OT notes · Orthopaedics

Tension band wiring of patella / olecranon

Usual anaesthesia
Patella: spinal. Olecranon: brachial plexus block or general anaesthesia
Position
Patella: supine, bump under ipsilateral hip. Olecranon: lateral decubitus with the arm over a bolster
Setting
emergency

Operative note template for tension band wiring of a transverse patella or olecranon fracture, with a filled example for a closed transverse patella fracture fixed with two K-wires and a stainless steel wire loop under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • prominent or painful wires needing removal later (common)
  • K-wire migration or wire breakage
  • wound infection or breakdown over the implant
  • loss of reduction, non-union
  • knee or elbow stiffness, extensor lag
  • post-traumatic arthritis
  • olecranon: injury to the anterior interosseous nerve or ulnar artery from K-wire tips
  • patella: partial patellectomy if fragments cannot be fixed

Pre-operative details for this operation

  1. Bone and sidePatellaOlecranonright / left
  2. Fracture patterntransverse / comminuted / pole fracture; displacement in mm; open or closed; skin over fracture (abrasion, blisters)
  3. Extensor mechanismpatella: active straight-leg raise possible or not; olecranon: active elbow extension possible or not
  4. Associated injuriesolecranon: elbow dislocation, radial head or coronoid fracture (if present, plate instead of TBW); patella: knee ligament injury
  5. Pre-op distal neurovascular statuspatella: dorsalis pedis / posterior tibial pulse, toe movement. Olecranon: radial pulse, ulnar, median, radial and AIN function
  6. Implants availableK-wires (sizes), SS wire (gauge), cannulated screws, wire tightener, plates as back-up

Anaesthesia and position

  1. AnaesthesiaSpinalBrachial plexus blockGeneral
  2. PositionSupine, bump under hip (patella)Lateral decubitus, arm over bolster (olecranon)Supine with hand table (olecranon with complex injury)
  3. Tourniquetsite (high thigh / sterile arm tourniquet), pressure, inflation and release times; patella: knee flexed and quadriceps pulled down before inflation
  4. C-armavailable, lateral view planned

Operative findings

  1. Fracture seen at surgerypattern, comminution, articular step, small loose fragments removed
  2. Retinacular tear (patella)medial / lateral, extent
  3. Trochlear groove / articular surfacepatella: femoral trochlea damage; olecranon: trochlear notch intact
  4. Reduction checkarticular surface felt with finger or Freer; lateral C-arm view
  5. Stability on range of motiondegree of flexion to which fixation stays closed without gap

Procedure (steps)

  1. IncisionLongitudinal midline (patella)Lateral parapatellar (patella)Transverse (patella)Dorsal longitudinal (olecranon)length
  2. Fracture cleanedclot and periosteum cleared, joint washed; retinaculum leaves tagged
  3. Reduction and clampPointed reduction (Weber) clampPatellar clampLarge tenaculum through drill hole (olecranon)
  4. K-wiresnumber, diameter (patella 1.6-2.0 mm; olecranon 1.0-2.0 mm), direction; patella: parallel, about 5 mm under anterior surface; olecranon: oblique, engaging anterior ulnar cortex distal to coronoid then pulled back 5-10 mm
  5. Cannulated screws instead of K-wiresNot usedTwo 4.0 / 4.5 mm partially threaded cannulated screws, short of far cortex
  6. Tension wiregauge (18 G = 1.0 mm single, or two 22 G), route (deep to K-wire ends, close to bone at both poles / through ulnar drill hole 2.0 mm), loop or figure-of-eight
  7. Wire tighteningTwo-knot twistSingle twistWire tightenertwists cut, bent and buried
  8. K-wire endsbent 180 degrees, cut, rotated and impacted into bone (under triceps / into superior pole); other end cut short
  9. Extra fixationNoneLag screws for comminuted piecesCerclage wirePartial patellectomy
  10. Retinaculum repaired (patella)absorbable braided suture, interrupted
  11. C-armAP and lateral; images saved (number)
  12. Tourniquet released, haemostasistime

Closure, drains and dressing

  1. Subcutaneous tissueburied absorbable
  2. SkinInterrupted nylonStaples
  3. DrainNoneSuction drain
  4. ImmobilisationKnee immobiliser / long knee brace in extensionPosterior slab in extension (knee)Sling only (olecranon, stable fixation)Above-elbow slab (olecranon, weak fixation)
  5. Distal neurovascular status at end

Specimens and implants

  1. K-wires / cannulated screwsnumber, diameter, length; make, lot/batch
  2. Tension wirestainless steel, gauge / diameter, number of loops; make, lot/batch, sticker
  3. Excised fragmentsif partial patellectomy: disposal or HPE
  4. C-arm images saved

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevation and neurovascular checkpulses, capillary refill, movement distal to the injury
  2. Weight bearing (patella)as tolerated with knee locked in extension in immobiliser or brace, with walker / crutches
  3. Quadriceps (patella)static quadriceps and straight-leg raise from day 1
  4. Knee flexion allowedlimit set at surgery from intra-operative stability (write degrees)
  5. Elbow exercises (olecranon)active-assisted elbow and forearm movement from day 1 to a few days if fixation good; splint for about a month if fixation weak
  6. Check X-rayAP and lateral
  7. Wound checkskin over wire knots and K-wire ends
  8. Follow-upX-ray for healing; brace weaning; implant removal if symptomatic

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. V.J., 45 years, fell on his flexed right knee on a staircase. Closed displaced transverse mid-patella fracture with 6 mm gap; unable to do straight-leg raise. Skin over knee intact.

Case details

Date: 03/08/2026. Emergency list. OT 4.

In OT 16:00. Spinal 16:08. Tourniquet inflated 16:22. Incision 16:24. Tourniquet released 17:12. Closure completed 17:28.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Closed transverse fracture right patella, 6 mm displaced, extensor mechanism disrupted (no active straight-leg raise). No knee ligament laxity on gentle testing. Skin intact, no abrasion.

Pre-op: dorsalis pedis and posterior tibial pulses palpable, toes moving, sensation normal.

Consent taken in Hindi, including risk of implant removal later. Site marked. WHO checklist done.

Inj cefazolin 2 g IV at 16:12, before tourniquet inflation.

Anaesthesia and position

Spinal anaesthesia. Supine on radiolucent table, bump under right hip.

Tourniquet on upper right thigh, knee flexed to 90 degrees before inflation. Parts painted with povidone-iodine and draped. Tourniquet inflated to 300 mmHg at 16:22.

Procedure

12 cm longitudinal midline incision over the patella. Prepatellar bursa opened, haematoma washed out.

Transverse fracture at the waist, two main fragments, no comminution. Medial and lateral retinaculum torn 3 cm each side; edges tagged. Femoral trochlea cartilage normal. Joint washed with saline.

Fracture reduced with a pointed reduction clamp with knee extended. Articular surface felt through the retinacular tear: smooth, no step.

Two 2.0 mm K-wires passed retrograde through the fracture into the proximal fragment, then driven across into the distal fragment, parallel, about 5 mm under the anterior surface, at the junction of medial-central and central-lateral thirds.

Lateral C-arm view: reduction anatomical, K-wires parallel.

18 G (1.0 mm) stainless steel wire passed through a 16 G cannula deep to the K-wire ends, close to bone at the quadriceps and patellar tendon attachments, then crossed over the front of the patella in a figure-of-eight. Tightened with two twists until compression seen at the fracture. Twists cut, bent and buried.

Upper K-wire ends bent, cut, rotated and impacted into the superior pole behind the wire loop. Lower ends cut leaving about 1 cm.

Knee flexed on table to 90 degrees: no gap at the fracture.

Retinaculum repaired with interrupted polyglactin 910 (Vicryl) No. 1.

C-arm AP and lateral: fracture reduced, implant position satisfactory. 3 images saved.

Tourniquet released at 17:12 (total 50 minutes). Haemostasis secured. Wound washed.

Closure

Subcutaneous tissue closed with buried Vicryl 2-0. Skin with interrupted nylon (Ethilon) 3-0. No drain.

Well-padded dressing from ankle to upper thigh. Knee immobiliser in full extension.

At end: dorsalis pedis pulse palpable, toes pink.

Specimens and implants

No specimen.

Implants: 2 K-wires 2.0 mm stainless steel; 1 stainless steel wire 18 G (1.0 mm), figure-of-eight. Make and lot/batch no. as on packets; stickers pasted in case sheet and implant register.

C-arm: 3 images saved.

End of procedure

Estimated blood loss 50 ml. Mop, needle and instrument count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 76/min, BP 122/80 mmHg.

Post-op orders

Right leg elevated. Check toe movement and pulses when spinal wears off.

Static quadriceps and straight-leg raise in immobiliser from POD 1. Full weight bearing as tolerated with walker, knee locked in extension.

Knee flexion: none for 3 weeks; then 0 to 30 degrees in hinged brace, as per consultant.

Analgesia as per anaesthesia chart. Check X-ray right knee AP and lateral.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 03/08/2026, 17:45.

Must document for this operation

  • Extensor mechanism state before surgery (straight-leg raise or active elbow extension). It is the indication for surgery and the baseline for judging the result.
  • Implant details: number and size of K-wires or screws, wire gauge, loop pattern, lot/batch number, stickers. Wire removal is common after tension band wiring, and the next surgeon needs to know what is in the bone.
  • The flexion range to which the fixation was stable on the table. The physiotherapist and ward team set the knee or elbow movement limits from this.
  • Retinacular repair (patella) or triceps handling (olecranon). Poor repair explains a later extensor lag.
  • Olecranon: position of K-wire tips relative to the anterior ulnar cortex, and AIN (anterior interosseous nerve) function and hand perfusion after surgery. Long wires past the anterior cortex can injure the AIN or ulnar artery; a recorded check protects the patient and the surgeon.
  • Tourniquet time and pressure, and C-arm images saved. Needed for audit and if a nerve or reduction problem is raised later.

Common mistakes in these notes

  • Writing 'TBW done' with no wire gauge, K-wire size or number.
  • Using TBW for a comminuted olecranon or a fracture-dislocation and not recording why a plate was not used.
  • Not recording the stable range of flexion found on the table.
  • No note of retinacular repair in a patella fracture.
  • Missing the pre-op neurovascular findings.

Indian practice and paperwork

  • Record the batch and serial number of implants in the case sheet; NABH also asks for it in the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))

Sources

  • Campbell's Core Orthopaedic Procedures. Elsevier; 2024, Technique 27, Tension band wiring fixation of patellar fractures (Rudloff MI), pp. 132-134.
  • Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 46, Open reduction and internal fixation of the patella (Mehta S); Ch 30, Open reduction and internal fixation of fractures of the proximal ulna (Ring D), pp. e-book markers P.493-P.501; P.283-P.289.
  • Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 62, Fractures of the olecranon (Table 62.12); Ch 2, Tourniquets, pp. 2813-2814; 137-138.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; cefazolin recommended for implantation of internal fixation devices. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, pp. 137-138: tourniquet time 2 hours or less in healthy adults under 50; 175-305 mmHg satisfactory for the lower limb, 135-255 mmHg for the upper limb.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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