|Year : 2013 | Volume
| Issue : 1 | Page : 65-69
A hospital based study of olecranon fracture treated by the figure of eight tension band wire loop without using kirschner's wire
Roel Langshong, I Ibomcha Singh, A Mahendra Singh, SN Chishti, Raj Kumar Meena, Arun GC Kumar
Department of Orthopedics, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||17-Aug-2013|
Department of Orthopedics, RIMS, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Aims: To determine the treatment outcome of Olecranon fracture by open reduction and internal fixation using figure of eight tension band wire loop without kirschner's wire and to assess the association between Olecranon fracture and selected variables of interest. Materials and Methods: Patients with Olecranon fractures Mayo type IIA were managed with tension band wire loop without kirschner's wire. Final result assessed at 12 weeks. Clinically and radiologically as regard to pain, range of movement, status of union and function. Results: Twenty patients (m: 13, f: 7) with a mean age of 39.7 were operated. They were assessed at 12 weeks. Final result was Excellent in 14 patients (70%). Good in 3 patients (15%) and Fair in 3 patients (15%), using Mayo's elbow performance score. There were 2 patients with stiffness and 1 patient with hypertrophied scar post-operatively. Conclusion: Olecranon fractures Mayo type IIA managed with tension band wiring using figure of eight wire loop without kirschner's wire results in improved patient oriented outcome, improved surgeon's oriented outcome, earlier return to function and decreased rate of non-union and the possible complication could be prevented by subjecting to open reduction and internal fixation in time.
Keywords: Kirschner′s wire, Mayo′s classification, Mayo′s elbow performance score, Olecranon fracture
|How to cite this article:|
Langshong R, Singh I I, Singh A M, Chishti S N, Meena RK, Kumar AG. A hospital based study of olecranon fracture treated by the figure of eight tension band wire loop without using kirschner's wire. J Med Soc 2013;27:65-9
|How to cite this URL:|
Langshong R, Singh I I, Singh A M, Chishti S N, Meena RK, Kumar AG. A hospital based study of olecranon fracture treated by the figure of eight tension band wire loop without using kirschner's wire. J Med Soc [serial online] 2013 [cited 2020 Oct 21];27:65-9. Available from: https://www.jmedsoc.org/text.asp?2013/27/1/65/116650
| Introduction|| |
In all fractures of the proximal ulna, the fracture pattern and concomitant injuries play a major role in surgical decision making and prognosis. The guiding principle in treating these fractures is to restore articular congruity and stability in order to begin a program of early active motion.
Fractures of the Olecranon probably occur in response to direct impact at the posterior surface of the elbow and to falls on the upper limb that indirectly load the joint. Undoubtedly, muscle-tendon tension, both resting, and active, creates forces that determine the fracture pattern and displacement.  One of the common classifications of Olecranon fracture is that of Mayo's classification Mayo classification for Olecranon fractures.
In 1883, Joseph Lister pioneered internal fixation for the Olecranon using a wire loop.  Since Lister's work, a number of fixation methods have been employed,
- Mayo type-I undisplaced fractures with 2 mm gap of fracture fragment even with flexion of the elbow to 90°. It has type I A and type 1B but essentially regarded and treated as the same lesion.
- Mayo Type-II:-stable fractures with > 3 mm of displacement, may be non-comnminuted (Type IIA) or comminuted (Type IIB).
- Mayo Type-III are unstable, displaced fractures and represent fracture dislocation. It is sub classified into non comminuted (IIIA) or comminuted (IIIB) types. 
The basic principle of tension band wiring is to counteract the tensile forces that act across the fracture site and convert them into compressive forces. To accomplish this, the wire is passed in the figure of eight fashion around the insertion of the triceps tendon and then distally beyond the fracture site into a transverse drill hole on the posterior (subcutaneous) border of the Olecranon. 
We have undertaken the present study to see the effect of figure of eight wire loop in terms of pain, range of movement, status of union and function.
| Aims and Objects|| |
- To determine the treatment outcome of Olecranon fractures by open reduction and internal fixation using figure of eight tension band wire loop without kirschner's wire.
- To assess the association between Olecranon fracture and selected variables of interest.
| Materials and Methods|| |
After due approval from the institution ethics committee and written informed consent of the individual patients, were taken, all patients with closed displaced Olecranon fracture Mayo's type IIA [Figure 1]a who came to the Department of orthopedics from the emergency services and out-patient department (OPD), were admitted between September 2010 to august 2012. The study was an intervention experimental without control, hospital based and patient with non-displaced Olecranon fracture, mental, and physical inability to cooperate and presence of complicating medical condition and patient's who refuses to give consent for operation were excluded. Data collected were analyzed by using the descriptive statistics like mean and percentages. Chi-square was used for analysis and a P value < 0.05 was considered as statistically significant. On admission the fractures were assessed by plain radiograph of elbow including both antero posterior and lateral view of the affected limb, routine investigations were done.
|Figure 1: (a) Pre-operative X-ray of Mayo type II A Olecranon fracture (b) Post-operative X-ray (c) Post-operative X-ray at 12 weeks showing union|
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An incision 2.5 cm proximal to the Olecranon and parallel with its lateral border carrying its distally 7.5 cm close to the lateral border of the shaft of the ulna was given. The fracture site exposed and a hole drilled from side to side in the distal fragment. Stainless steel No. 18 wire was passed beneath the aponeurosis of the triceps muscle and around the tip of the Olecranon, one end of the wire was carried obliquely across the posterior aspect of the fracture to the opposite side of the distal fragment and pass it through the drill hole and obliquely across the fracture again to the opposite side of the triceps. While the assistant grasps the Olecranon with a towel clip and exerts distal traction, reducing the fracture and the wire loop twisted tightly. A posterior plaster splint applied with elbow at 90° flexion ([Figure 1]b showing post operative X ray). Parental injectable antibiotics were given for 5 days.
At 5-7 days active, static and resistive exercises are encouraged (biceps and triceps) with plaster of paris slab intact provided that the wound is healing satisfactorily. Stitches removed on 11 th day and discharged and it is immobilized for another 10 days. After 21 days, plaster of paris is removed and physiotherapy started with active resistive flexion and extension of elbow started.
The patients were followed-up at 12 weeks at the OPD of Orthopedics. The patients were assessed clinically and radiologically as regards to
The final result was assessed at 12 weeks using Mayo's elbow performance score  as follows ([Figure 1]c showing callus in X-ray at 12 weeks and [Figure 2]a-c showing clinical photograph of patient in full extension and flexion at 12 weeks)
- Range of movement
- Status of union, and
|Figure 2: (a) Full extension of elbow at 12 weeks; (b) Full flexion of elbow at 12 weeks; (c) Full flexion of elbow joint at 12 weeks|
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- Excellent = symptom-free, motion equal to the intact side.
- Good = occasional pain or restriction of motion less than 10°.
- Fair = occasional pain and restriction of motion less than 30°, with no-pain.
- Poor = occasionally pain with restriction of motion over 30°. 
| Results and Observation|| |
Between September 2010 and August 2012, 20 patients with displaced Olecranon fracture Mayo type IIA underwent open reduction and internal fixation in the Department of Orthopaedics, Regional Institute of Medical Sciences (RIMS) Imphal. Patients were operated under regional anesthesia.
The mean duration of operation was 35.25 min (range 30-40 min). All patients were subjected to open reduction and internal fixation by tension band with the figure of '8' wire loop without kirschner's wires. There were no associated injuries in all patients. Patients were followed-up at 12 weeks in the out-patients Department of Orthopedics, RIMS.
Age of the patients was categorized into three groups such as 16-30 years, 31-50 years and 51-70 years and the mean age is 39.7 with the range of 16-70. It is found that the majority of them were in the age group of 16-50 years.
There was 13 males (65%) and 7 females (35%) The study subjects comprised of a higher percentage of male (65%) as compared to female (35%).
The right Olecranon was involved in 9 patients (45%) and left Olecranon was in 11 patients Majority of the study population who had Olecranon fracture were due to road traffic accident (RTA), which accounted for 75% (15). Twenty five percent (5) had injury.
The time taken from injury to operation ranges from 2 to 8 days with a mean time being 6 days. The time taken ranges from 30 to 40 min, mean time being 35.25 min.
There were no intra-operative or immediate post-operative complications; however, three cases of late complication in the form of stiffness with an Arc less than 30° in two subjects and one case of hypertrophic scar were encountered.
Final Result Interpretation
The final result was assessed at the end of 12 weeks using Mayo's elbow performance score for the present study and final outcome for all cases was Excellent in 14 cases (70%), Good in 3 cases (15%) and Fair in 3 cases (15%). This is represented in [Table 1] and [Figure 3]. The mean total score was Excellent.
This bar chart shows that 70% of the patient, among the present study subjects who underwent operation had excellence Mayo's elbow performance score.
[Table 2] shows the association between the sex of the study subjects and side of the Olecranon fracture. It is found that male subjects had more left side fracture than the right side while female had more on the right side than the left side of the Olecranon which is not found to be statistically significant.
|Table 2: Association between sex of the study subjects and side of Olecranon fracture|
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[Table 3] shows association between age distribution of the study subjects and side of Olecranon fracture. It shows that younger age groups had more left side fracture than the right side though it is not statistically significant.
|Table 3: Association between the age distribution and the side of Olecranon fracture|
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From [Table 4], it is found that RTA had more left side fracture than the right side of the Olecranon; however, it is not found to be significant.
There is excellence in the Mayo's elbow performance score, irrespective of the side of fracture comparing to either good or fair though it is not statistically significant. It is shown in [Table 5]. All of the patients were right sided dominant hand.
|Table 5: Association between Mayo's elbow performance score and side of fracture|
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| Discussion|| |
Twenty adult patients with Mayo type IIA Olecranon fractures underwent open reduction and internal fixation with tension band wiring with the figure of '8' without kirschner's wire in the Department of Orthopedics, RIMS, Imphal between September 2010 and August 2012.
Patients were between 16 and 70 years with a mean age of 39.75 years. The age group of 31-50 years comprised highest number of patients with 45%. This is closed to the findings of Kara et al.  where the mean age was 36.9 (range 9-69 Years).
Rettig et al.  in their fifty-two patients undergoing open reduction, internal fixation, or primary excision for fracture of the Olecranon are reviewed. Average age at the time of fracture was 35.8 years. The most common modes of injury were falling, auto accidents, and altercations.
There were 13 males (65%) and 7 females (35%). Similar findings were reported by Kara et al.  where 65.8% were males and 34.2% were females in their studies of 38 patients in the treatment of Olecranon fractures using the two different tension band techniques. Rommens et al.  reported that nearly half of men with Olecranon fractures were between 21 and 40 years of age and 40% of women between 61 and 80 years old.
RTA accounted for the majority of fracture (75%) and falls accounted for the remaining (25%). Karlson et al.  reported RTA (high energy trauma) as majority cause of Olecranon fracture with 60% and 40% with low energy trauma like a fall in their studies of 30 patients.
The left sided Olecranon was involved in 11 patients (55%) and right in 9 patients (45%). Rommens et al.  reported left sided involvement in 56.4% of patients and right sided involvement in 43.6% of patients. Gartsman et al.  reported 74 patients to be left sided and 33 patients to be right in a total of 107 patients. However, Akman et al.  observed predominance of right sided involvement in 60% of cases.
In the herein study, the incidence of Olecranon fractures showed a higher prevalence among men until the 5 th decade of life and among women in older ages.
The mean time since injury to operation was 5.9 days (range: 2-18 days) for all patients. Nimura et al.  reported operation on 6 days after injury. The mean operating time was 35.25 min.
Clinical union was seen on assessment at 12 weeks in all cases. On clinical assessment, it was found that fracture site was mildly tender, the bone moves in one piece and there was pain only on attempted angulation. Kundu et al.  reported union by 8-10 weeks. Maini et al.  reported clinical union by 6-8 weeks.
Radiological cortical bridging was seen at 12 weeks post-operatively. There was visible fracture line with fluffy callus around it. Macko et al.  reported at 12 weeks. Low et al.  in their series of 32 patients with Olecranon fractures treated by tension band wiring found that 31 patients showed clinical and radiological union at 6-12 weeks after the operation and the mean time to union was 9.94 weeks and union rate was 96.87%.
There were no intra operative and immediate post-operative complications in all cases. Late complication was found in 2 patients (10%) with a stiff elbow. The stiffness could be due to lack of patience compliance in the follow-up period of physiotherapy in spite of younger age with good bone quality. Ring et al.  and Teasdall et al.  reported patient compliance to be one of the reasons for various degrees of post-operative elbow stiffness and deficit of range of motion. One case developed hypertrophic scar (5%).
Based on the assessment parameters, the Mayo performance score was carried out at the end of 12 weeks. In these studies, 14 patients (70%) had excellent, 3 had good (15%) and 3 had fair (15%) grades.
Karlson et al.  in their series found 96% of individuals with a closed displaced fracture of Olecranon treated by open reduction and internal fixation with the figure of 8 wiring found excellent or good scores by Mayo Performance Score. There was no difference when compared to tension band wiring with kirschner's technique.
Herein the study, the association between the side of Olecranon fracture and sex of the study subjects shows that male subjects had more left side fracture than the right side while female had more on the right side than on the left side which is found to be not statistically significant. The association between age distribution of the study subjects and side of Olecranon fracture shows that younger age groups had more left side fracture than the right side though it is not statistically significant. The association between the side of Olecranon fracture and mode injury shows that RTA had more left side fracture than the right side of the Olecranon; however, it is not found to be significant. The association between Mayo's elbow performance score and side of fracture shows that there is excellence in the Mayo's elbow performance score, irrespective of the side of fracture though it is not statistically significant. All the patients were right sided dominant hand.
| Conclusion|| |
In conclusion, Olecranon fracture is known for decreased range of motion of elbow post traumatic arthritis, non-union, and ulnar nerve symptoms in the form of numbness and paresthesias.
To achieve a better functional result, rigid internal fixation of the fracture fragments is required by using tension band wire loop.
Herein the study, open reduction and internal fixation for the displaced Olecranon fracture Mayo Type IIA by tension band wiring using figure of '8' wire loop without kirschner's results in improved patient-oriented outcomes, improved surgeon oriented outcomes, earlier return to function, and decreased rates of nonunion.
There were no hard ware related operative complications. The patients were satisfied with the elbow and its appearance and also the functional outcomes like activities of daily living.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]