Olecranon Fracture: Tension Band Wiring (TBW) - Stepwise Operative Procedure

PHASE 1: Preoperative Setup

Step 1 - Patient Positioning

• Place the patient in the lateral decubitus or prone position on a radiolucent table (either is preferred over supine as it provides better fluoroscopic access).
• A radiolucent arm positioner is placed under the arm to allow free elbow flexion and extension intraoperatively.
• The C-arm is brought in from the head of the table.
• The lateral position is generally preferred to reduce the risks associated with prone positioning, especially if operative time may be prolonged.
• If lateral/prone is not possible (e.g., regional anesthetic use), supine with a bump and the arm placed across the chest is acceptable, but imaging and reduction are more challenging.
• Obtain test fluoroscopic images before draping to confirm adequate image quality.
• A sterile tourniquet is kept available (used at surgeon's discretion).

PHASE 2: Surgical Approach

Step 2 - Skin Incision

• Make a posterior midline longitudinal incision from the tip of the olecranon distally.
• The incision is placed just radial to the tip of the olecranon - this deliberate offset provides better soft-tissue coverage over the implants.
• Raise full-thickness medial and lateral fasciocutaneous flaps.

Step 3 - Ulnar Nerve Identification

• Identify the ulnar nerve in the cubital tunnel early in the dissection so it can be protected throughout.
• It is NOT necessary to formally transpose or dissect it free of the cubital tunnel - identification alone is sufficient.

Step 4 - Fracture Exposure

• Develop the interval between extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU).
• Expose the subcutaneous border of the ulna.
• On the ulnar side: elevate the FCU from the olecranon to visualize the joint.
• On the radial side: incise the anconeus fascia and elevate the anconeus from the olecranon fragment for additional visualization if needed.

PHASE 3: Fracture Reduction

Step 5 - Fracture Debridement and Joint Inspection

• Expose and clean the fracture edges carefully, preserving periosteum and any soft-tissue attachments to comminuted fragments.
• Inspect the articular surface for:
  • Damage to the trochlea
  • Intra-articular loose bodies
• A lateral capsulectomy may be helpful to confirm anatomic articular reduction and rule out impaction.

Step 6 - Fracture Reduction

• Reduce the fracture by extending the elbow - this relaxes the pull of the triceps.
• Place drill holes on the ulnar shaft - both radially and ulnarly - so that a pointed reduction clamp (tenaculum) can straddle the ulna: one tine in the drill hole, the other tine at the tip of the olecranon.
• Apply compression with the reduction clamp to hold the reduction.
• A shoulder hook or dental pick can assist in holding smaller fragments.
• Confirm anatomic articular reduction under direct vision and/or fluoroscopy.

PHASE 4: K-Wire Insertion

Step 7 - K-Wire Placement (the KEY step)

• Insert two 0.062-inch (1.6 mm) K-wires from the superior (dorsal) tip of the olecranon, directed distally in an intramedullary fashion.
• The wires must exit through the anteromedial cortex of the ulna (not the anterior cortex) - this engages solid cortical bone for anchorage.
• CRITICAL: Avoid lateral placement of K-wires - lateral exit near the biceps tuberosity risks impingement on the radial tuberosity, predisposing to rotational stiffness and radioulnar synostosis.
• CRITICAL: Avoid excessive length of the medial wire through the anteromedial cortex to prevent injury to the ulnar nerve (and median nerve anteriorly).
• Once the wires are across the fracture site and in satisfactory position, back them out slightly (1-2 mm) to accommodate the future impaction step.
• Confirm K-wire position on fluoroscopy in both AP and lateral views.

PHASE 5: Tension Band (Figure-of-Eight Wire) Construction

Step 8 - Transverse Drill Hole in Ulnar Shaft

• Place a transverse drill hole through the dorsal cortex of the ulnar shaft, distal to the coronoid process (approximately 3-4 cm distal to the fracture line).
• This hole provides the distal anchor point for the figure-of-eight wire.

Step 9 - Passing the Cerclage Wire

• Use an Angiocath catheter as a guide to pass the 20-gauge stainless steel wire.
• Pass the wire deep to the triceps tendon (underneath it) and around the proximal end of the K-wires.
• Thread the wire through the transverse drill hole distally to create a figure-of-eight configuration.
• One or two figure-of-eight tension bands may be constructed depending on fracture stability requirements.

Step 10 - Tensioning the Wire

• Tension the wire simultaneously on both the ulnar and radial sides to achieve equal, symmetric compression across the fracture.
• Unequal tensioning will cause rotational deformity at the fracture site.
• Verify articular reduction by direct inspection and fluoroscopy after tensioning.

PHASE 6: K-Wire Finishing

Step 11 - Bending and Impacting the K-Wires

• Bend the proximal ends of both K-wires 180 degrees (hook shape).
• Through small incisions in the triceps tendon, impact (hammer) the bent K-wire tips into the olecranon beneath the triceps.
• The wires must be buried under the triceps - prominent wire tips are the leading cause of symptomatic hardware requiring removal (occurs in >50% of cases).
• Similarly, bury the cerclage wire knots to minimize subcutaneous prominence.

PHASE 7: Verification and Closure

Step 12 - Intraoperative Assessment

• Take the elbow through a full range of motion (particularly assess in full flexion) to confirm:
  • Fixation is stable and does not toggle
  • Reduction is maintained through the arc of motion
  • No hardware impingement
• Obtain final fluoroscopic images in AP and lateral views.

Step 13 - Wound Closure

• Close the wound in layered fashion (deep fascia, subcutaneous tissue, skin).
• Layered closure is important to allow early range-of-motion while sutures are still in place.
• Apply a long-arm posterior splint in a semi-extended position.

PHASE 8: Postoperative Care

Surgical Pitfalls and Prevention

Principle of TBW (Mechanism)