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.

Primary hemiarthroplasty for treatment of proximal humeral fractures

Background: Primary hemiarthroplasty of the shoulder is used to treat complex proximal humeral fractures, although the reported functional results following this method of treatment have varied widely. The aim of this study was to prospectively assess the prosthetic survival and functional outcomes in a large series of patients treated with shoulder hemiarthroplasty for a proximal humeral fracture. By determining the factors that affected the outcome, we also aimed to produce models that could be used clinically to estimate the functional outcome at one year following surgery.

Methods: A thirteen-year observational cohort study of 163 consecutive patients treated with hemiarthroplasty for a proximal humeral fracture was performed. Twenty-five patients died or were lost to follow-up in the first year after treatment, leaving 138 patients who had assessment of shoulder function with use of the modified Constant score at one year postinjury.

Results: The overall rate of prosthetic survival was 96.9% at one year, 95.3% at five years, and 93.9% at ten years. The overall median modified Constant score was 64 points at one year, with a typically good score for pain relief (median, 15 points) and poorer scores, with a greater scatter of values, for function (median, 12 points), range of motion (median, 24 points), and muscle power (median, 14 points). Of the factors that were assessed immediately after the injury, only patient age, the presence of a neurological deficit, tobacco usage, and alcohol consumption were significantly predictive of the one-year Constant score (p < 0.05). Of the factors that were assessed at six weeks postinjury, those that predicted the one-year Constant score included the age of the patient, the presence of a persistent neurological deficit, the need for an early reoperation, the degree of displacement of the prosthetic head from the central axis of the glenoid seen radiographically, and the degree of displacement of the tuberosities seen radiographically.

Conclusions: Primary shoulder hemiarthroplasty performed for the treatment of a proximal humeral fracture in medically fit and cooperative adults is associated with satisfactory prosthetic survival at an average of 6.3 years. Although the shoulder is usually free of pain following this procedure, the overall functional result, in terms of range of motion, function, and power, at one year varies. A good functional outcome can be anticipated for a younger individual who has no preoperative neurological deficit, no postoperative complications, and a satisfactory radiographic appearance of the shoulder at six weeks. The results are poorer in the larger group of elderly patients who undergo this procedure, especially if they have a neurological deficit, a postoperative complication requiring a reoperation, or an eccentrically located prosthesis with retracted tuberosities.

Severely impacted valgus proximal humeral fractures : surgical technique

Background: The functional results associated with nonoperative treatment of severely impacted valgus fractures of the proximal part of the humerus are poor, and these injuries are difficult to treat with minimally invasive percutaneous fixation techniques. The aim of this study was to review the functional and radiographic results and complications of a new operative technique in a series of twenty-five patients.

Methods: Over a two-year period, we treated twenty-nine patients with a severely impacted valgus fracture of the proximal part of the humerus. Three patients were lost to follow-up and one died, leaving twenty-five patients who were available for the study. In all of the fractures, the head-shaft angle had been tilted into > or = 160 degrees of valgus and the greater tuberosity was displaced by >1 cm. All patients were treated with open reduction of the fracture, and the space created behind the humeral head was filled with Norian Skeletal Repair System (SRS) bone substitute. The fractures were stabilized with either screws or buttress plate fixation. Associated rotator cuff tears were repaired. All patients underwent functional outcome assessment with use of the Constant, DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores at one year, and twelve patients were followed for two years.

Results: All fractures united within the first year, all reductions were maintained, and no patient had signs of osteonecrosis of the humeral head on the latest follow-up radiographs. At one year, the median Constant score was 80 points and the median DASH score was 22 points. The functional results continued to be satisfactory in the twelve patients who were followed for two years. The results in our series were better than those achieved in studies of nonoperative treatment of similar fracture configurations. There were six clinically relevant complications, although none required a reoperation and all six patients had a satisfactory short-term functional outcome.

Conclusions: Internal fixation of severely impacted valgus fractures of the proximal part of the humerus, supplemented by Norian SRS bone substitute to fill the proximal humeral metaphyseal defect, produces good early functional and radiographic outcomes. Additional follow-up will be required to assess whether these initially satisfactory outcomes are maintained over the longer term.

Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT

Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (κ) measure. Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from "slight" to "fair." A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (κ = 0.35 compared with 0.30, p < 0.001) and on the AO classification (κ = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports.

The factors influencing the decision making of operative treatment for proximal humeral fractures

Background:
The factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations.
Methods: A total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment.
Results: Participants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture me chanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon.
Conclusion: Patient information - older age in particular - is associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations

Interobserver agreement of Neer and AO classifications for proximal humeral fractures

BACKGROUND:The classification of proximal humeral fractures remains challenging. The two main classification systems used, the Neer and the AO classification, have both been shown to have less than ideal interobserver agreement. Agreement in classification is required, however, to guide fracture management.

METHOD:Data from the Victorian Orthopaedic Trauma Outcomes Registry were collected and the X-rays of 104 proximal humeral fractures were reviewed by three orthopaedic consultants. They classified the fractures according to the Neer and AO classifications, as well as their simplified versions. Interobserver agreement was then assessed using kappa statistics.

RESULTS:Interobserver agreement was better overall in the Neer classification, which was moderate (kappa = 0.40-0.58), than the AO classification, which was fair to moderate (kappa = 0.31-0.54). When simplified, the Neer and AO classification interobserver agreement remained similar.

CONCLUSION:The classification of proximal humeral fractures with both the Neer and the AO systems remains difficult with minimal improvements seen when reducing the number of categories in each classification system. From these results, the Neer classification system would appear slightly more useful in clinical practice to guide treatment.

Severe impacted valgus proximal humerus fractures : results of operative treatment

Background: The functional results associated with nonoperative treatment of severely impacted valgus fractures of the proximal part of the humerus are poor, and these injuries are difficult to treat with minimally invasive percutaneous fixation techniques. The aim of this study was to review the functional and radiographic results and complications of a new operative technique in a series of twenty-five patients.

Methods: Over a two-year period, we treated twenty-nine patients with a severely impacted valgus fracture of the proximal part of the humerus. Three patients were lost to follow-up and one died, leaving twenty-five patients who were available for the study. In all of the fractures, the head-shaft angle had been tilted into =160° of valgus and the greater tuberosity was displaced by >1 cm. All patients were treated with open reduction of the fracture, and the space created behind the humeral head was filled with Norian Skeletal Repair System (SRS) bone substitute. The fractures were stabilized with either screws or buttress plate fixation. Associated rotator cuff tears were repaired. All patients underwent functional outcome assessment with use of the Constant, DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores at one year, and twelve patients were followed for two years.

Results: All fractures united within the first year, all reductions were maintained, and no patient had signs of osteonecrosis of the humeral head on the latest follow-up radiographs. At one year, the median Constant score was 80 points and the median DASH score was 22 points. The functional results continued to be satisfactory in the twelve patients who were followed for two years. The results in our series were better than those achieved in studies of nonoperative treatment of similar fracture configurations. There were six clinically relevant complications, although none required a reoperation and all six patients had a satisfactory short-term functional outcome.

Conclusions: Internal fixation of severely impacted valgus fractures of the proximal part of the humerus, supplemented by Norian SRS bone substitute to fill the proximal humeral metaphyseal defect, produces good early functional and radiographic outcomes. Additional follow-up will be required to assess whether these initially satisfactory outcomes are maintained over the longer term.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Sex- and age-specific associations between income and incident major osteoporotic fractures in Canadian men and women: a population-based analysis

We investigated sex- and age-specific associations between income and fractures at the hip, humerus, spine, and forearm in adults aged ≥50 years. Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women.

Changes in quality of life associated with fragility fractures: Australian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (AusICUROS).

We investigated change in health-related quality of life due to fracture in Australian adults aged over 50 years. Fractures reduce quality of life with the loss sustained at least over 12 months. At a population level, the loss was equivalent to 65 days in full health per fracture.

Use of calcium or calcuim in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis

Background:  Whether calcium supplementation can reduce osteoporotic fractures is uncertain. We did a meta-analysis to include all the randomised trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss.

Methods:  We identified 29 randomised trials (n=63 897) using electronic databases, supplemented by a hand-search of reference lists, review articles, and conference abstracts. All randomised trials that recruited people aged 50 years or older were eligible. The main outcomes were fractures of all types and percentage change of bone-mineral density from baseline. Data were pooled by use of a random-effect model.

Findings:  In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types (risk ratio 0·88, 95% CI 0·83–0·95; p=0·0004). In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0·54% (0·35–0·73; p<0·0001) at the hip and 1·19% (0·76–1·61%; p<0·0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0·0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0·80 vs 0·94; p=0·006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0·84 vs 0·87; p=0·03).

Interpretation:  Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation).

The evidence that exercise during growth or adulthood reduces the risk of fragility fractures is weak

There has never been, and will never be, a randomized double-blind placebo-controlled trial demonstrating that exercise in youth, adulthood or old age reduces fragility or osteoporosis-related fractures in old age. The next level of evidence, a randomized, controlled but unblinded study with fractures as an end-point is feasible but has never been done. The basis for the belief that exercise reduces fractures is derived from lower levels of ‘evidence’, namely, retrospective and prospective observation cohort studies and case–control studies. These studies are at best hypothesis generating, never hypothesis testing. They are all subject to many systematic biases and should be interpreted with extreme scepticism. Surrogate measures of anti-fracture efficacy are the next level of evidence, such as the demonstration of a reduction in risk factors for falls, a reduction in falls, a reduction in fractures due to falls, an increase in peak bone size and mass, prevention of bone loss in midlife and restoration of bone mass and structure in old age.

Ice and pulsed electromagnetic field to reduce pain and swelling after distal radius fractures

Objective: To examine the relative effectiveness of ice therapy and/or pulsed electromagnetic field in reducing pain and swelling after the immobilization period following a distal radius fracture.Methods: A total of 83 subjects were randomly allocated to receive 30 minutes of either ice plus pulsed electromagnetic field (group A); ice plus sham pulsed electromagnetic field (group B); pulsed electromagnetic field alone (group C), or sham pulsed electromagnetic field treatment for 5 consecutive days (group D). All subjects received a standard home exercise programme. A visual analogue scale was used for recording pain; volumetric displacement for measuring the swelling of the forearm; and a hand-held goniometer for measuring the range of wrist motions before treatment on days 1, 3 and 5.Results: At day 5, a significantly greater cumulative reduction in the visual analogue scores as well as ulnar deviation range of motion was found in group A than the other 3 groups. For volumetric measurement and pronation, participants in group A performed better than subjects in group D but not those in group B.Conclusion: The addition of pulsed electromagnetic field to ice therapy produces better overall treatment outcomes than ice alone, or pulsed electromagnetic field alone in pain reduction and range of joint motion in ulnar deviation and flexion for a distal radius fracture after an immobilization period of 6 weeks.