3-4 cm distal to the fracture site (distal to the coronoid)
• The hole is passed deep to the triceps tendon insertion
• This hole anchors the distal limb of the figure-of-eight wire

Step 5 - Figure-of-Eight Tension Band Wire Placement

• Thread a 20-gauge (0.8 mm) stainless steel wire through the transverse drill hole
• Pass the wire proximally on each side (ulnar and radial sides), looping it around the protruding K-wires, deep to the triceps tendon proximally
• Form a figure-of-eight configuration: the wire crosses over the dorsal surface of the fracture site, with each limb looping around one K-wire proximally and both ends passing through the transverse drill hole distally
• The cross of the figure-of-eight should lie at the fracture site on the dorsal surface of the ulna

Step 6 - Tightening the Tension Band Wire

• Create a twist loop on both the radial and ulnar sides simultaneously using wire twisters or needle drivers
• Tighten the wire symmetrically and evenly on both sides - asymmetric tightening causes malrotation at the fracture
• The wire should be taut enough to hold firm compression at the articular surface when the elbow is taken through a range of motion
• Trim excess wire, and tamp the twisted knots down flat against the ulnar cortex on both sides to minimize soft-tissue irritation and implant prominence

Step 7 - Final K-Wire Impaction

• Using a mallet, impact the K-wires distally so that their proximal tips are buried underneath the triceps tendon, just posterior to the olecranon tip
• Bend the distal ends of the K-wires (which protrude from the anteromedial cortex) 180 degrees using a needle driver as a fulcrum, trim to approximately 5 mm, and tamp them flush against the anterior ulnar cortex
• This prevents proximal K-wire migration and reduces symptomatic hardware at the tip of the olecranon

Step 8 - Intraoperative Assessment

• Confirm fracture reduction and hardware position with AP and lateral fluoroscopic views
• Take the elbow through a full passive range of motion (flexion, extension, pronation, supination) to:
  • Confirm fracture compression increases with elbow flexion (validating the tension band principle)
  • Ensure no hardware prominence between the anterior ulna and proximal radius
  • Rule out hardware impingement in the proximal radioulnar joint

Step 9 - Wound Closure

• Release the tourniquet and obtain hemostasis
• Irrigate the wound thoroughly
• Close the deep fascia and subcutaneous tissue in separate layers
• Close the skin with interrupted or running nylon sutures
• Apply a sterile dressing

Postoperative Care

• Apply a long-arm posterior splint with the elbow in a semi-extended position (approximately 45-60 degrees of flexion) to protect the wound
• Elevate the extremity
• Remove sutures at 2 weeks
• Begin active and active-assisted flexion and gravity-assisted extension at 2 weeks (once wound healed)
• Begin active extension at 6 weeks
• Begin strengthening at 3 months postoperatively
• Serial radiographs to confirm maintained reduction and healing

Key Pitfalls and How to Avoid Them

Implant Considerations

• Rockwood and Green's Fractures in Adults, 10th ed. (2025) - Olecranon Tension Band Wiring, Chapter 40
• Campbell's Operative Orthopaedics, 15th ed. (2026) - ORIF of Olecranon Fracture, Technique 62.13
• Bailey and Love's Short Practice of Surgery, 28th ed. - Olecranon Fractures