The management of distal humeral fractures in older patients

The number of fractures of the distal humerus in older adults is rising due to an ageing population and an increasing incidence of fragility fractures. The management is based on the patient's preference, the pattern of the fracture, the quality of the bone and soft-tissue, the patient's comorbidities and potential for rehabilitation, as well as balancing the risk of complications such as infection, nonunion, instability, or loosening. Nonoperative treatment remains appropriate for a few low-demand or medically unfit patients. Open reduction and internal fixation (ORIF) or arthroplasty, either hemiarthroplasty (HA) of the elbow or total elbow arthroplasty (TEA), provide good outcomes when appropriately selected. An increase in the use of arthroplasty for trauma is shown in registry data, although the indications and survival remain controversial with few robust comparative and long-term data. Similar short- to mid-term functional outcomes between ORIF and TEA have been reported in recent comparative studies, with a trend towards an increased reoperation rate after ORIF, but the evidence is derived largely from small retrospective observational studies. HA of the elbow may be a viable alternative for active older patients, particularly when stable fixation is not achievable, although instability and conversion to TEA may be required. The aim of this review was to synthesize the current evidence dealing with the indications, techniques, and outcomes for nonoperative management, ORIF and arthroplasty in older patients with a distal humeral fracture.