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Letter Regarding “Olecranon Fractures”
1263
LETTERS TO THE EDITOR
Letter Regarding “Olecranon Fractures” To the Editor: We read with interest your recent article by Baecher and Edwards.1 We commend the authors on their review—in particular, their detailed discussion on the variety of surgical options for fractures of the olecranon. As the authors discuss, recent literature from Edinburgh has reported an increasing mean age for fractures of the olecranon, with a rising number found to be osteoporotic fragility fractures (although the number of olecranon fractures documented was 64, not 78 as the authors quote).2 In elderly patients with osteoporotic bone, adequate reduction and internal fixation can be difficult to achieve, and issues associated with postoperative breakdown of the wound are reported.3 Given this, we think it is an oversight not to have included a section on the nonsurgical management of olecranon fractures, particularly given that one study has suggested that nonsurgical management gives a comparable outcome to surgical treatment for patients of all ages.4 A small number of retrospective case series document a good short-term outcome following the nonsurgical treatment of displaced fractures of the olecranon,4,5 and it is acknowledged that investigation is warranted to determine whether surgical management provides a significantly superior patient reported outcome over nonsurgical treatment. We would suggest, given the available literature, that nonsurgical management of displaced olecranon fractures in a subgroup of patients has a place in such a review. Andrew D. Duckworth, MSc Margaret M. McQueen, MD Edinburgh Orthopaedic Trauma Unit Royal Infirmary of Edinburgh Edinburgh, Scotland http://dx.doi.org/10.1016/j.jhsa.2013.04.013
In Reply: We appreciate the comments provided by the reader. It is a fair criticism of our discussion that nonsurgical management was limited to nondisplaced olecranon fractures. Given the imposed editorial limitations, a more thorough discussion on the topic was not possible at the time of publication, and we are grateful for the opportunity to present one now. Certainly, there have been a few level 5 studies demonstrating good results in low cohorts, most of which were composed of low-demand patients, with displaced olecranon fracture treated nonsurgically.1,2 The orthopedic literature is sprinkled with similar studies depicting good results of displaced intraarticular fractures treated nonsurgically in nearly every joint of the anatomy.3–5 Although we can acknowledge that these results can happen, they are not typical; hence, they are rogue reports. There is a natural tendency to treat low-demand patients with a minimalist approach and the rationale that the margin between the benefits and the risks are narrower than with more active patients. The reader specifies the difficulty in surgically treating olecranon fractures older patients with osteoporotic bone, a challenge for any fixation device. Although there may be temptation to avoid “fighting the good fight” if the outcome may be unpredictable, we would prefer to focus the attention on optimizing fixation rather than accepting a marginal outcome. For this reason, a great deal of our review discusses newer techniques and fixation strategies. Although we are not dismissing the potential for alternative treatments, until more convincing evidence is presented supporting nonsurgical treatment for displaced olecranon fractures— even in low-demand patients—surgical management will remain the standard of care in, at least, North America. Nicolai Baecher, MD Scott G. Edwards, MD Department of Orthopaedic Surgery Georgetown University Hospital Washington, DC
REFERENCES 1. Baecher N, Edwards S. Olecranon fractures. J Hand Surg Am. 2013; 38(3):593– 604. 2. Duckworth AD, Clement ND, Aitken SA, et al. The epidemiology of fractures of the proximal ulna. Injury. 2012;43(3):343–346. 3. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am. 1985;67(9):1396 –1401. 4. Parker MJ, Richmond PW, Andrew TA, et al. A review of displaced olecranon fractures treated conservatively. J R Coll Surg Edinb. 1990; 35(6):392–394. 5. Veras Del Monte L, Sirera Vercher M, Busquets Net R, et al. Conservative treatment of displaced fractures of the olecranon in the elderly. Injury. 1999;30(2):105–110.
http://dx.doi.org/10.1016/j.jhsa.2013.04.016 REFERENCES 1. Parker MJ, Richmond PW, Andrew TA, et al. A review of displaced olecranon fractures treated conservatively. J R Coll Surg Edinb. 1990;35(6):392–394.
JHS 䉬 Vol A, June
LETTERS TO THE EDITOR
Letter Regarding “Olecranon Fractures” To the Editor: We read with interest your recent article by Baecher and Edwards.1 We commend the authors on their review—in particular, their detailed discussion on the variety of surgical options for fractures of the olecranon. As the authors discuss, recent literature from Edinburgh has reported an increasing mean age for fractures of the olecranon, with a rising number found to be osteoporotic fragility fractures (although the number of olecranon fractures documented was 64, not 78 as the authors quote).2 In elderly patients with osteoporotic bone, adequate reduction and internal fixation can be difficult to achieve, and issues associated with postoperative breakdown of the wound are reported.3 Given this, we think it is an oversight not to have included a section on the nonsurgical management of olecranon fractures, particularly given that one study has suggested that nonsurgical management gives a comparable outcome to surgical treatment for patients of all ages.4 A small number of retrospective case series document a good short-term outcome following the nonsurgical treatment of displaced fractures of the olecranon,4,5 and it is acknowledged that investigation is warranted to determine whether surgical management provides a significantly superior patient reported outcome over nonsurgical treatment. We would suggest, given the available literature, that nonsurgical management of displaced olecranon fractures in a subgroup of patients has a place in such a review. Andrew D. Duckworth, MSc Margaret M. McQueen, MD Edinburgh Orthopaedic Trauma Unit Royal Infirmary of Edinburgh Edinburgh, Scotland http://dx.doi.org/10.1016/j.jhsa.2013.04.013
In Reply: We appreciate the comments provided by the reader. It is a fair criticism of our discussion that nonsurgical management was limited to nondisplaced olecranon fractures. Given the imposed editorial limitations, a more thorough discussion on the topic was not possible at the time of publication, and we are grateful for the opportunity to present one now. Certainly, there have been a few level 5 studies demonstrating good results in low cohorts, most of which were composed of low-demand patients, with displaced olecranon fracture treated nonsurgically.1,2 The orthopedic literature is sprinkled with similar studies depicting good results of displaced intraarticular fractures treated nonsurgically in nearly every joint of the anatomy.3–5 Although we can acknowledge that these results can happen, they are not typical; hence, they are rogue reports. There is a natural tendency to treat low-demand patients with a minimalist approach and the rationale that the margin between the benefits and the risks are narrower than with more active patients. The reader specifies the difficulty in surgically treating olecranon fractures older patients with osteoporotic bone, a challenge for any fixation device. Although there may be temptation to avoid “fighting the good fight” if the outcome may be unpredictable, we would prefer to focus the attention on optimizing fixation rather than accepting a marginal outcome. For this reason, a great deal of our review discusses newer techniques and fixation strategies. Although we are not dismissing the potential for alternative treatments, until more convincing evidence is presented supporting nonsurgical treatment for displaced olecranon fractures— even in low-demand patients—surgical management will remain the standard of care in, at least, North America. Nicolai Baecher, MD Scott G. Edwards, MD Department of Orthopaedic Surgery Georgetown University Hospital Washington, DC
REFERENCES 1. Baecher N, Edwards S. Olecranon fractures. J Hand Surg Am. 2013; 38(3):593– 604. 2. Duckworth AD, Clement ND, Aitken SA, et al. The epidemiology of fractures of the proximal ulna. Injury. 2012;43(3):343–346. 3. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am. 1985;67(9):1396 –1401. 4. Parker MJ, Richmond PW, Andrew TA, et al. A review of displaced olecranon fractures treated conservatively. J R Coll Surg Edinb. 1990; 35(6):392–394. 5. Veras Del Monte L, Sirera Vercher M, Busquets Net R, et al. Conservative treatment of displaced fractures of the olecranon in the elderly. Injury. 1999;30(2):105–110.
http://dx.doi.org/10.1016/j.jhsa.2013.04.016 REFERENCES 1. Parker MJ, Richmond PW, Andrew TA, et al. A review of displaced olecranon fractures treated conservatively. J R Coll Surg Edinb. 1990;35(6):392–394.
JHS 䉬 Vol A, June