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

[Indication for primary fracture prosthesis of the shoulder]

Although fractures of the proximal humerus are one of the most common osteoporotic fracture types, no generally accepted treatment algorithm exists in the current literature. For young patients with high functional demands and good rehabilitation potential, we recommend humeral head salvage therapy. If symptomatic humeral head necrosis occurs, the implantation of an anatomic endoprothesis is possible on a secondary basis. For patients with a biological age > 70 years suffering from a persisting defect of the rotator cuff along with a humeral head fracture or from a multiple fragment fracture of the humeral head, we increasingly prefer implantation of a reverse shoulder prosthesis due to good clinical results. However, because of technical aspects and a high complication rate, treatment using the reverse fracture prosthesis should be reserved for surgeons with expertise in this particular field. After analyzing the fracture- and patient-specific risk factors and performance expectations, the trauma surgeon can select the best individual therapy with the patient.

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.

Trends in incidence and costs of injuries to the shoulder, arm and wrist in The Netherlands between 1986 and 2008

Background

Upper extremity injuries account for a large proportion of attendances to the Emergency Department. The aim of this study was to assess population-based trends in the incidence of upper extremity injuries in the Dutch population between 1986 and 2008, and to give a detailed overview of the associated health care costs.

Methods

Age-standardized incidence rates of upper extremity injuries were calculated for each year between 1986 and 2008. The average number of people in each of the 5-year age classes for each year of the study was calculated and used as the standard (reference) population. Injury cases were extracted from the National Injury Surveillance System (non-hospitalized patients) and the National Medical Registration (hospitalized patients). An incidence-based cost model was applied in order to estimate associated direct health care costs in 2007.

Results

The overall age-adjusted incidence of upper extremity injuries increased from 970 to 1,098 per 100,000 persons (13%). The highest incidence was seen in young persons and elderly women. Total annual costs for all injuries were 290 million euro, of which 190 million euro were paid for injuries sustained by women. Wrist fractures were the most expensive injuries (83 million euro) due to high incidence, whereas upper arm fractures were the most expensive injuries per case (4,440 euro). Major cost peaks were observed for fractures in elderly women due to high incidence and costs per patient.

Conclusions

The overall incidence of upper extremity injury in the Netherlands increased by 13% in the period 1986–2008. Females with upper extremity fractures and especially elderly women with wrist fractures accounted for a substantial share of total costs.

Fall-related fracture trends among elderly in Sweden--exoring transitions among hospitalized cases

PROBLEM

Fall-related injuries have been a cause of worry during the end of the 20th century with increasing trends among the elderly.

METHOD

Using data from the Swedish National Patient Register (NPR) based on hospital admissions, this study explores the trends in fall-related fractures between 1998 and 2010.

RESULTS

The data shows a decreasing trend in fall-related fractures in all age- and sex-specific groups apart from men 80 years and above. While hip fracture incidence rates decreased in all age- and sex-specific groups, both central fractures and upper extremity fractures have increased in all age- and sex-specific groups apart from women 65-79 years. Lower extremity fractures have increased in the older age groups and decreased in the younger.

DISCUSSION

The differences found between the groups of fractures and by age- and sex-specific groups indicate a possible transition where more serious fractures are decreasing while less serious fractures increase among hospitalized cases.

SUMMARY

Perhaps due to a focus on hip fracture prevention, this study shows that while the incidence rate of hospitalized hip fractures has decreased, other fall-related hospitalized fractures have increased.

IMPACT ON INDUSTRY

Potentially, this could be indicative of a healthier younger elderly, coupled with a frailer older elderly requiring more comprehensive healthcare also for less serious injuries. Further research is needed to confirm our results.

The complexity of proximal humeral fractures is age and gender specific

BACKGROUND

Studies that investigated possible associations between the complexity of proximal humeral fractures and patient characteristics are rare. We hypothesized that the grade of fracture complexity may correlate with age and gender of hospitalized, adult patients.

METHODS

Based on the Neer classification, we defined four radiological grades of fracture complexity. The data of adult patients that were treated during a 9-year period at a German hospital serving a town of 80,000 inhabitants was reviewed.

RESULTS

Seven hundred and eighty fractures were evaluated [518 female/262 male (66.41/33.59 %), average age 64.2 years (range 17.4-99.2)]. During the study period, the number of fractures increased to 167 %. Almost two-thirds of the patients were females and older than 60 years. Of all fractures, 86 % were displaced fractures. In patients younger than 60 years, 1.99-fold more complex fractures occurred in males (32.4 %) than in females (16.2 %). In contrast, in patients older than 60 years, 1.72-fold more complex fractures occurred in females (54.1 %) than in males (31.5 %). There was a significant association between low-energy trauma and female gender older than 60 years.

CONCLUSIONS

Our study demonstrated an overall increase of displaced proximal fractures. The vast majority of patients with more complex fractures consisted of female patients older than 60 years.

Trends in the surgical treatment of proximal humeral fractures - a nationwide 23-year study in Finland

Background

Proximal humeral fractures are common osteoporotic fractures. Most proximal humeral fractures are treated non-surgically, although surgical treatment has gained popularity. The purpose of this study was to determine changes in the surgical treatment of proximal humeral fractures in Finland between 1987 and 2009.

Methods

The study covered the entire adult (>19 y) population in Finland over the 23-year period from 1st of January 1987 to 31st of December 2009. We assessed the number and incidence of surgically treated proximal humeral fractures in each year of observation and recorded the type of surgery used. The cohort study was based on data from Finnish National Hospital Discharge Register.

Results

During the 23-year study period, a total of 10,560 surgical operations for proximal humeral fractures were performed in Finland. The overall incidence of these operations nearly quadrupled between 1987 and 2009. After the year 2002, the number of patients treated with plating increased.

Conclusion

An increase in the incidence of the surgical treatment of proximal humeral fractures was seen in Finland in 1987–2009. Fracture plating became increasingly popular since 2002. As optimal indications for each surgical treatment modality in the treatment of proximal humeral fractures are not known, critical evaluation of each individual treatment method is needed.

Clinical review: Ethnic differences in bone mass--clinical implications

CONTEXT

Differences in bone mineral density (BMD) as assessed with dual-energy x-ray absorptiometry are observed between geographic and ethnic groups, with important implications in clinical practice.

EVIDENCE ACQUISITION

PubMed was employed to identify relevant studies. A review of the literature was conducted, and data were summarized and integrated.

EVIDENCE SYNTHESIS

The available data highlight the complex ethnic variations in BMD, which only partially account for observed variations in fracture rates. Factors contributing to ethnic differences include genetics, skeletal size, body size and composition, lifestyle, and social determinants. Despite BMD differences, the gradient of risk for fracture from BMD and other clinical risk factors appears to be similar across ethnic groups. Furthermore, BMD variation is greater within an ethnic population than between ethnic populations. New imaging technologies have identified ethnic differences in bone geometry, volumetric density, microarchitecture, and estimated bone strength that may contribute to a better understanding of ethnic differences in fracture risk.

CONCLUSIONS

Factors associated with ethnicity affect BMD and fracture risk through direct and indirect mechanisms.

Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures

OBJECTIVE

In the treatment of proximal humeral fractures, the decision between open fixation and arthroplasty is often difficult. Applicable radiographic prognostic factors would be useful. The purpose of the present study was to investigate the influence of calcar comminution on the clinical and radiologic outcome after locking plate fixation of these fractures.

METHODS

In patients with proximal humeral fractures that were treated by locking plate fixation, fracture morphology and the presence of comminution of the calcar were documented on preoperative radiographs. Follow-up for at least 2 years with radiologic assessment and functional outcome measurements including Constant score, subjective shoulder value (SSV), disabilities of the arm, shoulder and hand score (DASH), visual analogue scale (VAS) and short form (SF)-36 was performed.

RESULTS

Follow-up examination (50.8±20.6 months) was possible in 74 patients (46 female, 28 male, age 63.0±15.9 years). Mean absolute Constant score (CS abs), CS adapted to age and gender (CS adap), DASH, SSV and VAS were 72.4±14.5, 85.2±17.3%, 15.7±17.3, 80.3±19.6% and 2.1±2.2. Nonunion was present in 1.3%, cut-out in 5.4% and implant failure in 1.3%. Avascular necrosis (AVN) was seen in 12.2%, in three cases >24 months after the initial trauma. In the presence of calcar comminution, the clinical outcome (CS abs, CS adap, SSV and several parameters of SF-36) was significantly impaired, the odds ratio for these patients to have an absolute CS<65 was 4.4 (95% confidence interval (CI): 1.4-13.7).

CONCLUSIONS

The treatment of proximal humeral fractures with locking plate fixation achieves good clinical mid-term results. Calcar comminution is a relevant and easy-to-detect prognostic factor for the functional and subjective outcome in these fractures.

Epidemiology of proximal humerus fractures managed in a trauma center

Proximal humerus fractures (PHF) are osteoporotic fractures that affect women over 70 years of age. Like fractures of the femoral neck they have become a public health concern. As the population ages there is an increase in the number of people in poor general condition with an increased risk of falls on fragile bones. The incidence of these fractures has increased by 15% per year. All patients managed for PHF in our center in the past year were included in this prospective study (prospective cohort study; level 2). Three hundred and twenty-five patients were included with 329 fractures. There was a ratio of two women to one man. At the final follow-up 50 patients had died (15%) and 25 patients were lost to follow-up. The mean age was 70 years old. There were two types of risk factors. The first was fragile bones, and the second was patient specific risk of falls. The severity of the fracture increased with the age of the population. In the study by Charles S. Neer in 1970, 85% of PHF were not or were only slightly displaced, while this category percentage was only 42% in our study. Hospitalization was necessary in 43% of the cases in our study. Surgical management was necessary in 21%. This lack of relationship between the percentage of displaced fractures (58%) and the percentage of surgically treated fractures is a sign of the difficulties of managing this population, which is usually in poor general condition.

Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008

OBJECTIVE

To evaluate the occurrence of emergency department (ED) visits due to humerus fractures in the US.

METHODS

We analyzed the 2008 Nationwide Emergency Department Sample, which contained approximately 28 million ED records. We identified the cases of interest using diagnostic codes for proximal, shaft, and distal humerus fractures.

RESULTS

In 2008, approximately 370,000 ED visits in the US resulted from humerus fractures. Proximal humerus fractures were the most common, accounting for 50% of humerus fractures. The incidence rate of proximal humerus fractures followed the shape of an exponential function in the age groups 40-84 years for women (R(2) = 97.9%) and 60-89 years for men (R(2) = 98.2%). After the exponential increase in these age intervals, the growth rate of proximal humerus fracture slowed and eventually decreased. The peak occurrence of distal humerus fractures was in children ages 5-9 years; however, elderly women had an increased risk. As the baby boomer generation ages, unless fracture prevention programs improve, more than 490,000 ED visits due to humerus fractures are expected in 2030 when the youngest of the baby boomers turn age 65 years.

CONCLUSION

Compared to epidemiologic studies in Japan and European countries, the incidence rates of humerus fractures are substantially higher in the US. The high incidence rate of humerus fractures in the expanding elderly population may contribute to the recent trend of rapid increase in shoulder arthroplasty in the US. Rigorous safety measures to reduce falls and improved preventive treatments of osteoporosis are needed.

[Proximal humerus fracture: new aspects in epidemiology, fracture morphology, and diagnostics]

The incidence of proximal humerus fractures is rising and they constitute the third most frequent fracture in the elderly after femoral fractures in the hip area and radius fractures. They are caused by the age-related increase in osteoporosis. In contrast to young people, low-energy trauma involved in simple falls represents the mechanism that leads to the injury in older people. Numerous authors have introduced systems for the classification of proximal humerus fractures.After a thorough clinical examination of the affected extremity including assessment of circulation, motor function, and sensitivity, attention should be directed toward concomitant injuries, especially in the region of the shoulder girdle and thorax. Advocated imaging consists of anteroposterior and axial views of the affected shoulder. Disagreement over management of this fracture is quite considerable and treatment ranges from a conservative approach through to procedures for minimally invasive plate osteosynthesis, open fixed-angle locked plating, and nailing up to prosthetic replacement.

Declining age-adjusted incidence of fall-induced injuries among elderly Finns

BACKGROUND

Elderly people's fall-induced injuries are a major public health challenge.

METHODS

We determined the current trends in the number and age-adjusted incidence (per 100,000 persons) of fall-induced injuries among older adults in Finland by taking into account all persons 80 years of age or older who were admitted to Finnish hospitals for primary treatment of a first fall injury over the period 1970-2009.

RESULTS

The number of fall-induced injuries in elderly Finns increased considerably during the study period: for women and men separately, these numbers were from 927 to 10,333 (an 11-fold rise), and from 212 to 3,258 (a 15-fold rise), respectively. In both genders, the age-adjusted incidence (per 100,000 persons) of fall-induced injuries increased till the late 1990s but decreased thereafter, the incidence being 2,729 (women) and 1,455 (men) in 1970, and 5,930 (women) and 4,240 (men) in 2009. Even with the current injury incidence the number of these injuries is expected to more than double by the year 2030.

CONCLUSION

The rise in the age-adjusted incidence of hospital-treated fall injuries of 80 year old and older Finns from the 1970s to the late 1990s has been followed by declining injury rates. Despite this we have to effectively continue implementation of fall prevention actions.

Conflicting trends in fall-related injury hospitalisations among older people: variations by injury type

Despite advances in prevention, fall-related hospitalisation rates among older people are still increasing. Rates between 1998/1999 and 2008/2009 for non-facture-related injuries increased by 6.1% while fracture injuries declined by -0.4%. Varying trends in rates of different injury types makes it difficult to provide a definitive explanation for these changes.

INTRODUCTION

Despite advances in fall prevention research and practice, the rate of fall-related hospitalisations continues to increase. However, hip fracture rates appear to be declining. An examination of trends in types of injuries that contribute to the overall fall injury rate is required to establish which injuries are driving the falls admission rate. The aim of this paper is to examine trends in fall-related injury hospital admissions by injury type in New South Wales (NSW), Australia.

METHODS

A retrospective review of fall-related injury hospitalisations in NSW among individuals aged 65+ years, by injury type, was conducted from 1 July 1998 to 30 June 2009. Direct age-standardised admission rates were calculated. Negative binomial regression was used to examine the statistical significance of changes in trend over time of different hospitalised fall-related injuries.

RESULTS

The fall-related hospitalisation rate increased by 1.7% each year (p < 0.0001; 95% confidence interval (CI), 1.3-2.1%). However, the rate of fracture declined by -0.4% (p < 0.03; 95% CI, -0.8-0.0%); whereas, the non-fracture rate increased by 6.1% (p < 0.0001; 95% CI, 5.5-6.7%) annually. Rates for severe head injuries, rib and pelvic fracture increased while those for hip and forearm fracture declined.

CONCLUSIONS

It appears that while fall prevention efforts in NSW are not yet affecting the overall rate of injury hospitalisation, there has been a significant decline in the rates of some fractures. Opposing trends in the rates of other fracture admissions and a significant increase in the rate of non-fracture injuries associated with falls makes a definitive explanation for these changes difficult.

Secular decreases in fracture rates 1986-2006 for Manitoba, Canada: a population-based analysis

SUMMARY

We examined trends in fracture rates over 20 years in the Province of Manitoba, Canada. Hip fractures, major low-trauma fractures, and high-trauma fractures declined significantly from 1986 to 2006.

INTRODUCTION

Secular decreases in hip fracture rates have been reported in some countries. Whether this phenomenon applies to other fracture sites is not well described.

METHODS

We used 20 years of data from the Population Health Research Data Repository for the Province of Manitoba, Canada. Age-adjusted fracture rates were calculated for men and women age 50 years and older 1986-2006 according to fracture site and mechanism (presence/absence of external injury codes). Generalized linear models with generalized estimating equations were used to derive adjusted annual rates and test for linear change in men and women.

RESULTS

Major low-trauma fractures (hip, forearm, spine, and humerus) showed a significant annual linear decline in women (-1.2% [95% CI, -0.7% to -1.8%]) and in men (-0.4% [95% CI, -0.7% to -0.2%]). Hip fracture showed a significant annual decline for both sexes, while forearm and humerus fractures showed a significant decline only in women. The only fracture category that did not show a significant annual decline in either sex was the spine. The observed annual reduction in high-trauma fractures was even larger and did not show a sex difference (-1.8% [95% CI, -2.8% to -0.7%]).

CONCLUSION

We observed a decrease in both low-trauma and high-trauma fracture rates over the study period. This decline was apparent in years prior to widespread osteoporosis testing or availability of modern pharmacotherapy.

Effects of FRAX(®) model calibration on intervention rates: a simulation study

The WHO fracture risk assessment tool (FRAX(®)) estimates an individual's 10-yr major osteoporotic and hip fracture probabilities using a tool customized to the fracture epidemiology of a specific population. Incorrect model calibration could therefore affect performance of the model in clinical practice. The current analysis was undertaken to explore how simulated miscalibration in the FRAX(®) tool would affect the numbers of individuals meeting specific intervention criteria (10-yr major osteoporotic fracture probability ≥20%, 10-yr hip fracture probability ≥3%). The study cohort included 36,730 women and 2873 men aged 50yr and older with FRAX(®) probability estimates using femoral neck bone mineral density. We simulated relative miscalibration error in 10% increments from -50% to +50% relative to a correctly calibrated FRAX(®) model. We found that small changes in model calibration (even on the order of 10%) had large effects on the number of individuals qualifying for treatment. There was a steep gradient in the relationship between relative change in calibration and relative change in intervention rates: for every 1% change in calibration, there was a 2.5% change in intervention rates for women and 4.1% for men. For hip fracture probability, the gradient of the relationship was closer to unity. These results highlight the importance of FRAX(®) model calibration, and speak to the importance of using high-quality fracture epidemiology in constructing FRAX(®) tools.

Functional data modelling approach for analysing and predicting trends in incidence rates--an application to falls injury

SUMMARY

Policy decisions about the allocation of current and future resources should be based on the most accurate predictions possible. A functional data analysis (FDA) approach improves the understanding of current trends and future incidence of injuries. FDA provides more valid and reliable long-term predictions than commonly used methods.

INTRODUCTION

Accurate information about predicted future injury rates is needed to inform public health investment decisions. It is critical that such predictions derived from the best available statistical models to minimise possible error in future injury incidence rates.

METHODS

FDA approach was developed to improve long-term predictions but is yet to be widely applied to injury epidemiology or other epidemiological research. Using the specific example of modelling age-specific annual incidence of fall-related severe head injuries of older people during 1970-2004 and predicting rates up to 2024 in Finland, this paper explains the principles behind FDA and demonstrates their superiority in terms of prediction accuracy over the more commonly reported ordinary least squares (OLS) approach.

RESULTS

Application of the FDA approach shows that the incidence of fall-related severe head injuries would increase by 2.3-2.6-fold by 2024 compared to 2004. The FDA predictions had 55% less prediction error than traditional OLS predictions when compared to actual data.

CONCLUSIONS

In summary, FDA provides more accurate predictions of long-term incidence trends than commonly used methods. The production of FDA prediction intervals for future injury incidence rates gives likely guidance as to the likely accuracy of these predictions.

Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007

In some types of low-trauma fractures of older adults the number and incidence of fractures are stabilizing or even decreasing. However, very little population-based information is available concerning the nationwide numbers, incidences and especially secular trends of low-trauma fractures of the distal humerus. Therefore, we assessed the current trends in the number and incidence of low-trauma distal humeral fractures in Finnish women 60 years of age or older by taking into account all women who were admitted to Finnish hospitals for primary treatment of such fracture in 1970-2007. The annual total number of low-trauma distal humeral fractures among women 60 years of age or older more than quintupled between 1970 (42 fractures) and 1998 (224 fractures) but after that the number decreased down to 192 fractures in 2007. The age-adjusted incidence (per 100,000 persons) of these fractures also increased during 1970-1998 (from 12 to 34), but thereafter, this incidence decreased to 25 in 2007. Also, in all age groups (60-69, 70-79, and 80-) the trend of age-specific incidence was increasing from 1970 till the end of 1990s, and decreasing thereafter. In conclusion, the clear rise in the rate of low-trauma distal humeral fractures in Finnish women 60 years of age and older from 1970 till late 1990s has been followed by stabilized or even decreased fracture rates. The precise reasons for this secular change are unknown, but a cohort effect towards improved functionality among older women and actions and interventions in preventing falls and minimizing fall severity cannot be ruled out.