Outcomes of nonoperative management of displaced olecranon fractures in medically unwell patients

Abstract

Background Surgical treatment of displaced olecranon fractures in the elderly has a high rate of complications, including wound breakdown and fixation failure. The purpose of this study was to assess the clinical, radiographic, and functional outcomes of nonsurgical management of displaced olecranon fractures in low-demand elderly and medically unwell patients. Methods A retrospective review of 28 patients with displaced closed olecranon fractures was performed with an average follow-up of 11 months. The mean age at the time of injury was 79 ± 10 years. The average Charlson Comorbidity Index was 6.4 ± 2.6. Treatment modalities were at the discretion of the treating surgeon. A sling alone was used in 3 cases, an extension circumferential cast in 9, or a plaster or thermoplastic splint in 16. The mean period of immobilization was 5 ± 1 weeks. Outcomes included range of motion, ability to perform active overhead extension, as well as radiographic and functional outcomes. Results At final follow-up, the mean elbow range of motion for the cohort was from 28° ± 21° extension to 127° ± 15° flexion. Active overhead elbow extension against gravity was noted or documented in 24 (86%) patients. Two patients (7%) were unable to perform active extension. No pain was noted in 18 elbows, severe pain was present in 1 elbow, and the remainder reported mild occasional pain. All olecranon fractures in this cohort were displaced on the initial lateral radiograph. The mean displacement was 11 ± 7 mm. Nonunion at final radiographic outcome was observed in 23 (82%) elbows. Two (7%) patients developed skin complications related to posteriorly placed splints; one of which was severe. Discussion This study adds to the growing literature that supports nonoperative management of displaced olecranon fractures in elderly and medically unwell patients with low upper extremity demand. Patients can be counseled that they have a good chance of obtaining overhead extension, with minimal pain. Posteriorly based splints should not be used to minimize skin complications.

Olecranon fractures

“…nonoperative management may be considered for both mayo type IIa and type IIB displaced olecranon fractures in select elderly patients, given the conflicting outcomes observed following the surgical management of these injuries. 15,16 there is now a growing body of evidence supporting the role of nonoperative treatment for displaced olecranon fractures in older patients with low functional demands (table III), 10,22,29,[104][105][106] where comorbidities, preinjury functional status, bone quality, and potential complications following surgery may affect the outcome. Knots buried on dorsal surface underneath anconeus nonoperative management routinely involves early active range of motion, with a cast or sling required for pain alone.…”

“…The authors reported that just over one-third of patients (n = 9; 35%) had a minor loss of extension strength and 22 (85%) developed a radiological nonunion, but with a high mean satisfaction score. More recently, Aibinder et al 105 similarly reported on 28 patients (mean age 79 years) treated nonoperatively with either a sling, an above-elbow cast, or an above-elbow splint. At a mean follow-up of 11 months, the mean elbow flexion arc was from 28° to 127°, and the majority of patients had regained active extension strength against gravity with no or minimal discomfort at the fracture site.…”

Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults

“…Nonoperative management or fragment excision with triceps advancement are generally reserved for low-demand elderly patients or those who would not otherwise tolerate an operation. 1,3,4…”

“…Nonoperative management or fragment excision with triceps advancement are generally reserved for low-demand elderly patients or those who would not otherwise tolerate an operation. 1,3,4 The goal of ORIF of olecranon fractures is to restore congruity at the articular surface, restore triceps function, and provide stable fixation sufficient to allow for early active range of motion (ROM). [1][2][3]5 Depending on the fracture pattern, different fixation techniques may be employed.…”