AAOS Now

Published 1/1/2018
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Maureen Leahy

Tips for Successful Fixation of Upper Extremity Fragility Fractures

R. Glenn Gaston, MD, offers key surgical considerations for a variety of fractures
The prevalence of fragility fractures is high, particularly among individuals with low bone mineral density (BMD). The National Osteoporosis Foundation estimates that more than 54 million people in the United States have low BMD and more than 200,000 distal radius fractures are sustained yearly.

“Although distal radius fractures are the most common fragility fractures we treat, elbow fractures—distal humerus, radial head, and olecranon—account for nearly one-quarter of upper extremity fragility fractures,” explained R. Glenn Gaston, MD, of OrthoCarolina Hand Center, Charlotte, N.C. “Unfortunately, we do a poor job identifying upper extremity fragility fractures, and little is known about their optimal treatment.”

Dr. Gaston discussed surgical management of upper extremity fragility fractures during a symposium at the 2017 annual meeting of the American Society for Surgery of the Hand (ASSH).

Elbow fragility fractures
The main surgical consideration for distal humerus fractures is whether to fix or replace, yet there is limited data on open reduction and internal fixation (ORIF) versus arthroplasty for treatment of these fractures, according to Dr. Gaston. “For ORIF, the role of locking plates should be considered. The optimal locking plate configuration is debatable but most of the biomechanical and outcomes studies would support either parallel or perpendicular plating,” he said.

According to principles presented in a 2005 paper on distal humeral fracture fixation, locking plates should be used with all screws passing through the plate, engaging fragments on the opposite side that are also attached to a plate. Dr. Gaston added, “Screws should be as numerous and as long as possible, engage as many articular fragments as possible, and lock together by interdigitization, creating a fixed angle structure.”

Dr. Gaston also referenced a 2009 study that prospectively evaluated ORIF and primary total elbow arthroplasty (TEA). The study found that in patients with an average age of 77 years, ORIF took 32 minutes longer to perform than TEA, and the reoperation rate in the ORIF group was twice as high as in the TEA group at 2-year follow-up. TEA patients also had slightly better range of motion.

“Similarly, mid-range studies are starting to emerge that indicate the average satisfaction for TEA is around 94 percent at 5-year follow-up. So total elbow certainly seems to be a very reasonable choice for this fragility fracture,” he said.

Like distal humerus fractures, the surgical consideration for radial head fractures is ORIF versus arthroplasty, according to Dr. Gaston. “Although we don’t often think of these as fragility fractures, radial head fractures occur in approximately 10 percent of men and 33 percent of woman over the age of 60 and are frequently associated with low-energy falls in older patients. Because fixation can be difficult due to poor bone quality, an arthroplasty should always be available. Remember, however, that nonsurgical treatment is often successful in the absence of mechanical symptoms, especially in this patient population,” he said.

With respect to olecranon factures, Dr. Gaston noted that nonsurgical treatment will often lead to an asymptomatic nonunion in high-risk patients but is acceptable in the very low demand patient. “And because the triceps fascia blends laterally into the anconeus expansion, they will typically maintain extension,” he said.

To help prevent escape of the proximal fragment during surgical fixation of olecranon fractures, Dr. Gaston said surgeons should consider placing a tension band beneath the locking plate and using a proximally extended locking plate. An additional consideration is use of a load sharing suture technique. “Take a running locking Krackow suture through the triceps and weave that into the plate itself, such that the when the triceps fires, it’s pulling on the plate rather than the proximal fragment,” he said. 

Wrist fragility fractures
When it comes to treating wrist fragility fractures, orthopaedic surgeons are left with more questions than answers, Dr. Gaston noted. For example, is closed reduction and casting successful? “It depends on how you define success,” he said. “It’s probably not successful at maintaining reduction, but…in terms of clinical success, functional outcomes far exceed radiographic outcomes.”

Dr. Gaston pointed to a study in which 53 of 60 distal radius fractures reduced under general or regional anesthesia resulted in malunion. In addition, a randomized controlled trial comparing patients with distal radius fractures treated with closed reduction versus no reduction found no differences in radiographic alignment between the two groups at final follow-up.

He added, “Two separate randomized controlled trials comparing casting and volar plating for distal radius fractures found no difference in range of motion, pain, or functional outcomes measures between the two methods, although patients in the volar plate group demonstrated better grip strength. Similarly, a randomized trial comparing short-arm casting and pinning found no functional differences among the study’s 57 patients,” he said.

According to Dr. Gaston, the best surgical treatment for distal radius fractures “depends on what you are looking for.” In terms of radiographic alignment, for example, numerous studies support volar locking plates (VLP). However, with respect to functional outcomes, no singular method appears to be superior. “There are plenty of studies that show that closed reduction and percutaneous pinning, VLP, external fixation, and bridge plating all achieve very good functional outcomes,” he said.

Dr. Gaston added that from an evidence-based approach, the surgical indications for distal radius fractures are currently unclear. “I think most of us apply more standard distal radius indications, particularly to the higher demand, older patient with a fragility fracture. For lower demand patients, we may be less stringent. Yet despite this lack of evidence, there is an increasing trend in this country, with an increased cost, toward surgical management,” he said.

In summary, Dr. Gaston said that although little is known about the optimal treatment for upper extremity fragility fractures, trends suggest increased utilization of TEA for distal humerus fractures and VLP for distal radius fractures. 

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org.

Bottom Line
R. Glenn Gaston, MD, offered the following surgical considerations for upper extremity fragility fractures:

  • If surgical intervention is elected for radial head fractures and distal humerus fractures, have an arthroplasty system available.
  • Consider load sharing sutures in olecranon fracture fixation.
  • Advise patients that nonsurgical distal radius fracture treatment will result in greater clinical deformity but will yield similar results to surgery at 1 year.
  • Evidence suggests that all forms of surgery for distal radius fractures, including closed reduction and percutaneous pinning, VLP, external fixation, and bridge plating, achieve good outcomes.

References:

  1. O’Driscoll SW: “Optimizing stability in distal humeral fracture fixation,” J Shoulder Elbow Surg 2005;14(1 suppl S):186S-194S
  2. M. D. McKee, C. J. H. Veillette, J. A. Hall, E. H. Schemitsch, L. M. Wild, R. McCormack, et al., “A Multicenter, Prospective, Randomized, Controlled Trial of Open Reduction—Internal Fixation versus Total Elbow Arthroplasty for Displaced Intra-Articular Distal Humeral Fractures in Elderly Patients,” Journal of Shoulder and Elbow Surgery/American Shoulder and Elbow Surgeons, Vol. 18 No. 1, 2009, pp. 3-12.
  3. Beumer, A., McQueen, M.M. “Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists.” Acta Orthop Scand. 2003;74:98–100.
  4. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. “A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.” J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597.
  5. Azzopardi T, Ehrendorfer S, Coulton T, Abela M (2005). “Unstable extra-articular fractures of the distal radius a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning.” J Bone Joint Surg Br 87(6):837–840.