Epidemiology of proximal humerus fractures

The epidemiology of adult fractures is changing quickly. An analysis of 5953 fractures reviewed in a single orthopaedic trauma unit in 2000 showed that there are eight different fracture distribution curves into which all fractures can be placed. Only two fracture curves involve predominantly young patients; the other six show an increased incidence of fractures in older patients. It is popularly assumed that osteoporotic fractures are mainly seen in the thoracolumbar spine, proximal femur, proximal humerus and distal radius, but analysis of the data indicates that 14 different fractures should now be considered to be potentially osteoporotic. About 30% of fractures in men, 66% of fractures in women and 70% of inpatient fractures are potentially osteoporotic.

We present a 5-year prospective study of the epidemiology of 1,027 proximal humeral fractures. These fractures, which tend to occur in fit elderly persons, have a unipolar age distribution and the highest age-specific incidence occurs in women between 80 and 89 years of age. The commonest was the B1.1 impacted valgus fracture, found in one-fifth of the cases in this series, a type that is not included in the Neer classification. We used both Neer and AO classifications. The AO classification proved to be more comprehensive because in the Neer classification, half of the fractures are minimally displaced and almost nine-tenths fall into only three categories. In the AO classification, the B1.1, A2.2, A3.2 and A1.2 sub-groups comprise over half of all proximal humeral fractures, while the AO type C fractures occur in only 6%. We suggest that the literature does not adequately reflect the spectrum of proximal humeral fractures.

the treatment of proximal humeral fractures in the elderly remains controversial. Options include nonoperative treatment, open reduction with internal fixation (ORIF), and hemiarthroplasty. Locking plate technology has expanded the indications for ORIF for certain fracture types in osteoporotic bone. This study was performed to characterize the incidence, treatment, and revision surgery of proximal humeral fractures according to geographic region both before (1999 to 2000) and after (2004 to 2005) the introduction of locking plates. we used a 20% sample of Medicare Part-B data and the Medicare denominator file for the years 1998 to 2006. Proximal humeral fractures were identified by Common Procedural Terminology codes for treatment, categorized as nonoperative, ORIF, or hemiarthroplasty. Geographic variation in treatment type was determined with use of 306 hospital referral regions. Odds ratios for revision surgery were calculated by the need for repeat surgery within one year of the index procedure. Rates were adjusted for age, sex, race, and comorbidities. there were 14,774 proximal humeral fractures in the 20% sample from 1999 to 2000 (an estimated total of 73,870 fractures) and 16,138 fractures in the sample from 2004 to 2005 (an estimated total of 80,690 fractures). The overall age, sex, and race-adjusted incidence of proximal humeral fractures was unchanged from 1999 to 2005 (2.47 vs. 2.48 per 1000 Medicare beneficiaries; p = 0.992). However, the absolute rate of surgically managed proximal humeral fractures rose 3.2 percentage points from 12.5% to 15.7%, a relative increase of 25.6% (p < 0.0001). The relative increase in the percentage of fractures treated with ORIF was 28.5% (p < 0.0001), while the percentage of fractures treated with hemiarthroplasty increased 19.6% (p < 0.0001). There were large regional variations in the proportion treated surgically (range, 0% to 68.18%). The rates of repeat surgery were significantly higher in 2004 to 2005 compared with 1999 to 2000 (odds ratio = 1.47, p = 0.043). although the incidence of proximal humeral fractures in the elderly did not change from 1999 to 2005, the rate of surgical treatment increased significantly. The marked regional variation in the rates of surgical treatment highlights the need for better consensus regarding optimal treatment of proximal humeral fractures. Additional research is needed to help to determine which fractures are best treated operatively in order to maximize outcome and minimize the need for revision surgery. therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.