Non-operative management of distal humerus fractures in the elderly: a review of functional outcomes

Abstract

Comminuted distal humerus fractures in the elderly have traditionally been managed by ORIF or total elbow arthroplasty (TEA). This poses a treatment dilemma in elderly patients where anaesthetic and surgical risks combine with poor bone and wound healing. We aimed to assess the functional outcomes in patients managed non-operatively, with TEA being used as the salvage procedure. Retrospective analysis of patients over 65 years presenting to our unit between 2005 and 2015 was undertaken. Sixty-two patients were identified, 38 had died, and 5 were lost to follow-up leaving 5 with immediate TEA and 14 non-operatively managed, available for review. Mean follow-up was 55 months (range 17-131). Patient outcomes were measured using VAS scores for pain at rest and during activity, and the Oxford elbow score (OES) for TEA and non-operatively managed patients. Conversion to TEA for non-operative treatment and complications were also recorded. Notes interrogation of patients who had died or were lost to follow-up to ascertain outcomes was undertaken. The mean age at injury was 76 years (range 65-90) of which 79% (11/14) were females. The mean score on the OES was 46.2 (range 29-48). The mean VAS score at rest was 0.4 (range 0-6), and the mean VAS score during activity was 1.3 (range 0-9). 93% (13/14) of patients reported no pain in their injured elbow at rest and 79% (11/14) reported no pain during activity. No patients converted to TEA, and there were no complications. Of deceased patients, notes demonstrated one who had ongoing stiffness after physiotherapy, but no conversions to TEA were undertaken. Those managed primarily with TEA had worse OES (mean 40.8), but slightly better pain scores with means 0.2 at rest and 0.8 at activity. Non-operative management of comminuted distal humerus fractures should be considered for elderly patients, avoiding surgical risks whilst giving satisfactory functional outcomes in this low-demand group.

Elbow hemiarthroplasty vs. open reduction internal fixation for acute Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 13C fractures—A systematic review

“…Some studies show acceptable functional outcomes with nonoperative treatment in elderly, low-demand populations. 5 , 13 , 40 This could indicate that surgical treatment with ORIF, EHA, or TEA might not necessarily be the best treatment choice in this selected group of patients. In addition, there is a high variation in length of follow-up among the included studies ranging from 6 to 174 months.…”

Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review

“…1,3,10,30,35 Reported studies were conducted in Canada (n=1), 10 France (n=1), 30 Japan (n=1), 35 , and the UK (n=2). 1,3 Risk of bias was assessed using MINORS criteria, with scores ranging from 8 to 12 (Table I).…”

Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia

“…2 Although the treatment of proximal, midshaft, and distal humerus fractures has been heavily studied, to date no absolute consensus has been reached on their management. [3][4][5][6] There are strong data to support nonoperative management of proximal humerus and humeral shaft fractures. [3][4][5] Even so, to our knowledge, no data have been published on the nonoperative management of these injuries in the severely hemiparetic (weak) or hemiplegic (paralyzed) upper extremity in patients who have sustained a brain injury.…”

“…7,8 The purpose of this study was to retrospectively review outcomes of nonoperative treatment of acute humerus fractures in patients with severe hemiparesis or hemiplegia due to a brain injury to better guide management of these fractures in this unique patient population. We hypothesized that nonoperative treatment of humerus fractures in patients with upper motor neuron (UMN) injuries would result in union with adequate pain relief, a low rate of HAND 18 (6) conversion to surgery, and low rates of wound development from the use of well-padded splints even in the setting of spasticity and contracture.…”