Operative versus nonoperative management of olecranon fractures in older adults: a systematic review and meta-analysis

Introduction Displaced olecranon fractures in the frail geriatric patient represent a therapeutic challenge, involving the decision between operating to achieve anatomical reduction of the articular surface or not operating due to the high risks associated with poor bone quality and failure of mechanical fixation. Materials and methods PubMed, Embase, and Cochrane were systematically searched for studies published from inception through February 2026 comparing tension band wiring, plate fixation, or cerclage wiring with nonoperative treatment for displaced olecranon fractures in geriatric patients. Risk ratio (RR) was used to evaluate binary outcomes, and standard mean difference (SMD) for continuous outcomes, with 95% confidence intervals (CIs). Results Of 459 articles, eight studies were included. A total of 723 older adults were included. Most patients had Mayo type IIA or IIB fractures. Tension band wiring was the most frequently performed surgical technique, followed by plate fixation and cerclage wiring. Operative treatment was associated with a lower risk of radiographic nonunion (RR 0.19; 95% CI 0.04, 0.8) but increased the risk of overall complications (RR 3.21; 95% CI 1.63, 6.35) and reoperation (RR 4.85; 95% CI 1.72, 13.65) compared to nonoperative treatment. Physical function showed a non-significant trend toward improvement with operative treatment (SMD −0.29; 95% CI -0.72, 0.14). At final follow-up, pain intensity was low and comparable between the two treatment groups across the majority of studies. Approximately half of the reoperation excess comprised elective or symptomatic implant removal, and the overall certainty of the evidence is low. Conclusion In older adults with displaced olecranon fractures, operative management was associated with a reduced risk of radiographic nonunion and with a higher risk of complications and reoperation compared to nonoperative management. Level of evidence Level III Systematic Review/MetaAnalysis Treatment Study.