Risk factors for proximal humerus fracture

Reverse Shoulder Arthroplasty for Proximal Humeral Fractures: Is the Bigliani-Flatow Stem Suitable for Tuberosity Fixation and Healing?

Background/Objectives: The aim of the study was to investigate the clinical, functional, and radiographic results of patients affected by three- or four-part proximal humeral fractures treated with reverse total shoulder arthroplasty, to investigate whether a prosthetic stem nonspecifically designed for fractures (i.e., the Bigliani-Flatow stem) promotes tuberosities' healing, and to evaluate the impact of tuberosity fixation and healing on the outcomes. Methods: Patients' data such as gender, age, side and dominancy, comorbidities, complications during or after surgery, and time lapse between trauma and surgery were prospectively collected. The type of fixation of the stem, the thickness and type of liner, and whether the tuberosities were fixed or not were also recorded. The Constant score weighted on the contralateral limb, QuickDASH, Oxford Shoulder Score, and Subjective Shoulder Value were collected. Tuberosities' healing was assessed with X-rays (anteroposterior, Grashey, and axillary views). Results: Overall, 34 patients were included, with an average follow-up of 42 months. Tuberosities were reinserted in 24 cases and their healing rate was 83%. The mean values were the following: a Constant score of 64, Oxford Shoulder Score of 39, Subjective Shoulder Value of 71, and QuickDASH score of 27. There were no significant differences in the scores or range of motion between patients with tuberosities healed, reabsorbed, or not reattached. There was a better external rotation in the group with healed tuberosities and a longer duration of surgery to reattach tuberosities. Conclusions: The treatment of proximal humerus fractures with the Bigliani-Flatow stem is associated with good clinical and functional results. The healing rate of the tuberosities was high and comparable, if not even better, than the mean rates reported for the stems dedicated to fractures of the proximal humerus and was, therefore, also appropriate for this indication.

Primary stability in locking plate fixation for proximal humeral fractures may be increased by using an additional nail osteosynthesis in combination with locking plate osteosynthesis-A biomechanical comparison

BACKGROUND

Stability is regarded as an important factor for proper healing and avoiding secondary dislocation in osteoporotic fractures of the proximal humerus. Several surgical techniques have been proposed for treatment, including intramedullary nail osteosynthesis and locking plate fixation. This study introduces a novel approach that combines both techniques and compares its primary stability with conventional methods.

METHODS

The study involved 25 osteoporotic humeri with two-part fracture models, which were randomly assigned to locking-plate fixation, intramedullary nailing, or a combination of both techniques. The specimens were subjected to sinusoidal loading at 250 N in 20° abduction for 5000 cycles and then to quasi-static loading until failure. Fracture movement, failure mode, and failure load were measured and compared among the groups.

FINDINGS

The groups fixated with intramedullary nailing and the groups fixated with intramedullary nailing and locking plate fixation showed significantly lower fracture motion than the group using locking plate fixation only (p < 0.005) and significantly higher load to failure (p = 0.007 and p = 0.0062, respectively). There was no significant difference between the group using intramedullary nailing and the group using locking-plate fixation and intramedullary nailing in fracture movement or load-to-failure (p > 0.005).

INTERPRETATION

The results indicate that locking plate fixation provides less primary stability than intramedullary nailing or the combined of both techniques. This combined approach may offer advantages as a treatment for complex proximal humeral fractures in osteoporotic bone, and specific implants should be developed to ensure optimal treatment.

Assessing complications and functional outcomes in proximal humerus fracture management: a retrospective comparison between conservative and intramedullary nailing treatments

INTRODUCTION

Fractures of the proximal end of the humerus (FPH) are the second most common fractures in the upper limb after fractures of the distal radius and are two to three times as common in women than in men. Therefore, the main objective of the present study was to compare and analyze the complications and the functional outcomes in patients with displaced FPH receiving conservative and surgical treatments with intramedullary nailing.

METHODS

A retrospective cross-sectional study was conducted to establish the differences in complications risks between surgical and non-surgical treatment of the FPH. For this purpose, the clinical and radiological results of 67 consecutive patients were analyzed.

RESULTS

A total of 25 patients were included in the non-surgically treated group. A total of 42 patients were included in the surgically treated group. Complications occurred in a total of 4 (16.0%) patients after the non-surgical treatment. Those included frozen shoulder (n = 2), nonunion (n = 1), and avascular necrosis of the humeral head (n = 1). Complications occurred in a total of 18 (42.6%) patients after the surgical treatment. Non-surgically treated patients had statistically significantly (p < 0.05) lower scores in the Constant-Murley scale in all of the categories.

CONCLUSION

The present study demonstrates an overall prevalence of complications to be 16% in patients treated conservatively and 42.6% in patients treated surgically. In the non-surgical cohort, the frozen shoulder was the most frequently observed complication (8%). Interestingly, non-anatomical repositioning was the most prevalent complication in surgically treated patients. Due to the complexity of the FPH, we believe that the surgeon needs to have comprehensive knowledge regarding the characteristics of this fracture, the available treatment options, and the possible complications that may occur. This can enhance patient safety and provide satisfactory clinical outcomes.

GJB2 p.V37I Mutation Associated With Moderate Nonsyndromic Hearing Loss in an Adult Taiwanese Population

BACKGROUND

Gap junction protein beta 2 ( GJB2 ) p.V37I mutations are the most important hereditary cause of sensorineural hearing loss (SNHL) in Taiwan. Hearing outcomes are associated with hearing levels at baseline and the duration of follow-up. However, the audiological features of GJB2 p.V37I mutations in the adult population are unknown. The objectives of the present study were to investigate the audiological features, progression rate, and allele frequency of GJB2 p.V37I mutations among an adult Taiwanese population.

METHODS

Subjects of this case-control study were chosen from 13,580 participants of the Taiwan Precision Medicine Initiative. The genetic variations of GJB2 p.V37I were determined by polymerase chain reaction. We analyzed existing pure-tone threshold data from 38 individuals who were homozygous or compound heterozygotes for GJB2 p.V37I, 129 who were heterozygotes, and 602 individuals who were wild-type. Phenome-wide association studies (PheWAS) analysis was also performed to identify phenotypes associated with GJB2 p.V37I.

RESULTS

The minor allele frequency of GJB2 p.V37I was 0.92% in our study population. The mean hearing level of participants with a p.V37I mutation indicated moderate to severe hearing loss with 38.2% ± 22.3% binaural hearing impairment. GJB2 p.V37I was associated with an increased risk of hearing disability (odds ratio: 21.46, 95% confidence interval: 8.62 to 53.44, p < 0.001) in an autosomal recessive pattern. In addition, PheWAS discovered a significant association between GJB2 p.V37I and fracture of the humerus. GJB2 p.V37I is a pathogenic and prevalent variant of SNHL among the adult population.

CONCLUSIONS

The present study recommends patients with known GJB2 p.V37I mutations receive regular audiometric evaluation and genetic counseling. Early assistive listening device intervention is suggested to improve the quality of hearing.

Consistent hearing aid use is associated with lower fall prevalence and risk in older adults with hearing loss

BACKGROUND

Falls and their sequelae cost more than $50 billion every year. Older adults with hearing loss are at 2.4 times greater risk of falls than their normal hearing peers. Current research is inconclusive about whether hearing aids can offset this increased fall risk, and no previous studies considered if outcomes differed based on the consistency of hearing aid use.

METHODS

Individuals 60 years and older with bilateral hearing loss completed a survey consisting of the Fall Risk Questionnaire (FRQ) and questions about hearing loss history, hearing aid use, and other common fall risk factors. In this cross-sectional study, fall prevalence, as well as fall risk (based on FRQ score), was compared between hearing aid users and non-users. A separate group of consistent hearing-aid users (at least 4 h daily use for more than 1 year) was also compared with inconsistent/non-users.

RESULTS

Responses from 299 surveys were analyzed. Bivariate analysis found 50% reduced odds of experiencing a fall for hearing aid users compared with non-users (OR = 0.50 [95% CI: 0.29-0.85], p = 0.01). After adjusting for age, sex, hearing loss severity, and medication usage, those who reported any hearing aid use still had lower odds of falls (OR = 0.48 [95% CI: 0.26-0.90], p = 0.02) and lower odds of being at risk for falls (OR = 0.36 [95% CI: 0.19-0.66] p < 0.001) than non-users. Results for consistent hearing aid users demonstrate an even stronger association of lowered odds of falling (OR = 0.35 [95% CI: 0.19-0.67], p < 0.001) and lower odds of being at risk for falls (OR = 0.32 [95% CI: 0.12-0.59], p < 0.001), suggesting a potential dose-response relationship.

CONCLUSIONS

These findings suggest that use of hearing aids-especially consistent hearing aid use-is associated with lower odds of experiencing a fall or being classified as at risk for falls in older individuals with hearing loss.

Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement

PURPOSE OF REVIEW

Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating.

RECENT FINDINGS

Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.

Fracture risk across a wide range of physical activity levels, from sedentary individuals to elite athletes

OBJECTIVE

To examine how physical activity is associated with risk of different fracture outcomes across the full range of physical activity.

METHODS

By combining information from three cohort studies and using generalized structural equation modelling, we estimated a continuous unitless latent variable reflecting physical activity that ranged from sedentary through elite athlete levels. Associations between physical activity and fracture outcomes were assessed with proportional hazards regression using restricted cubic splines with the mean physical activity (corresponding to 20-40 min walking or bicycling/day or 2-3 h exercise/week) as reference.

RESULTS

Among 63,980 men and women (49-68 years) and during 13 years of follow-up, 8506 fractures occurred, including 2164 distal forearm, 779 proximal humerus, 346 clinical spine, and 908 hip fractures. Both lower and higher physical activity was associated with higher risk of any fracture compared to the mean. Physical activity at 1 standard deviation (SD) below the mean, corresponding to walking/bicycling <20 min/day or exercising <1-1 h/week, was associated with a lower risk of distal forearm fracture (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.85-0.99) and higher risk of hip fracture (HR: 1.24, 95% CI: 1.13-1.37), but no associations were seen above the mean physical activity level for these fractures. Physical activity was not associated with proximal humerus fracture but had a possible U-shaped association with clinical spine fracture.

CONCLUSION

Physical activity was non-linearly associated with fracture risk and the association differed across fracture sites. Up to 2-3 h weekly exercise is beneficial for the prevention of hip fracture but may increase the risk of distal forearm fracture.

Incidence of avascular necrosis following biceps tenodesis during proximal humerus open reduction and internal fixation

Avascular necrosis (AVN) may occur in up to 77% of proximal humeral fractures and can cause fixation failure. Risk factors include fracture position, calcar length and medial hinge integrity. We routinely perform intra-articular biceps tenotomy with tenodesis at the level of pectoralis major to facilitate fragment identification and potentially ameliorate post-operative pain relief. Concern exists that tenotomising the biceps damages the adjacent arcuate artery, potentially increasing the rate of AVN. The purpose of this study was to evaluate whether biceps tenodesis is associated with an increased risk of radiographically evident humeral head AVN. 61 fractures surgically treated over a 52-month period were retrospectively reviewed and radiographically assessed in accordance with Neer’s classification, calcar-length and medial hinge integrity. 40, 20 and 1 were four-, three- and two-part fractures respectively. 37 had a calcar-length less than 8mm and 26 suffered loss of the medial hinge. The median radiographic follow-up was 23 months. There was radiographic evidence of humeral head AVN in only one case, comparing favourably to rates quoted in current literature. In our experience, intra-articular biceps tenotomy with the deltopectoral approach was thus not associated with a significantly increased risk of humeral head AVN, even in complex four-part fractures.

One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures: A Prospective Randomized Trial

BACKGROUND

There is no consensus on the duration of immobilization for nonoperatively treated proximal humeral fractures (PHFs). The main objective of the study was to determine the differences in pain between PHFs that were treated nonoperatively with 3-week immobilization and those treated with 1-week immobilization.

METHODS

A prospective randomized trial was designed to evaluate whether the immobilization time frame (1-week immobilization [group I] versus 3-week immobilization [group II]) for nonoperatively treated PHFs had any influence on pain and functional outcomes. Pain was assessed using a 10-cm visual analog scale (VAS) that was administrated 1 week after the fracture, at 3 weeks, and then at the 3, 6, 12, and 24-month follow-up. The functional outcome was evaluated using the Constant score. To assess the functional disability of the shoulder, a self-reported shoulder-specific questionnaire, the Simple Shoulder Test (SST), was used. The Constant score and the SST were recorded at the 3, 6, 12, and 24-month follow-up. Complications and secondary displacement were also recorded.

RESULTS

One hundred and forty-three patients were randomized, and 111 (88 females and 23 males) who had been allocated to group I (55 patients) or group II (56 patients) were included in the final analysis. The mean age of the patients was 70.4 years (range, 42 to 94 years). No significant differences were found between the 2 groups in terms of pain as measured with the VAS at any time point (1 week [5.9 versus 5.6; p = 0.648], 3 weeks [4.8 versus 4.1; p = 0.059], 3 months [1.9 versus 2.4; p = 0.372], 6 months [1.0 versus 1.2; p = 0.605], 1 year [0.65 versus 0.66; p = 0.718], and 2 years [0.63 versus 0.31; p = 0.381]). No significant differences were found in the Constant score or SST score at any time point. No significant differences were noted in the complication rate.

CONCLUSIONS

Short and long periods of immobilization yield similar results for nonoperatively treated PHFs, independent of the fracture pattern. These fractures can be successfully managed with a short immobilization period of 1 week in order to not compromise patients' independence for an overly extended period.

LEVEL OF EVIDENCE

Randomized controlled trial Level II. See Instructions for Authors for a complete description of levels of evidence.

The effects of antiepileptic drugs on bone health: A systematic review

PURPOSE

Epilepsy may be treated with antiepileptic drugs (AEDs), which have been reported to decrease bone mineral density (BMD). Current data is conflicting and variable, and little is known with regard to how duration of AED use or specific AEDs, such as CYP-450 enzyme-inducing (EIAEDs) versus non-enzyme inducing (NEIAEDs) drugs affect BMD. We sought to systematically review BMD changes due to AED use to identify trends in reporting.

METHODS

A literature search via Medline (PubMed), EMBASE, and Cochrane databases was performed. Peer-reviewed articles were identified that reported on BMD measurements in conjunction with AEDs.

RESULTS

Twenty-six studies met inclusion criteria. Long-term therapy was shown across multiple, well-controlled studies to have the most significant BMD loss. Carbamazepine had the most frequent reporting of unfavorable effects on bone health and Lamotrigine seemed to show the most bone-protective qualities. Serum biochemical markers of bone turnover did not significantly correlate with measured BMD changes.

CONCLUSION

The present study provides evidence that long-term AED therapy is the most significant risk factor for BMD loss. Furthermore, there was little compelling evidence to support that EIAEDs, as a class, were more harmful to bone than NEIAEDs, which has been previously suggested in multiple studies. Early clinical concern for significant loss of BMD may not be warranted as lower BMD was less likely to be observed during the initial years of AED therapy. Furthermore, serum markers of bone turnover are not clinically reliable in assessing BMD changes in patients taking AEDs.

Factors Influencing the Varus Deformity of Humeral Head in Proximal Humerus Fractures and Its Relation to Functional Outcome

BACKGROUND

Fractures of the proximal humerus represent approximately 4% of all fractures and 26% of humerus fractures. Proper reduction, stable internal fixation and early initiation of physiotherapy help to achieve a good functional outcome. Aim of this study was to evaluate varus fixation/malunion of proximal humerus fractures and its relation to functional outcome.

MATERIALS AND METHODS

We retrospectively evaluated 32 patients with proximal humerus fractures who were surgically treated between 2015 and 2017 at tertiary care hospital. We divided the patients into three groups on the basis of the neck-shaft angle as valgus group, normal group and varus group to observe the influence of neck-shaft angle on efficacy. Patients were evaluated for functional outcome using the Constant-Murley score.

RESULTS

Two-part fractures had better functional outcome (Constant score = 75.15) compared to three parts with the moderate functional outcome (Constant score = 68.81) and the four-part fracture had poor functional outcome (Constant score = 52.66). After 6 months of follow-up, 13 patients had a neck-shaft angle of less than 126°. The functional outcome is significantly better among patients with normal neck-shaft angle and had a mean Constant score of 76.63 as compared to patients with varus deformity had a mean Constant score 60 (p = 0.001). 10 patients did not have medial support, in which 08 patients had neck-shaft angle less than 126° and 2 had a normal neck-shaft angle.

CONCLUSION

High fracture comminution, improper restoration of medial continuity causes varus deformity of the humeral head and it leads to poor functional outcome. The small sample size is the limitation of our study.

Biological sex impacts perioperative complications after reverse shoulder arthroplasty for proximal humeral fracture

Background

The purpose of this study was to determine the difference in complication rates between males and females undergoing reverse shoulder arthroplasty for proximal humerus fractures. We hypothesized that (1) females were more likely to undergo reverse shoulder arthroplasty for fracture, and (2) males were more likely to sustain a perioperative complication.

Methods

The National Surgical Quality Improvement Program database was queried to identify patients who underwent reverse shoulder arthroplasty for proximal humerus fracture between 2011 and 2018. Patients were stratified based on biological sex. Patient demographics, comorbidities, and 30-day perioperative complication rates were collected. Univariate analyses and multiple variable logistic regression modeling were performed.

Results

About 905 patients were included in the analysis—175 (19.3%) were male and 730 (80.7%) were female. Males were more likely to sustain perioperative complications (26.3% vs. 14.1%; P < .001)—pneumonia (2.9% vs. 0.5%; P = .016), unplanned intubation (2.3% vs. 0.4%; P = .029), and unplanned reoperation (9.1% vs. 1.1%; P < .001). On multivariate analysis, males were at a 2.4-fold increase risk of developing any complication (OR = 2.38 [95% CI 1.55-3.65]; P < .001) and a 10-fold increase risk of returning to the operating room for an unplanned reoperation (OR = 10.59 [95% CI 4.23-27.49]; P < .001) compared with females.

Conclusion

Females were more likely to undergo reverse shoulder arthroplasty for proximal humerus fracture, but males were at increased risk of sustaining short-term complications. This study provides useful information for clinicians to consider when counseling their patients during the perioperative period.

National electronic injury surveillance system sports-related arm fractures in the United States: thrower's fractures

BACKGROUND

Humerus fractures are common in the United States. The purpose of this study was to utilize the National Electronic Injury Surveillance System (1) to compare overall and age stratified incidence rates of proximal and distal arm fractures presenting to United States emergency departments, (2) to compare relative humerus fracture locations by age, and (3) to compare anatomical humerus fracture locations stratified by sports between 2005-2009 and 2015-2019.

METHODS

The National Electronic Injury Surveillance System was used to obtain estimated proximal and distal arm fractures between 2005-2009 and 2015-2019. Fracture rates were normalized using United States census estimates and stratified by age. Case summaries were filtered for anatomical and non-specific (proximal, middle, distal third) humerus fractures. Relative humerus fractures, inclusive of anatomical and non-specific fractures, were stratified by age and compared between 2005-2009 and 2015-2019. Anatomical fractures were stratified by sports. Chi-squared tests was used to compare fracture rates between time periods.

RESULTS

There was a decrease (p<.0001) in proximal and distal arm fracture rates and a difference (p<.0001) in fracture rates with respect to age between 2005-2009 and 2015-2019. There was a significant difference in reported relative humeral fractures (p<.0001) between the two periods. Impact related sports trauma accounted for most fracture cases for both periods. Non-impact related sports trauma consisted entirely of thrower's fractures.

CONCLUSIONS

United States proximal and distal arm fracture rates decreased, and distributions differed by age between 2005-2009 and 2015-2019. Relative humerus fractures differed by time periods. One major non-impact sports related humerus fracture was extreme external rotational torque from throwing.

Pre-operative Hypoalbuminemia Is Associated with Complications Following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients

BACKGROUND

Proximal humerus fractures are among the most common presenting fractures to orthopedic surgeons in the USA. Hypoalbuminemia is accepted as a nutrition marker associated with post-operative complications following common orthopedic interventions.

QUESTIONS/PURPOSES

Thus, the authors sought to (1) describe the national demographic trends of patients undergoing surgical fixation for proximal humerus fracture and (2) investigate the association between pre-operative hypoalbuminemia, a malnutrition marker, and post-operative complications within 1 year of surgical intervention.

METHODS

The PearlDiver Humana Claims Database was queried to identify a nationally representative cohort of patients who underwent surgical intervention for proximal humerus fractures from 2008 to 2015. Demographic and comorbid characteristics were collected. Pearson's χ-squared analysis was used to compare rates of 90-day and 1-year outcomes between hypoalbuminemia (albumin ≤ 3.5 mg/dL) and control groups. Multivariate logistic regression was then used to determine the isolated effect that hypoalbuminemia had on post-operative outcomes.

RESULTS

Of the 3337 patients identified, 919 (27.5%) had available serum albumin data. Seventy (7.6%) patients had hypoalbuminemia. Hypoalbuminemia was more likely to be associated with post-operative sepsis (7.1% vs. 1.5%, respectively) and pneumonia (15.7% vs. 4.6) compared with controls. Additionally, hypoalbuminemia was associated with increased 90-day rates of discharge to extended care (4.3% vs. 0.8), emergency room visits (38.6% vs. 21.7), and total cost ($24,051.96 ± 24,972.74 vs. $15,429.74 ± 24,492.30).

CONCLUSION

Our study suggests hypoalbuminemia is associated with an increased risk of complications, specifically pneumonia and sepsis, and total health care costs in patients undergoing surgery for proximal humerus fractures. These findings provide insight for individualized patient care that will aid in evaluating the potential risk of surgical complications in an effort to improve outcomes and reduce costs.

Is antegrade nailing a proper option in 2- and 3-part proximal humeral fractures?

PURPOSE

To report our experience with antegrade short locked intramedullary nail for treatment of proximal humeral fractures and to review the current literature.

MATERIALS AND METHODS

From January 2012 to July 2013, 41 patients affected by two and three-part proximal humeral fractures were treated with surgical internal fixation with short locked intramedullary nails. Outcome analysis included standard clinical follow-up, Constant shoulder score and plain radiographs. The mean follow-up was 30 months (range 24-42). Moreover, a review of the literature was carried out.

RESULTS

The mean Constant shoulder score was 81.5, excellent functional outcomes in 24/38 patients. All the fractures healed in an average time of 3.7 months. Five patients underwent additional operations, complications included hardware penetration into the joint (n = 2), backed out screw (n = 1), shoulder impingement due to protrusion of the nail (n = 2) and superficial infection (n = 1). The literature review showed 530 patients affected by proximal humeral fracture and treated with intramedullary nail with mean age of 65 years, mean follow-up of 22.2 months and a Constant shoulder score of 72.9 points; the major complications reported were backing out of the screws, shoulder impingement and joint protrusion of the screws.

CONCLUSIONS

Antegrade short locked intramedullary nail allows stable fixation, minimal soft tissue dissection, early mobilization of the shoulder and good outcomes. It is an efficacious therapeutic solution for 2- and 3-part proximal humeral fractures.

Antegrade intramedullary nailing in proximal humeral fractures: results of 23 cases

Introduction:

the metaepiphyseal fractures of the proximal humerus represent 5% of all fractures and mainly affect elderly patients. The type of treatment remains controversial. This retrospective study aimed to evaluate the clinic and radiographic results of 23 patients affected by two or three fragments fractures of the proximal humerus with or without metaphyseal extension treated with antegrade intramedullary nailing.

Materials and Methods:

all patients were clinically evaluated using the “Constant score” (CS) and individual satisfaction was assessed with a visual scale (VS). Moreover, the fracture’s healing process and the neck shaft angle (NSA) were assessed radiographically.

Results:

the mean follow-up was 72 months (24-120). Clinical evaluation and individual satisfaction were positive in most cases (mean CS 79,39 and VS 3,17). Worse results were observed in patients over 65 years.

Discussion:

among the different surgical options intramedullary nailing ensures good fracture stability and high consolidation rate. The entry point through the rotator cuff is of main importance as well as proximal nail positioning and choice of the locking screws length. In this study the functional results of the shoulder were worse in the elderly, who were supposed to have already a degenerated rotator cuff.

Conclusions:

antegrade intramedullary nailing should be considered a valid therapeutic option in this type of fractures. The surgical technique may influence functional results, as consequence of iatrogenic damage of the rotator cuff. (www.actabiomedica.it)

Failed Proximal Humerus Osteosynthesis Using Intramedullary Fibular Strut Allograft Conversion to Reverse Shoulder Arthroplasty

Comminuted proximal humerus fractures are more frequently being treated utilizing an intramedullary fibular strut allograft to assist with open reduction internal fixation. Although this technique has led to improved outcomes, avascular necrosis, rotator cuff failure, and/or prominent hardware may still occur necessitating conversion to reverse shoulder arthroplasty. The presence of an intramedullary strut allograft makes this conversion technically demanding and creates certain potential complications unique to this group. This manuscript details the conversion of a proximal humerus open reduction internal fixation with a fibular strut allograft to reverse shoulder arthroplasty including presurgical workup, surgical techniques, and pitfalls for undertaking this increasingly common scenario.

Early displacement of two part proximal humerus fractures treated with intramedullary proximal humeral nail

Introduction

Proximal humerus nails (PHN) are commonly used for the treatment of simple proximal humerus fractures, and have a reported malunion rate of about 10%. The surgeons who used PHN in one medical institution have noticed a high rate of fracture re-displacement in the early post-operative period. This study's aim is to evaluate the rate of secondary displacement and malunion of patients treated for two part proximal humerus fractures with an angle-stable PHN (MultiLoc), and to assess possible risk factors for this secondary displacement.

Methods

A retrospective study comprised of 25 consecutive patients with 2 part surgical neck or metaphysis displaced proximal humerus fracture, treated with PHN between the years 2014-2017. Results assessed included radiographic measures (neck-shaft angle) and clinical data: range of motion (ROM) and functional scores (Constant, DASH, SSV). A univariate regression analysis was used to assess possible risk factors for secondary displacement.

Results

Mean age was 66.6 (range 17-93), and mean follow up was 20 months (range 6-40). Mean neck shaft angle (NSA) changed from 139.1° post operatively to 122.6° at last follow up, with 6 patients (24%) having a NSA change larger than 20°. Two patients (8%) ended up with NSA less than 90°, defined as malunion. The deltoid tuberosity index was found to correlate with the degree of displacement (-0.41, p = 0.04).

Conclusions

PHN for simple displaced proximal humerus fractures was associated with fair clinical results but an unacceptable rate secondary displacement. The deltoid tuberosity index was found to correlate with the degree of this secondary displacement.

Hypoalbuminemia is a risk factor for predicting early postoperative complications after proximal humerus fracture fixation

Background

Hypoalbuminemia is a marker for malnourishment and is associated with poor outcomes in the setting of hip fractures, periprosthetic joint fractures, and spine surgery. We hypothesized that hypoalbuminemia is associated with higher rates of early complication in patients undergoing surgical treatment for proximal humerus fractures.

Methods

Utilizing the ACS NSQIP database, all proximal humerus fractures treated with plate fixation were extracted from 2006 to 2015. Two cohorts were compared based on hypoalbuminemia (albumin <3.5 g/dL) versus normoalbuminemia (albumin >3.5 g/dL). Patient demographics and postoperative complications were analyzed with multivariable regression.

Results

Out of 916 patients undergoing PHF surgery, 290(31.7%) satisfied criteria for hypoalbuminemia (mean age: 65.9, female: 71%). Among 339 obese patients with BMI>30, 87 (25.7%) were hypoalbuminemic. Patients with hypoalbuminemia were overall at higher risk of any (29.7% vs 12.1%, p < 0.001), major (10.0% vs 2.4%, p < 0.001), and minor complications (24.1% vs 11.0%, p < 0.001) as well as readmissions (12.7% vs 5.1%, p < 0.001). Obese hypoalbuminemic patients had similar rates of complication as non-obese hypoalbuminemic patients. Multivariable regression showed that hypoalbuminemia had an odds ratio of 1.85(p = 0.003) for predicting any complication within 30 days of surgery.

Conclusion

Hypoalbuminemia is associated with higher risk for complications and readmission after PHFs. It occurs more frequently in patients with chronic disease and is predictive of malnourishment. Paradoxically, hypoalbuminemia is not uncommon in obese patients.

Level of evidence

III; Retrospective Cohort Study.

The "FraMo" System: A New Mini-Invasive Technique in the Treatment of Proximal Humerus Fractures

Fractures of the proximal humerus are relatively common injuries in adults accounting for 5% of fractures. Nowadays the most common technique used is open reduction internal fixation with LCP plates. The risks associated with open reduction internal fixation had led us to develop and apply a "hybrid" system, which is based on external fixation and closed surgery principles. This system is capable of stabilize up to 4 fragment fractures on different planes while conferring a strong enough fixation to maintain fracture reduction while allowing the patient to perform passive and active movement since the first day following the surgery. Our study group started on November 2009 until December 2015 and consisted of 118 patients with a mean age of 68.84±10.52 years for females (76) and 65.62±12.56 for males (44). Patients were classified according to the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma association) Classification. In a few patients we performed mini lateral accesses to allow reduction of the humeral head and greater tuberosity. Shoulder mobilization was initiated from the first day following surgery. The external fixator was removed at 5 weeks with successive check-ups at 3, 6, and 12 months. The majority of type B and type C1 fractures had almost a complete functional recovery. Patients also, especially in the elderly, reported a good quality of life without pain during any range of motion. Our group of patients, after removal of the apparatus at 5 weeks following the surgery, had a mean articular range of motion with active abduction of 90 degrees and about 100 degrees with passive abduction. Postoperative CS scores at 12 months follow-up was 75,47±8.02. In addition there was also significant (P<0.05) improvement between preoperative and postoperative visual analog scale measurements (in cm), 7.67±2.70 and 1.71±2.08, respectively. This technique has shown good functional results with reduced surgical risks and complications that are typical of open reduction surgical fixation of proximal humerus fractures, is quick in execution and minimally invasive. Given the very good results of the study of this new external fixation technique has shown to be a viable option for the treatment of proximal humerus fractures.

A comparative retrospective study of locking plate fixation versus a dedicated external fixator of 3- and 4-part proximal humerus fractures: Results after 5 years

INTRODUCTION

Fractures of the proximal humerus (PHF) represent a common injury among orthopedic department; especially for three- and four-part fractures no consensus about the best treatment is still achieved. The aim of our study was to compare clinical and radiological outcomes in patients alternatively treated with plates and screws or external fixation system for a type III-IV proximal humerus fracture.

MATERIAL AND METHODS

Sixty-nine patients went surgery for type III-IV PHF between January 2011 and January 2014. According to the Neer classification, fractures were classified as type III in 50 cases (72,46%) and type IV in 19 cases (24,56%). 45 patients were treated with plates (65%) and 24 external fixators (35%). The patients' mean age was 62 years (range, 31-87 y). At five years, 60 patients (86,9%) were assessed using the visual analog scale (VAS) pain score, Constant Score (CS), the range of motion, and radiological evaluation. The CS at five years was the primary outcome measure. Results were evaluated and compared with the contralateral unaffected side to avoid bias related to different ages.

RESULTS

At the final follow up, we found no clinical differences when comparing the two procedures. Moreover, when age was considered as a variable, a significative difference of the CS was observed in the group of patients younger than 65 years treated with a plate (Plate Group Mean: 79; SD: +/- 15. Ex Fi Mean: 58; SD:+/- 4. P = 0,008). In the group of patients older than 65 years, the two procedures did not show significative differences in outcomes (Plate Group Mean: 69; SD: +/- 15. Ex Fi Mean: 63; SD:+/- 7. P = 0,032). External fixation procedure was overall associated with a reduction in blood loss, surgical time, length of hospital stay.

CONCLUSION

Percutaneous techniques have a long tradition in PHF treatment; the introduction of dedicated external fixation system has the advantage to improve the stability and allow early rehabilitation when compared to the classical pinning technique. In our experience, the indication elderly patients with osteoporosis and comorbidities may benefit by this type of mini-invasive surgery with low soft tissue damages.

Number, Location, and Time Since Prior Fracture as Predictors of Future Fracture in the Elderly From the General Population

Prognostic tools are available to identify individuals at high risk of osteoporotic fracture and to assist physicians in management decisions. Some authors have suggested improving the predictive ability of these tools by integrating characteristics of prior fractures (number, location, and time since prior fracture). The objectives of this study were: (1) to evaluate the sex- and age-specific associations between characteristics of prior fractures and the occurrence of a future osteoporotic fracture; and (2) to assess whether the characteristics of prior fractures could increase the discriminative ability of fracture risk prediction tools. A retrospective cohort study was conducted using administrative data. Men and women aged ≥66 years were selected and grouped into two cohorts. In cohort #1 (N = 759,500), history of fractures was measured between fiscal years 1997-1998 and 2003-2004, and future fractures were identified between 2004-2005 and 2013-2014. In cohort #2 (N = 807,245), history of fractures was measured between 1997-1998 and 2008-2009, and future fractures were identified between 2009-2010 and 2013-2014. Time until a first hip/femur and major osteoporotic fracture were the outcomes of interest. Adjusted HRs and c-indices were calculated. The association between history of prior fractures and future fracture was stronger in men and younger individuals. The locations of prior fractures associated with the lowest and highest risks were foot/ankle/tibia/fibula (maximal HR = 1.64) and hip/femur (maximal HR = 9.02), respectively. The association was stronger for recent fractures (maximal HR = 4.93), but was still significant for fractures occurring 10 to 12 years prior to the beginning of follow-up (maximal HR = 1.99). Characteristics of prior fractures did not increase model discrimination. Our study confirms that the risk of future fracture increases with the number of prior fractures, varies according to prior fracture location, and decreases with time since prior fracture. However, the integration of these characteristics in current fracture risk prediction tools is not required because it does not improve predictive ability. © 2018 American Society for Bone and Mineral Research.

Mortality After Complex Displaced Proximal Humerus Fractures in Elderly Patients: Conservative Versus Operative Treatment With Reverse Total Shoulder Arthroplasty

Introduction

Proximal humerus fractures (PHFs) are a common fragility fracture and have been shown to increase mortality in elderly patients. In the last decade, reverse total shoulder arthroplasty (RTSA) was introduced as a reliable operative treatment option for this indication. In other fragility fractures, most notably hip fractures, urgent surgical treatment can reduce mortality. The purpose of this study is to evaluate whether treatment with RTSA can reduce 1-year mortality in elderly patients with complex displaced PHFs.

Materials and Methods

A retrospective study was performed to compare 1-year mortality between 2 groups of elderly patients (>75 years old) who presented to a level 1 trauma center emergency department with complex displaced PHFs. The conservative treatment group (n = 83; mean age, 83.7 years) presented from 2008 to 2010 when RTSA was not yet available, and treatment was nonoperative. The surgical treatment group (n = 62; mean age, 82.2 years) presented from 2012 to 2015 and underwent RTSA.

Results

One-year mortality was 8.1% (male 7.1%; female 8.3%) in the surgical treatment group and 10.8% (male 18.8%; female 9.0%) in the conservative treatment group. The reduction in mortality in the surgical treatment group was not significant (entire cohort P = .56; males P = .35; females P = .59).

Discussion

Recent studies failed to show better functional results after surgical treatment with RTSA when compared to conservative treatment. This study suggests that a benefit of surgical treatment with RTSA that was not examined until now might exist-a reduction in the increased mortality risk associated with PHFs.

Conclusions

There was no significant difference in 1-year mortality between the groups, although there was a trend showing lower mortality with RTSA, mostly in men. Further studies with larger populations and longer follow-up times are needed to determine whether this trend is of clinical significance.

Sports participation and fracture in older Australian men

Older men who participated in a sporting activity were less likely to sustain any fracture or major osteoporotic fracture over a 6-year follow-up period.

PURPOSE

Regular weight-bearing physical activity can reduce fracture risk through an increase in bone strength, as well as reducing falls risk by improving muscle strength and balance. In this study, we aimed to determine whether a specific type of physical activity, sports participation, reduces fracture risk in older Australian men.

METHODS

Participation in sporting activities was documented for men aged 60 years and over enrolled in the Geelong Osteoporosis Study situated in south-eastern Australia. Fractures at any skeletal site (excluding skull, face, fingers and toes) and major osteoporotic fracture sites (MOF; wrist, proximal humerus, spine and hip) were ascertained through examination of radiological reports (median follow-up 6.63 years, IQR 5.58-7.29). Multivariable logistic regression was used to investigate the association between sports participation (either binary or continuous) and any fracture or MOF. Other clinical measures and lifestyle variables (such as comorbidity, falls and mobility) were included as potential confounders.

RESULTS

During follow-up, 82 of 656 men (12.5%) sustained at least one fracture at any site and 58 sustained at least one MOF (8.8%). Of those who did and did not fracture (any site), 17 (20.7%) and 204 (35.5%) participated in at least one sporting activity. For MOF, the values were 11 (19.0%) and 210 (35.1%), respectively. Participation in any sporting activity was associated with a reduction in the likelihood of any fracture during follow-up (unadjusted: OR 0.47, 95%CI 0.27-0.83), which persisted after adjusting for other factors (adjusted: OR 0.52, 95%CI 0.29-0.91). The results for MOF were similar (unadjusted: OR 0.43, 0.22-0.85; adjusted 0.48, 0.24-0.95). When considering sports participation as a continuous variable, a trend was observed (adjusted: p = 0.051 and p = 0.059 for any and MOF, respectively). A sensitivity analysis showed similar results when excluding men who reported using a walking aid.

CONCLUSIONS

In this group of older men, participation in sporting activity was associated with a reduced risk of fracture during the subsequent follow-up period.

Editorial Commentary: Shoulder Subpectoral Biceps Tenodesis Significantly Increases the Humeral Fracture Risk-Is This a Reason to Look for Alternatives?

Subpectoral tenodesis is performed at the surgical neck of the humerus. In a cadaveric study, the insertion of a unicortical PEEK (polyether ether ketone) screw decreased the torsional load to failure (fracture) by 30% compared with intact control specimens but was similar to unicortical reaming without screw insertion. Placing the biceps tendon into the tunnel and securing it with a unicortical screw reduced the torsional load to failure by 20%. Whether these facts are significant is currently unknown, but the creation of a stress riser is a concern and may possibly result in surgical neck fractures.

Trends in incidence of proximal humerus fractures, surgical procedures and outcomes among elderly hospitalized patients with and without type 2 diabetes in Spain (2001-2013)

BACKGROUND

Several studies have reported that diabetic persons have an increased risk for fractures than non-diabetes patients. The association between proximal humerus fractures and type 2 diabetes (T2DM) is unclear and some studies point to insulin treatment, hypoglycaemic episodes consequently to inadequate control of diabetes or, more recently, to an alteration of trabecular bone. We examined trends in the incidence of proximal humerus fractures, surgical procedures and outcomes among hospitalized patients aged ≥65 years, with and without T2DM in Spain, 2001-2013.

METHODS

This retrospective, observational study was conducted using the Spanish National Hospital Discharge Database to select all hospital admissions with proximal humerus fracture. We calculated incidences overall and stratified by diabetes status, year and sex. We analyzed surgical procedures, comorbidities, length of stay, in-hospital complications and in-hospital mortality.

RESULTS

We identified 43,872 patients with proximal humerus fracture (18.3% had a T2DM diagnosis). Age-adjusted incidence rates elevated steadily over the study period for men and women with and without T2DM, independently of diabetes status, although we found a stable trend in the later years. Patients with T2DM had lower relative risk of proximal humeral fracture incidence: 0.87 (95%IC 0.82-0.93) for men and 0.97 (95%IC 0.95-1.00) for women. In-hospital complications were 4.0% of diabetic men vs. 2.6% in non-diabetic (p < 0.001) and 2.9% among T2DM women vs. 1.7% in those without (p < 0.05). The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime and closed reduction with internal fixation is decreasing. Presence of T2DM in women was associated with higher in-hospital mortality (OR 1.67; 95%CI 1.29-2.15). Comorbidities, in-hospital complications and older age were predictors of higher in-hospital mortality in both sexes.

CONCLUSIONS

The incidence of proximal humerus fractures seems to be increasing in Spain. The incidence is lower among men with than without T2DM. T2DM is associated to higher in-hospital complications in both sexes. The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime beside diabetes status. Women with T2DM have higher in-hospital mortality than those without the disease.

Epidemiology of proximal humeral fractures: a detailed survey of 711 patients in a metropolitan area

BACKGROUND

Literature lacks data concerning several epidemiologic aspects of proximal humeral fractures (PHFs).

METHODS

This retrospective study included 711 consecutive patients (209 men, 502 women) who sustained a PHF in the last 3 years. Participants were divided into 2 groups, adults and children. Data regarding age, sex, date, and fracture side were collected. According to the mechanism of injury, we arbitrarily distinguished 7 subgroups. PHFs were classified according to the head-greater-lesser-shaft (HGLS)-Hertel classification and to the Salter-Harris classification using x-ray and computed tomography imaging.

RESULTS

PHFs represent 5.03% of the overall fractures. The right side was involved in 389 patients (54.7%; P = .6). The mean age of male and female patients was 55.4 (standard deviation,  21.9) years and 67.0 (standard deviation, 16.1) years, respectively (P = .0001). Significant differences in the trauma mechanism between female patients (street/home low-energy trauma) and male patients (high-energy trauma) were found. A significant correlation between trauma mechanisms from 1 to 5 and fracture patterns H-G-L-S, HL-G-S, HGL-S, and HLS-G was observed. The occurrence of the same patterns significantly varied according to different age subgroups. Considering the pediatric population, a significant incidence of Salter-Harris 2 in both genders was found. No correlation was observed between the fracture patterns and the trauma mechanism.

CONCLUSIONS

PHFs have a higher prevalence and incidence in females and in older age, respectively; they are more frequent in the winter months. In addition, male fractures are due to different traumatic events than those in females. A correlation between trauma and PHF pattern was evident only for adults. Some fracture patterns are correlated with different ranges of age in all patients.

Leisure-Time Physical Activity and Risk of Fracture: A Cohort Study of 66,940 Men and Women

Physical activity has been associated with reduced risk of fracture, but it is not known how the intensity or frequency of physical activity influences this risk reduction. We aim to compare the risk of hip fracture and fracture of any locale between men and women with different levels of leisure-time walking/bicycling and exercise. A total of 37,238 women (born 1914-1948) from the Swedish Mammography Cohort and 45,906 men (born 1918-1952) from the Cohort of Swedish Men were followed for a maximum of 17 years. Exposure and covariate information was collected through a self-administered questionnaire in 1997. Incident fractures (5153 individuals with hip fracture and 15,043 with any type of fracture) and comorbidities were gathered from national and local patient registries. Hazard ratios (HRs) were calculated using Cox proportional hazards regression. Individuals who walked/bicycled less than 20 minutes per day had a lower rate of hip fracture (multivariable adjusted HR = 0.77; 95% confidence interval [CI] 0.70 to 0.85) and any fracture (HR = 0.87; 95% CI 0.82 to 0.92) compared with those who hardly ever walked/bicycled. These reduced rates were also evident in both sexes, in different age categories, for vertebral fractures and for non-hip, non-vertebral fractures. Those who reported exercise 1 hour per week had a lower rate of hip fracture (HR = 0.87; 95% CI 0.80 to 0.96) and any fracture (HR = 0.94; 95% CI 0.89 to 0.99) compared with those who exercised less than 1 hour per week. Only minor differences in HRs were observed in individuals with moderate compared with higher levels of walking/bicycling or exercise. Walking/bicycling and exercise showed almost equal reductions in rate of fracture when compared with those in a joint category with lowest activity. In conclusion, both moderate and high self-reported frequency of physical activity is associated with reduced future risk of fracture. © 2017 American Society for Bone and Mineral Research.

Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program database

Background

Prior database studies have shown that complication rates following surgical treatment of proximal humerus fractures are low. However, diabetes has been shown across orthopedics to have significantly increased risks of postoperative complications. The purpose of our study was to identify complications for which diabetic patients are at increased risk following operative treatment of proximal humerus fractures.

Methods

The National Surgical Quality Improvement Program database from 2005 to 2014 identified patients >18 years undergoing open reduction-internal fixation for proximal humerus fractures. Patients with incomplete perioperative data were excluded. Patients with non–insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were compared with nondiabetic patients using multivariate logistic regression analysis. Odds ratio (OR) was calculated with a 95% confidence interval, and the significance level was held at P < .05.

Results

There were 1391 patients identified; 1147 (82%) were not diabetic, 91 (7%) had IDDM, and 153 (11%) had NIDDM. Of these, 39.68% (550) were obese (body mass index >30.0). Hypertension, dyspnea, and chronic obstructive pulmonary disease were the most frequent concurrent patient factors in diabetic patients. Postoperatively, patients with diabetes had a statistically significant higher risk of pneumonia (OR, 217.80; P = .002) and length of stay >4 days (OR, 2.05; P = .010). Among diabetics, non–insulin-dependent diabetics had a greater risk of sepsis (OR, 25.84; P = .022) and pneumonia (OR, 12.19; P = .013) than insulin-dependent diabetics.

Conclusion

Both NIDDM and IDDM were associated with a number of adverse postoperative events. Importantly, NIDDM was found to be an independent risk factor for postoperative sepsis and pneumonia, whereas IDDM was identified as an independent risk factor for pneumonia and prolonged length of stay (≥4 days).

Falling Down on the Job: Evaluation and Treatment of Fall Risk Among Older Adults With Upper Extremity Fragility Fractures

BACKGROUND

Clinical practice guidelines recommend fall risk assessment and intervention for older adults who sustain a fall-related injury to prevent future injury and mobility decline.

OBJECTIVE

The aim of this study was to describe how often Medicare beneficiaries with upper extremity fracture receive evaluation and treatment for fall risk.

DESIGN

Observational cohort.

METHODS

Participants were fee-for-service beneficiaries age 66 to 99 treated as outpatients for proximal humerus or distal radius/ulna ("wrist") fragility fractures. -Participants were studied using Carrier and Outpatient Hospital files. The proportion of patients evaluated or treated for fall risk up to 6 months after proximal humerus or wrist fracture from 2007-2009 was examined based on evaluation, treatment, and diagnosis codes. Time to evaluation and number of treatment sessions were calculated. Logistic regression was used to analyze patient characteristics that predicted receiving evaluation or treatment. Narrow (gait training) and broad (gait training or therapeutic exercise) definitions of service were used.

RESULTS

There were 309,947 beneficiaries who sustained proximal humerus (32%) or wrist fracture (68%); 10.7% received evaluation or treatment for fall risk or gait issues (humerus: 14.2%; wrist: 9.0%). Using the broader definition, the percentage increased to 18.5% (humerus: 23.4%; wrist: 16.3%). Factors associated with higher likelihood of services after fracture were: evaluation or treatment for falls or gait prior to fracture, more comorbidities, prior nursing home stay, older age, humerus fracture (vs wrist), female sex, and white race.

LIMITATIONS

Claims analysis may underestimate physician and physical therapist fall assessments, but it is not likely to qualitatively change the results.

CONCLUSIONS

A small proportion of older adults with upper extremity fracture received fall risk assessment and treatment. Providers and health systems must advance efforts to provide timely evidence-based management of fall risk in this population.

The reliability and reproducibility of the Hertel classification for comminuted proximal humeral fractures compared with the Neer classification

INTRODUCTION

The Neer classification is the most commonly used fracture classification system for proximal humeral fractures. Inter- and intra-observer agreement is limited, especially for comminuted fractures. A possibly more straightforward and reliable classification system is the Hertel classification. The aim of this study was to compare the inter- and intra-observer variability of the Hertel with the Neer classification in comminuted proximal humeral fractures.

MATERIALS AND METHODS

Four observers evaluated blinded radiographic images (X-rays, CT-scans, and CT-scans with 3D-reconstructions) of 60 patients. After at least two months classification was repeated.

RESULTS

Inter-observer agreement on plain X-rays was fair for both Hertel (κ = 0.39; 95% CI 0.23-0.62) and Neer (κ = 0.29; 0.09-0.42). Inter-observer agreement on CT-scans was substantial (κ = 0.63; 0.56-0.72) for Hertel and moderate for Neer (κ = 0.51; 0.29-0.68). Inter-observer agreement on 3D-reconstructions was moderate for both Hertel (κ = 0.60; 0.53-0.72) and Neer (κ = 0.51; 0.39-0.58). Intra-observer agreement on plain X-rays was fair for both Hertel (κ = 0.38; 0.27-0.59) and Neer (κ = 0.40; 0.15-0.52). Intra-observer agreement on CT-scans was moderate for both Hertel (κ = 0.50; 0.38-0.66) and Neer (κ = 0.42; 0.35-0.52). Intra-observer agreement on 3D-reconstructions was moderate for Hertel (κ = 0.55; 0.45-0.64) and substantial for Neer (κ = 0.63; 0.48-0.79).

CONCLUSIONS

The Hertel and Neer classifications showed a fair to substantial inter- and intra-observer agreement on the three diagnostic modalities used. Although inter-observer agreement was highest for Hertel classification on CT-scans, Neer classification had the highest intra-observer agreement on 3D-reconstructions. Data of this study do not confirm superiority of either classification system for the classification of comminuted proximal humeral fractures.

Non-hip and non-vertebral fractures: the neglected fracture sites

SUMMARY

Non-hip, non-vertebral fractures (NHNVF) were compared with hip, vertebral and controls. NHNVF were younger and heavier than controls and hip/vertebral fractures in both men and women, respectively. Falls and prior fractures were less common in NHNVF than hip fractures. Glucocorticoid use was lower in NHNVF compared to vertebral fracture (VF) in men.

INTRODUCTION

Although hip fracture (HF) and vertebral fractures (VF) receive the most attention in the literature and are the targeted sites for fracture prevention, non-hip, non-vertebral fracture (NHNVF) sites account for a greater proportion of fractures than the hip or vertebrae. This study aimed to assess risk factors for NHNVF and compare them with those for HF, VF and controls.

METHODS

Incident fractures during 2005-2007 for men and 1994-1996 for women were identified using computerised keyword searches of radiological reports, and controls were selected at random from electoral rolls for participation in the Geelong Osteoporosis Study. Participants aged 60+ years were included in this study.

RESULTS

Compared to controls, men and women with NHNVF were younger (ORs, 0.90, 95% CI 0.86-0.94; and 0.96, 0.93-0.98, respectively) and had a lower femoral neck bone mineral density (BMD) T-score (age-adjusted; difference [men] 0.383, P = 0.002; [women] 0.287, P = 0.001). Compared to HF, men and women with NHNVF were heavier (difference [men] 9.0 kg, P = 0.01; [women] 7.6 kg, P < 0.001). Heavier weight was also a risk factor for women with NHNVF compared to VF (1.03, 1.01-1.06). In men with NHNVF, falls (0.37, 0.14-0.97) and prior fractures (0.38, 0.15-0.98) were less common compared to HF; and glucocorticoid use was less common for NHNVF (0.30, 0.11-0.85) compared to VF.

CONCLUSIONS

Given the high numbers of NHNVF sustained by men and women in this study, fracture prevention strategies should focus on individuals with high risk of sustaining these types of fractures, as well as on individuals who are more likely to sustain a HF or VF.

Humeral Fractures in South-Eastern Australia: Epidemiology and Risk Factors

In this study, we report the epidemiology and risk factors for humeral fractures (proximal humerus and shaft) among men and women residing in south-eastern Australia. Incident fractures during 2006 and 2007 were identified using X-ray reports (Geelong Osteoporosis Study Fracture Grid). Risk factors were identified using data from case-control studies conducted as part of the Geelong Osteoporosis Study. Median age of fracture was lower in males than females for proximal humerus (33.0 vs 71.2 years), but not for humeral shaft (8.9 vs 8.5 years). For females, proximal humerus fractures occurred mainly in the 70-79 and 80+ years age groups, whereas humeral shaft fractures followed a U-shaped pattern. Males showed a U-shaped pattern for both proximal humerus and humeral shaft fractures. Overall age-standardised incidence rates for proximal humerus fractures in males and females were 40.6 (95% CI 32.7, 48.5) and 73.2 (95% CI 62.2, 84.1) per 100,000 person years, respectively. For humeral shaft fractures, the age-standardised rate was 69.3 (95% CI 59.0, 79.6) for males and 61.5 (95% CI 51.9, 71.0) for females. There was an increase in risk of proximal humerus fractures in men with a lower femoral neck BMD, younger age, prior fracture and higher milk consumption. In pre-menopausal women, increased height and falls were both risk factors for proximal humerus fractures. For post-menopausal women, risk factors associated with proximal humerus fractures included a lower non-milk dairy consumption and sustaining a prior fracture. Humeral shaft fractures in both sexes were sustained mainly in childhood, while proximal humerus fractures were sustained in older adulthood. The overall age-standardised rates of proximal humerus fractures were nearly twice as high in females compared to males, whereas the incidence rates of humeral shaft fractures were similar.

Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes

OBJECTIVE

The purpose was to study whether racial disparities in total shoulder arthroplasty (TSA) utilization and outcomes have declined over time.

METHODS

We used the US Nationwide Inpatient Sample from 1998 to 2011.We used chi-squared test to compare characteristics, Cochran-Armitage test to compare utilization rates, and Cochran-Armitage test and logistic regression to compare time-trends in outcomes by race.

RESULTS

From 1998 to 2011, 176,141 Whites and 7694 Blacks underwent TSA. Compared to Whites, Blacks who underwent TSA were younger (69.1 vs. 64.2 years; p<0.0001), more likely to be female (54.9 vs. 71.0 %; p<0.0001), and have rheumatoid arthritis or avascular necrosis as the underlying diagnosis (1.7 vs. 3.0%and 1.7 vs. 6.1 %; p<0.0001 for both) and a Deyo-Charlson index of 2 or higher (8.5 vs. 16.7 %; p<0.0001). Compared to Whites, Blacks had much lower TSA utilization rate/100,000 in 1998 (2.97 vs. 0.83; p<0.0001) and in 2011 (12.27 vs. 3.33; p<0.0001); racial disparities increased from 1998 to 2011 (p<0.0001). A higher proportion of Blacks than Whites had a hospital stay greater than median in 1998-2000, 62 vs. 51.4 % (p=0.02), and in 2009-2011, 34.4 vs. 27.3 % (p<0.0001); disparities did not change over time (p=0.31). These disparities in utilization were borderline significant in adjusted analyses. There were no racial differences in proportion discharged to inpatient medical facility in 1998-2000, 15.2 vs. 15.0 % (p=0.95), and in 2009-2011, 12.3 vs. 11.1%(p=0.37), respectively.

CONCLUSIONS

We found increasing racial disparities in TSA utilization. Some disparities in outcomes exist as well. Patients, surgeons, and policy-makes should be aware of these findings and take action to reduce racial disparities.

Effects of resveratrol treatment on bone and cartilage in obese diabetic mice

Background

Resveratrol is a polyphenolic phytoalexin that has been shown to exhibit osteoprotective and chondroprotective properties. We examine the effects of resveratrol treatment on bone and cartilage tissue of obese, diabetic ob/ob mice.

Methods

Eight-week-old ob/ob and lean control mice were given trans-resveratrol at an oral dose of 25 mg/kg for 3 weeks. Histomorphometric and cross-sectional-geometric variables were analyzed.

Results

Ob/ob mice in our study exhibit significantly reduced femoral length, resistance to loading, and tibial growth plate total area and calcified area than lean controls (P < 0.05). Resveratrol treatment significantly increased cortical area in both ob/ob and control mice, but did not improve cross-sectional indicators of resistance to bending. Resveratrol treatment also reduced tibial length and calcified growth plate cartilage area in comparison to untreated mice (P < 0.05).

Conclusion

Resveratrol treatment of ob/ob mice had mixed effects on bone histomorphometry at the femoral midshaft. Treatment increased cortical area but decreased bone length.

Evolving trends in surgically managed patients with proximal humerus fracture: are we different after ten years?

INTRODUCTION

New knowledge, and improved surgical hardware and fixation techniques have changed surgical management. We review the evolving trends of surgically managed proximal humerus fractures.

METHODS

Patients who underwent surgery for proximal humerus fractures from 1 January 2001 to 31 December 2010 were identified from the hospital's electronic diagnosis and operative coding database. Data extracted from the database included patient demographics, comorbidities, clinical and radiological findings, operative techniques, and complications.

RESULTS

In total, 95 patients with 97 surgically managed proximal humerus fractures were identified. The median age of the patients was 50 (range 12-85) years, and the male to female ratio was 1.2:1.0. Male patients tended to present at a younger age than female patients (peak age 30-39 years vs. 70-79 years, p < 0.001). Two-part surgical neck fracture was the most common type of fracture (n = 33, 34.0%). Plate osteosynthesis was predominantly used for two- and three-part surgical neck fractures involving the greater tuberosity (p = 0.03, p = 0.0002, respectively). Hemiarthroplasty was commonly performed for four-part fractures (p < 0.001). Wound infections, implant failure, avascular necrosis of the humeral head and nonunion were seen in 8 (8.3%) cases. Minimally invasive plate osteosynthesis (MIPO) had been in use since 2007 (p < 0.001).

CONCLUSION

Surgically managed proximal humerus fractures predominantly involved young men following high velocity injury and elderly women following osteoporotic fractures. Open plating was most commonly used for two- and three-part fractures, and hemiarthroplasty for four-part fractures. MIPO techniques have been practised in our institution since 2007.

Allogenic bone grafting for augmentation in two-part proximal humeral fracture fixation in a high-risk patient population

INTRODUCTION

The surgical fixation of unstable, varus displaced two-part fractures of the proximal humerus remains challenging.

MATERIALS AND METHODS

In a case series of 10 non-compliant, high-risk patients (median age 63 years; range 52-78), a cancellous allograft was used to augment plate fixation of the fractures.

RESULTS

After a median follow-up of 28.5 months, all but one fracture were healed, with the bony allografts incorporated without any systemic or local complications. No significant loss of reduction or evidence of avascular necrosis of the humeral head was seen. The median Constant-Murley Score was 72.0 (range 45-86). Median pain on a visual analog scale was 1 (range 0-7). Median values for the range of motion were flexion: 155° (range 90-170), abduction: 168° (range 95-180) and external rotation: 43° (range: 30-50). Compared to the uninjured contralateral side, flexion was impaired by 13 %, abduction by 14 %, and external rotation by 15 %. Median abduction power was 64 % of the uninjured side. The median varus displacement was 51° (range 45-59) preoperatively, 4° (range -5 to 19) intraoperatively, and 13° (range 1-18) at the time of the final follow-up, relating to an improvement of 38° compared to the preoperative status.

CONCLUSIONS

The augmentation of proximal humeral fracture fixation using a cancellous allograft might be a viable and reliable alternative to prevent early varus failure and to, moreover, lead to bony union in a non-compliant or high-risk patient population.

The risk of fractures among patients with cirrhosis or chronic pancreatitis

BACKGROUND & AIMS

Cirrhosis and chronic pancreatitis (CP) are accompanied by inflammation and malnutrition. Both conditions can have negative effects on bone metabolism and promote fractures. We evaluated the risk of fractures among patients with CP or cirrhosis and determined the effect of fat malabsorption on fracture risk among patients with CP.

METHODS

We performed a retrospective cohort study using the Danish National Patient Register to identify patients diagnosed with CP or cirrhosis. We analyzed data collected from January 1, 1995, to December 31, 2010, on 20,769 patients (35.5% women with cirrhosis and 11,972 patients (33.5% women) with CP. Each patient was compared with 10 age- and sex-matched controls. We also assessed the risk of fractures among patients with CP who received pancreatic enzyme substitution (PES) for fat malabsorption.

RESULTS

During the study period, bone fractures occurred in 3954 patients with cirrhosis and 2594 patients with CP. The adjusted hazard ratio (HR) for any fracture was 2.4 in patients with cirrhosis (95% confidence interval [CI], 2.2-2.5) and 1.7 in patients with CP (95% CI, 1.6-1.8). The relative risk of low-trauma fractures was highest among individuals younger than 50 years old. Alcohol as an etiology was associated with an increased risk of fracture compared with patients with nonalcoholic cirrhosis (HR, 2.4 vs 1.5; P < .0001) and CP (HR, 2.0 vs 1.5; P < .0001). Patients with CP receiving PES for fat malabsorption had a lower risk of fractures than other CP patients (HR, 0.8; 95% CI, 0.7-0.9). However, increasing the duration of treatment with PES was associated with an increased risk of fracture.

CONCLUSIONS

Patients, especially younger patients, with cirrhosis or CP have an increased risk of fractures of all types.

The occurrence of ipsilateral or contralateral foot disorders and hand dominance: the Framingham foot study

BACKGROUND

To our knowledge, hand dominance and side of foot disorders has not been described in the literature. We sought to evaluate whether hand dominance was associated with ipsilateral foot disorders in community-dwelling older men and women.

METHODS

Data were from the Framingham Foot Study (N = 2,089, examined 2002-2008). Hand preference for writing was used to classify hand dominance. Foot disorders and side of disorders were based on validated foot examination findings. Generalized linear models with generalized estimating equations were used to estimate odds ratios and 95% confidence intervals, accounting for intraperson variability.

RESULTS

Left-handed people were less likely to have foot pain or any foot disorders ipsilateral but were more likely to have hallux valgus ipsilateral to the left hand. Among right-handed people, the following statistically significant increased odds of having an ipsilateral versus contralateral foot disorder were seen: 30% for Morton's neuroma, 18% for hammer toes, 21% for lesser toe deformity, and a twofold increased odds of any foot disorder; there was a 17% decreased odds for Tailor's bunion and an 11% decreased odds for pes cavus.

CONCLUSIONS

For the 2,089 study participants, certain forefoot disorders were shown to be ipsilateral and others were contralateral to the dominant hand. Future studies should examine whether the same biological mechanism that explains ipsilateral hand and foot preference may explain ipsilateral hand dominance and forefoot disorders.

Age-related changes in proximal humerus bone health in healthy, white males

The proximal humerus is a common site for osteoporotic fracture. The current study demonstrates the rate of age-related decline in proximal humerus bone health. The data suggest aging is associated with considerable loss of bone mass, structural deterioration and reduced bone strength at the proximal humerus.

INTRODUCTION

The proximal humerus is relatively under investigated despite being the fourth most common site for osteoporotic fracture.

METHODS

A cross-sectional study was performed to assess age-related changes in dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT) properties of the proximal humerus in a cohort of 170 healthy, white males.

RESULTS

Regression models estimated considerable age-related loss of DXA measured bone quantity at the proximal humerus, with areal bone mineral density modeled to decline by 29% (95% confidence interval [CI], 17.5-35.0%) in the 50 years between ages 30 and 80 years (p < 0.001). pQCT measures indicated aging was associated with progressive periosteal and endosteal expansion, with the later occurring more rapidly as indicated by age-related declines in cortical bone mass, area and thickness (all p < 0.01). The net result of the density, mass and structural changes was a 26% (95% CI, 13.5-38.0%) decline in pQCT estimated proximal humerus bone strength in the 50 years between ages 30 and 80 years (p < 0.001).

CONCLUSION

Aging is associated with considerable declines in proximal humeral bone health which, when coupled with a traumatic event such as a fall, may contribute to osteoporotic fracture at this site.

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.

Effect of sitting pause times on postural stability after supine-to-standing transfer in dimly lit environments

BACKGROUND AND PURPOSE

Falls are common and often take place in the home. Risk of fall increases if the environment is dimly lit. Longer sitting pause times, before standing, might improve postural stability after standing from a supine position. The purpose of this investigation was to measure the effects of sitting pause times on postural sway velocity immediately following a supine-to-standing transfer in a dimly lit room in older and younger adult women.

METHODS

Five women aged 65 to 70 years and 5 aged 23 to 30 years participated in the study. On each of 2 consecutive days, study participants lay on a mat table with their eyes closed for 45 minutes before performing a supine-to-standing transfer in a dimly lit room. Sitting pause times of 2 seconds and 30 seconds preceded the transfers.

RESULTS

Mean postural sway velocity for the whole sample and for younger and older groups was less after a 30-second pause time than that after a 2-second pause time (sample, P = .001; young, P = .019; old, P = .021). No significant difference in mean postural sway velocity was observed between the 2 groups (P > .05).

CONCLUSIONS

Total mean postural sway velocity was less when study participants performed a sitting pause of 30 seconds before standing in a dimly lit room. These results suggest that longer sitting pause times may provide improved adaptability to dimly lit environments contributing to improved postural stability.

Previous fractures at multiple sites increase the risk for subsequent fractures: the Global Longitudinal Study of Osteoporosis in Women

Previous fractures of the hip, spine, or wrist are well-recognized predictors of future fracture, but the role of other fracture sites is less clear. We sought to assess the relationship between prior fracture at 10 skeletal locations and incident fracture. The Global Longitudinal Study of Osteoporosis in Women (GLOW) is an observational cohort study being conducted in 17 physician practices in 10 countries. Women aged ≥55 years answered questionnaires at baseline and at 1 and/or 2 years (fractures in previous year). Of 60,393 women enrolled, follow-up data were available for 51,762. Of these, 17.6%, 4.0%, and 1.6% had suffered 1, 2, or ≥3 fractures, respectively, since age 45 years. During the first 2 years of follow-up, 3149 women suffered 3683 incident fractures. Compared with women with no previous fractures, women with 1, 2, or ≥3 prior fractures were 1.8-, 3.0-, and 4.8-fold more likely to have any incident fracture; those with ≥3 prior fractures were 9.1-fold more likely to sustain a new vertebral fracture. Nine of 10 prior fracture locations were associated with an incident fracture. The strongest predictors of incident spine and hip fractures were prior spine fracture (hazard ratio [HR] = 7.3) and hip (HR = 3.5). Prior rib fractures were associated with a 2.3-fold risk of subsequent vertebral fracture, and previous upper leg fracture predicted a 2.2-fold increased risk of hip fracture. Women with a history of ankle fracture were at 1.8-fold risk of future fracture of a weight-bearing bone. Our findings suggest that a broad range of prior fracture sites are associated with an increased risk of incident fractures, with important implications for clinical assessments and risk model development.