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Olecranon fractures in the very elderly have surprisingly good outcomes without surgery, and can avoid a high risk of complications.

The olecranon is part of the elbow joint – it connects the triceps muscle to the lower arm, and contributes some of the stability of the elbow joint. With this orthopaedic paradigm in mind, operative treatment in young people is invariably undertaken. The elderly group though have a few differences: the physical demands might be low, the skin can be paper thin, and the bone quality not great to hold internal fixation devices.

Duckworth from the Edinburgh Orthopaedic Trauma Centre has two papers published on the subject. The first was a series of 43 patients aged 40-98 with at least 2mm displacement of the fracture. They were reviewed at 2-15 years, and had 91% of those available for followup satisfied, and non underwent a secondary operation for non union. This lead the a prospective randomised controlled trial of patients aged over 75. The project was abandoned with only 19 patients in the trial, as the operative complication rate was deemed unacceptable. No patients in the non operative group required an operation for non union. But the numbers did not prove the point. They had a high infection rate with plate fixation, and a high loss of fixation with tension band wiring. Excluded from the study were 80% of olecranon fractures because of inability to comply with instructions of give informed consent, associated fractures of the radial head or coronoid, or associated ligamentous injury, dislocation, or subluxation. The non operative treatment were treated with a collar and cuff sling for two weeks, the mobilised under the supervision of a physiotherapist. Some were immobilised in a plaster slab at 60 degrees initially.

Proponents of internal fixation suggest: plate fixation is stronger than tension band wires, if tendon band wires are to be used, the tip of the wire should be transcortical, the figure of 8 component should be at least 1.0mm thick, sutures can be used instead of wires, bone grafting should be undertaken if the bone surfaces are impacted, and accepting that internal fixation of elbow fracture often requires subsequent removal of metal. But maybe we shouldn’t fix them every time.

References:

Duckworth AD, Bugler KE, Clement ND, Court-Brown CM, McQueen MM. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. J Bone Joint Surg Am. 2014 Jan 1;96(1):67-72.
Duckworth AD, Clement ND, McEachan JE, White TO, Court-Brown CM, McQueen MM. Prospective randomised trial of non-operative versus operative management of olecranon fractures in the Bone Joint J. 2017 Jul;99-B(7):964-972.
Karlsson MK, Hasserius R, Besjakov J, Karlsson C, Josefsson PO. Comparison of tension-band and figure-of-eight wiring techniques for treatment of olecranon fractures. J Shoulder Elbow Surg 2002;11:377–382.

Update, 17th June 2019

Andy Murray announces he is signed up for Wimbledon this year!!!
Go Andy!

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