Factors affecting hospital admission, hospital length of stay and new discharge destination post proximal humeral fracture: a retrospective audit

BACKGROUND

Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF.

METHODS

Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination.

RESULTS

Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination.

CONCLUSIONS

Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

Complication rates following reverse and anatomic shoulder replacement in treatment of glenohumeral arthritis: a 10-year Medicare review study

BACKGROUND

We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population.

METHODS

Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years.

RESULTS

Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups.

CONCLUSION

An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

Blood transfusion and surgical treatment increase mortality in patient with proximal humeral fractures

INTRODUCTION

Proximal humeral fractures (PHFs) often occur in elderly patients with osteoporosis and associated comorbidities. These patients constitute a special risk group. This study aimed to identify associations between comorbidities, treatment type, and mortality risk.

PATIENTS AND METHODS

We conducted a retrospective chart review of a cohort of 350 patients with a diagnosis of PHF and a mean follow-up of 4.5 years. We analysed the 19 prefracture comorbidities included in the Charlson Comorbidity Index (CCI), haemoglobin (Hb) levels, blood transfusion needs, and treatment administered (surgery versus conservative). The nonparametric Kaplan-Meier method and Cox proportional hazards model were used to estimate the mortality risk.

RESULTS

Over a 4.5-year average follow-up of 350 patients, primarily elderly females, with proximal humerus fractures, several factors were associated with increased mortality. The Charlson Comorbidity Index (CCI) was a significant predictor, with patients having a CCI > 5 facing higher mortality risks, especially if they underwent surgery. Additionally, osteosynthesis was linked to a lower mortality rate compared to arthroplasty. Age, dementia, medical complications, and postfracture Hb level also influenced mortality rates. CONCLUSIóN: These findings emphasize the importance of considering comorbidities, specifically the Charlson Comorbidity Index (CCI), in determining patient outcomes, especially amongst elderly patients with proximal humerus fractures. Factors like age, dementia, and postfracture Hb level also play a crucial role in influencing mortality rates.

TRIAL REGISTRATION

The study received written approval from the regional Ethics Committee for Clinical Research (code 2016/125).

[One-year outcomes after proximal humeral fractures : A risk-adjusted regression analysis of routine data based on 17,322 cases]

BACKGROUND

Proximal humeral fractures (PHF) are the third most common fracture in geriatric traumatology. No standard evidence-based treatment has been established so far. The epidemiology and economic burden highlight the importance of a targeted treatment strategy.

OBJECTIVE

Epidemiology of PHF and analysis of the influence of preoperative length of stay, comorbidities and quality of patient life. Additionally, a comparison to the more frequently studied proximal femoral fractures.

MATERIAL AND METHODS

A routine data analysis of 17,322 cases admitted for inpatient treatment with an observational period of 1 year was performed following an established model. Descriptive statistics included comorbidities, treatment procedures and mortality. Analytical statistics using logistic regression with the primary endpoints of early revision, mortality and decubitus within 1 year.

RESULTS

In the investigated PHFs there was a mortality of 13% within 1 year, which is increased three-fold in patients with comorbidities such as cancer. There was an increase of 57% in patients who first received a care level following PHF. A preoperative care level in general significantly decreased survival. The most frequently used surgical procedure was fixation via stable-angle plate (used in 43%). The preoperative length of stay did not impact survival.

DISCUSSION

Intrinsic factors such as preoperative comorbidities are crucial for the mortality after PHF. The PHF affects patients' lives less than proximal femoral fractures. With comparable comorbidity profiles, possible reasons are the lower levels of immobilization and less dependency on care before the fracture in comparison to proximal femoral fractures.

Incidence of secondary displacement after osteosynthesis of proximal humerus fractures: a retrospective study of 185 cases

Proximal humerus fractures are the third most common fracture in patients over 65 years of age. There is no clear consensus regarding their treatment. The objective of this retrospective observational study was to calculate the incidence of secondary displacement after osteosynthesis of these fractures and to identify possible risk factors. 185 cases were reviewed and all osteosynthesized fractures between January 2008 and December 2016 were included. Data collected included age, sex, body mass index, alcohol and tobacco use, bone mineral density of the proximal humerus, fracture type, initial displacement, management time, type of treatment, surgeon's experience and expertise, and postoperative reduction quality. A radiographic follow-up was done at least 3 months following the fracture (until consolidation). The definition of secondary displacement was: varus/valgus displacement >10°, tuberosity translation >5 mm, articular effraction or material breakage. 53 secondary displacements were found, with an incidence of 28.6%. Seventy-two percent were diagnosed at the first follow-up visit, which occurred at an average of 29 days postoperatively. Among all factors studied, only two were statistically significant for secondary displacement: 1) low proximal humeral bone density (defined by a Tingart index <4) appears to be a risk factor, with a calculated relative risk of 2.71 (p = 0.04); and 2) the operator's specialization in the upper limb appears to be a protective factor, with a relative risk of 0.27 (p = 0.01). A similar high incidence of complications after osteosynthesis of the proximal humerus is found in the literature, confirming the difficulty in managing these fractures. More attention should be given to patients with low bone density.

Mortality following proximal humerus fracture-a nationwide register study of 147,692 fracture patients in Sweden

Little is known about survival after proximal humerus fracture. In this manuscript, we found the mortality to be high (almost four times higher than in age- and sex-matched controls). While frailty hip fracture has gained attention, we hope our manuscript will shed light on frailty proximal humerus fracture patients.

INTRODUCTION

Proximal humerus fractures (PHF) are common and occur mostly after the 6th decade of life. While mortality following PHF has been reported previously, mortality data after longer follow-up on a national level is lacking.

METHODS

We obtained data from the Swedish Hospital Discharge Register (SHDR), on all adult patients (≥ 18 years) with a diagnosis of PHF (S42.2, S42.20, or S42.21) for the period between 2001 and 2016. We used the Swedish Cause of Death Register (SCDR) to investigate mortality in the fracture cohort. We compared the mortality of fracture patients with age- and sex-matched population-based mortality data obtained from Statistics Sweden.

RESULTS

A total of 147 692 PHF patients were identified, with a male to female ratio of 1:3. The mean age was 69 years (range, 18 to 111). Most patients were treated non-surgically (n = 126,487, 86%). The crude mortality rate was 2.2% at 1 month, 4.1% at 3 months, 8.5% at 12 months, and 24% at 48 months after sustaining a PHF. Mortality increased with age; however, the standardized mortality rate (SMR) was highest among young patients. SMR was 5.4 in the 18- to 39-year age group, 3.9 in the 40- to 64-year age group, 1.8 in the 65-79-year age group, and 1.2 in the ≥ 80-year-old population. The age-adjusted SMR was 3.9 in the whole adult PHF population.

CONCLUSION

The mortality rate and SMR suggest that PHF patients are heterogeneous. Some older PHF patients may benefit from specialized care (e.g., orthogeriatric), and this should be evaluated in future studies.

Acromioclavicular dislocation associated with scapular fractures - pathoanatomy of the injury

INTRODUCTION

No detailed study dealing with an injury to the AC joint in combination with scapular fractures has been published to date. The aim of this study is to describe pathoanatomy of these injuries.

METHODS

In a series of 519 scapular fractures in adult patients from the period of 20022020 we identified a total of 20 (3.9%) cases associated with AC dislocation. The group comprised 17 men and 3 women with the mean age of 49 years (range, 2178). Radiographs of the shoulder joint followed by CT examination, including 3D reconstructions, were performed in all patients. This documentation allowed assessment of the scapular fracture pattern and type of injury to the AC joint.

RESULTS

AC dislocation was associated with a simple scapular fracture in 15 cases (7 fractures of the coracoid base, 4 fractures of the acromion or the lateral spine, 2 fractures of the scapular body, 1 fracture of the superior and 1 fracture of the inferior glenoid). In 5 cases AC dislocation accompanied multiple or complex scapular fractures (once a combination of a coracoid fracture and a fracture of the lateral scapular spine, once a combination of a fracture of the superior glenoid and of the acromion, 2 cases of a complex intraarticular fracture and 1 case of scapulothoracic dissociation).

CONCLUSION

AC dislocation is relatively infrequent injury accompanying scapular fractures. It is most commonly associated with fractures of coracoid, acromion/lateral spine or superior glenoid. No case of AC dislocation was recorded in a fracture of the scapular neck.

Comorbidities, substance abuse, weight and age are independent risk factors for postoperative complications following operation for proximal humerus fractures: a retrospective analysis of 1109 patients

INTRODUCTION

This study aimed to investigate the influence of epidemiologic parameters on complications that needed operative revision of operatively treated proximal humerus fractures.

METHODS

We performed a retrospective single-center study in a level 1 trauma center. We included all patients with operatively treated proximal humerus fractures from January 1 2005 to December 31 2015. We characterized our cohort and subgroup using descriptive statistics. The primary outcome was postoperative complications. For this purpose, postoperative complications were defined in advance, an operative revision was necessary on a general rule. The secondary outcome was a model of the risk factors for complications created with multiple logistic regression.

RESULTS

We included 1109 patients. The average age was 67.2 years (± 16.4), and 71.4% of the fractures occurred in women. A total of 644 patients (58.1%) had between one to three comorbidities, and 27.8% had four or more. The fracture morphology was as follows: 3 part 41.8%, 4 part 26.9%, 2 part 24.3%, and dislocation fracture 6.7%. Complications occurred in 150 patients (13.5%). The number of comorbidities [odds ratio (OR) 2.85, p < 0.01], body weight (OR 1.15, p = 0.02), and substance abuse (OR 1.82, p = 0.04) significantly correlated with the risk of complications. We achieved a sensitivity of 48% and a specificity of 74% for the variables body weight, substance abuse, age, and comorbidities CONCLUSION: The epidemiologic parameters, comorbidities, substance abuse, weight, and age are independent risk factors for complications. If these factors are present, one can predict a postoperative complication requiring surgical revision with low sensitivity and moderate specificity. Therefore, concerning the high number of multi-morbid patients with proximal humerus fractures, an increased postoperative complication rate can be expected.

LEVEL OF EVIDENCE

Level of evidence IV.

Non-medical patient-related factor influence in proximal humeral fracture outcomes: a multicentric study

PURPOSE

Age, sex, and type of fracture have traditionally been described as prognostic factors for proximal humeral fractures (PHFs). Some non-medical patient-related factors may play a role in the outcome. This paper evaluates the association of comorbidities and socioeconomic factors with clinical outcomes for PHF.

METHODS

A total of 217 patients with PHF were evaluated according to Neer's classification with X-ray. Comorbidities were assessed through the Charlson comorbidity index and, non-medical patient-related factors were determined with a 52-item questionnaire concerning personal behaviors such as social activities, family support, economic solvency, and leisure-time activities. The clinical outcome was assessed with the Constant-Murley Score (CMS), with a minimum 1-year follow-up. The minimal clinically relevant difference for the CMS was set at 10 points. A multivariable analysis was performed to adjust for comorbidities and non-medical patient-related factors, such as age, sex, fracture classification, and treatment.

RESULTS

One hundred and eighty-three patients completed the initial research protocol, while 126 of them completed the 1-year follow-up. The mean age was 71.6 years (SD ± 13.3), and 79.3% of the patients were women. In the bivariable analysis, age and comorbidities were correlated with the CMS (correlation coefficient: - 0.34 [- 0.49, 0.17] and 0.35 [0.18, 0.50], respectively), as well as non-medical patient-related factors and the fracture pattern (p value ANOVA < 0.001). In the multivariable regression model, the effects of considering oneself socially active, without economic problems, and self-sufficient were associated with a higher CMS than the effect of the fracture pattern (beta coefficient: 11.69 [6.09-17.30], 15.54 [8.32-22.75], and 10.61 [3.34-17.88], respectively).

CONCLUSION

Socioeconomic status had a higher impact on functional outcomes than fracture pattern in patients with PHF.

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

INTRODUCTION

Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making.

METHODS

This study included patients aged 65 years and older that were treated at one Level 1 trauma center between 2007 and 2018. Inclusion criteria: Proximal humerus fracture treated with or without allograft, conclusive data-sets. Exclusion criteria: prior surgical treatment of the proximal humerus, open fracture with bone loss, neurological damage. Patients were stratified according to the use of allograft augmentation in two groups: Group NA (no allograft augmented PHILOS) and Group A (PHILOS with allograft augmentation). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Fractures were graded according to the classification by Neer. Radiographic union was analyzed at 6 weeks, 12 weeks, and at year follow up. Complications include surgical site infection, implant failure, humeral head necrosis, or delayed union. Allograft was used in cases of 1inch/3cm3 bone-loss or an egg-shell situation, where the patient refused arthroplasty.

RESULTS

This study included 167 patients, with 143 (85%) in the Group NA, and 24 (15%) in the Group A. There were no significant differences in age, gender, injury distribution, and distribution of Neer classification or CCI. Patients in Group A had significantly lower T-scores preoperatively (-2.87 ± 1.08 versus -0.9 ± 2.12, p = 0.003). No difference occurred in any of the complications. At one-year follow-up, the range of motion was comparable in both groups.

CONCLUSION

In patients with allograft augmentation and severe osteopenia, similar clinical and radiological results were obtained when compared with patients with better preoperative bone density scores (T-scores, DEXA). In view of a lack of guidelines indicating the indication for the use of allograft, this difference may be worth further study.

Association of Surgical Treatment With Adverse Events and Mortality Among Medicare Beneficiaries With Proximal Humerus Fracture

IMPORTANCE

Meta-analyses of randomized clinical trials suggest that the advantages and risks of surgery compared with conservative management as the initial treatment for proximal humerus fracture (PHF) vary, or are heterogeneous across patients. Substantial geographic variation in surgery rates for PHF suggests that the optimal rate of surgery across the population of patients with PHF is unknown.

OBJECTIVE

To use geographic variation in treatment rates to assess the outcomes associated with higher rates of surgery for patients with PHF.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study analyzed all fee-for-service Medicare beneficiaries with proximal humerus fracture in 2011 who were continuously enrolled in Medicare Parts A and B for the 365-day period before and immediately after their index fracture. Data analysis was performed January through June 2019.

EXPOSURE

Undergoing 1 of the commonly used surgical procedures in the 60 days after an index fracture diagnosis.

MAIN OUTCOMES AND MEASURES

Risk-adjusted area surgery ratios were created for each hospital referral region as a measure of local area practice styles. Instrumental variable approaches were used to assess the association between higher surgery rates and adverse events, mortality risk, and cost at 1 year from Medicare's perspective for patients with PHF in 2011. Instrumental variable models were stratified by age, comorbidities, and frailty. Instrumental variable estimates were compared with estimates from risk-adjusted regression models.

RESULTS

The final cohort included 72 823 patients (mean [SD] age, 80.0 [7.9] years; 13 958 [19.2%] men). The proportion of patients treated surgically ranged from 1.8% to 33.3% across hospital referral regions in the United States. Compared with conservatively managed patients, surgical patients were younger (mean [SD] age, 80.4 [8.1] years vs 78.0 [7.2] years; P < .001) and healthier (Charlson Comorbidity Index score of 0, 14 863 [24.4%] patients vs 3468 [29.1%] patients; Function-Related Indicator score of 0, 20 720 [34.0%] patients vs 4980 [41.8%] patients; P < .001 for both), and a larger proportion were women (49 030 [80.5%] patients vs 9835 [82.5%] patients; P < .001). Instrumental variable analysis showed that higher rates of surgery were associated with increased total costs ($8913) during the treatment period, increased adverse event rates (a 1-percentage point increase in the surgery rate was associated with a 0.19-percentage point increase in the 1-year adverse event rate; β = 0.19; 95% CI, 0.09-0.27; P < .001), and increased mortality risk (a 1-percentage point increase in the surgery rate was associated with a 0.09-percentage point increase in the 1-year mortality rate; β = 0.09; 95% CI, 0.04-0.15; P < .01). Instrumental variable mortality results were even more striking for older patients and those with higher comorbidity burdens and greater frailty. Risk-adjusted estimates suggested that surgical patients had higher costs (increase of $17 278) and more adverse events (a 1-percentage point increase in the surgery rate was associated with a 0.12-percentage point increase in the 1-year adverse event rate; β = 0.12; 95% CI, 0.11 to 0.13; P < .001) but lower risk of mortality after PHF (a 1-percentage point increase in the surgery rate was associated with a 0.01-percentage point decrease in the 1-year mortality rate; β = -0.01; 95% CI, -0.015 to -0.005; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that higher rates of surgery for treatment of patients with PHF were associated with increased costs, adverse event rates, and risk of mortality. Orthopedic surgeons should be aware of the harms of extending the use of surgery to more clinically vulnerable patient subgroups.

Epidemiology of osteoporotic fracture in Kazakhstan and development of a country specific FRAX model

Retrospective and prospective population-based survey in a region of the Republic of Kazakhstan determined the incidence of fractures at the hip, proximal humerus and distal forearm. The hip fracture rates were used to create a FRAX® model to enhance fracture risk assessment in Kazakhstan.

OBJECTIVE

This paper describes the epidemiology of osteoporotic fractures in the Republic of Kazakhstan that was used to develop a country specific FRAX® tool for fracture prediction.

METHODS

We carried out a retrospective population-based survey in Taldykorgan in the Republic of Kazakhstan representing approximately 1% of the country's population. Hip, forearm and humerus fractures were identified retrospectively in 2015 and 2016 from hospital registers and the trauma centre. Hip fractures were prospectively identified in 2017 from the same sources and additionally from primary care data. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Kazakhstan. Fracture probabilities were compared with those from neighbouring countries having FRAX models.

RESULTS

The difference in hip fracture incidence between the retrospective and prospective survey indicated that approximately 25% of hip fracture cases did not come to hospital attention. The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 11,690 and is predicted to increase by 140% to 28,000 in 2050. Hip fracture incidence was a good predictor of forearm and humeral fractures in men but not in women.

CONCLUSION

The FRAX model should enhance accuracy of determining fracture probability among the Kazakh population and help guide decisions about treatment.

Fragility fractures and imminent fracture risk in Hong Kong: one of the cities with longest life expectancies

INTRODUCTION

Imminent fracture risk, or fractures within 2 years of an initial fracture, is a pressing issue worldwide. Hong Kong is a city with one of the longest life expectancies. The concern of fragility fractures and the imminent risk of a subsequent fracture is becoming a top priority. The objective of this study was to present the epidemiology of incident fragility fractures of all public acute hospitals and the imminent risk of a subsequent fracture in Hong Kong.

METHODOLOGY

This was a retrospective population-based analysis. Patient records from all acute hospitals in Hong Kong from 1 January 2004 to 31 December 2018 were retrieved for patients ≥ 50 years of age with hip, distal radius, or proximal humerus fractures. Secondary fractures and falls were identified in the subsequent 5 years. Post hoc analysis in recent 2013-2018 period was performed. Overall survival (re-fracture incidence) on age subgroups using Kaplan survival analysis and variables was compared using the log-rank test. Cox proportional hazard regressions, obtaining the hazard ratios (HR) and their respective 95% confidence intervals (CI), were used.

RESULTS

There is an overall increasing trend of fragility fractures (hip, distal radius, proximal humerus) from 5596 in 2004 to 8465 in 2018. The average cumulative imminent risk of fractures from recent 5 years is 3.87% at 1 year and 6.50% at 2 years. 49.5% of the patients with a secondary fracture occurred within 2 years since the initial major fragility fracture. Post hoc analysis in recent 2013-2018 period (N = 7039) showed male patients were 1.21 times more likely to have further fractures with time (HR = 1.21 (1.02, 1.45), p = 0.03) compared with female patients. Patients over age 95 were 2.01 times higher than patients of age under 75 to have further fracture over time.

CONCLUSIONS

Following an initial fracture, prompt treatment strategies should be adopted to avoid imminent risk of fractures. This window of opportunity in the first 2 years is a golden period to treat osteoporosis and prevent falls. Our post hoc analysis has shown that male patients and patients older than 95 are at even higher risk. Clinicians and allied healthcare professionals should be alert on these patients.

Evaluating osteoporotic fracture risk with the Fracture Risk Assessment Tool in Chinese patients with rheumatoid arthritis

This study aims to evaluate the discriminative and predictive capacity of the Fracture Risk Assessment Tool (FRAX) to determine the 10-year risk of osteoporotic fracture in Chinese rheumatoid arthritis (RA) patients.This study included 168 RA patients and 168 healthy individuals as controls. The Chinese mainland FRAX model was applied to calculate the 10-year risk of osteoporotic fractures, defined as fracture of the spine, forearm, hip, or shoulder.The incidence of osteoporosis was significantly increased in RA patients compared to controls (P < .05). Bone mineral density (BMD), lumbar vertebra T-score, and femoral neck T-score were significantly lower in RA patients compared to controls (P < .05). BMD, disease duration, DAS28, and glucocorticoid use were important risk factors for osteoporotic fractures in Chinese RA patients. Ten-year osteoporotic fracture risk in Chinese RA patients was higher when BMD was incorporated in FRAX.There was a higher incidence of osteoporosis and reduced BMD in RA patients compared to controls. The FRAX model should integrate femoral neck BMD with other risk factors to evaluate osteoporotic fracture risk in RA patients, making it a valuable screening tool.

Proximal humeral fractures in Sweden-a registry-based study

Proximal humeral fracture is the third most common osteoporotic fracture. To our knowledge, this is the first nationwide population-based registry study in adults that includes both inpatient and outpatient visits. Thus, we were able to report the true incidence rates and trends in the treatment of proximal humeral fractures.

INTRODUCTION

Proximal humeral fractures are among the most common osteoporotic fractures. Valid epidemiologic population-based data, including both inpatient and outpatient visits, however, are lacking.

METHODS

To investigate the Swedish national incidence rates and treatment trends of proximal humeral fractures, we obtained data from the Swedish Hospital Discharge Register between 2001 and 2012. All adult patients (≥18 years of age) in the Swedish Hospital Discharge Register were included. Outpatient visits have been included in the register since 2001.

RESULTS

We identified 98,770 patients (women n = 72,063; 73 %) with proximal humeral fractures between 2001 and 2012. In 2001, the sex-specific incidence of proximal humeral fractures was 134.5 per 100,000 person-years for women and 49.2 for men. In 2012, the corresponding values were 174.6 for women and 68.1 for men, increasing 30 % in women and 39 % in men. A total of 17,013 surgical procedures were conducted between 2001 and 2012. Open reduction and internal fixation with a plate was the most common procedure (n = 5050, 30 %), followed by endoprosthetic implantation (n = 3962, 23 %) and intramedullary nailing (n = 3376, 20 %). The proportion of surgically treated patients increased from 12.1 % in 2001 to 16.8 % in 2012 for women and from 15.1 % in 2001 to 17.1 % in 2012 for men.

CONCLUSION

The Swedish national incidence of proximal humeral fractures has been increasing, although it seems to have peaked in the elderly population during 2008-2010. The rate of surgical treatment has increased substantially, particularly open reduction and internal fixation with a plate. To our knowledge, this is the first nationwide epidemiologic study for Sweden reporting the incidence of proximal humeral fractures and including all inpatient and outpatient visits.

Trends in Upper Extremity Fracture Caseload Reporting During Orthopaedic Residency

BACKGROUND

The objectives of this investigation were to report temporal trends in resident performed upper extremity fracture procedures and analyze case volume variability.

METHODS

Orthopaedic resident case logs from the Accreditation Council for Graduate Medical Education were reviewed for graduating years 2007 to 2014. The mean number of wrist, forearm, elbow, humerus, and shoulder fracture-dislocation procedures performed by residents was analyzed. The median number of procedures reported by the top 30% and bottom 30% of residents (by case volume) was also recorded. Linear regression modeling was used to assess temporal trends.

RESULTS

The mean number of wrist and forearm fracture cases performed per resident fell from 55.3 in 2007 to 46.7 in 2014 (p = 0.325) while the number of elbow and humerus fracture procedures remained relatively constant (45.6 to 45.4; p = 0.224). The mean number of shoulder fracture cases increased significantly (14.7 to 22.5; p < 0.001). Over the 8-year period, residents in the 70th percentile of caseload performed significantly more wrist and forearm (62.6 versus 39.5; p < 0.001), elbow and humerus (55 versus 34.9; p < 0.001), and shoulder (23 versus 12.9; p < 0.001) fracture procedures than residents in the 30th percentile.

CONCLUSION

Resident case volume for wrist, forearm, elbow, and humerus fractures is constant or falling. However, shoulder fracture caseloads are increasing. Regardless, there is substantial disparity in upper extremity fracture case volume among residents. Further investigation is needed to assess possible educational effects of resident caseload disparity.

Second fractures among older adults in the year following hip, shoulder, or wrist fracture

We report on second fracture occurrence in the year following a hip, shoulder or wrist fracture using insurance claims. Among 273,330 people, 4.3 % had a second fracture; risk did not differ by first fracture type. Estimated adjusted second fracture probabilities may facilitate population-based evaluation of secondary fracture prevention strategies.

INTRODUCTION

The purpose of this study was estimate second fracture risk for the older US population in the year following a hip, shoulder, or wrist fracture.

METHODS

Observational cohort study of Medicare fee-for-service beneficiaries with an index hip, shoulder, or wrist fragility fracture in 2009. Time-to-event analyses using Cox proportional hazards models to characterize the relationship between index fracture type (hip, shoulder, wrist) and patient factors (age, gender, and comorbidity) on second fracture risk in the year following the index fracture.

RESULTS

Among 273,330 individuals with fracture, 11,885 (4.3 %) sustained a second hip, shoulder or wrist fracture within one year. Hip fracture was most common, regardless of the index fracture type. Comparing adjusted second fracture risks across index fracture types reveals that the magnitude of second fracture risk within each age-comorbidity group is similar regardless of the index fracture. Men and women face similar risks with frequently overlapping confidence intervals, except among women aged 85 years or older who are at greater risk.

CONCLUSIONS

Regardless of index fracture type, second fractures are common in the year following hip, shoulder or wrist fracture. Secondary fracture prevention strategies that take a population perspective should be informed by these estimates which take competing mortality risks into account.

Functional Outcome Of Proximal Humeral Fractures Treated With Philos Plate In Adults

BACKGROUND

Proximal humeral fractures account for 4-5% of all fractures. Most fractures are minimally displaced and can be managed non-operatively in adults. Displaced and unstable fractures are difficult to manage and should be treated to achieve painless shoulder and full function. Our aim was to evaluate the functional outcome of proximal humerus fractures (Neers classification 2 part, 3 part and 4 part) treated with PHILOS (Proximal humeral internal locking system).

METHODS

We retrospectively reviewed 22 patients who had proximal humerus fractures treated with PHILOS plate from Jan 2012 to June 2013 conducted at Orthopaedic Department Liaquat National Hospital. Clinical outcome was measured using DASH (disability of arm, shoulder and hand) Score System. Radiological union was assessed by serial X rays.

RESULTS

Two patients were lost to follow up. Mean age was 40 years (20-70). Mean follow up was 6 months. 4 patients had two-part fracture, 10 patients had three-part and 6 patients had four-part fracture. Radiological union was achieved in average 8.31 weeks (±1.37SD). Average DASH score in young patients was 15.14 (±1.91SD) and in elderly was 31.66 (±4.08SD). One case of implant failure was noted. Better results in younger patients were achieved as compared to elderly proved by DASH score.

CONCLUSIONS

Increase in number of fracture parts and delay in treatment did not affect the outcome. Our study concluded that this implant provides stable fixation in younger patients with good quality bone sufficient to allow mobilization.

Epidemiology of fragility fractures in Sakaiminato, Japan: incidence, secular trends, and prognosis

We investigated the incidence of fragility fractures from 2010 to 2012 in Sakaiminato, Japan. The incidence rates of limb fractures in Sakaiminato were lower than in Caucasian populations but had increased relative to data obtained in Japan in the 1990s. Clinical vertebral fractures occurred at higher rates in Sakaiminato than in Caucasian populations.

INTRODUCTION

To elucidate the incidence and prognosis of fragility fractures in Sakaiminato, Japan.

METHODS

A survey of all hip, distal radius, proximal humerus, and clinical vertebral fractures was performed from 2010 to 2012 in patients aged 50 or older in Sakaiminato city, Tottori prefecture, Japan. The age- and gender-specific incidence rates (per 100,000 person-years) were calculated based on the population of Sakaiminato city each year. The incidence rates of hip, distal radius, and proximal humerus fractures were compared with previous reports. We conducted a follow-up study assessing patients within 1 year following their initial treatment at two Sakaiminato hospitals.

RESULTS

The age-adjusted incidence rates in population aged 50 years or older (per 100,000 person-years) of hip, distal radius, proximal humerus, and clinical vertebral fractures were, respectively, 217, 82, 26, and 412 in males and 567, 432, 96, and 1229 in females. Age-specific incidence rates of hip, distal radius, and proximal humerus fractures all increased since the 1990s. Our study also revealed that anti-osteoporotic pharmacotherapy was prescribed 1 year post-fracture at rates of 29, 20, 30, and 50 % for patients with hip, distal radius, proximal humerus, and clinical vertebral fractures, respectively.

CONCLUSIONS

The incidence rates of limb fractures in Sakaiminato were substantially lower than Caucasian populations in northern Europe but had increased relative to data obtained in Japan in the 1990s. Unlike upper and lower limb fractures, clinical vertebral fractures occurred at higher rates in our study population than in other Asian and North European countries.

Economic and social impact of upper extremity fragility fractures in elderly patients

BACKGROUND

Fragility fractures of the proximal humerus and distal radius can have a significant impact on the elderly population, both economically and physically. Limited data are available to demonstrate the functional and economic impact of upper extremity fragility fractures.

AIMS

To investigate the economic and social impact that proximal humerus fragility fractures may have on an older population.

METHODS

A retrospective chart review for patients ≥50 years old treated as an inpatient at a local hospital between 2006 and 2012 for a proximal humerus or a distal radius fracture was done. Patients were divided into two groups to show age impact; Group 1 = 50-79 years old and Group 2 = 80 years and older. Eighty-six charts were reviewed, 38 for Group 1 and 48 for Group 2. Demographic, admission, inpatient, and discharge data were compared between groups.

RESULTS

A third of patients in each group had a previous fragility fracture. Inpatient length of stay was comparable between groups. Surgical treatment was used at a higher rate in the younger cohort (p = 0.06). Approximate average hospital charges for an inpatient surgical treatment were about twice those of the non-surgically treated patients.

DISCUSSION

Our results illustrate the significant burden of upper extremity fractures in terms of loss of independence, inpatient hospitalizations and prolonged nursing home or rehabilitation needs, which account for considerable health care costs.

CONCLUSION

Fractures of the humerus, forearm and wrist account for one-third of the total incidence of fractures and can be a significant burden to individuals and the community.

Burden of proximal humerus fractures in the French National Hospital Database

OBJECTIVE

To describe the characteristics of patients hospitalized for osteoporotic proximal humerus fracture in 2009 in France, in-patient mortality, and further hospitalizations for hip fracture.

METHODS

Data were extracted from the French Hospital National Database. We selected patients aged 40 years and over hospitalized for proximal humerus fracture in 2009, without cancer. Based on their unique identification number, we described the next hospitalizations occurring in 2009-2011 whatever the causes. Incidence, in-patient mortality, and hospital costs were calculated.

RESULTS

We numbered 10,874 patients (77% of women, mean age 72.5 years). The incidence per million was 477 and 163 in women and men, respectively. This incidence increased with age and was higher in women (i.e. 1374 and 320 in women and men aged over 74 years, respectively). Surgical treatment was applied in 56% of patients; median hospital stay was 5 days. Rehabilitation unit was necessary in 26% of cases. In-patient mortality was 1.1%. The overall hospital costs was €34 millions. Rehospitalizations occurred for 61% of the patients and had more co-morbidities than others. Near 8% of the rehospitalized patients were for hip fractures occurring in a median of 353 days after hospitalization for proximal humerus fracture. The hospital costs for these rehospitalizations was €52 millions.

CONCLUSION

Proximal humerus fractures incidence increases with aging, especially in women. These fractures are associated with a significant in-patient mortality and health care resources utilization. Patients with such fracture must receive high priority for optimal post fracture treatment.

Civilian gunshot injuries of the humerus

An institutional review board-approved retrospective study was performed at a level 1 trauma center to evaluate the adequacy of current treatment guidelines in the management of humerus fractures following civilian gunshot injuries. Fifty-four patients with a humerus shaft fracture from a low-velocity gunshot wound were included in the study. Twenty-nine patients were treated nonoperatively, while 25 patients had operative treatment, with 14 undergoing plate fixation, 6 having application of an external fixator, 3 receiving an intramedullary rod, and 2 having irrigation and debridement with fracture immobilization provided by a brace. Patient demographics and injury data, radiographic analyses, and treatment complications were recorded. Healing of soft tissue and bony injuries, including fracture alignment in patients treated nonoperatively, was also evaluated. Fifty-two of 54 patients had minor soft tissue damage and were treated successfully with minimal local wound care. Two patients with larger wounds required extended wound care with repeated irrigation and debridement. Overall, 47 of 54 fractures healed with the primary mode of treatment, and 7 patients went on to nonunion requiring further intervention. Of the patients treated nonoperatively, the average deformity was 16.5°±7.4° in the coronal plane and 4.4°±4.0° in the sagittal plane. This study supports the view that the majority of humerus fractures following civilian gunshot wounds may be treated nonoperatively, with a select group of patients requiring surgical stabilization.

Epidemiology of proximal humeral fractures in Austria between 1989 and 2008

Incidence rates of proximal humeral fractures in Austria over a period of twenty years (1989-2008) were estimated. Age standardized incidence rates increased until 2008, primarily driven by an increase in incidence rates in women.

INTRODUCTION

The aim of the prevailing study was to estimate incidence rates of proximal humeral fractures and to assess changes in trend in the Austrian population aged 50 years and above, over a period of 20 years (1989-2008).

METHODS

Number of proximal humeral fractures were obtained from the Austrian Hospital Discharge Register for the entire population >50 years of age. Adjustment factors were determined for multiple registrations of the same diagnosis, and for the fact that not all patients with proximal humeral fractures are treated in an inpatient setting. To analyze the overall change in this type of fracture for the period, average annual changes expressed as incidence rate ratios were calculated.

RESULTS

The estimated age-standardized incidence (fractures per 100,000 individuals) of proximal humeral fractures among Austrians >50 years of age increased in men from 112 (95% CI, 99-124) to 141 (129-153) and in women from 222 (202-241) to 383 (360-406). The increase appeared to be linear with no leveling off towards the end of the study period.

CONCLUSION

While some caution is necessary when interpreting the results given the use of adjustment factors, there appears to have been a rise in the incidence of proximal humeral fractures in Austria in both men and women, with no leveling off in recent years. The reasons for this are not clear, but in the light of previously reported leveling off in the increase in the incidence of hip fractures, a change in the patterns of falls cannot be ruled out.

Do concomitant fractures with hip fractures influence complication rate and functional outcome?

BACKGROUND

Owing to the aging population, the incidence of hip fractures is increasing. While concomitant fractures are not uncommon, it is unclear how they influence subsequent function.

QUESTIONS/PURPOSES

Therefore, we determined (1) the incidence, type and treatment of concomitant fractures accompanying hip fractures, (2) the length of hospital stay, (3) the impact of concomitant fractures on mortality and complication rate, and (4) patients' function.

METHODS

We retrospectively reviewed 402 patients older than 60 years with hip fractures. We recorded the presence of concomitant fractures and their treatment. We analyzed the duration of hospital stays, in-hospital mortality, perioperative complications, and function. We recorded function with the Barthel Index, Harris hip score, and timed up and go test. For this study we followed patients 1 year.

RESULTS

Twenty-two patients (5%) had concomitant fractures, the most frequent being proximal humeral fractures (n = 8) and distal radius fractures (n = 6). Patients without and with concomitant fractures had similar lengths of hospitalization (mean, 14 days; 95% CI, 13-15 days), in-hospital mortality (5% with concomitant fractures, 6% without concomitant fractures), and incidence of complications (41% versus 40%). Function at discharge and last followup were similar in both groups.

CONCLUSION

The most frequent concomitant fractures were typical osteoporotic fractures (radial and humeral fractures). Concomitant fractures did not influence length of hospitalization, in-hospital mortality, complication rate, and function. Hip fracture and comorbidities predicted the incidence of complications and patients' function.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

[Common fractures in a general practice: indication for operations and modern operative technique]

Distal radius, clavicle, malleolar and proximal humerus fractures belong to the most frequent fracture types in every day practice. The initial diagnose with conservative therapy or the postoperative care is often carried out by the general practitioner. In recent years, therapy modality of these fractures changed. With the development of angular stable implants and minimal invasive operations technique, operative treatment is favoured mainly in osteoporotic bone. The mentioned fractures are highlighted.

Remaining lifetime and absolute 10-year probabilities of osteoporotic fracture in Swiss men and women

SUMMARY

Remaining lifetime and absolute 10-year probabilities for osteoporotic fractures were determined by gender, age, and BMD values. Remaining lifetime probability at age 50 years was 20.2% in men and 51.3% in women and increased with advancing age and decreasing BMD. The study validates the elements required to populate a Swiss-specific FRAX model.

INTRODUCTION

Switzerland belongs to high-risk countries for osteoporosis. Based on demographic projections, burden will still increase. We assessed remaining lifetime and absolute 10-year probabilities for osteoporotic fractures by gender, age and BMD in order to populate FRAX algorithm for Switzerland.

METHODS

Osteoporotic fracture incidence was determined from national epidemiological data for hospitalised fractured patients from the Swiss Federal Office of Statistics in 2000 and results of a prospective Swiss cohort with almost 5,000 fractured patients in 2006. Validated BMD-associated fracture risk was used together with national death incidence and risk tables to determine remaining lifetime and absolute 10-year fracture probabilities for hip and major osteoporotic (hip, spine, distal radius, proximal humerus) fractures.

RESULTS

Major osteoporotic fractures incidence was 773 and 2,078 per 100,000 men and women aged 50 and older. Corresponding remaining lifetime probabilities at age 50 were 20.2% and 51.3%. Hospitalisation for clinical spine, distal radius, and proximal humerus fractures reached 25%, 30% and 50%, respectively. Absolute 10-year probability of osteoporotic fracture increased with advancing age and decreasing BMD and was higher in women than in men.

CONCLUSION

This study validates the elements required to populate a Swiss-specific FRAX model, a country at highest risk for osteoporotic fractures.

Rate of proximal humeral fractures in older Finnish women between 1970 and 2007

Low-trauma fractures of older women are a major public health problem. Nevertheless, nationwide information on recent trends of proximal humeral fractures is sparse. We assessed the current trend in the number and rate (per 100,000 persons) of low-trauma fractures of the proximal humerus among 80-year-old or older women in Finland, a European Union country with a well-defined white population of 5.3 million, by taking into account all women who were admitted to our hospitals for primary treatment of such fracture in 1970-2007. The number of low-trauma fractures of the proximal humerus among 80-year-old or older Finnish women rose continuously between 1970 (32 fractures) and 2007 (478 fractures), but because of a simultaneous, sharper rise in population at risk, the age-adjusted fracture rate (showing a clear rise from 88 fractures per 100,000 persons in 1970 to 304 fractures in 1995) became stabilized between 1995 and 2007 (298 fractures per 100,000 persons in 2007). In conclusion, the clear rise in the rate of low-trauma fractures of the proximal humerus in Finnish elderly women from early 1970s until mid 1990s has been followed by stabilized fracture rates. Reasons for this are largely unknown, but a cohort effect toward a healthier aging population with improved functional ability and reduced risk of injurious falls cannot be ruled out.

[Epidemiology and perspectives in traumatology of the elderly]

Corresponding to the demographic development, fractures of the humerus, wrist, or hip will occur noticeably more often during the next four decades. The number of patients with hip fractures will increase to 170% of present-day numbers, and in the age group >80 years to 250%. Trauma surgical departments should train their staff as well as adapt their workflows and ambient conditions to this demanding clientele to be prepared for these changes. For the elderly, a fracture may lead to need for permanent home care, which is why postoperative transfer to ambulatory care is especially important. The expected cost progression in traumatology of the elderly may be moderated by the conjunction of inpatient and ambulatory care, the utilization of synergies among the different service types, and by implementation of prophylaxis for osteoporosis and falls.

[Epidemiology and economic implications of fractures of proximal femur, proximal humerus, distal radius and fracture-dislocation of ankle]

The authors analyze the results of their long-term follow-up of basic epidemiological characteristics in fractures of proximal humerus (1,464 patients), distal radius (2,514 patients), proximal femur (3,340 patients) and fracture-dislocation of the ankle (1 195 patients). In fractures of the proximal femur, the average age was 78 years; 71.6 years in men and 80.3 years in women; male-female ratio was 27:73. In fractures of the proximal humerus, the average age was 67 years; 58.8 years in men and 71.2 years in women; male-female ratio was 30:70. In fractures of the distal radius, the average age was 59 years; 45.8 years in men and 64.7 years in women; male-female ratio was 29:71. In fracture-dislocation of the ankle the average age was 49 years; 43.4 years in men and 54.7 years in women; male-female ratio was 50:50. Until 5th decade men had higher representation in all groups of fractures, starting from 6th decade the ratio changed. Introduction of new implants (locking plate, new generation of nails) for fractures of the distal radius and proximal humerus increased significantly the percentage of patients operated on.

Isolated tuberosity fractures of the proximal humeral: current concepts

Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes.

Second-generation concepts for locked plating of proximal humerus fractures

Displaced fractures of the proximal humerus remain particularly difficult to treat. Because of the poor quality of cancellous bone, it seemed that locking plates would be ideally suited for fixation in this region. However, as clinical reports begin to become available, it appears that these plates are not a panacea for these fractures and may be associated with a high complication rate. Coupled with the generally poor long-term outcomes of hemiarthroplasty, new fixation methods must be sought. Several technical factors, techniques, and alternative approaches have recently been described as possibly improving fixation stability in these fractures. Specifically, the anterolateral acromial approach, which avoids vascularity exposure, allows direct access to the lateral plating zone, and minimizes soft-tissue dissection, may be useful. Mechanical support of the medial column when anatomic cortical contact is not possible is also critical to maximizing stability. This may be achieved either with purposeful inferomedial humeral head screws or endosteal fibula allograft augmentation.

Complex posterior fracture-dislocation of the shoulder. Epidemiology, injury patterns, and results of operative treatment

BACKGROUND

Complex posterior fracture-dislocations of the shoulder are rare and often associated with poor long-term function regardless of the choice of treatment. The purposes of this study were to evaluate the epidemiology and pathological anatomy of posterior fracture-dislocations of the shoulder and to assess the clinical and radiographic outcomes of a specific treatment protocol of open reduction and internal fixation.

METHODS

We studied the demographic details of a consecutive series of twenty-six patients (twenty-eight shoulders in nineteen men and seven women with a mean age of fifty-three years) who sustained acute posterior dislocation of the humeral head with an associated Neer two, three, or four-part fracture. We used age and gender-specific local census data to assess the incidence of injury in our local population. All patients were treated by open relocation of the humeral head, bone-grafting of humeral head defects if they were causing residual shoulder instability, and internal fixation of the fracture. We recorded the prevalence of fracture complications that were clinically and radiographically apparent and assessed the functional outcome using three validated scoring systems (the Short Form-36 general health measure, the Disabilities of the Arm, Shoulder and Hand score, and the Constant score).

RESULTS

The overall incidence of posterior fracture-dislocations was 0.6 per 100,000 population per year. The peak incidence was in middle-aged men, and most injuries were sustained during a seizure or a fall from a height. In all patients, there was a displaced primary fracture of the anatomic neck of the humerus, propagating from the area of an osteochondral fracture of the anterior aspect of the humeral head (a reverse Hill-Sachs lesion). We recognized three subtypes determined by the extent of the secondary fracture lines. At two years after surgery, the median Constant score was 83.5 points and the median Disabilities of the Arm, Shoulder and Hand score was 17.5 points. The eight components of the Short Form-36 score were not significantly different from those of age and sex-matched controls at two years.

CONCLUSIONS

Acute complex posterior fracture-dislocations of the shoulder are rare, but they occur in patients who are younger than the majority of other patients who sustain a proximal humeral fracture. The use of open reduction and internal fixation to treat these fractures is associated with a relatively low risk of postoperative complications, and the functional outcome is generally favorable.

Shoulder dystocia with and without brachial plexus injury: experience from three centers

This article compares the maneuvers used to relieve shoulder dystocia (SD) at three centers and discerns risk factors for brachial plexus injury (BPI) following SD. Retrospectively SD managed at three tertiary centers was identified and charts reviewed. Unconditional logistic regression was used to identify risk factors for BPI. SD was encountered in 2% of vaginal deliveries (624/29,591), and BPI followed impacted shoulders in 6% (38/624). The rate of SD among the three institutes varied significantly (1.5%, 2%, 0.8% of vaginal births; P < 0.0001). The use of the McRoberts' maneuver to relieve SD differed significantly by center (98%, 80%, 90%; P < 0.0001) as did the use of suprapubic pressure (83%, 66%, 54%; P < 0.0001). The rate of BPI per case of SD (10%, 3%, 5%) was significantly different at the three centers ( P = 0.009). A multivariate predictive model indicates that among those with and without concomitant fractures, there is a significantly increased risk of BPI if three or more maneuvers are used rather than two or fewer. In conclusion, not only does the rate of SD and BPI following it occur at significantly different rates, the management differs too. Compared with two maneuvers or fewer, there is an increased risk of BPI if three or more maneuvers are used to relieve SD.

Defining the relationship between rotator cuff injury and proximal humerus fractures

The purpose of our study was to correlate radiographic characteristics with rotator cuff tendon injury on magnetic resonance imaging after fractures of the proximal humerus. We prospectively obtained magnetic resonance imaging on 30 patients with proximal humerus fractures after classifying each fracture radiographically using Neer and AO systems and determining the displacement of the greater tuberosity. Twelve patients (40.0%) had either complete ruptures or avulsions of at least one of the rotator cuff muscles. No abnormality was identified in the rotator cuff musculature in nine patients (29%). Severity of injury to the rotator cuff tendons increased substantially with respect to increasing AO and Neer classes and 5 mm or greater displacement of the greater tuberosity fragment. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures.

Refractures of the upper extremity in children

PURPOSE

To investigate the etiologic factors related to refractures of the upper extremity in children.

PATIENTS AND METHODS

Eighteen refractures were divided into three groups according to the location of the initial fractures. They were analyzed in terms of the type of refractures, fracture patterns, and the existence of an underlying deformity.

RESULTS

Of nine supracondylar fractures of the humerus, two involved refractures at the supracondylar region, and the other seven involved the lateral condyle. Underlying cubitus varus was present in six cases. Of three lateral condylar fractures of the humerus, one had a refracture at the supracondylar region, and two cases involved the lateral condyle. One had an underlying cubitus varus. All but one case in the humeral fractures group were late refractures, and were treated with surgery. Of six repeat forearm fractures, five were early type and occurred at the original site within nine weeks, four at the diaphysis of both bones of the forearm, and one at the diaphysis of the ulna. All cases in the forearm fractures group, save one, had volar angulation before the refracture, and were treated conservatively.

CONCLUSION

In the humerus, the underlying cubitus varus was the most important predisposing factor for refractures and lateral condyle fractures were common. In the forearm, volar angulation of the diaphysis was related to refractures, and complete and circular consolidation of the primary fracture of the forearm was thought to be important in prevention.

Self-reported diseases and the risk of non-vertebral fractures: the Tromsø study

We wanted to estimate the independent fracture risk associated with chronic diseases for men and women separately, adjusting for other known risk factors. This is a population-based study of all those who attended the fourth survey (1994-1995) in the Tromsø Study (n=27,159) who were followed until 31 December 2000 with respect to non-vertebral fractures. At baseline the age range was 25-98 years. Chronic disease cases were defined by self-report in questionnaires. All non-vertebral fractures were registered by computerized search in radiographic archives in the sole provider of radiographic service in the area. A total of 446 and 803 non-vertebral fractures were registered among men and women, respectively. Self-reported diabetes mellitus, stroke, asthma, hypo- and hyperthyroidism and psychiatric disorders were associated with increased fracture risk. Multivariate analyses showed an independent risk of fractures associated with self-reported diabetes mellitus, hypothyroidism and psychiatric disorders among men. Among women the independent risk was associated with self-reported asthma, hypo- and hyperthyroidism and psychiatric disorders. Self-reported heart disease had a protective effect on wrist fracture, especially in women. Increased burden of chronic diseases increase the risk of all non-vertebral (P<0.0001), wrist (P=0.005), proximal humerus (P=0.0004) and hip fracture (P=0.0002) in men, and for the proximal humerus (P=0.003) and hip fracture (P=0.04) in women. There was an independent fracture risk associated with self-reported diabetes mellitus, asthma, hypo- and hyperthyroidism and psychiatric disorders in men and women. Increasing burden of disease increased fracture risk in both men and women.

Clinical importance of comorbidity in patients with a proximal humerus fracture

The aim of this prospective study of 100 consecutive patients with a proximal humerus fractures primarily was to investigate the prevalence and importance of poor health and comorbidity. Seventeen men and 83 women with a mean age of 73 years were involved together with 138 age and gender-matched controls. Twenty patients with a mean age of 81 years, were severely ill with a physical and/or mental disorder when they got their proximal humerus fracture. The 1-year mortality of this subgroup was 40% compared with 8% in the control group. Fifty-seven patients with a mean age of 74 years reported concomitant disorders compared with 54 of 78 (69%) controls. Twenty-three patients with a mean age of 67 years, reported no comorbidity compared with 25 of 34 (74%) in the control group. Sixty-seven patients were followed up on for 1 year and were evaluated clinically and radiographically. The Constant-Murley shoulder assessment was used. The 12 surviving severely ill patients were not able to attend the followup evaluation. In the remaining patients there was no significant difference after 1 year in pain, function, Constant-Murley score or radiographic healing of the injured shoulder between individuals with or without comorbidity. Patients with symptomatic shoulders at followup initially had significantly more frequently displaced fractures.

LEVEL OF EVIDENCE

Prognostic study, Level II (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Update in the epidemiology of proximal humeral fractures

We sought to determine current trends in the number of fall-related and osteoporosis-related proximal humeral fractures in elderly Finns during last three decades. We collected data from the National Hospital Discharge Register on all patients 60 years or older who were admitted to Finnish hospitals from 1970 to 2002 for primary treatment of proximal humeral fractures. Fractures induced by traffic accidents or other high-energy traumas were excluded. The number and incidence (per 100,000 patients) of fractures increased from 208 (number) and 32 (incidence) in 1970 to 1120 (number) and 105 (incidence) in 2002. The age adjusted incidence of proximal humeral fractures also showed an increase, from 51 (1970) to 129 (2002) in women, and from 14 (1970) to 48 (2002) in men. In women 80 years or older, the age specific incidence of fracture increased from 90 (1970) to 294 (2002), while in the other age groups trend changes were less extensive. The mean patient age also increased, from 73 years (1970) to 78 years (2002) in women and from 70 years (1970) to 73 years (2002) in men. If these trends continue, the number of fractures in elderly Finns will triple during the next three decades.

LEVEL OF EVIDENCE

Prognostic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Characteristics of an isolated greater tuberosity fracture of the humerus

BACKGROUND

Most classification systems tend to include isolated greater tuberosity fractures in the group of proximal humeral fractures. The purpose of this study was to elucidate demographic differences between isolated greater tuberosity fractures and the other proximal humeral fractures.

METHODS

Altogether, 610 proximal humeral fractures were divided into isolated greater tuberosity fractures of the proximal humerus (group I) and all other proximal humeral fractures (group II). The two groups were analyzed according to their incidence, age and sex distribution, presence of dislocation, and associated chronic medical problems.

RESULTS

Group I comprised 18.9% and group II 81.1% off all fractures. The mean age of group I was 42.8 years, and that of group II was 54.2 years. Of the 115 (67.8%) patients in group I, 78 (67.8%) were male. In contrast, most of the group II patients were female (332/495, 67.1%). A higher incidence of glenohumeral dislocation occurred in group I (6.9%) than in group II (3.4%). Of the 495 group II patients, 175 (35.4%) had medical problems, including endocrine, cardiovascular, pulmonary, hepatic, and renal disease, whereas only 15 of the 115 (13%) patients in group I had such problems.

CONCLUSIONS

Patients with isolated greater tuberosity fractures of the proximal humerus were different demographically, and their treatment and classification should be considered separately from that for other proximal humeral fractures.

[Treatment of two-part proximal humeral fractures with external fixators]

BACKGROUND

We aimed to evaluate the results of the closed manipulation or transcutaneous reduction and external fixation in the treatment of two-part fractures.

METHODS

Eight patients with two-part proximal humerus fractures who had been treated in our clinic with closed manipulation or transcutaneous reduction and external fixation between 1996-2001 were evaluated for this study. We evaluated the final functional status according to the Neer's classification system.

RESULTS

Mean age of the patients was 42 (21-75) years. The major aetiologic factor was motor vehicle accident (in 5 cases). Follow-up time was 2 to 4.5 years. Mean union time was 16 weeks (10 to 24). Nonunion and avascular necrosis of the humeral head have not been observed in none of the cases. Superficial pin tract infection was developed in three cases. All of them were treated successfully with antibiotics. Functional results according to Neer's classification were as follows: 5 good. 2 fair and 1 failed. Mean score 77, 25 (50 to 89).

CONCLUSION

External fixation of displaced two-part fractures of proximal humerus can be assessed as a reliable method with respect to satisfactory fracture reduction and stability, low rate of complications and good early functional results-obtained with this technique.

Risk factors for proximal humerus fracture

This case-control study of proximal humerus fracture included 448 incident female and male cases and 2,023 controls aged 45 years or older identified in five Northern California Kaiser Permanente Medical Centers in 1996-2001. Data were collected by using an interviewer-administered questionnaire. Some factors related to low bone mass, including number of fractures since age 45 years and low dietary calcium intake, were associated with increased risks of fracture, and factors thought to protect against bone loss, such as menopausal hormone therapy and calcium carbonate tablet use, were associated with reduced risks. Fall-related risk factors included previous falls, diabetes mellitus, and difficulty walking in dim light. Possible fall-related risk factors suggested for the first time in this study were seizure medication use (adjusted odds ratio (OR) = 2.80, 95% confidence interval (CI): 1.45, 5.42), depression (OR = 1.34, 95% CI: 0.98, 1.84), almost always using a hearing aid (OR = 1.92, 95% CI: 1.12, 3.31 vs. never prescribed), and left-handedness (OR = 2.36, 95% CI: 1.51, 3.68 vs. right-handedness). Difficulty with activities of daily living and lack of physical activity tended to be associated with increased risk. Prevention of falls among frail, osteoporotic persons would likely reduce the frequency of proximal humerus fracture.

Clinical factors predicting fractures associated with an anterior shoulder dislocation

OBJECTIVES

To identify risk factors for fractures associated with an anterior shoulder dislocation treated in an emergency department (ED).

METHODS

A retrospective case-control study over five years of patients with an anterior shoulder dislocation was accomplished in a university-affiliated ED. Chart review identified possible predictors of fractures. Comparing the profile of patients having a clinically important fracture associated with their shoulder dislocation (cases) with those sustaining a noncomplicated dislocation (controls) provided the outcome measure.

RESULTS

A total of 334 patients were included in the study. Eighty-five (25.5%) had a clinically important fracture-dislocation, and the remaining 249 (74.5%) sustained a noncomplicated shoulder dislocation. Chi-square, logistic regression, and recursive partitioning analysis showed three significant factors for the presence of fracture-dislocation: 1) age 40 years or older, 2) a first episode of dislocation, and 3) mechanism of injury (i.e., a fall greater than one flight of stairs, a fight/assault episode, or a motor vehicle crash). A multiple logistic regression model estimated the significant adjusted odds ratios (and their 95% confidence intervals [95% CIs]) for each of the three factors: 5.18 (95% CI = 2.74 to 9.78), 4.23 (95% CI = 1.82 to 9.87), and 4.06 (95% CI = 1.95 to 8.48), respectively. A predictive model using any one of the three factors reached a sensitivity of 97.7% (95% CI = 91.8% to 99.4%), a specificity of 22.9% (95% CI = 18.1% to 28.5%), and a negative predictive value of 96.6% (95% CI = 88.3% to 99.6%).

CONCLUSIONS

Three risk factors predict clinically important fractures that are associated with shoulder dislocation: age, first episode, and mechanism of dislocation. A prospective validation may lead to standardized use of prereduction radiographs of the shoulder in the ED.

The influence of an insulin-like growth factor I gene promoter polymorphism on hip bone geometry and the risk of nonvertebral fracture in the elderly: the Rotterdam Study

The absence of the wildtype allele of a promoter polymorphism of the IGF-I gene is associated with increased risk (1.5; 95% CI, 1.1-2.0) of fragility fracture in women (n = 4212) but not in men (n = 2799). An approximation of hip bone geometry (from DXA) suggested the polymorphism is associated with bone strength and stability in gender-specific ways.

INTRODUCTION

Previously, we found a CA-repeat promoter polymorphism in the insulin-like growth factor I (IGF-I) gene associated with IGF-I levels and BMD in postmenopausal women, but the relationship with fractures is unclear. In this large population-based study of elderly men and women, we examined the association between this IGF-I promoter polymorphism with parameters of bone geometry and the occurrence of fractures.

MATERIAL AND METHODS

Within the Rotterdam Study, a prospective population-based cohort, the IGF-I polymorphism was analyzed in relation to incident nonvertebral fractures in 2799 men and 4212 women followed on average for 8.6 years. Furthermore, we estimated structural parameters of hip bone geometry indirectly from DXA outputs of the femoral neck in 2372 men and 3114 women. We studied neck width, cortical thickness, and the cortical buckling ratio and the section modulus as indexes of bone stability and bending strength.

RESULTS

Women heterozygotes and noncarriers of the allele had, respectively, 1.2 (95% CI, 1.0-1.5) and 1.5 (95% CI, 1.1-2.0) increased risk of having a fragility fracture at older age compared with homozygotes for the 192-bp allele (p trend = 0.0007). In men, fracture risk was not influenced by the polymorphism. Compared with homozygotes for the 192-bp allele, noncarrier males had approximately 1% narrower femoral necks and 2.2% lower section moduli (p trend < 0.05). Noncarrier females had 1.7% thinner cortices and 1.6% higher buckling ratios (p trend < 0.05) but no significant differences in femoral neck widths and section moduli. In women with low body mass index, genotype differences in bone strength (section modulus) and fracture risk were accentuated (p interaction = 0.05). The genotype-dependent differences in hip bone geometry did not fully explain the genotype-dependent differences in fracture risk.

CONCLUSIONS

The CA-repeat promoter polymorphism in the IGF-I gene is associated with the risk for fragility fracture at old age in women and with bone structure in both genders.

Increased fragility in patients with fracture of the proximal humerus: a case control study

The aim of this study was to evaluate whether a fracture of the proximal humerus is associated with an increased prevalence of preceding fractures or a risk of subsequent fractures. All patients who were treated at the Malmö General Hospital in 1987 for a fresh fracture of the proximal humerus were identified, representing practically all fractures of the proximal humerus in Malmö city (250,000) that year. Two hundred fifty-three adult patients, 54 men with an average age of 66 (24-90) and 199 women with a mean age of 74 (22-98) years, were included in the study together with 475 age- and gender-matched control persons. In 1999, fracture prevalence of patients and controls were rated by a survey at the Dept. of Radiology. There was a significantly increased prevalence of previous fractures before 1987 in the humerus fracture group with an odds ratio (OR) of 3.5 [95% confidence interval (95% CI), 2.2-5.5] for a spinal fracture, OR 1.8 (95% CI, 1.3-2.6) for a previous fracture to the upper extremity, and OR 1.8 (95% CI, 1.2-2.6) for a preceding fracture of the lower limb. The proximal humerus fracture also predicted a significantly increased risk of a subsequent fracture. The hazard ratio (HR) was 2.5 (95% CI, 1.7-3.7) for a forthcoming spinal fracture, HR 2.8 (95% CI, 2.0-3.7) for a future fracture of the upper extremity, and HR 2.0 (95% CI, 1.2-3.5) for a lower limb fracture. In a subgroup of male patients, an almost five times increased risk of sustaining subsequent extremity fractures was observed. In summary, a fracture of the proximal humerus is associated both with increased prevalence of previous fractures of the spine and extremities and also predicting an increased risk of future fractures.

The prognosis following acute primary glenohumeral dislocation

We have studied 105 patients with 107 acute, primary, dislocations of the glenohumeral joint seen between January 1, 1991 and July 1, 1994. The mean time of follow-up was 71 months (46 to 91). In 34% the injury occurred during a sports activity and in 28% at home. The bias toward sport was even greater in patients less than 40 years of age, and in men. In patients older than 40 years of age, and in women, the dislocation occurred more often at home. The overall probability of recurrence within four years was 26%. Age was the most significant prognostic factor in recurrence which took place in 64% of patients less than 20 years of age and in 6% of those older than 40 years. Statistically, there was no difference between the rates of recurrence in patients who were active in sport and those who were not. The mean Rowe score for the whole group was 87 (15 to 100). Associated fractures were found in 20 patients (19%) and nerve injuries in 22 (21%). None of those in whom a fracture of the greater tuberosity was seen subsequently suffered a recurrent dislocation. At follow-up we found that 36 patients (34%) had not returned to their former employment but in only 2% was this owing to the injured shoulder.

Radiographic analysis of bone defects in chronic anterior shoulder instability

PURPOSE

To describe the incidence of bony lesions accompanying chronic anterior shoulder instability using fluoroscopically controlled radiography.

TYPE OF STUDY

Case series of radiographic findings of patients with chronic anterior shoulder instability.

METHODS

Radiographs of 160 shoulders in 156 patients with recurrent anterior shoulder instability were retrospectively evaluated; 132 shoulders had experienced recurrent dislocations, 18 shoulders had experienced recurrent subluxations, and 10 shoulders showed evidence of anterior instability at arthroscopy despite no reported history of instability. Fluoroscopically controlled radiographic views included an anteroposterior view with the humeral head in 3 rotations and a glenoid profile view with a comparison view of the contralateral shoulder.

RESULTS

A humeral impaction fracture was identified on the anteroposterior radiographs in 117 of 160 shoulders (73.1%). The glenoid profile view showed an osseous lesion of the glenoid in 126 of 160 shoulders (78.8%). The anteroposterior radiograph showed an osseous lesion of the glenoid in an additional 13 shoulders (8.2%). Overall, an osseous lesion, either humeral or glenoid, was identified in 152 of 160 shoulders (95.0%).

CONCLUSIONS

This study shows the frequent presence of bony lesions in patients with anterior shoulder instability.