What factors influence outcomes in olecranon fractures in older adults? A cohort study of operative and non-operative management.

Abstract

Olecranon fractures occur more commonly in older individuals. For patients ≥70 years of age, operative management is often considered standard of care, although recent evidence has supported non-operative treatment in frail and/or elderly patients. With evolving treatment indications, more granular evidence is beneficial to guide patient-specific decision making. The aim of this investigation was to explore patient and treatment factors associated with outcomes after displaced, closed olecranon fractures in older individuals. This retrospective cohort study with prospective data collection included 113 patients (mean age 81; 81% female) ≥70 years of age with displaced, stable olecranon fractures (Mayo 2A/2B). Patients were treated operatively via precontoured olecranon locking plates (n=68) or tension band wiring (n=6) or non-operatively (n=39) with progressive mobilization. Frailty was quantified using the Clinical Frailty Scale. The primary outcome was Quick Disability of the Arm, Shoulder, Hand (QuickDASH) score. Secondary outcomes included range of motion, PROMIS global health, and complications. Mean time from injury to outcome collection was 16 ± 2 months. Mean QuickDASH was lower in the operative cohort (mean difference -8.3; 95% CI 0.4 to 16.2; p = 0.021) although the difference was not clinically meaningful (minimal clinically important difference = 15). Subgroup analysis by frailty revealed no differences between operative and non-operative management in the mildly frail and moderate to severely frail subgroups. Linear regression identified frailty was associated with limb-specific disability (β=4.86, p=0.001); age was not a significant predictor when controlling for frailty. In the plate fixation group, engaging the proximal fragment fixation with < 3 screws was associated with proximal fragment escape (β=3.13, SE=0.94, OR=22.9, 95% CI 3.63 to 144.8, p=0.001) independent of fragment size, comminution, and triceps reinforcement. In the non-operative group, increasing immobilization duration was associated with decreased arc of motion (β=-4.1, SE=1.3, R²=0.29, p=0.006). This study reinforces recent Level I evidence suggesting that operative management of displaced olecranon fractures does not result in superior long-term functional outcomes for the average older patient. Frailty, rather than chronological age, is a primary driver of limb-related disability. Early mobilization is a low-risk alternative to operative management. When surgery is pursued to achieve faster recovery or improved early elbow extension, surgeons should ensure robust proximal fragment fixation with at least three screws to minimize the risk of failure.