Treatment of Displaced Olecranon Fractures in the Elderly: Should the Pendulum Swing?

Commentary Dr. Joshi and the SOFIE research group performed a multicenter, prospective, pragmatic, randomized controlled trial (RCT) in which they found no significant difference in the Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (their primary outcome) between surgical and nonsurgical treatment of closed, displaced olecranon fractures in patients over the age of 75 years. They thus concluded that nonoperative treatment of displaced olecranon fractures is a reasonable option in elderly patients. This study aimed to answer a relevant and timely question, as we can expect the incidence of displaced olecranon fractures to increase as our population ages. The traditionally accepted treatment for these fractures—i.e., operative fixation1— has been called into question as several studies have reported satisfactory outcomes with nonoperative treatment for elderly patients. Furthermore, operative treatment results in substantially greater costs and complication rates compared with nonoperative treatment2. However, although the authors suggested that nonoperative treatment is a reasonable option, should the pendulum swing? Should we treat all stable olecranon fractures in elderly patients nonoperatively? The results from this study should be closely examined before definitively answering that question. While the authors found no difference in DASH scores between the operative and nonoperative cohorts at 12 months, the DASH score, Mayo Performance Elbow Score (MEPS), and active elbow flexion were statistically superior in the operative group at 3 months. Active elbow extension was statistically superior in the operative group at 3 months and at 12 months. Improved patient-reported outcome measures and range of motion at 3 months suggest that there may indeed be a benefit to surgery for some elderly patients, particularly those who desire an earlier recovery. Greater active elbow extension at both time points is perhaps not surprising given the anatomic location of the triceps insertion on the olecranon. It is logical that, in a displaced fracture, the change in the distance between the origin and insertion of the triceps may affect its excursion and result in a decreased range of motion. In addition, while the authors were unable to test strength in their study, it is also possible that a change in the distance between the origin and insertion of the triceps could decrease the maximum force generated by the elbow and result in decreased elbow extension strength. A potential loss of elbow extension strength may be an important consideration for some patients, particularly those who use assistive devices. Interestingly, unlike in prior studies3, the authors of this study found no significant difference in complication rates between groups. However, the types of complications did differ. While we cannot make definitive conclusions about the relative risks of different types of complications based on this study, it is worth noting that the authors reported no nonunions in the operative group and (obviously) no hardware-related complications in the nonoperative group. This may be an important factor to consider and discuss when deciding treatment options. Although this study provides us with important data about outcomes up to 12 months postoperatively, certain outcomes, such as symptomatic arthritis, may not be evident until after 12 months. Because articular malreduction is generally more likely to lead to arthritis in periarticular fractures, this may affect longer-term outcomes and patient-reported outcome scores for patients with displaced olecranon fractures. In conclusion, the authors deserve commendation for conducting a well-designed, multicenter RCT that addresses an important research question. While they did not definitively settle the debate about whether we should manage olecranon fractures nonoperatively in patients over 75, they did offer valuable data that surgeons and patients can use to develop personalized treatment plans tailored to each patient’s needs.