Proximal Humerus Fractures: Epidemiology and trends in surgical management of hospital-admitted patients in Portugal

Secular trend of humeral fractures incidence rates in patients ≥ 50 years requiring hospitalization: a retrospective analysis of the public health system data in Brazil from 2004 to 2013

This study examined the incidence trend of humeral fragility fractures among Brazilian adults over age 50 admitted to public hospitals from 2004 to 2013. The findings revealed significant increases in annual rates of humeral fractures, especially among elderly women and patients from the Southeast region. It is essential for the implementation of effective public health policies.

PURPOSE

Humeral fragility fractures are associated with a significant health care burden, especially those requiring surgeries. With limited epidemiological data, the present study aimed to determine the annual rate of humeral fractures requiring hospitalization in the public health system among Brazilian adults ≥ 50 years-old between 2004 and 2013. A secular trend analysis of the humeral fracture rate was also investigated.

METHODS

This was a retrospective, observational study of admissions in the Brazilian public hospitals from 2004 to 2013, including patients 50 years and older admitted for primary treatment with a primary diagnosis of humerus fractures (ICD-10 S-42.2, S-42.3 and S-42.4) associated with low-trauma events. The annual rates of humeral fractures were calculated according to sex, age, and geographic region, and a linear regression analysis was used to determine secular trends.

RESULTS

Most of the total of 34,071 humeral fractures occurred in women (59.21%), among the age group 50-59 years (33.14%) and in residents from the Southeast region (60%). The average annual rate of humeral fractures for the overall population, women and men was 12.56, 14.11 and 10.85 per 100,000 inhabitants-years, respectively. Secular trend analysis showed a 21.18% significant increase in the crude humeral fracture rate among women (P = 0.024). There was a reduction in humeral fracture rate between 2004 and 2008 followed by an increase from 2009 to 2013. The Southeast region had the highest fracture rates with a significant 11.95% increase in secular trend for women (P = 0.031).

CONCLUSION

Hospitalizations for humeral fractures in Brazil increased significantly from 2004 to 2013, particularly among elderly women and those living in the most densely populated Southeast region. As osteoporotic humeral fractures are often associated with an increased risk of subsequent major osteoporotic fractures, especially hip fractures, understanding this trend is essential for implementing effective public health policies.

LEVEL OF EVIDENCE

Level III-Retrospective Design Using a Large Database. Prognosis Study.

The role of photobiomodulation in the functional recovery of proximal humerus fractures: a randomized controlled clinical protocol

Pain and joint stiffness contribute to functional limitation in the postoperative period following proximal humeral fractures (PHF). Photobiomodulation (PBM) has demonstrated positive outcomes in fracture repair, analgesia, and functional improvement, as evidenced by randomized controlled trials (RCTs) and experimental animal studies. Clinical studies have shown PBM's efficacy in reducing pain and improving functional outcomes, while preclinical studies have demonstrated enhanced bone regeneration through PBM application. This clinical study is a randomized, double-blind, controlled trial to investigate the effects of PBM on the shoulder functional recovery after proximal humerus fractures. A total of forty-two participants, aged 18-65 years of both genders, will be randomly divided into two groups: the Control group (receiving physiotherapy combined with simulated PBM) and the PBM group (receiving physiotherapy combined with active PBM). The PBM application (10 minutes) will be performed daily by the participants at home, using a device equipped with 318 light-emitting diodes (LEDs), consisting of 159 LEDs at 660 nm (28.5 mW; 12 J/cm²; 17 J per LED) and 159 LEDs at 850 nm (23 mW; 10 J/cm²; 14 J per LED). The PBM sessions, along with physiotherapy sessions (30 minutes, twice weekly), will be conducted over a 12-week period. Participants will be blinded to their group allocation and will be assessed by a single evaluator at 24 hours, 1 week, 2 weeks, 4 weeks, 8 weeks, and 12 weeks post-surgery. The evaluator will also be blinded to the participants' group assignments. The primary outcome will be shoulder functional recovery after proximal humerus fractures, assessed using the Quick-DASH scale at all experimental time points. Secondary outcomes will include range of motion (measured with a digital goniometer), quality of life (evaluated using the SF-6D questionnaire), pain on pressure and the incidence of adverse effects, all assessed at each time point. Spontaneous pain, nocturnal pain and analgesic use will be evaluated over a 12-week period. Fracture consolidation will be assessed through radiography at weeks 4, 8, and 12. Muscle strength will be measured through dumbbell lifting at weeks 8 and 12. If the data are normally distributed, ANOVA will be used, and results will be presented as means ± standard deviation (SD). If the data are not normally distributed, they will be presented as medians and interquartile ranges, with comparisons made using non-parametric tests. A p-value of less than 0.05 will be considered statistically significant.

Admission of Upper Extremity Injuries Presenting to the Emergency Department: An NEISS Study

BACKGROUND

Upper extremity injuries account for 36.5% of presentations to the emergency department in the United States. This study seeks to determine current rates of upper extremity injuries that present to the emergency department and the injury characteristics of patients requiring admission.

METHODS

National Electronic Injury Surveillance System was queried for a 10-year period for upper extremity injuries. Further analysis was done to evaluate specific patient demographics, injury characteristics, and mechanisms of injury of those patients who were admitted to the hospital.

RESULTS

Between 2012 and 2021, 39 160 365 persons are estimated to have presented to 100 United States emergency departments for managing upper extremity injuries, accounting for 28.8% of total presentations. A total of 12 662 041 upper extremity patients were pediatric (32.3%). Admissions occurred in 4.6% of presentations. The most common presenting diagnosis was laceration (24.9%), while the most common admission diagnosis was fracture (49.7%). The majority had injuries involving their forearms (19.9%). The most common injury-associated consumer product group was stairs, ramps, landings, and floors at 28.5%. Of the 445 644 patients, those estimated to have been injured by stairs, ramps, landings, and floors adults were 429 435 or 96.4%. The most common injury-associated product in pediatric populations was playground equipment (23.6%), of which 53.7% was from monkey bars and other climbing apparatuses.

CONCLUSION

This study demonstrates an overall increase in admissions for upper extremity injuries in the setting of similar rates of overall upper extremity injuries with fractures and forearm being the most common diagnosis and body part involved, respectively.

LEVEL OF EVIDENCE

IV; Database.

Reverse total shoulder arthroplasty versus locked plate fixation for proximal humeral fractures in the elderly: a systematic review

INTRODUCTION

For surgical treatment of proximal humeral fractures (PHF) in older patients, there is no consensus if locked plate fixation (LPF) or reverse total shoulder arthroplasty (RTSA) yields better clinical results. The purpose of this study was to systematically review the clinical and functional outcomes of LPF and RTSA. We hypothesized that RTSA would outperform LPF in patients with PHF aged 65 years or older.

MATERIALS & METHODS

A comprehensive literature search was performed on PubMed and Google Scholar from 1 July 2022 up to 12 January 2024 by two independent reviewers. Comparative studies reporting on the functional outcome using the Constant-Murley score (CMS) in patients aged 65 years or older, treated after 2012 for PHF with LPF or RTSA and with a mean follow-up time of at least 12 months were included. Ten studies with 244 LPF and 287 RTSA patients were included into the statistical analysis. We used a frequentist network meta-analysis to assess the comparative effectiveness of the treatments. Individual risk of bias of the studies was assessed using the ROB2 and ROBINS-I tools.

RESULTS

Our network meta-analysis of the CMS resulted in the following order ranked from lowest to highest: LPF, LPF +  screw augmentation, hemiarthroplasty (HA), RTSA +  cemented stem, non-surgical treatment, LPF +  fibular allograft, RTSA with an inclination angle of 135° (RTSA IA 135°), RTSA. However, none of the direct or indirect comparisons resulted in statistically noticeable differences.

CONCLUSION

In conclusion, functional superiority of either treatment method is still unknown, with even high-powered RCT not being able to detect statistically noticeable differences in terms of function. Patient-individual factors, such as bone quality, sex and age have to be included when making treatment decisions.

Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options

Background and Objective

Proximal humerus fractures (PHFs) occur in all age groups but more in elderly population with variety of treatment options. The choice of treatment of PHFs is rather controversial in the middle-aged and active elderly population. This review article highlights the current literature on the efficacy of treatment options for PHFs in middle-aged and active elderly patients which could help surgeons in decision making in clinical practice.

Methods

PubMed and Scopus databases from January 1953 to February 2024 were searched and screened for studies, including systematic reviews, on the treatment of PHFs in middle-aged and elderly that served for narrative review of rationale behind such design.

Key Content and Findings

Patients with minimally displaced fractures should be treated nonoperatively. Internal fixation with intramedullary nailing is a viable option in cases of two-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced three- or four-part PHFs fractures with intact rotator cuff muscles should be treated with locking plate fixation if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed fixation treated with salvage reverse shoulder arthroplasty (RSA) have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs.

Conclusions

The treatment of choice in middle-aged and active elderly patients with three- or four-part PHFs depends on several factors such as fracture pattern, bone quality, possibility of anatomical reduction, status of rotator cuff, and patient expectations. The success of treatment is based on patient selection while setting correct patient expectations.

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty

BACKGROUND

Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients.

AIMS

The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years.

METHODS

A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes.

RESULTS

Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed.

CONCLUSIONS

There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

Trends in Epidemiology and Treatment of Humerus Fractures in the United States, 2017-2022

Background Fractures of the humerus are one of the more common fractures in the United States and a cause of fragility fractures in the elderly population. This study aims to understand recent trends in the demographic factors correlated with humeral shaft fractures (HSF) and humeral shaft fracture nonunion (HSFN) following open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Methods The TriNetX database was used to query using International Classification of Diseases-10 (ICD10) diagnosis codes for patients who sustained HSF between 2017 and 2022. Patients were then organized into cohorts based on Current Procedural Terminology (CPT) codes 24515 and 24516 for ORIF and IMN of HSFs, respectively. Subsequent nonunion after operative management was queried. Descriptive and comparative analysis was performed to examine the differences observed between patients based on age, sex, ethnicity, race, and smoking status as well as surgical management across the six-year study period. Results The incidence of HSF increased from 7,108 in 2017 to 8,450 in 2022. The rate of HSF ORIF increased from 12% to 17% while the nonunion rate following ORIF decreased from 4% to 3%. The rate of HSF IMN increased from 4% to 6% and the rate of nonunion following IMN increased from 2% to 4%. The overall rate of HSFN surgery was 1.7% with slight decreasing trend over the past year. Conclusion It is speculated that improved care and surgical indications resulted in a lower rate of nonunion despite an increase in the overall rate of HSF and its operative managements.

Prediction of the Proximal Humerus Morphology Based on a Statistical Shape Model with Two Parameters: Comparison to Contralateral Registration Method

(1) Background: Complex proximal humerus fractures often result in complications following surgical treatment. A better understanding of the full 3D displacement would provide insight into the fracture morphology. Repositioning of fracture elements is often conducted by using the contralateral side as a reconstruction template. However, this requires healthy contralateral anatomy. The purpose of this study was to create a Statistical Shape Model (SSM) and compare its effectiveness to the contralateral registration method for the prediction of the humeral proximal segment; (2) Methods: An SSM was created from 137 healthy humeri. A prediction for the proximal segment of the left humeri from eight healthy patients was made by combining the SSM with parameters. The predicted proximal segment was compared to the left proximal segment of the patients. Their left humerus was also compared to the contralateral (right) humerus; (3) Results: Eight modes explained 95% of the variation. Most deviations of the SSM prediction and the contralateral registration method were below the clinically relevant 2 mm distance threshold.; (4) Conclusions: An SSM combined with parameters is a suitable method to predict the proximal humeral segment when the contralateral CT scan is unavailable or the contralateral humerus is unhealthy, provided that the fracture pattern allows measurements of these parameters.

Epidemiology of proximal humerus fractures in Qatar

OBJECTIVE

This study aimed to investigate the epidemiological characteristics and treatment options of proximal humerus fractures at a level one trauma center and to compare our data with the current literature.

METHODS

A retrospective review was conducted on all patients diagnosed and treated for proximal humerus fractures at Hamad General Hospital, a level one trauma center, between January 2018 and December 2019. Age, gender, mechanism of injury, fracture classification, mode of treatment, implant type, length of hospital stay, associated injuries and complications were analyzed.

RESULTS

A total of 190 patients with a mean age of 52.4 years were included; 56.8% were males. The incidence of proximal humerus fracture was 4.1/100,000 per year. Falling from a standing height was the most common cause of injury (50.5%). Additionally, Neer's two-part fracture was found to be the most common type (n = 132, 69%). Forty-one patients (21.3%) had other associated injuries. Most fractures were treated nonoperatively with an arm sling (n = 138, 72.6%).

CONCLUSION

In summary, the incidence of proximal humerus fractures during the two-year study period was found to be 4.1 per 100,000 persons per year. Our results showed a lower incidence of proximal humerus fractures with a predominance of males and younger patients in Qatar's population compared to females and older patients in the developed countries. Our results may contribute to the development of effective strategies for preventing and treating proximal humerus fractures, and can provide important data for further high-level clinical research.

LEVEL OF EVIDENCE

IV.

Quality of Life and Pain after Proximal Humeral Fractures in the Elderly: A Systematic Review

Background and Objectives: The proximal humeral fracture (PHF) is one of the most common fractures in elderly patients. A PHF might influence the quality of life (QoL) on several different levels, especially in elderly patients, but it is unclear which treatment option results in a better QoL outcome. Therefore, we aimed to systematically review the current literature for studies that have analyzed the QoL and pain of elderly patients treated either surgically or non-operatively for PHF. Materials and Methods: A comprehensive search of the literature was performed in the PubMed database from January to April 2023. Studies describing the QoL or the level of pain of patients older than 60 years with the EuroQoL-5 Dimension (EQ-5D) score or the visual analogue scale (VAS) after the treatment of PHF, either non-operatively (non-OP), with open-reduction and internal fixation using a locking plate (LPF), or with reverse total shoulder arthroplasty (RTSA) were included. Twelve studies were analyzed descriptively and the individual risk of bias was assessed using the ROB2 and ROBINS-I tools. Results: A total of 12 studies with 712 patients at baseline were included (78% female sex, mean age 75.2 years). The reported VAS scores at 12-month follow-up (FU) ranged from 0.7 to 2.5. The calculated overall mean VAS score across all studies showed a decreasing tendency for all treatments, with an increasing FU time up to 12 months after PHF. None of the studies reported any significant differences of the EQ-5D across the groups. The overall calculated EQ-5D indices showed an increasing trend after 6-8 weeks FU, but did not differ significantly between the three treatments. Conclusions: In conclusion, the current literature suggests that there are no clinically important differences between the QoL or pain in elderly patients with PHF after non-operative treatment or surgical treatment with LPF or RTSA. However, the number of studies and level of evidence is rather low and further trials are urgently needed.

Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges

Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.

Proximal humerus fractures - epidemiology, comparison of mortality rates after surgical versus non-surgical treatment, and analysis of risk factors based on Medicare registry data

AIMS

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

METHODS

PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments.

RESULTS

From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture.

CONCLUSION

Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making.Cite this article: Bone Joint Res 2023;12(2):103-112.