Tension Suture Fixation of Olecranon Fractures
Authors: Phadnis Joideep , Eves Timothy , Watts Adam C. 
Published: June 2021

Background:
Mayo type-IIA olecranon fractures are characterized by a transverse or short oblique fracture without articular comminution or ulnohumeral instability. Traditionally, these fractures are treated with a tension-band wiring technique. Despite good rates of fracture union, tension-band wiring is associated with a reoperation rate of 30% to 60%, usually for removal of prominent metalwork. The tension suture technique was developed as an alternative method of fixing Mayo type-IIA fractures using only high-tensile braided nonabsorbable number-2 sutures, with the aim of reducing the reoperation rate associated with tension-band wiring without compromising outcomes. The tension suture technique has subsequently become the only technique we use when treating these fractures.

Description:
The patient is positioned in the lateral decubitus position under general or regional anesthesia. A direct posterior approach is made, centered over the fracture. The fracture is identified, cleared of hematoma, and reduced with use of a large, pointed reduction clamp to provide interfragmentary compression. A 2.5-mm transverse drill hole is made through the ulna distal to the fracture site. Two sets of number-2 braided nonabsorbable sutures are utilized. The first sutures are passed lateral to medial through the drill hole and used to grasp the medial triceps insertion onto the proximal fragment, then passed back through the transverse drill hole from medial to lateral and used to grasp the lateral triceps insertion onto the proximal fragment. The suture ends are tensioned to remove slack and tied on the lateral aspect of the olecranon. The second sutures are then passed lateral to medial through the transverse drill hole but this time used to grasp the posterolateral triceps insertion on the proximal fragment, then re-passed through the transverse drill hole from medial to lateral, and finally used to grasp the posteromedial triceps insertion. The suture limbs are tensioned and tied on the lateral aspect of the ulna next to the first suture. The clamp is removed, and the construct is tested under full range of motion to ensure there is no evidence of gapping. Fluoroscopy is utilized to confirm reduction before the wound is irrigated and closed in a standard fashion.

Alternatives:
Mayo type-IIA fractures may be treated nonoperatively in frail or low-demand patients. Surgical treatment is traditionally performed with the tension-band wiring technique, but plate or intramedullary fixation may also be utilized.

Rationale:
This technique negates the metalwork-related complications associated with all other surgical techniques for this fracture type.

Expected Outcomes:
In a recent study comparing the tension suture technique with tension-band wiring and plate fixation for Mayo type-IIA fractures, the tension suture technique had a significantly lower reoperation rate compared with tension-band wiring and a lower complication rate compared with plate fixation.

Important Tips:

The tension-suture technique is primarily for Mayo type-IIA fractures without ulnohumeral instability or marked articular comminution.
Ensure the transverse tunnel in the ulna is at least 3 cm distal to the fracture site and 1 cm anterior to the dorsal cortex of the ulna in order to prevent fracture of the tunnel.
Grasp as much of the triceps tendon as possible when placing the sutures through the proximal fragment to prevent pull-out.
Tension and tie the sutures with the elbow semi-extended to prevent the construct slackening in elbow extension and to facilitate interfragmentary compression during flexion.