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Fixation of olecranon fractures: Four cases of hardware impingement restricting forearm and elbow motion
Injury Extra (2008) 39, 23—29
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CASE REPORT
Fixation of olecranon fractures: Four cases of hardware impingement restricting forearm and elbow motion§ Axel Gamulin a, Hassan Sadri a, Beat Fischer b, Pierre Hoffmeyer a, Richard Stern a,* a
Orthopaedic Surgery Service, University Hospital of Geneva, 24 rue Micheli-du-Crest, 1205 Geneva, Switzerland b 18 Chemin des Clochettes, 1206 Geneva, Switzerland Accepted 30 April 2007
Introduction It is generally accepted that displaced olecranon fractures deserve open reduction and internal fixation 4,6,11,28 which provides sufficient stability for early range of motion to avoid elbow stiffness.2,28 Two general methods of fixation are commonly used, either tension-band wiring or plate osteosynthesis, and the indication for one over the other depends primarily upon the fracture pattern. Plate fixation is recommended for comminuted fractures and oblique fractures distal to the mid-point of the semilunar notch, as well as for more complex injuries involving the coronoid process, fracture-dislocation or Monteggia fractures.11,25,28 Tension band fixation of olecranon fractures was originally popularised by Weber and Vasey 29 and the AO Group,20 and is commonly regarded as the gold §
Investigation performed at the Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland. * Corresponding author at: Service de chirurgie orthope ´dique et traumatologie de l’appareil moteur, Ho ˆpitaux Universitaires de Gene `ve, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland. Tel.: +41 22 372 78 49; fax: +41 22 372 77 99. E-mail address: [email protected] (R. Stern).
standard for treating most simple transverse and, with a supplementary lag screw across the fracture line, some simple oblique fractures.11,19,21,25 The original technique with Kirschner wires placed intramedullary in the proximal ulna is favoured by some authors.4,20,28,29,31 However, the problem with this technique is that intramedullary placed Kirschner wires tend to back out, causing pain, pressure on the overlying soft tissues, eventual skin breakdown, and infection, and at times warrants premature removal of the wires.1,5,8—10,12—14,17,22,26,27,30 The incidence of backing out of the Kirschner wires has been shown to be reduced by passing the Kirschner wires through the anterior ulnar cortex,2,21,27 and this is actually the current recommended AO technique.25 While placement of the wires into the anterior ulnar cortex considerably decreases their incidence of backing out, overpenetration may restrict forearm rotation, incite heterotopic ossification or radioulnar synostosis, or injure anterior neurovascular structures of the forearm.7,24 In fact, Schatzker 28 advises against such a technique. Recently, two reports 3,18 have described either Kirschner wire or screw impingement upon the cortex of the radius, supinator
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.04.027
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A. Gamulin et al.
muscle, or biceps tendon. To the best of our knowledge these are the only two reports in the literature. We describe four cases of olecranon osteosynthesis (two tension-band wiring and two plate osteosynthesis) where the hardware penetrated the proximal ulnar cortex into the proximal radioulnar joint or near the radial tuberosity, causing impairment of forearm and elbow motion. Our patients were informed that their case would be submitted for publication.
Case reports Case 1 A healthy 64-year-old woman sustained a closed, displaced, and comminuted oblique fracture of the right olecranon after falling on the ice (Fig. 1A and B). Preoperatively, she noted paraesthesia and hypaesthesia in the ulnar nerve distribution in the hand. Open reduction and internal fixation was performed on the same day utilising a dorsal approach curved laterally over the tip of the olecranon. The ulnar nerve was explored and found to be compressed by one of the fracture fragments. Two small (2.4 mm and 2.0 mm) lag screws were used to reconstruct the proximal fragment followed by the modified bicortical tension-band wiring technique to fix the proximal reconstructed fragment to the distal fragment. Intraoperatively there was a full range of forearm supination and pronation, and full elbow flexion and extension. Anteroposterior and lateral fluoroscopy images were felt to be satisfactory. Her postoperative course was unremarkable with undisturbed wound healing and complete disappearance of her ulnar nerve symptoms within a few weeks. Four weeks postoperative she was noted to have elbow motion from 458 to 908. Pronation and supination were painful and provoked a palpable and audible ‘‘clunk’’ when these movements were passively forced. Radiographs (Fig. 1C and D) revealed maintenance of reduction with no change in the position of the Kirschner wires or tension band. However, it was the opinion of the surgeon at that time that perhaps the protruding Kirschner wires were responsible for the decreased motion and ‘‘clunk.’’ Computed tomography revealed the tip of one Kirschner wire very close to the radial tuberosity and the biceps tendon (Fig. 1E and F). At 7 weeks postoperative, the two Kirschner wires were removed, while the two lag screws and tension band wire were left in place. At 3 months followup, elbow range of motion was 0—1308 with 908 of pronation and 908 of supination.
Figure 1 Case 1. (A) Anterior—posterior injury radiograph. (B) Lateral injury radiograph. (C) Anterior—posterior radiograph 4 weeks postoperative. (D) Lateral radiograph 4 weeks postoperative. (E) Transverse computed tomography image 4 weeks postoperative. (F) Sagittal computed tomography image 4 weeks postoperative.
Case 2 A 16-year-old young man sustained a closed, displaced oblique right olecranon fracture with extension into the proximal third of the ulna following a motor vehicle accident. (Fig. 2A). Open reduction and internal fixation with a 3.5 mm reconstruction plate was performed 3 days after injury. Intraoperatively following fracture fixation, range of motion testing revealed full and undisturbed forearm pronation and supination, as well as flexion and extension of the elbow. A lateral radiograph immediately postoperative (Fig. 2B) was felt to be satisfactory. His postoperative course was marked by an anterior compartment syndrome of the forearm treated
Hardware impingement after olecranon fracture fixation
25
Figure 2 Case 2. (A) Lateral injury radiograph. (B) Lateral radiograph immediately postoperative. (C) Lateral radiograph 3 months postoperative. (D) Anterior—posterior radiograph 3 months postoperative. (E) Sagittal computed tomography image 3 months postoperative. (F) Transverse computed tomography image 3 months postoperative.
by an emergency fasciotomy and carpal tunnel release on the first postoperative day. The fasciotomy incision was closed 7 days later and the limb was immobilised in a long arm splint for an additional 2 weeks to allow for further wound healing. No nerve or muscle deficit was noted on follow-up examinations. While working with the physiotherapist on range of motion, the patient noted progressive pain with pronation and supination of the forearm, and what he described as a clicking and block to movement. At 3 months postoperative, elbow motion was flexion 1008 and extension minus 158. There was 908 of pronation and no supination. Standard radiographs (Fig. 2C and D) showed new bone formation at the tips of two screws near the radial tuberosity. Computed tomography (Fig. 2E and F) revealed the tips of two screws apparently touching the radial tuberosity with some new bone formation. Early hardware removal was performed at 6 months postoperative followed by intensive physiotherapy. No resection of the new bone was performed. Range of forearm and elbow
motion progressively returned to normal without symptoms.
Case 3 A 62-year-old man sustained a closed, minimally displaced oblique right olecranon fracture following a fall on the sidewalk (Fig. 3A and B). Two days post-injury, he underwent open reduction and internal fixation with a one-third tubular plate. At the end of the operation, a full range of elbow and forearm motion was noted, and anterior—posterior and lateral radiographs were interpreted as normal. At 8 weeks postoperative examination revealed a painful range of elbow motion from 358 to 908, with 208 of pronation and no supination. Standard radiographs (Fig. 3C and D) were interpreted as normal, but radiographs performed under dynamic fluoroscopy revealed three screws very close to, if not touching, the radial head and tuberosity (Fig. 3E). The three screws were removed and replaced by shorter ones. This led to a progressive
26
A. Gamulin et al.
Figure 3 Case 3. (A) Anterior—posterior injury radiograph. (B) Lateral injury radiograph. (C) Anterior—posterior radiograph 8 weeks postoperative. (D) Lateral radiograph 8 weeks postoperative. (E) Dynamic fluoroscopy view 8 weeks postoperative.
and rapid total recovery of a painless range of motion.
Case 4 Following a simple fall, a healthy 38-year-old man sustained a closed displaced oblique right olecranon fracture (Fig. 4A and B). Open reduction and internal fixation with the modified bicortical tension-band wiring technique was performed 2 days following injury. Intraoperative range of elbow and forearm motion was noted to be complete, with apparent satisfactory radiographs. His postoperative course was marked by sterile wound drainage requiring frequent local dressing changes during the first 2 weeks. At 4 weeks postoperative, forearm rotation was noted to be very painful and completely blocked, with painful elbow motion from 208 to 1208. Standard radiographs 4 weeks postoperative (Fig. 4C and D) revealed satisfactory position with no change from immediately postoperative. Dynamic fluoroscopic
examination showed one Kirschner wire penetrating the anterior ulnar cortex in close proximity to the radial tuberosity and biceps tendon insertion (Fig. 4E). Immediate replacement of this wire with a shorter one rapidly led to a return of normal forearm and elbow motion without pain.
Discussion Tension-band wiring and plate osteosynthesis are widely used methods of osteosynthesis of olecranon fractures. Most postoperative complications are related to hardware prominence, particularly with the tension-band wiring technique. In order to prevent proximal migration and prominence of the Kirschner wires, several methods have been advocated, such as burying them deeply under the triceps tendon,7,24,25 contouring the proximal wire ends to impact them into the bone of the proximal fragment,7,24,25 using modified pins with
Hardware impingement after olecranon fracture fixation
27
Figure 4 Case 4. (A) Anterior—posterior injury radiograph. (B) Lateral injury radiograph. (C) Anterior—posterior radiograph 4 weeks postoperative. (D) Lateral radiograph 4 weeks postoperative. (E) Dynamic fluoroscopy view 4 weeks postoperative.
a transverse hole in their proximal extremity able to accept the passage of the figure-of-8 wire,15,16,23 and engaging the anterior cortex of the ulna with the distal end of the Kirschner wires.2,25,27 Concerning this latter technique, some authors insist to take care not to penetrate the anterior cortex of the ulna with the Kirschner wires in order to prevent restricting forearm rotation, the formation of heterotopic ossification or radioulnar synostosis, or injuring the neurovascular structures of the forearm.7,24 Although the problem may be more frequent than actually reported, we were able to find only two reports of hardware impingement in the region of the proximal radius following fixation of an olecranon fracture.3,18 In the first report, 3 the authors described two clinical cases in which bicortical placement of the Kirschner wires led to impaired forearm rotation with normal flexion and extension of the elbow. In the first case, the tip of the most radial Kirschner wire had penetrated the radial neck and the forearm was fixed in pronation. Removal of the wire restored a normal range of motion. In the second case, the tip of the most radial Kirschner
wire protruded twice the thickness of the anterior cortex and was blocking supination of the radius, probably by soft-tissue impingement at the level of the supinator muscle or biceps brachii tendon. Pronation was not restricted. Removal of the wire restored normal range of motion. In order to investigate ways to prevent this complication, these authors performed a cadaver study to determine the optimal position and insertion technique of the Kirschner wires. They concluded the following: (a) the forearm must be supinated during Kirschner wire insertion as pronation leads to penetration of the wires into the supinator muscle or biceps brachii tendon (which both lie on the anterior metaphysis of the ulna during pronation), or into the radius; (b) the posteromedial ridge of the olecranon must be identified and the Kirschner wires must be inserted at 308 of ulnar angulation to this landmark in the coronal plane in order to exit through the ulnar side, rather than through the anterior cortex of the proximal ulnar metaphysis; (c) the Kirschner wires must also be inserted at 308 in the sagittal plane to optimally exit through the medial border of the proximal ulnar metaphysis; (d) anterior cortical
28 penetration must be kept to an absolute minimum; and (e) forearm rotation must be checked for fluidity and completeness at the end of the osteosynthesis and radiographic documentation must be obtained. In the second more recent report, 18 five patients (four after tension band wiring, one following plate and screw fixation) were noted to have impaired forearm rotation associated with palpable crepitation on examination. Postoperative plain radiographs could not explain the limitation of forearm rotation. CT revealed perforation of the Kirschner wires through the far ulnar cortex and passage into the interosseous space abutting or actually contacting the proximal aspect of the radius. In the one patient treated with plate-and-screw fixation, CT reconstruction demonstrated that the tip of the long lag screw was lying adjacent to the proximal aspect of the radius. In this report, the authors used three-dimensional simulation of the forearm bones to evaluate misplaced hardware. Their conclusions are important for understanding how this can be missed in the operating room, and include: (1) varying wire or screw insertion in the coronal plane can result in an identical lateral radiographic projection, (2) the proximal ulna is tear-shaped in cross-section which cannot be appreciated with standard intraoperative radiographs, and (3) the proximal ulna has a varus orientation. The authors recommend choosing a more lateral entry point on the olecranon for Kirschner wire insertion, and direct the wires towards the ulnar midshaft. While it may seem intuitive to do what we need to do in order to avoid this complication, our teaching has always been to rely upon intraoperative radiographs. However, it is important to realise from these two previous reports, and from our four patients, that wire or screw protrusion may not be recognizable intraoperatively simply by viewing standard anterior—posterior and lateral radiographs. Of the four patients we have presented, two confirm that protruding Kirschner wires near the proximal radius or radial tuberosity may result in impingement upon bone and/or soft tissue resulting in a block to forearm rotation and elbow motion. The other two patients demonstrate that a similar phenomenon is possible following plate osteosynthesis, which to our knowledge has been previously described only once.18 In all cases, care should be taken not to overpenetrate the ulnar cortex. As all four of our patients demonstrated, full forearm rotation and elbow motion, as well as the absence of any grating sensation or blocking, intraoperatively under anaesthesia, does not ensure that there is no impingement of hardware upon bone, or most importantly soft tissue. Such
A. Gamulin et al. findings are more likely to be found with the patient awake, and may occur later when reactive inflammation develops at the tip of a wire or screw. In order to diminish the incidence of this complication, the most important suggestion that can be made is that no Kirschner wire or screw should overpenetrate the ulnar cortex. If this is noted on careful intraoperative fluoroscopic examination the offending hardware should be removed and a shorter one utilised. The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or non-profit organisation with which the authors are affiliated or associated.
References 1. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fixation of olecranon fractures. J Orthop Trauma 2001;15:542—8. 2. Cabanela M, Morrey B. Fractures of the olecranon. In: Morrey B, editor. The elbow and its disorders. 3rd ed., Philadelphia: WB Saunders; 2000. p. 365—79. 3. Candal-Couto JJ, Williams JR, Sanderson PL. Impaired forearm rotation after tension-band-wiring fixation of olecranon fractures: evaluation of the transcortical K-wire technique. J Orthop Trauma 2005;19:480—2. 4. Colton CL. Fractures of the olecranon in adults: classification and management. Injury 1973;5:121—9. 5. Doursounian L, Prevot O, Touzard RC. Osteosynthesis by tension band wiring of displaced fractures of the olecranon. Ann Chir 1994;48:169—77. 6. Gartsman GM, Sculco TP, Otis JC. Operative treatment of olecranon fractures. Excision or open reduction with internal fixation. J Bone Joint Surg Am 1981;63:718—21. 7. Hak DJ, Golladay GJ. Olecranon fractures: treatment options. J Am Acad Orthop Surg 2000;8:266—75. 8. Helm RH, Hornby R, Miller SW. The complications of surgical treatment of displaced fractures of the olecranon. Injury 1987;18:48—50. 9. Holdsworth BJ, Mossad MM. Elbow function following tension band fixation of displaced fractures of the olecranon. Injury 1984;16:182—7. 10. Horne JG, Tanzer TL. Olecranon fractures: a review of 100 cases. J Trauma 1981;21:469—72. 11. Hotchkiss R. Fractures and dislocations of the elbow. In: Rockwood C, Green D, Bucholz R, Heckman J, editors. Rockwood and Green’s fractures in adults. 4th ed., Philadelphia: Lippincott-Raven; 1996. p. 929—1024. 12. Hume MC, Wiss DA. Olecranon fractures. A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop Relat Res 1992;285:229—35. 13. Jensen CM, Olsen BB. Drawbacks of traction-absorbing wiring (TAW) in displaced fractures of the olecranon. Injury 1986;17:174—5.
Hardware impingement after olecranon fracture fixation 14. Karlsson MK, Hasserius R, Besjakov J, Karlsson C, Josefsson PO. Comparison of tension-band and figure-of-eight wiring techniques for treatment of olecranon fractures. J Shoulder Elbow Surg 2002;11:377—82. 15. Larsen E, Jensen CM. Tension-band wiring of olecranon fractures with nonsliding pins. Report of 20 cases. Acta Orthop Scand 1991;62:360—2. 16. Larsen E, Lyndrup P. Netz or Kirschner pins in the treatment of olecranon fractures? J Trauma 1987;27:664—6. 17. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am 1985;67:1396—401. 18. Matthews F, Trentz O, Jacob AL, Kikinis R, Jupiter JB, Messmer P. Protrusion of hardware impairs forearm rotation after olecranon fixation. A report of two cases. J Bone Joint Surg Am 2007;89:638—42. 19. Molloy S, Jasper LE, Elliott DS, Brumback RJ, Belkoff SM. Biomechanical evaluation of intramedullary nail versus tension band fixation for transverse olecranon fractures. J Orthop Trauma 2004;18:170—4. 20. Mu ¨ller ME, Allgo ¨wer M, Willenegger H. Manual of Internal Fixation. Berlin: Springer-Verlag; 1970. p. 130. 21. Mullett JH, Shannon F, Noel J, Lawlor G, Lee TC, O’Rourke SK. K-wire position in tension band wiring of the olecranon–—a comparison of two techniques. Injury 2000;31:427—31. 22. Murphy DF, Greene WB, Dameron Jr TB. Displaced olecranon fractures in adults. Clinical evaluation. Clin Orthop Relat Res 1987;224:215—23.
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23. Netz P, Stromberg L. Non-sliding pins in traction absorbing wiring of fractures: a modified technique. Acta Orthop Scand 1982;53:355—60. 24. Nork SE, Jones CB, Henley MB. Surgical treatment of olecranon fractures. Am J Orthop 2001;30:577—86. 25. Quintero J. Olecranon injuries. In: Ru ¨edi T, Murphy W, editors. AO Principles of fracture management. Stuttgart: Thieme; 2000. p. 323—38. 26. Romero JM, Miran A, Jensen CH. Complications and re-operation rate after tension-band wiring of olecranon fractures. J Orthop Sci 2000;5:318—20. 27. Rommens PM, Kuchle R, Schneider RU, Reuter M. Olecranon fractures in adults: factors influencing outcome. Injury 2004;35:1149—57. 28. Schatzker J. Fractures of the olecranon. In: Schatzker J, Tile M, editors. The rationale of operative fracture care. Berlin: Springer-Verlag; 1987. p. 93. 29. Weber B, Vasey H. Osteosynthese bei olecranonfraktur. Z Unfallchir Versicherungsmed Berufskr 1963;2:90. 30. Wolfgang G, Burke F, Bush D, Parenti J, Perry J, LaFollette B, et al. Surgical treatment of displaced olecranon fractures by tension band wiring technique. Clin Orthop Relat Res 1987;224:192—204. 31. Wu CC, Tai CL, Shih CH. Biomechanical comparison for different configurations of tension band wiring techniques in treating an olecranon fracture. J Trauma 2000;48: 1063—7.
www.elsevier.com/locate/inext
CASE REPORT
Fixation of olecranon fractures: Four cases of hardware impingement restricting forearm and elbow motion§ Axel Gamulin a, Hassan Sadri a, Beat Fischer b, Pierre Hoffmeyer a, Richard Stern a,* a
Orthopaedic Surgery Service, University Hospital of Geneva, 24 rue Micheli-du-Crest, 1205 Geneva, Switzerland b 18 Chemin des Clochettes, 1206 Geneva, Switzerland Accepted 30 April 2007
Introduction It is generally accepted that displaced olecranon fractures deserve open reduction and internal fixation 4,6,11,28 which provides sufficient stability for early range of motion to avoid elbow stiffness.2,28 Two general methods of fixation are commonly used, either tension-band wiring or plate osteosynthesis, and the indication for one over the other depends primarily upon the fracture pattern. Plate fixation is recommended for comminuted fractures and oblique fractures distal to the mid-point of the semilunar notch, as well as for more complex injuries involving the coronoid process, fracture-dislocation or Monteggia fractures.11,25,28 Tension band fixation of olecranon fractures was originally popularised by Weber and Vasey 29 and the AO Group,20 and is commonly regarded as the gold §
Investigation performed at the Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland. * Corresponding author at: Service de chirurgie orthope ´dique et traumatologie de l’appareil moteur, Ho ˆpitaux Universitaires de Gene `ve, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland. Tel.: +41 22 372 78 49; fax: +41 22 372 77 99. E-mail address: [email protected] (R. Stern).
standard for treating most simple transverse and, with a supplementary lag screw across the fracture line, some simple oblique fractures.11,19,21,25 The original technique with Kirschner wires placed intramedullary in the proximal ulna is favoured by some authors.4,20,28,29,31 However, the problem with this technique is that intramedullary placed Kirschner wires tend to back out, causing pain, pressure on the overlying soft tissues, eventual skin breakdown, and infection, and at times warrants premature removal of the wires.1,5,8—10,12—14,17,22,26,27,30 The incidence of backing out of the Kirschner wires has been shown to be reduced by passing the Kirschner wires through the anterior ulnar cortex,2,21,27 and this is actually the current recommended AO technique.25 While placement of the wires into the anterior ulnar cortex considerably decreases their incidence of backing out, overpenetration may restrict forearm rotation, incite heterotopic ossification or radioulnar synostosis, or injure anterior neurovascular structures of the forearm.7,24 In fact, Schatzker 28 advises against such a technique. Recently, two reports 3,18 have described either Kirschner wire or screw impingement upon the cortex of the radius, supinator
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.04.027
24
A. Gamulin et al.
muscle, or biceps tendon. To the best of our knowledge these are the only two reports in the literature. We describe four cases of olecranon osteosynthesis (two tension-band wiring and two plate osteosynthesis) where the hardware penetrated the proximal ulnar cortex into the proximal radioulnar joint or near the radial tuberosity, causing impairment of forearm and elbow motion. Our patients were informed that their case would be submitted for publication.
Case reports Case 1 A healthy 64-year-old woman sustained a closed, displaced, and comminuted oblique fracture of the right olecranon after falling on the ice (Fig. 1A and B). Preoperatively, she noted paraesthesia and hypaesthesia in the ulnar nerve distribution in the hand. Open reduction and internal fixation was performed on the same day utilising a dorsal approach curved laterally over the tip of the olecranon. The ulnar nerve was explored and found to be compressed by one of the fracture fragments. Two small (2.4 mm and 2.0 mm) lag screws were used to reconstruct the proximal fragment followed by the modified bicortical tension-band wiring technique to fix the proximal reconstructed fragment to the distal fragment. Intraoperatively there was a full range of forearm supination and pronation, and full elbow flexion and extension. Anteroposterior and lateral fluoroscopy images were felt to be satisfactory. Her postoperative course was unremarkable with undisturbed wound healing and complete disappearance of her ulnar nerve symptoms within a few weeks. Four weeks postoperative she was noted to have elbow motion from 458 to 908. Pronation and supination were painful and provoked a palpable and audible ‘‘clunk’’ when these movements were passively forced. Radiographs (Fig. 1C and D) revealed maintenance of reduction with no change in the position of the Kirschner wires or tension band. However, it was the opinion of the surgeon at that time that perhaps the protruding Kirschner wires were responsible for the decreased motion and ‘‘clunk.’’ Computed tomography revealed the tip of one Kirschner wire very close to the radial tuberosity and the biceps tendon (Fig. 1E and F). At 7 weeks postoperative, the two Kirschner wires were removed, while the two lag screws and tension band wire were left in place. At 3 months followup, elbow range of motion was 0—1308 with 908 of pronation and 908 of supination.
Figure 1 Case 1. (A) Anterior—posterior injury radiograph. (B) Lateral injury radiograph. (C) Anterior—posterior radiograph 4 weeks postoperative. (D) Lateral radiograph 4 weeks postoperative. (E) Transverse computed tomography image 4 weeks postoperative. (F) Sagittal computed tomography image 4 weeks postoperative.
Case 2 A 16-year-old young man sustained a closed, displaced oblique right olecranon fracture with extension into the proximal third of the ulna following a motor vehicle accident. (Fig. 2A). Open reduction and internal fixation with a 3.5 mm reconstruction plate was performed 3 days after injury. Intraoperatively following fracture fixation, range of motion testing revealed full and undisturbed forearm pronation and supination, as well as flexion and extension of the elbow. A lateral radiograph immediately postoperative (Fig. 2B) was felt to be satisfactory. His postoperative course was marked by an anterior compartment syndrome of the forearm treated
Hardware impingement after olecranon fracture fixation
25
Figure 2 Case 2. (A) Lateral injury radiograph. (B) Lateral radiograph immediately postoperative. (C) Lateral radiograph 3 months postoperative. (D) Anterior—posterior radiograph 3 months postoperative. (E) Sagittal computed tomography image 3 months postoperative. (F) Transverse computed tomography image 3 months postoperative.
by an emergency fasciotomy and carpal tunnel release on the first postoperative day. The fasciotomy incision was closed 7 days later and the limb was immobilised in a long arm splint for an additional 2 weeks to allow for further wound healing. No nerve or muscle deficit was noted on follow-up examinations. While working with the physiotherapist on range of motion, the patient noted progressive pain with pronation and supination of the forearm, and what he described as a clicking and block to movement. At 3 months postoperative, elbow motion was flexion 1008 and extension minus 158. There was 908 of pronation and no supination. Standard radiographs (Fig. 2C and D) showed new bone formation at the tips of two screws near the radial tuberosity. Computed tomography (Fig. 2E and F) revealed the tips of two screws apparently touching the radial tuberosity with some new bone formation. Early hardware removal was performed at 6 months postoperative followed by intensive physiotherapy. No resection of the new bone was performed. Range of forearm and elbow
motion progressively returned to normal without symptoms.
Case 3 A 62-year-old man sustained a closed, minimally displaced oblique right olecranon fracture following a fall on the sidewalk (Fig. 3A and B). Two days post-injury, he underwent open reduction and internal fixation with a one-third tubular plate. At the end of the operation, a full range of elbow and forearm motion was noted, and anterior—posterior and lateral radiographs were interpreted as normal. At 8 weeks postoperative examination revealed a painful range of elbow motion from 358 to 908, with 208 of pronation and no supination. Standard radiographs (Fig. 3C and D) were interpreted as normal, but radiographs performed under dynamic fluoroscopy revealed three screws very close to, if not touching, the radial head and tuberosity (Fig. 3E). The three screws were removed and replaced by shorter ones. This led to a progressive
26
A. Gamulin et al.
Figure 3 Case 3. (A) Anterior—posterior injury radiograph. (B) Lateral injury radiograph. (C) Anterior—posterior radiograph 8 weeks postoperative. (D) Lateral radiograph 8 weeks postoperative. (E) Dynamic fluoroscopy view 8 weeks postoperative.
and rapid total recovery of a painless range of motion.
Case 4 Following a simple fall, a healthy 38-year-old man sustained a closed displaced oblique right olecranon fracture (Fig. 4A and B). Open reduction and internal fixation with the modified bicortical tension-band wiring technique was performed 2 days following injury. Intraoperative range of elbow and forearm motion was noted to be complete, with apparent satisfactory radiographs. His postoperative course was marked by sterile wound drainage requiring frequent local dressing changes during the first 2 weeks. At 4 weeks postoperative, forearm rotation was noted to be very painful and completely blocked, with painful elbow motion from 208 to 1208. Standard radiographs 4 weeks postoperative (Fig. 4C and D) revealed satisfactory position with no change from immediately postoperative. Dynamic fluoroscopic
examination showed one Kirschner wire penetrating the anterior ulnar cortex in close proximity to the radial tuberosity and biceps tendon insertion (Fig. 4E). Immediate replacement of this wire with a shorter one rapidly led to a return of normal forearm and elbow motion without pain.
Discussion Tension-band wiring and plate osteosynthesis are widely used methods of osteosynthesis of olecranon fractures. Most postoperative complications are related to hardware prominence, particularly with the tension-band wiring technique. In order to prevent proximal migration and prominence of the Kirschner wires, several methods have been advocated, such as burying them deeply under the triceps tendon,7,24,25 contouring the proximal wire ends to impact them into the bone of the proximal fragment,7,24,25 using modified pins with
Hardware impingement after olecranon fracture fixation
27
Figure 4 Case 4. (A) Anterior—posterior injury radiograph. (B) Lateral injury radiograph. (C) Anterior—posterior radiograph 4 weeks postoperative. (D) Lateral radiograph 4 weeks postoperative. (E) Dynamic fluoroscopy view 4 weeks postoperative.
a transverse hole in their proximal extremity able to accept the passage of the figure-of-8 wire,15,16,23 and engaging the anterior cortex of the ulna with the distal end of the Kirschner wires.2,25,27 Concerning this latter technique, some authors insist to take care not to penetrate the anterior cortex of the ulna with the Kirschner wires in order to prevent restricting forearm rotation, the formation of heterotopic ossification or radioulnar synostosis, or injuring the neurovascular structures of the forearm.7,24 Although the problem may be more frequent than actually reported, we were able to find only two reports of hardware impingement in the region of the proximal radius following fixation of an olecranon fracture.3,18 In the first report, 3 the authors described two clinical cases in which bicortical placement of the Kirschner wires led to impaired forearm rotation with normal flexion and extension of the elbow. In the first case, the tip of the most radial Kirschner wire had penetrated the radial neck and the forearm was fixed in pronation. Removal of the wire restored a normal range of motion. In the second case, the tip of the most radial Kirschner
wire protruded twice the thickness of the anterior cortex and was blocking supination of the radius, probably by soft-tissue impingement at the level of the supinator muscle or biceps brachii tendon. Pronation was not restricted. Removal of the wire restored normal range of motion. In order to investigate ways to prevent this complication, these authors performed a cadaver study to determine the optimal position and insertion technique of the Kirschner wires. They concluded the following: (a) the forearm must be supinated during Kirschner wire insertion as pronation leads to penetration of the wires into the supinator muscle or biceps brachii tendon (which both lie on the anterior metaphysis of the ulna during pronation), or into the radius; (b) the posteromedial ridge of the olecranon must be identified and the Kirschner wires must be inserted at 308 of ulnar angulation to this landmark in the coronal plane in order to exit through the ulnar side, rather than through the anterior cortex of the proximal ulnar metaphysis; (c) the Kirschner wires must also be inserted at 308 in the sagittal plane to optimally exit through the medial border of the proximal ulnar metaphysis; (d) anterior cortical
28 penetration must be kept to an absolute minimum; and (e) forearm rotation must be checked for fluidity and completeness at the end of the osteosynthesis and radiographic documentation must be obtained. In the second more recent report, 18 five patients (four after tension band wiring, one following plate and screw fixation) were noted to have impaired forearm rotation associated with palpable crepitation on examination. Postoperative plain radiographs could not explain the limitation of forearm rotation. CT revealed perforation of the Kirschner wires through the far ulnar cortex and passage into the interosseous space abutting or actually contacting the proximal aspect of the radius. In the one patient treated with plate-and-screw fixation, CT reconstruction demonstrated that the tip of the long lag screw was lying adjacent to the proximal aspect of the radius. In this report, the authors used three-dimensional simulation of the forearm bones to evaluate misplaced hardware. Their conclusions are important for understanding how this can be missed in the operating room, and include: (1) varying wire or screw insertion in the coronal plane can result in an identical lateral radiographic projection, (2) the proximal ulna is tear-shaped in cross-section which cannot be appreciated with standard intraoperative radiographs, and (3) the proximal ulna has a varus orientation. The authors recommend choosing a more lateral entry point on the olecranon for Kirschner wire insertion, and direct the wires towards the ulnar midshaft. While it may seem intuitive to do what we need to do in order to avoid this complication, our teaching has always been to rely upon intraoperative radiographs. However, it is important to realise from these two previous reports, and from our four patients, that wire or screw protrusion may not be recognizable intraoperatively simply by viewing standard anterior—posterior and lateral radiographs. Of the four patients we have presented, two confirm that protruding Kirschner wires near the proximal radius or radial tuberosity may result in impingement upon bone and/or soft tissue resulting in a block to forearm rotation and elbow motion. The other two patients demonstrate that a similar phenomenon is possible following plate osteosynthesis, which to our knowledge has been previously described only once.18 In all cases, care should be taken not to overpenetrate the ulnar cortex. As all four of our patients demonstrated, full forearm rotation and elbow motion, as well as the absence of any grating sensation or blocking, intraoperatively under anaesthesia, does not ensure that there is no impingement of hardware upon bone, or most importantly soft tissue. Such
A. Gamulin et al. findings are more likely to be found with the patient awake, and may occur later when reactive inflammation develops at the tip of a wire or screw. In order to diminish the incidence of this complication, the most important suggestion that can be made is that no Kirschner wire or screw should overpenetrate the ulnar cortex. If this is noted on careful intraoperative fluoroscopic examination the offending hardware should be removed and a shorter one utilised. The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or non-profit organisation with which the authors are affiliated or associated.
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