Management of Geriatric Elbow Injury Naoko Onizuka, MD, PhD, MPHa,b, Julie Switzer, MDa,b, Chad Myeroff, MDc,* KEYWORDS Geriatric trauma Elderly Elbow trauma Distal humerus fracture Olecranon fracture Elbow dislocation Terrible triad injury Radial head fracture KEY POINTS Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making. MANAGEMENT OF GERIATRIC ELBOW elbow fractures.1 Distal humeral fractures have TRAUMA an estimated incidence of 5.7 per 100,000 per- Introduction sons per year.4 Most distal humerus fractures in Approximately 4.1% of fractures in the elderly geriatric patients occur from low-energy injuries, involve the elbow.1 Elderly patients are at risk such as falling from standing height.5 They have for elbow injuries following low-energy falls. a bimodal age distribution, with peak incidences Such injuries occur secondary to deconditioning, between 12 and 19 years and those aged 80 years muscle weakness, gait and balance deficits, poor and older.6 vision, and concomitant osteopenia or osteopo- 2 rosis. In 1 study of 287 patients, it was deter- Clinical Assessment mined that nearly 70% of patients who sustain It is imperative to understand the patient’s an elbow fracture fall directory onto their elbow medical and physical frailty and level of indepen- because they cannot break the fall with an out- dence, including gait assistance, living situation, 3 stretched arm. Older patients with elbow and level of function. The physical evaluation in- trauma tend to be more fit than those with prox- cludes assessing the ipsilateral shoulder and imal humerus fractures but less fit than those wrist. Skin needs to be carefully examined for 3 with distal radius fractures. Regardless of a pa- abrasions, fracture blisters, skin tenting, and tient’s underlying state of health or age, elbow open wounds.7 Open elbow injuries are common injuries in the elderly can impact mobility, func- and should be treated with standard open frac- tion, and ultimately, independence. ture protocols that involve removing gross contamination, soft tissue coverage, splinting, DISTAL HUMERUS FRACTURE early antibiotics, and timely surgical irrigation Epidemiology and debridement.7–9 Neurologic examinations Distal humerus fractures comprise approximately must be performed and accurately documented 2% of all fractures but represent one-third of preoperatively and postoperatively. Incomplete a Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; b Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA; c TRIA Orthopedic Center, 155 Radio Drive, Woodbury, MN 55125, USA * Corresponding author. E-mail address: [email protected] Orthop Clin N Am - (2021) -–- https://doi.org/10.1016/j.ocl.2021.05.009 0030-5898/21/ª 2021 Elsevier Inc. All rights reserved. OCL1224_proof ■ 27 July 2021 ■ 1:38 pm 2 Onizuka et al ulnar neuropathy is present in 26% of patients Open reduction and internal fixation with Arbeitsgemeinschaft fu¨ r Osteosynthesefra- In the active patient, nonoperative treatment gen/Orthopaedic Trauma Association (AO/ often results in loss of function and disability OTA) type C distal humerus fractures at the because of prolonged immobilization.7,19–21 time of presentation.10 Vascular injuries should Nauth and colleagues19 demonstrated that pa- be ruled out by examining the distal pulses, tients treated nonoperatively have almost 3 capillary refill, and color.7,10 times the risk of an unacceptable result (relative risk 5 2.8, 95% confidence interval, 1.78–4.4). In 20 Imaging a study of 497 patients, Obert and colleagues Standard anteroposterior and lateral radio- reported the conservative treatment group’s graphs of the elbow are necessary for diagnosis, complication rates were 60%. In this analysis, classification, and surgical templating. Radio- the main complication was malunion. Thus, graphs of the joints above and below are essen- anatomic reduction and rigid internal fixation tial as concomitant distal radius fractures are not with early physiologic motion is considered the uncommon (case 2, see Fig. 5; case 3, see gold standard for most fractures of the distal hu- 6,19–30 Fig. 10).11 In elderly patients who have highly merus (case 2, Figs. 4–7). comminuted fractures, a computed tomographic Good to excellent outcomes of open reduc- (CT) scan is helpful to identify and visualize frac- tion and internal fixation (ORIF) for distal humer- ture patterns.10,12 us fractures in elderly patients have been reported. A retrospective cohort study of distal humerus fractures in patients older than 70 years Classifications of age reported an average flexion arc of 20.9 There are several classification systems, but the to 127 , average pronation and supination of AO/OTA classification is used most frequently 68.3 and 75.3, respectively, and a mean Mayo (Fig. 1).13,14 Type A fractures are extra-articular Elbow Performance Score (MEPS) of 88.7.31 and may involve the epicondyles or occur at Similarly, Ducrot and colleagues32 retrospec- the distal humerus metaphyseal level. Type B tively studied 43 elderly patients (mean age of fractures are partial articular and include unicon- 80) who were treated with locking plate fixation. dylar fractures or fractures of the articular sur- They reported a mean flexion arc of 23 to 127 face involving the capitellum, trochlea, or both. and satisfactory functional recovery, with 95% Type C fractures are complete articular frac- good and excellent results. Clavert and col- tures. In type C fractures, there is no continuity leagues33 reported satisfactory results with a between the articular segments and the humeral mean MEPS of 87 in elderly patients with ORIF. shaft. Complication rates were reported in a wide range (19% to 53%) and included neuropathies, Treatment mechanical failure, elbow stiffness, nonunions, The treatment of distal humerus fractures in deep infections, or wound dehiscence.20,33–38 15,16 older patients can be challenging. High de- An olecranon osteotomy is commonly used grees of comminution, insufficient bone stock, for AO/OTA type C fractures, as it allows visual- underlying osteoarthritis, and preexisting medi- ization of the distal humerus articular surface.39 cal comorbidities weigh heavily on treatment de- The complications associated with an osteotomy cision making. include nonunion/malunion (3.3%) and hardware irritation (10%–82%).40,41 Kaiser and col- Nonoperative treatment leagues42 reported a limited columnar fixation Nonoperative treatment is generally reserved and olecranon-sparing approach for intraarticu- for patients who are medically unfit to undergo lar fractures in an elderly population as a valid surgery. In patients for whom anesthesia or treatment option with similar elbow motion, surgery-related risks are too high, conservative function, and pain relief when compared with treatment is considered to be appropriate.17,18 ORIF with an osteotomy. This approach may Low-demand patients with severe osteoporosis, be used in geriatric patients who are medically patients with poor-quality skin, or patients with unwell or who have such poor bone quality nondisplaced fractures may also be managed that anatomic reduction with an olecranon with nonoperative management (case 1, see osteotomy would be challenging. Avoiding an Fig. 1; Figs. 2 and 3).17 They can be managed osteotomy may allow not only more aggressive with immobilization for 2 to 3 weeks followed rehabilitation but also arthroplasty as an intrao- by early mobilization.17 perative fallback. OCL1224_proof ■ 27 July 2021 ■ 1:38 pm Management of Geriatric Elbow Injury 3 Fig. 1. The AO/OTA classification of distal humerus fractures. Total elbow arthroplasty reconstructible fracture pattern to reserve TEA Distal humerus fractures present complex chal- for low-demand patients with unreconstructible lenges in the elderly patient because of osteope- fractures (case 3, Figs. 8–12). Several studies nia, comminution, articular fragmentation, and have compared ORIF and TEA for distal humerus preexisting conditions of the elbow, such as oste- fractures. However, sample sizes in these studies oarthritis or rheumatoid arthritis. In those patients were limited, and inconsistent results have been with these common diagnoses, rigid internal fixa- reported. Egol and colleagues46 reported good tion and early mobilization can be challenging. In outcomes with either TEA or ORIF with no signif- certain low, transcolumnar or coronal shear frac- icant difference in functional outcomes, whereas tures in older patients with severe osteopenia, McKee and colleagues50 and Morrey51 reported comminution, or preexisting arthritis, total elbow TEA had improved functional outcomes based arthroplasty (TEA) has become a recognized on the MEPS and concluded TEA is a preferred alternative treatment. However, it is imperative alternative in elderly patients with complex distal to choose only low-demand patients for this inter- humeral fractures. Varecka and Myeroff52 re- vention to minimize risk of failures,