For geriatric patients, a fall is rarely just a localized injury. it can be a systemic challenge to independence. When an 81-year-old patient presented to the clinic after a ground-level fall, her injuries—a displaced proximal humerus fracture and a comminuted olecranon fracture—created a complex scenario that required a sophisticated, integrated surgical approach to restore her ability to perform basic daily tasks.
The patient, who had a history of remote left distal humerus surgery, initially attempted nonoperative management. However, the severity of the fractures and the resulting functional impairment made it clear that a surgical intervention was necessary to regain the mobility required for personal hygiene and feeding. This case highlights the evolving standard of care in orthopedic trauma, moving away from traditional metal-heavy fixation toward more modern, low-profile techniques that prioritize early functional recovery.
Managing concomitant upper extremity fractures in older adults requires a careful balance between bone quality, fracture stability, and the patient’s need for immediate mobilization. With a displaced four-part proximal humerus fracture and a comminuted, displaced olecranon fracture, the surgical team faced two distinct challenges: the shoulder required a reconstruction that could overcome poor bone quality, while the elbow required stable fixation that would not cause irritation or require secondary removal of hardware.
Figure 1. Left shoulder radiographs (anteroposterior and scapular Y) are shown, demonstrating a displaced four-part proximal humerus fracture. Source: Sree Vemu, MD; Sanjiv V Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Figure 2. Left elbow radiographs (anteroposterior and lateral) are shown, demonstrating a displaced olecranon fracture. Source: Sree Vemu, MD; Sanjiv V Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Advanced Surgical Strategies for Complex Fractures
For the shoulder, the surgical team opted for a reverse total shoulder arthroplasty (RTSA). In geriatric patients with displaced three- or four-part proximal humerus fractures, RTSA has become an increasingly favored option over open reduction internal fixation (ORIF). This shift is largely due to the predictable nature of the recovery and more reliable functional outcomes in patients with osteoporotic bone. During the procedure, the team utilized a deltopectoral approach to identify the four primary fracture fragments. Due to significant comminution and poor bone quality, the humeral head was removed, and the tuberosities were carefully repaired around the prosthesis using a high-strength suture cerclage and tension-band configuration to optimize long-term stability.
The management of the olecranon fracture represented a departure from traditional tension-band wiring or rigid plate fixation. The surgeons utilized a suture-based, all-suture construct. This approach is gaining traction in orthopedic literature because it provides comparable biomechanical load-to-failure resistance while significantly reducing the risk of complications related to prominent metallic hardware, which is a common source of reoperation in older patients. By creating transosseous tunnels and using suture tapes, the team achieved a double-row repair that compressed the fracture site without the need for bulky metal plates or screws.
Figure 3. Left elbow radiographs (anteroposterior and lateral) are shown, demonstrating a displaced olecranon fracture. Source: Sree Vemu, MD; Sanjiv V Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Figure 4. Left elbow radiographs (anteroposterior and lateral) are shown, demonstrating a displaced olecranon fracture. Source: Sree Vemu, MD; Sanjiv V Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Prioritizing Early Functional Recovery
The postoperative protocol was designed to minimize the duration of immobility. The patient was discharged on the second day following surgery, having been cleared by both the hospitalist and the physical therapy team. At the two-week follow-up, the patient reported manageable pain and appropriately healing incisions. By the one-month mark, the results were promising: the right elbow demonstrated a functional range of motion from 20° to 135°, and the left shoulder achieved 110° of forward flexion and 30° of external rotation.
This case underscores the importance of tailored management strategies in geriatric trauma. The primary goal is to facilitate early mobilization—an essential component for patients who rely on assistive devices like walkers to maintain their independence. By choosing an RTSA for the shoulder and a suture-based construct for the elbow, the surgical team was able to address the specific biological constraints of the patient’s bone density and soft tissue health.
Figure 5. Left elbow radiographs (anteroposterior and lateral) are shown, demonstrating a displaced olecranon fracture. Source: Sree Vemu, MD; Sanjiv V Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Figure 6. Left elbow radiographs (anteroposterior and lateral) are shown, demonstrating a displaced olecranon fracture. Source: Sree Vemu, MD; Sanjiv V Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Figure 7. Left elbow radiographs (anteroposterior and lateral) are shown, demonstrating a displaced olecranon fracture. Source: Sree Vemu, MD; Sanjiv V Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Clinical Implications and Future Outlook
The success of this case suggests that for appropriately selected geriatric patients, modern surgical techniques can significantly mitigate the burden of bilateral upper extremity injuries. The use of suture-anchor fixation is particularly advantageous in patients where traditional metal hardware might lead to skin breakdown or persistent pain. While suture cutout remains a potential risk in patients with severely compromised bone, the current clinical data indicate that these techniques offer a favorable alternative to traditional hardware in many simple to moderate fracture patterns.
As the population ages, the incidence of complex upper extremity fractures is expected to rise. Future research will likely continue to focus on optimizing these minimally invasive, high-stability constructs to further improve patient outcomes. The patient in this case continues to progress through her routine physical and occupational therapy protocols, representing a successful transition from injury to functional recovery.
Disclaimer: This article is provided for informational purposes only and does not constitute medical advice. Treatment plans for complex orthopedic fractures should be determined by a board-certified surgeon based on individual patient health, bone quality, and injury patterns.
The patient remains under routine follow-up care as she continues her rehabilitation, with no further surgical interventions currently planned. For those interested in the evolving standards for fracture management, further clinical updates and case studies are periodically published by major orthopedic research centers.
