Double Tension Band Wiring Versus Plating for Internal Fixation of Distal Humeral Fractures

Abstract

Background:

Distal humeral fracture (DHF) needs rigid internal fixation to allow early elbow movement. Also, double plating (DP) necessitates more dissection and hence more adhesions and stiffness. It was suggested that double tension band wiring (DTBW) could be applied to distal humerus.

Patients and methods:

Overall, 73 Patients with DHF were divided into two groups. DTBW group included 34 patients with an average age of 31 years. DP group included 39 patients with an average age of 36 years. Posterior approach with either triceps reflecting approach or olecranon osteotomy was used. In DTBW group, tension band wiring was applied to each one of the medial and lateral columns. In DP group, plating of both columns were constructed. Active movement started within few days postoperatively.

Results:

In DTBW group, total elbow movement arc was 125° with an extension lag of 6°, whereas in DP group, they were 100° and 3°, respectively (P = 0.03). In DTBW group, the elbow flexor force was 34 lb (78%) versus 40 lb (91%) in DP group (P = 0.07). Regarding the total Mayo Elbow Performance Score (MEPS), DTBW group patients had an average MEPS of 94 points, and 100% of them had excellent to good grades. Those of DP group had an average MEPS of 83 points, and 58% of them had excellent to good grades (P = 0.07).

Conclusion:

DTBW is a valuable option for the management of DHF, as it is associated with less surgery duration, less soft-tissue dissection compared with DP. Also, DTBW is more cost-effective treatment.

Distal humeral fractures are classified according to the AO/OTA classification into three categories: extra-articular fractures (type A), partial articular fractures (type B), and complete articular fractures (type C). In adults, open reduction and internal fixation (ORIF) with double plating (DP) is considered the standard treatment for unstable distal humeral fractures. However, stable fixation may be difficult to achieve because the distal fracture fragment is often small, allowing the insertion of only a limited number of screws. In addition, DP requires extensive soft-tissue dissection and prolonged surgical time, both of which may increase postoperative adhesions and elbow stiffness. Furthermore, the distal humerus is intrinsically unstable because the bone between the olecranon and coronoid fossae is markedly thinned, creating a structural configuration analogous to two opposing knife edges.¹

The distal humeral fragment consists predominantly of cancellous bone, which provides limited purchase for one or two fixation screws. During elbow flexion, the only movement occurring at the humeroulnar joint, the supracondylar region, is subjected to opposing biomechanical forces: compression along the anterior cortex and tension along the posterior cortex. These forces result from both static and dynamic factors. The static component is related to the anatomical configuration of the distal humerus, which is curved anteriorly, producing a convex posterior surface and a concave anterior surface. The dynamic component arises during elbow flexion when the brachialis and biceps muscles contract concentrically, generating anterior compression across the supracondylar region, whereas the triceps and anconeus muscles contract eccentrically to control flexion, thereby generating posterior tensile forces.²

From a biomechanical perspective, tension band constructs may provide an alternative to plate fixation by neutralizing the posterior tensile forces acting on the medial and lateral columns of the distal humerus. This construct converts tensile forces into compressive forces at the fracture site during elbow motion, thereby providing dynamic compression and potentially allowing earlier postoperative mobilization. These biomechanical principles constitute the rationale for applying double tension band wiring (DTBW) to the posterior aspects of both the medial and lateral columns of the distal humerus.³

Research Question

Does open reduction and internal fixation of distal humeral fractures using double tension band wiring (DTBW) result in superior clinical and functional outcomes compared with double plating (DP)?

PATIENTS and METHODS

This prospective, single-blinded, randomized, controlled trial included 73 patients with closed distal humeral fractures (DHFs) who underwent surgical treatment between March 2019 and September 2023. Patients were randomly allocated to one of two treatment groups using stratified randomization, taking into account age, duration of injury, and arm dominance. Stratified randomization was done using PASS (Power Analysis and Sample Size) software. Patients were blinded to the surgical technique used; however, the inherent differences between the two procedures limited the extent of blinding (Tables 1–3).

Table 1.

Comparison Between DTBW and DP Patients in Our Study

Category	Parameter	DTBW	DP
Patient demographics	No.	34	39
	Average age	31 years	36 years
	Sex
	Male	26 (76%)	31 (80%)
	Female	3 (24%)	8 (20%)
	Arm dominance	14 (44%)	23 (59%)
Fracture geometry	Associated olecranon fracture	4 (12%)	Non
	AO Type
	A	26 (76%)	27 (70%)
	C	8 (24%)	12 (30%)
	Surgical approach
	Olecranon osteotomy	27 (37%)
	Triceps reflecting	46 (63%)

Table 3.

Comparison Between DTBW and DP Patients in Our Study

Category	Parameter	DTBW	DP
Average Muscle strength
Elbow	Flexors	43 lb (96%)	25 lb (56%)
		P = 0.04
	Extensors	29 lb (94%)	22 lb (78%)
		P = 0.21
	Pronators	24 lb (93%)	15 lb (67%)
		P = 0.09
	Supinators	30 lb (92%)	20 lb (64%)
		P = 0.05
Hand	Hand grip	56 lb (93%)	40 lb (72%)
		P = 0.05
MEPS	Total score	94 points	83 points
		P = 0.05
	Excellent and good scores	100%	58%
Complications	Wound infection	2 (6%)	3 (8%)
	Ulnar neuropathy	None	None
	Nonunion incidence	None	2 (5%)
	Implant failure	None	None
	Ulnohumeral instability	None	3 (8%)
	Heterotopic ossification	None	2 (5%)

Table 2.

Comparison Between DTBW and DP Patients in Our Study

Category	Parameter	DTBW	DP
Results	Average surgery duration	80 minutes	115 minutes
		P = 0.02
	Average healing time	13 weeks	15 weeks
		P = 0.09
Average elbow movements	Flexion arc	135°	90°
		P = 0.03
	Extension lag	8°	21°
		P = 0.04
	Pronation	74°	65°
		P = 0.26
	Supination	80°	70°
		P = 0.11

The control group (DP group) comprised 39 patients who underwent open reduction and internal fixation using double plating of the medial and lateral columns. None of the patients in either group had clinical evidence of preoperative ulnar nerve dysfunction.

Demographic Data

DTBW Group

The DTBW group comprised 34 patients who underwent open reduction and internal fixation using double tension band wiring of the medial and lateral columns. The group included 26 men (76%) and eight women (24%), with a mean age of 31 years (range, 18 to 67 years). The nondominant elbow was affected in 19 patients (56%), whereas the dominant elbow was involved in 15 patients (44%).

DP Group

The DP group included 39 patients, comprising 31 men (80%) and eight women (20%), with a mean age of 36 years (range, 19 to 58 years). The dominant elbow was involved in 23 patients (59%), whereas the nondominant elbow was affected in 16 patients (41%). All patients had an intact neurovascular status at presentation.

Radiological Evaluation

All patients underwent standard anterior-posterior and lateral radiographs of both the injured and the contralateral elbows. CT was done in patients with comminuted fractures or when intra-articular extension was suspected.

Inclusion Criteria

1. Acute distal humeral fracture presenting within 10 days of injury.

2. Adult patients (skeletally mature).

Exclusion Criteria

1. Open fractures.

2. Polytrauma involving either the ipsilateral upper limb or other body regions.

3. Associated neurovascular injuries.

In the DTBW group, four patients (12%) had an associated ipsilateral olecranon fracture. One patient sustained an unstable oblique olecranon fracture, which was treated using a combination of tension band wiring and a 3.5-mm one-third tubular antiglide plate. The remaining three patients had stable transverse olecranon fractures, which were treated with conventional tension band wiring. In the DP group, three patients (8%) had associated stable transverse olecranon fractures, all of which were managed using conventional tension band wiring.

According to the AO/OTA classification, 26 patients (76%) in the DTBW group had type A fractures and eight patients (24%) had type C fractures. In the DP group, 27 patients (70%) had type A fractures and 12 patients (30%) had type C fractures. CT was done in 20 patients (27%) with suspected intra-articular extension or fracture comminution to facilitate preoperative planning.

Surgical Technique

All procedures were performed under general anesthesia with tourniquet control and ×4 loupe magnification.⁴ Patients were positioned in the lateral decubitus position, and a posterior midline skin incision was made (Figure 1A). The ulnar nerve was identified proximally and traced distally to the groove behind the medial epicondyle (Figure 1B).

FIGURE 1.

Intraoperative photographs demonstrating the posterior surgical approach. A, Posterior skin incision. B, Mobilization of the ulnar nerve. C, Anterior transposition of the ulnar nerve. D, Sites of ulnar nerve release before anterior transposition: (1) arcade of Struthers, (2) medial intermuscular septum, (3) Osborne ligament, and (4) the interval between the two heads of the flexor carpi ulnaris muscle. Abbreviations: H, humerus. T, triceps muscle. FCU, flexor carpi ulnaris muscle. White arrow, ulnar nerve. Blue arrow, motor branch to the flexor carpi ulnaris muscle.

Proximal dissection began by dividing the deep fascia tethering the ulnar nerve to the medial head of the triceps (Figure 1D). The arcade of Struthers was identified where the nerve pierced the medial intermuscular septum, and it was carefully released by blunt dissection. The nerve was then mobilized from the posterior aspect of the medial intermuscular septum and followed distally through the cubital tunnel behind the medial epicondyle. The Osborne ligament, which forms the roof of the cubital tunnel, was divided to achieve complete decompression of the nerve. Subsequently, the two heads of the flexor carpi ulnaris (FCU) were separated, and the overlying aponeurosis was divided to further expose the nerve. The motor branch to the FCU was identified and meticulously preserved throughout the procedure (Figure 1C).

In patients with an associated olecranon fracture, the distal humerus was exposed through the fracture site. In the remaining patients, one of the following two posterior approaches was used.

Transolecranon Approach

This approach was used in patients with comminuted fractures involving the articular surface. Twenty-seven patients (37%) underwent this approach, including nine patients in the DTBW group and 18 patients in the DP group.

Triceps-Reflecting Approach

The triceps-reflecting approach was used in patients with extra-articular fractures or fractures with minimal or no comminution (46 patients, 63%).⁵ The triceps was elevated from the posterior aspect of the medial intermuscular septum. Using a thin osteotome, the triceps tendon insertion was elevated from the superior surface of the olecranon together with a thin wafer of bone. Dissection was then continued distally by incising the aponeurosis medially and laterally along both sides of the proximal third of the posterior ulnar border while maintaining continuity with the triceps tendon.

The triceps mechanism remained intact throughout the procedure, with its proximal and distal attachments preserved. With the elbow in full flexion and the triceps mechanism reflected laterally, excellent visualization of the distal humerus, including the articular surface, was achieved (Figure 2). Whenever an intra-articular fracture extension was present, it was reduced and stabilized first using a partially threaded 4.0-mm cancellous lag screw with a washer before definitive fixation of the supracondylar component. The first step was to anatomically reduce and stabilize any intra-articular fracture extension using a partially threaded 4.0-mm cancellous lag screw with a washer before definitive fixation of the supracondylar fracture.

• 1. DTBW Group⁶

FIGURE 2.

Intraoperative photographs demonstrating the triceps-reflecting approach. After exposure and medial mobilization of the ulnar nerve, the triceps mechanism was elevated from the posterior aspect of the distal humerus while preserving its insertion on the olecranon (A). A thin wafer of bone was osteotomized from the tip of the olecranon, carrying the triceps tendon insertion together with an aponeurotic flap over the posterior border of the ulna (B). With lateral reflection of the triceps mechanism, gentle medial retraction of the ulnar nerve, and full elbow flexion, excellent visualization of the distal humerus, and articular surface was achieved (C). The intra-articular fracture extension (green arrow) was clearly visualized and anatomically reduced using a reduction clamp (D).

In each of the medial and lateral columns of the distal humerus, an approximately transverse osseous tunnel was drilled using a 2.7-mm drill bit approximately 2.5 cm (1 inch) proximal to the fracture site. An 18-gauge (1.25-mm) stainless steel malleable wire was then passed through each tunnel (Figure 3A).

FIGURE 3.

Images showing surgical technique of double tension band wiring. Two parallel 2.0-mm Kirschner wires were inserted into each of the medial and lateral columns through the corresponding epicondyles, as illustrated on a plastic model and in the intraoperative photograph (A and B). An 18-gauge stainless steel wire was passed through the previously prepared osseous tunnel in each column, wrapped around the protruding ends of the Kirschner wires, and tightened in a figure-of-eight configuration. The protruding ends of the Kirschner wires were subsequently bent over the tension band construct and buried within the bone (C and D). M = medial, L = lateral. White arrows, Kirschner wires. Blue arrows, tension band wires before burying the Kirschner wires. Green arrows, final construct after the Kirschner wires had been bent and buried within the bone.

Following anatomical reduction, the fracture was temporarily stabilized using bone reduction clamps. Two smooth 2.0-mm Kirschner wires were then inserted retrograde into each column through the corresponding epicondyle until they either penetrated or firmly abutted the opposite cortex. The limbs of each previously threaded stainless steel wire were crossed and wrapped around the protruding ends of the corresponding Kirschner wires, creating a figure-of-eight tension band construct for each column (Figure 3, B–E).

• 2. DP Group⁷

Following fracture reduction, the medial and lateral columns were stabilized using contoured 3.5-mm reconstruction plates. The lateral plate was applied to the posterior aspect of the lateral column, whereas the medial plate was positioned along the medial border of the medial column, with the two plates oriented perpendicular to each other.

In patients with associated olecranon fractures (3 patients, 9%) and in the 20 patients (57%) who underwent olecranon osteotomy, the proximal ulna was repaired using conventional tension band wiring. In one patient with an unstable long oblique olecranon fracture, fixation was augmented with a combination of tension band wiring and a one-third tubular antiglide plate.

Prophylactic anterior transposition of the ulnar nerve was performed in all patients.⁸ The medial intermuscular septum was completely excised, whereas the motor branch to the flexor carpi ulnaris (FCU) was carefully identified and preserved. The ulnar nerve was then transposed anteriorly into a subcutaneous position (Figure 4, A and B).

FIGURE 4.

Images showing anterior transposition of the ulnar nerve. A, Exposure and dissection of the ulnar nerve. B, Complete excision of the medial intermuscular septum. C, Identification and preservation of the motor branch to the flexor carpi ulnaris (FCU). D, Two rectangular fascial flaps (A and B) were fashioned from the fascia overlying the common flexor-pronator muscle mass in a zigzag (Z-shaped) configuration. E, The fascial flaps were elevated. F, Their free ends were sutured together over the transposed ulnar nerve, creating a fascial sling that allowed controlled mobility of the nerve during elbow motion. G and H, Joint stability and full elbow range of motion were assessed before wound closure.

To prevent excessive nerve mobility, the transposed nerve was secured in its new bed using two rectangular fascial flaps fashioned from the thick aponeurosis of the common flexorpronator origin. The flaps were designed in a zigzag (Z-shaped) configuration with opposing bases. After elevation, their free ends were sutured together over the transposed nerve, creating a fascial sling with sufficient space beneath to allow unrestricted gliding of the nerve during elbow motion (Figure 4, C–F). Before wound closure, the elbow was passively moved through its full range of flexion and extension to confirm fracture stability and unrestricted gliding of the transposed ulnar nerve (Figure 4, G and H). The limb was then supported in an arm sling, and active elbow mobilization was initiated within a few days after surgery as pain permitted.

Statistical Methods

The patient data and results were evaluated using IBM SPSS software package. Descriptive statistics include the average and standard deviation. The inferential one included the use of two tailed two nonpaired sample Student t-test with a 95% confidence interval (α significance level i.e. P value of 0.05). Required sample size for either patients or controls was estimated according to the following formula:

$$\mathrm{N}={\mathrm{Z}}^2\hspace{0.17em}\mathrm{X}\hspace{0.17em}\mathrm{P}\hspace{0.17em}(1―\hspace{0.17em}\mathrm{P})÷{\mathrm{d}}^2$$

where,

• N: adequate sample size.

• Z: It is a standard normal variate, which equals 1.96 at a confidence level of 0.95.

• P: prevalence of distal humeral fracture from previous studies, which is 0.00007 among general population.

• d: precision factor, which is around 20% of the prevalence of distal humeral fracture.

RESULTS

Clinical outcomes were evaluated after a mean follow-up of 41 months (range, 33 to 53 months). The mean surgical time was 80 minutes (range, 65 to 100 minutes) in the DTBW group compared with 115 minutes (range, 95 to 145 minutes) in the DP group, representing a statistically significant reduction in surgical duration with DTBW (P = 0.02). In the DTBW group, all fractures achieved radiographic union within a mean of 13 weeks (range, 11 to 16 weeks). In the DP group, two patients (5%) developed nonunion, whereas the remaining fractures united within a mean of 15 weeks (range, 11 to 18 weeks). The difference in time to union was not statistically significant (P = 0.09). Postoperative complications in both groups are summarized in Figure 5.

FIGURE 5.

Histogram comparing the postoperative complications observed in the DTBW and DP groups.

The clinical outcomes were assessed using the following parameters.

Elbow Flexion and Extension

In the DTBW group, the mean elbow flexion was 135° (93% of the contralateral side), ranging from 120° to 140°, with a mean extension deficit of 8° (range, 5° to 12°). In the DP group, elbow flexion ranged from 70° to 100°, with a mean flexion of 90° (60% of the contralateral side). The mean extension deficit was 21° (range, 10° to 30°). The difference between the two groups was statistically significant (P = 0.03) (Figure 6).

FIGURE 6.

Histogram comparing postoperative elbow and forearm range of motion in the DTBW and DP groups.

Forearm Pronation and Supination

Patients in the DTBW group achieved a mean forearm supination of 80° (94% of the contralateral side), ranging from 70° to 85°. In comparison, patients in the DP group achieved a mean supination of 70° (83% of the contralateral side), with a range of 55° to 80°. This difference was not statistically significant (P = 0.11) (Figure 6). The mean forearm pronation in the DTBW group was 74° (89% of the contralateral side), ranging from 65° to 80°, whereas the DP group achieved a mean pronation of 70° (87% of the contralateral side), ranging from 60° to 80°. No statistically significant difference was observed between the groups (P = 0.26) (Figure 6).

Assessment of Elbow Muscle Strength

Elbow muscle strength was assessed using a Hoggan microFET3 handheld digital dynamometer (HMD) (Figure 7A).⁹ The device measures the maximal force generated by the patient against examiner-applied resistance and displays the value in pounds (lb). The dynamometer is equipped with two liquid crystal display (LCD) windows (Figure 7, B–D). The left display indicates the measurement settings, including sensitivity and measurement units, whereas the right display shows the peak force recorded during testing. The instrument is supplied with three interchangeable transducer attachments designed for testing different anatomical regions (Figure 7, E–H).

FIGURE 7.

Images of instruments used for the assessment of upper-limb muscle strength and hand grip strength. A, Hoggan microFET3 handheld digital dynamometer. The front of the device contains two liquid crystal display (LCD) windows: the left LCD displays the sensitivity setting, high (H) (thin red arrow in B) or low (L) (thin yellow arrow in C), whereas the right LCD displays the measured muscle strength (D and E). The rear aspect of the device showing the socket for attachment of the transducer pad (F–H). Interchangeable transducer pads: curved pad for arm and forearm muscle testing (F), large flat circular pad for hand testing (G), and small flat circular pad for finger testing (H). Handgrip dynamometer showing the fixed handle (F), movable handle (m), and dial (D) (I). Adjustable handle positions according to the distance between the fixed and movable handles. The second, third, and fifth positions were used for hand grip strength assessment (indicated by thick red, green, and yellow arrows, respectively (J–L).

Elbow Flexor Muscle Strength

Elbow flexor strength was assessed with the elbow flexed to 90° and the forearm in the neutral position. The dynamometer was applied to the radial aspect of the distal forearm (Figure 8A). The examiner applied an extending force while the patient resisted by maintaining the elbow at 90° of flexion. The DTBW group demonstrated a mean elbow flexor strength of 43 lb (96% of the contralateral side), ranging from 38 to 49 lb. In comparison, the DP group demonstrated a mean strength of 25 lb (56% of the contralateral side), with a range of 20 to 32 lb. The difference was statistically significant (P = 0.04) (Figure 9).

FIGURE 8.

Clinical photographs demonstrating the assessment of elbow flexor (A) and extensor (B) muscle strength using the Hoggan microFET3 handheld digital dynamometer. With the elbow flexed to 90° and the forearm in the neutral position, the examiner applies an extending force (A) or a flexing force (B) (yellow arrows), whereas the patient resists the applied force (red arrows) to maintain the elbow at 90° of flexion. Assessment of forearm pronator and supinator muscle strength. With the elbow flexed to 90° and the forearm in the neutral position, the examiner applies a supinating force (C) or a pronating force (D), whereas the patient resists the applied force to maintain the forearm in the neutral position.

FIGURE 9.

Histogram comparing postoperative elbow muscle strength, forearm muscle strength, and hand grip strength between the DTBW and DP groups.

Elbow Extensor Muscle Strength

Elbow extensor strength was measured with the elbow flexed to 90° and the forearm in the neutral position. The dynamometer was applied to the ulnar aspect of the distal forearm (Figure 8B). The examiner applied a flexing force while the patient resisted by maintaining the elbow at 90° of flexion. The DTBW group achieved a mean elbow extensor strength of 29 lb (94% of the contralateral side), with values ranging from 25 to 34 lb. The DP group demonstrated a mean strength of 22 lb (78% of the contralateral side), ranging from 19 to 26 lb. This difference was not statistically significant (P = 0.21) (Figure 9).

Forearm Pronator Muscle Strength

Forearm pronator strength was assessed with the forearm in the neutral position. The dynamometer was placed on the volar aspect of the distal forearm (Figure 8C). The examiner attempted to supinate the forearm while the patient resisted by maintaining the forearm in the neutral position. The DTBW group demonstrated a mean pronation strength of 24 lb (93% of the contralateral side), ranging from 21 to 29 lb. The corresponding values in the DP group were 15 lb (67% of the contralateral side), with a range of 11 to 20 lb. The difference did not reach statistical significance (P = 0.09) (Figure 9).

Forearm Supinator Muscle Strength

Forearm supinator strength was measured with the forearm in the neutral position. The dynamometer was applied to the dorsal aspect of the distal forearm (Figure 8D). The examiner attempted to pronate the forearm while the patient resisted by maintaining the forearm in the neutral position. The DTBW group achieved a mean supination strength of 30 lb (92% of the contralateral side), ranging from 27 to 34 lb. The DP group demonstrated a mean strength of 20 lb (64% of the contralateral side), with values ranging from 15 to 24 lb. This difference reached the threshold of statistical significance (P = 0.05) (Figure 9).

Hand Grip Strength

Hand grip strength was measured using a handgrip dynamometer at the second, third, and fifth handle positions.¹⁰ The mean of the three measurements was recorded as the representative hand grip strength for each patient (Figure 7, I–L). The DTBW group demonstrated a mean hand grip strength of 56 lb (93% of the contralateral side), ranging from 48 to 68 lb. In comparison, the DP group achieved a mean hand grip strength of 40 lb (72% of the contralateral side), with a range of 32 to 45 lb. This difference reached the threshold of statistical significance (P = 0.05) (Figure 9).

Mayo Elbow Performance Score (MEPS)

At the final follow-up, 26 patients (75%) in the DTBW group achieved an excellent MEPS, whereas the remaining eight patients (25%) achieved a good result.¹¹ Thus, all patients (100%) in the DTBW group had good-to-excellent outcomes. In the DP group, two patients (5%) achieved an excellent result, 21 patients (53%) had a good result, 12 patients (32%) had a fair result, and four patients (10%) had a poor result (Figure 10).

FIGURE 10.

Histogram showing the distribution of postoperative Mayo Elbow Performance Score (MEPS) categories in the DTBW and DP groups.

The mean postoperative MEPS was 94 points (range, 89 to 98) in the DTBW group compared with 83 points (range, 78 to 91 points) in the DP group. Although the DTBW group demonstrated a higher mean score, the difference did not reach statistical significance (P = 0.07).

Study Limitations

This study has several limitations. First, the sample size was relatively small, limiting the statistical power to detect differences between treatment groups. Second, despite the use of stratified randomization, complete randomization was difficult to achieve because of the limited number of eligible patients. Finally, although the mean follow-up period exceeded 3 years, longer follow-up would be valuable to assess long-term functional outcomes, implant-related complications, and the development of posttraumatic arthritis.

Case Presentations

Representative clinical cases from both the DTBW group (Figures 11–16) and the DP group (Figures 17–19) are presented to illustrate postoperative functional outcomes.

FIGURE 11.

Preoperative anterior-posterior and lateral radiographs of the dominant elbow of an 18-year-old young lady showing a closed supracondylar fracture of the distal humerus (A and B). The fracture was treated using the double tension band wiring (DTBW) technique through a posterior triceps-reflecting approach without olecranon osteotomy (C and D). At the final follow-up, the patient had regained a reasonable range of elbow motion, was satisfied with the functional outcome, and had returned to her previous occupation without restrictions (E and F).

FIGURE 16.

Preoperative anterior-posterior and lateral radiographs of the nondominant elbow of a 43-year-old man showing a closed comminuted supracondylar fracture of the distal humerus (A and B). Intraoperative photographs demonstrate fixation using the double tension band wiring (DTBW) technique through a posterior approach with olecranon osteotomy (C and D). Postoperative radiographs are shown in (E and F). At the final follow-up, clinical photographs demonstrate a residual limitation of elbow flexion-extension; however, the patient was satisfied with the functional outcome and had returned to his previous occupation without restrictions (G–J). L = lateral, M = medial; P = proximal. Blue arrow, olecranon fragment with attached triceps tendon. White arrows, double tension band wiring constructs along the medial and lateral columns. Green arrow, olecranon osteotomy. Black arrow, ulnar nerve.

FIGURE 17.

Preoperative anterior-posterior and lateral radiographs of the dominant elbow of a 36-year-old man showing a closed comminuted supracondylar fracture of the distal humerus (A and B). The fracture was treated using double plating (DP) through a posterior triceps-reflecting approach. An undisplaced intra-articular fracture extension identified intraoperatively was stabilized with a transverse 4.0-mm partially threaded cancellous lag screw inserted through the lateral plate. A one-third tubular plate was applied to the medial column, and a 3.5-mm dynamic compression plate (DCP) was applied to the lateral column in an orthogonal (90°) configuration (C and D). Despite early postoperative active and passive elbow mobilization, the patient developed marked limitation of elbow flexion-extension and a conspicuous scar secondary to a superficial wound infection over the tip of the olecranon (E). At the final follow-up, the patient remained dissatisfied with the restricted elbow motion, particularly the limited flexion that interfered with hand-to-mouth and hand-to-face activities. He was unemployed and reported substantial limitations in his activities of daily living (F–I).

FIGURE 19.

Preoperative anterior-posterior and lateral radiographs of the nondominant elbow of a 54-year-old man with a closed comminuted bicondylar distal humeral fracture (A and B). The fracture was treated using double plating (DP) through a posterior triceps-reflecting approach without olecranon osteotomy. The intra-articular fracture component was anatomically reduced and stabilized using two transverse 4.0-mm partially threaded cancellous lag screws, one inserted through the medial plate and the other placed independently outside the plate. A one-third tubular plate was applied to the medial column, and a 3.5-mm reconstruction plate was applied to the radial column in an orthogonal (90°) configuration (C and D). At the final follow-up, the patient remained dissatisfied with the restricted elbow range of motion, particularly the limited flexion that impaired hand-to-mouth and hand-to-face activities (E–H).

FIGURE 12.

Preoperative anterior-posterior and lateral radiographs of the dominant elbow of a 35-year-old gentleman showing a closed low supracondylar fracture of the distal humerus (A and B). The fracture was treated with double tension band wiring (DTBW) through a posterior triceps-reflecting approach without olecranon osteotomy (C and D). At the final follow-up, the patient was satisfied with the functional outcome and elbow range of motion and had resumed his normal daily activities (E–H).

FIGURE 13.

Preoperative anterior-posterior and lateral radiographs of the dominant elbow of a 32-year-old man showing a closed comminuted supracondylar fracture of the distal humerus associated with an ipsilateral oblique olecranon fracture (A and B). The distal humeral fracture was exposed through the olecranon fracture and stabilized using the double tension band wiring (DTBW) technique. The olecranon fracture was subsequently anatomically reduced and fixed using a combination of tension band wiring and a one-third tubular antiglide plate. The fixation strategy is illustrated schematically (C) and demonstrated intraoperatively (D). At the final follow-up, the patient had regained a satisfactory range of elbow motion, was satisfied with the functional outcome, and had returned to his previous occupation without restrictions, as shown in the clinical photographs (E–J). L = lateral, M = medial, P = proximal.

FIGURE 14.

Preoperative plain radiographs (A and B) and CT 3D CT images (C and D) of the dominant elbow of a 19-year-old young man showing a closed complete articular (bicondylar) distal humeral fracture. Through a posterior triceps-reflecting approach, the intra-articular fracture component was first anatomically reduced and stabilized using two 4.0-mm partially threaded cancellous lag screws with washers inserted from the lateral condyle toward the medial column. The medial and lateral columns were subsequently stabilized using the double tension band wiring (DTBW) technique (E, F). At the final follow-up, the patient had regained a reasonable range of elbow motion, was satisfied with the functional outcome, and had returned to his previous occupation without restrictions (G–J).

FIGURE 15.

Preoperative anterior-posterior and lateral radiographs of the nondominant elbow of a 37-year-old gentleman showing a closed comminuted bicondylar distal humeral fracture (A and B). Intraoperative photographs demonstrate the associated olecranon fracture. The olecranon fragment, with the attached triceps tendon, was reflected proximally to expose the posterior aspect of the distal humerus (C). The intra-articular fracture component was anatomically reduced and stabilized with a 4.0-mm partially threaded cancellous lag screw with a washer, followed by fixation of the medial and lateral columns using the double tension band wiring (DTBW) technique (D). Postoperative anterior-posterior and lateral radiographs are shown in E and F. At the final follow-up, the patient demonstrated a mild limitation of elbow flexion-extension, which remained functionally satisfactory, allowing return to normal daily activities and previous employment without restrictions (G–J). L = lateral, M = medial, P = proximal. White arrow, olecranon fragment with attached triceps tendon. Green arrow, olecranon fracture. Blue arrow, ulnar nerve.

FIGURE 18.

Preoperative anterior-posterior and lateral radiographs (A and B) and three-dimensional CT (3D CT) images (C) of the nondominant elbow of a 53-year-old man with a closed comminuted supracondylar fracture of the distal humerus. The fracture was treated using double plating (DP) through a posterior triceps-reflecting approach without olecranon osteotomy. An undisplaced intra-articular fracture extension identified intraoperatively was stabilized with a transverse 4.0-mm partially threaded cancellous lag screw inserted through the medial plate. A one-third tubular plate was applied to the lateral column, and a 3.5-mm reconstruction plate was applied to the medial column in an orthogonal (90°) configuration (D and E). Despite early initiation of active and passive postoperative elbow mobilization, the patient developed marked limitation of elbow flexion-extension. At the final follow-up, he remained dissatisfied with the restricted elbow motion, particularly the limited flexion that interfered with hand-to-mouth and hand-to-face activities. Owing to these functional limitations, he changed to a less physically demanding occupation and reported substantial restrictions in his activities of daily living (F–I).

Discussion

Open reduction and internal fixation of distal humeral fractures using double plating remains the standard treatment for complex fractures; however, it is associated with several complications, including postoperative elbow stiffness, limited flexion, ulnar nerve irritation resulting from extensive soft-tissue dissection, and reduced hand grip strength.¹² Therefore, a fixation construct with a lower hardware profile that provides biomechanical stability comparable to double plating may improve functional outcomes while minimizing soft-tissue injury. This concept formed the rationale for the development of the double tension band wiring (DTBW) technique, which applies tension band constructs to the posterior tension surfaces of the medial and lateral columns of the distal humerus.

Several authors have reported a relatively high incidence of postoperative ulnar neuropathy following ORIF of distal humeral fractures. In 2025, Ogasawara et al¹³ reported postoperative ulnar neuropathy in 35% of 40 patients treated with double plating (55% AO/OTA type C and 45% type B fractures). Likewise, Liu et al¹⁴ reported an incidence of 33% postoperative ulnar neuropathy among 168 patients and strongly recommended routine anterior transposition of the ulnar nerve during surgery.

In this study, prophylactic anterior transposition of the ulnar nerve was performed in all patients, and no cases of postoperative ulnar neuropathy were observed. Although this finding is encouraging, the relatively small sample size limits definitive conclusions regarding the effectiveness of routine nerve transposition. The mean surgical time was markedly shorter in the DTBW group than in the DP group (80 versus 115 minutes, P = 0.02). Rahman et al¹⁵ reported a mean tourniquet time of 70 minutes in a series of 25 patients with distal humeral fractures treated using DTBW, which is comparable to the surgical duration observed in this study.

The mean time to fracture union was 13 weeks in the DTBW group and 15 weeks in the DP group, with no statistically significant difference between the groups (P = 0.09). Chou et al¹⁶ reported fracture union between 12 and 24 weeks in 48 patients with AO/OTA type C fractures treated with double plating. Jitprapaikulsarn et al¹⁷ reported a mean healing time of 7 weeks following DTBW in a predominantly AO/OTA type A fracture population. Rahman et al¹⁵ reported a mean union time of 14 weeks after DTBW, which is similar to the findings of this study.

Patients treated with DTBW achieved markedly greater elbow motion than those treated with double plating. The mean flexion-extension arc was 135° in the DTBW group compared with 90° in the DP group, whereas the mean extension deficit was 8° and 21°, respectively (P = 0.03). Mean forearm rotation (pronation plus supination) was 154° in the DTBW group compared with 140° in the DP group, although this difference was not statistically significant (P = 0.11). Chou et al¹⁶ reported a mean flexion-extension arc of 121°, an extension deficit of 8°, and a mean forearm rotation of 163° following double plating. Kokly et al¹⁸ reported a mean flexion-extension arc of 106° with an extension deficit of 18° following DTBW.

Muscle strength was generally higher in the DTBW group. Mean elbow flexor strength was 43 lb (96% of the contralateral side) compared with 25 lb (56%) in the DP group (P = 0.04). Mean elbow extensor strength was 29 lb (94%) versus 22 lb (78%), respectively (P = 0.21). Similarly, mean forearm pronator and supinator strength ranged from 24 to 30 lb (93% of the contralateral side) in the DTBW group compared with 15 to 20 lb (67%) in the DP group (P = 0.05). These findings may be attributable to the less extensive soft-tissue and muscle dissection required with the DTBW technique, potentially resulting in fewer adhesions and improved muscle function.

Postoperative complications occurred in two patients (6%) in the DTBW group and 10 patients (26%) in the DP group. Superficial wound infection occurred in both groups (6% in the DTBW group and 8% in the DP group) and resolved with local wound care and oral antibiotics. No additional complications were observed in the DTBW group. By contrast, the DP group experienced two cases of nonunion (5%), three cases of mild elbow instability (8%), and two cases of heterotopic ossification (5%). Schmidt-Horlohé et al¹⁹ reported an overall complication rate of 37% following double plating, including implant failure (13%), nonunion (7%), elbow stiffness (13%), and capitellar osteonecrosis (4%). Rahman et al¹⁵ reported an overall complication rate of 40% following DTBW, including wound infection, ulnar neuropathy, implant failure, heterotopic ossification, elbow instability, and cubitus varus. Kokly et al¹⁸ reported only minor wound-related complications after DTBW.

Functional outcomes also favored the DTBW group. The mean Mayo Elbow Performance Score (MEPS) was 94 points, and all patients achieved good or excellent results, compared with a mean MEPS of 83 points and 58% good-to-excellent outcomes in the DP group (P = 0.07). The DTBW group also demonstrated markedly better Oxford Elbow Scores (OES) (41 versus 34 points, P = 0.04) and substantially lower QuickDASH scores (3 versus 39 points, P = 0.02), indicating less disability. Al-Hamdani et al²⁰ reported a mean MEPS of 85 points, with 78% good-to-excellent outcomes and a mean OES of 42 points following double plating. Moursy et al²¹ reported a mean MEPS of 89 points after double plating. Rahman et al¹⁵ reported that 86% of patients treated with DTBW achieved good-to-excellent MEPS results. Similarly, Jitprapaikulsarn et al¹⁷ reported good-to-excellent MEPS outcomes in all patients and a mean QuickDASH score of eight points following DTBW.

CONCLUSION

Double tension band wiring (DTBW) is a promising treatment option for selected distal humeral fractures, including both extra-articular and complete intra-articular fracture patterns. Compared with conventional double plating (DP), DTBW was associated with a markedly shorter surgical time, potentially reducing blood loss and anesthesia-related risks. The less extensive soft-tissue dissection and periosteal stripping required with DTBW may contribute to reduced postoperative adhesions and improved elbow mobility.

Although DTBW may provide less rigid fixation than double plating, the construct was sufficiently stable to permit early postoperative elbow mobilization while achieving satisfactory fracture union and favorable functional outcomes. In this study, DTBW demonstrated superior elbow range of motion, muscle strength, and patient-reported functional outcomes, with fewer postoperative complications than DP. Furthermore, DTBW represents a more cost-effective alternative to double plating. Further prospective multicenter studies with larger sample sizes and longer follow-up are warranted to validate these findings and to define the optimal indications for DTBW in the management of distal humeral fractures.