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

BACKGROUND: Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF. METHODS: Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination. RESULTS: Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination. CONCLUSIONS: Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

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

BACKGROUND: We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population. METHODS: Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years. RESULTS: Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups. CONCLUSION: An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

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

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

[One-year outcomes after proximal humeral fractures : A risk-adjusted regression analysis of routine data based on 17,322 cases]. / Einjahresverläufe nach proximalen Humerusfrakturen : Eine risikoadjustierte Regressionsanalyse mittels Routinedaten anhand von 17.322 Fällen.

BACKGROUND: Proximal humeral fractures (PHF) are the third most common fracture in geriatric traumatology. No standard evidence-based treatment has been established so far. The epidemiology and economic burden highlight the importance of a targeted treatment strategy. OBJECTIVE: Epidemiology of PHF and analysis of the influence of preoperative length of stay, comorbidities and quality of patient life. Additionally, a comparison to the more frequently studied proximal femoral fractures. MATERIAL AND METHODS: A routine data analysis of 17,322 cases admitted for inpatient treatment with an observational period of 1 year was performed following an established model. Descriptive statistics included comorbidities, treatment procedures and mortality. Analytical statistics using logistic regression with the primary endpoints of early revision, mortality and decubitus within 1 year. RESULTS: In the investigated PHFs there was a mortality of 13% within 1 year, which is increased three-fold in patients with comorbidities such as cancer. There was an increase of 57% in patients who first received a care level following PHF. A preoperative care level in general significantly decreased survival. The most frequently used surgical procedure was fixation via stable-angle plate (used in 43%). The preoperative length of stay did not impact survival. DISCUSSION: Intrinsic factors such as preoperative comorbidities are crucial for the mortality after PHF. The PHF affects patients' lives less than proximal femoral fractures. With comparable comorbidity profiles, possible reasons are the lower levels of immobilization and less dependency on care before the fracture in comparison to proximal femoral fractures.

Assessing the Risk of Postoperative Complications for Proximal Humeral Fractures Treated by Open Reduction and Internal Fixation in Patients With Diabetes and Chronic Kidney Disease.

BACKGROUND: The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) has markedly risen over the past three decades. Patients with DM and CKD are at increased risk of infection, immune dysfunction, as well as bone and mineral disorders. Although we know that patients with DM and CKD have these risks, we do not know how these translate to proximal humeral fracture (PHF) healing. We sought to analyze whether these established comorbidities had increased rates of complications after open reduction and internal fixation (ORIF) for PHF treatment. METHODS: Using a national insurance database, 72,365 patients with PHF managed with ORIF were identified using records from 2010 to 2022. Patients were initially split into those with DM and those without and were further stratified by the presence or absence of CKD. For our comparison baseline cohort, patients were not diagnosed with either DM or CKD. Post-ORIF complication rates were assessed looking specifically at nonunion, postoperative infection, and all-cause revision surgery. A logistic regression statistical analysis was also conducted. RESULTS: Of the 72,365 patients with PHF treated by ORIF, 41,047 were non-DM without CKD (comparison); 17,025 had DM alone (no CKD); 11,729 had DM and CKD; and 2564 had CKD alone (non-DM). Multivariate analysis indicated that patients with DM and/or CKD were at increased risk of developing nonunion (odds ratio [OR] = 1.37, 1.48, 1.23) and all-cause revision surgery (OR = 1.21, 1.11, 1.18) after ORIF for PHF compared with our comparison cohort. In addition, all patients with DM alone (non-CKD) and DM with CKD had an increased risk of postoperative infection (OR = 1.39, 1.26). CONCLUSION: The management of PHF is a controversial topic, particularly regarding the degree of intervention and optimal treatment choice. Regardless, using a pragmatic design and reviewing a national insurance database, this study provides information for patients in high-risk populations, specifically patients with DM and CKD, and may prove beneficial when selecting a patient-specific treatment plan. Additional studies are needed to assess varying stages of both DM and CKD in patients who sustain PHF treated by ORIF along with postoperative strategies to minimize complications.

Hounsfield units predicts the occurrence but not the patterns of proximal humerus fracture in the elderly patients.

BACKGROUND: Increased incidence of fragility fractures of the proximal humerus has been reported. Proximal humerus Hounsfield unit (HU) measurements based on computed tomography (CT) scans of the shoulder can be used to evaluate bone mineral density (BMD). It is unknown whether HU values can predict the risk of proximal humerus osteoporotic fracture and /or fracture patterns. Therefore, the objectives of this study were to identify whether the HU value is associated with proximal humeral osteoporotic fracture risk, and whether or not it has an impact on the complexity of the fracture. METHODS: We identified 60 + years old patients' CT scans between 2019 and 2021 according to the inclusion and exclusion criteria. All patients were divided into two groups based on the presence or lack of a fracture in the proximal humerus, meanwhile, patients with fractures were stratified into simple and comminuted fractures based on the Neer classification. HU values were calculated within the proximal humerus and compared between groups using the Student t-test, and receiver operating characteristic (ROC) curve analysis was used to determine the ability of HU values to predict fracture. RESULTS: A total of 138 patients with proximal humerus fracture (PHF) including 62 simple PHFs and 76 complex PHFs and 138 non-fracture patients were enrolled in the study. The HU values decreased as age increased among all patients. Both male and female patients with PHF had significantly lower HU values compared with non-fracture patients, the area under the curve (AUC) of the ROC curve for males and females was 0.8 and 0.723 respectively. Nevertheless, no significant differences were found between simple and complex fractures of the proximal humerus in the HU values. CONCLUSION: Decreasing HU values on CT may be an early warning sign of fracture potential, however, it was not a predictive factor for comminuted fracture of the proximal humerus.

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

Little is known about survival after proximal humerus fracture. In this manuscript, we found the mortality to be high (almost four times higher than in age- and sex-matched controls). While frailty hip fracture has gained attention, we hope our manuscript will shed light on frailty proximal humerus fracture patients. INTRODUCTION: Proximal humerus fractures (PHF) are common and occur mostly after the 6th decade of life. While mortality following PHF has been reported previously, mortality data after longer follow-up on a national level is lacking. METHODS: We obtained data from the Swedish Hospital Discharge Register (SHDR), on all adult patients (≥ 18 years) with a diagnosis of PHF (S42.2, S42.20, or S42.21) for the period between 2001 and 2016. We used the Swedish Cause of Death Register (SCDR) to investigate mortality in the fracture cohort. We compared the mortality of fracture patients with age- and sex-matched population-based mortality data obtained from Statistics Sweden. RESULTS: A total of 147 692 PHF patients were identified, with a male to female ratio of 1:3. The mean age was 69 years (range, 18 to 111). Most patients were treated non-surgically (n = 126,487, 86%). The crude mortality rate was 2.2% at 1 month, 4.1% at 3 months, 8.5% at 12 months, and 24% at 48 months after sustaining a PHF. Mortality increased with age; however, the standardized mortality rate (SMR) was highest among young patients. SMR was 5.4 in the 18- to 39-year age group, 3.9 in the 40- to 64-year age group, 1.8 in the 65-79-year age group, and 1.2 in the ≥ 80-year-old population. The age-adjusted SMR was 3.9 in the whole adult PHF population. CONCLUSION: The mortality rate and SMR suggest that PHF patients are heterogeneous. Some older PHF patients may benefit from specialized care (e.g., orthogeriatric), and this should be evaluated in future studies.

Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review.

PURPOSE: Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures. METHODS: The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. RESULTS: One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33). CONCLUSION: TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence. LEVEL OF EVIDENCE: Systematic Review, Therapeutic Level II.

Health Care for Inpatients with a Proximal Humeral Fracture - an Analysis of Health Insurance Data. / Versorgungsrealität stationär behandelter Patienten mit proximaler Humerusfraktur ­ Eine Analyse auf Basis von GKV-Daten.

The proximal humeral fracture is one of the most common fractures in the elderly. While epidemiological factors have been well studied, the influence of a proximal humeral fracture on morbidity, mortality and associated costs has not yet been adequately analysed.On a basis of 4.1 million insurance holders of the German public health insurance (GKV), patients with (study population, SP) and without (comparison group, VG) a proximal humeral fracture (pHF) were compared with regard to comorbidity, rehospitalisation, mortality, drug and aid needs as well as number of physician contacts. Study period was between 2012 and 2016.6068 patients of the SP met the inclusion and exclusion criteria (age 69.4 ± 14.3 years; male : female = 28.2% : 71.8%). 4781 patients (78.8%) received surgical, 1287 patients (21.2%) conservative treatment of the pHF. Rehospitalisations and visits to the general practitioner occurred more frequently in the SP vs. VG (p < 0.01). Contacts with specialists after pHF varied according to specialty, as did newly occurring diseases. Typical specialities for preventive examinations were significantly less common (gynaecology p < 0.01, pathology p < 0.01, dermatology p < 0.01). According to pHF, the costs of SP for drugs (2490.76 ± 1395.51 € vs. 2167.86 ± 1314.43 €; p = 0.04), medical therapies (867.01 ± 238.67 € vs. 393.26 ± 217.55 €; p < 0.01) and aids (821.02 ± 415.73 € vs. 513.52 ± 368.76 €; p < 0.01) were significantly above the VG. The two-year survival after pHF is lower in the SP than in the VG (p < 0.01).The results show increased morbidity and mortality as well as medical costs after a proximal humeral fracture. Preventive examinations and treatments are rarer. In the future, care concepts for patients with proximal humeral fractures should not only be optimised with regard to functional scores and reduced complication rates, but also with regard to quality of life and preservation of general health.

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

INTRODUCTION: Proximal humeral fractures (PHFs) often occur in elderly patients with osteoporosis and associated comorbidities. These patients constitute a special risk group. This study aimed to identify associations between comorbidities, treatment type, and mortality risk. PATIENTS AND METHODS: We conducted a retrospective chart review of a cohort of 350 patients with a diagnosis of PHF and a mean follow-up of 4.5 years. We analysed the 19 prefracture comorbidities included in the Charlson Comorbidity Index (CCI), haemoglobin (Hb) levels, blood transfusion needs, and treatment administered (surgery versus conservative). The nonparametric Kaplan-Meier method and Cox proportional hazards model were used to estimate the mortality risk. RESULTS: Over a 4.5-year average follow-up of 350 patients, primarily elderly females, with proximal humerus fractures, several factors were associated with increased mortality. The Charlson Comorbidity Index (CCI) was a significant predictor, with patients having a CCI > 5 facing higher mortality risks, especially if they underwent surgery. Additionally, osteosynthesis was linked to a lower mortality rate compared to arthroplasty. Age, dementia, medical complications, and postfracture Hb level also influenced mortality rates. CONCLUSIóN: These findings emphasize the importance of considering comorbidities, specifically the Charlson Comorbidity Index (CCI), in determining patient outcomes, especially amongst elderly patients with proximal humerus fractures. Factors like age, dementia, and postfracture Hb level also play a crucial role in influencing mortality rates. TRIAL REGISTRATION: The study received written approval from the regional Ethics Committee for Clinical Research (code 2016/125).

Epidemiology and trends in management of acute proximal humeral fractures in adults: an observational study of 137,436 cases from the Danish National Patient Register, 1996-2018.

BACKGROUND AND PURPOSE: Proximal humeral fractures (PHF) can be managed surgically or non-surgically. Locking plates have been the preferred head-preserving surgical technique while hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA) have been used in joint replacement surgery. We describe the epidemiology and trends in management of acute PHF in Denmark with a focus on (i) changes in the incidence of PHF; (ii) changes in the proportion of surgical cases; and (iii) changes in preferred surgical techniques. PATIENTS AND METHODS: Data on diagnoses and interventions was retrieved from the Danish National Patient Register. Patients aged 18 years and above were included. Surgical treatment was defined as the diagnosis of PHF combined with a predefined surgical procedure code within 3 weeks of injury. Data on plate osteosynthesis, HA, RSA, and "other techniques" was retrieved. Non-surgical treatment was defined as no relevant surgical procedure code within 3 weeks. RESULTS: We identified 137,436 PHF (72% women) in the Danish National Patient Register. The overall mean incidence was 138/100,000/year (500 for women 60 years or above). Non-surgical treatment accounted for 119,966 (87%). The 17,470 surgical procedures included 42% locking plates, 34% arthroplasties, and 25% other techniques. The rate of surgery declined from 17% in 2013 to 11% in 2018. INTERPRETATION: The overall incidence of PHF remained stable between 1996 and 2018 but the absolute number increased. The approach to PHF remains predominantly non-surgical. The number of surgeries in Denmark have decreased since 2013, especially for locking plates and HA, while RSA is increasingly used.

Acromioclavicular dislocation associated with scapular fractures - pathoanatomy of the injury.

INTRODUCTION: No detailed study dealing with an injury to the AC joint in combination with scapular fractures has been published to date. The aim of this study is to describe pathoanatomy of these injuries. METHODS: In a series of 519 scapular fractures in adult patients from the period of 20022020 we identified a total of 20 (3.9%) cases associated with AC dislocation. The group comprised 17 men and 3 women with the mean age of 49 years (range, 2178). Radiographs of the shoulder joint followed by CT examination, including 3D reconstructions, were performed in all patients. This documentation allowed assessment of the scapular fracture pattern and type of injury to the AC joint. RESULTS: AC dislocation was associated with a simple scapular fracture in 15 cases (7 fractures of the coracoid base, 4 fractures of the acromion or the lateral spine, 2 fractures of the scapular body, 1 fracture of the superior and 1 fracture of the inferior glenoid). In 5 cases AC dislocation accompanied multiple or complex scapular fractures (once a combination of a coracoid fracture and a fracture of the lateral scapular spine, once a combination of a fracture of the superior glenoid and of the acromion, 2 cases of a complex intraarticular fracture and 1 case of scapulothoracic dissociation). CONCLUSION: AC dislocation is relatively infrequent injury accompanying scapular fractures. It is most commonly associated with fractures of coracoid, acromion/lateral spine or superior glenoid. No case of AC dislocation was recorded in a fracture of the scapular neck.

Glenohumeral joint dislocation is rare in children with proximal humeral fractures: a descriptive study and literature review.

BACKGROUND: Glenohumeral dislocation combined with fracture of the proximal humerus is extremely rare in children, and this study aims to investigate its incidence in the pediatric population and review the treatment strategy for this condition. METHODS: Between Jan 2014 and Jan 2019, 280 patients with unilateral proximal humeral fractures were retrospectively reviewed. Imaging and follow-up notes were reviewed for patients with a predilection for glenohumeral joint dislocation. Six (2.14%) patients between the ages of 5 and 10 years were confirmed as glenohumeral joint dislocation and included in the study. All these patients underwent closed reduction and external fixation under general anesthesia. RESULTS: Out of 280 patients with proximal humeral fractures, only 6 patients, including 4 males and 2 females, were confirmed as glenohumeral joint dislocation. ROM was normal compared with the contralateral shoulder in every patient at the last follow-up. There was no case of radiological abnormality, including avascular necrosis or devascularization of the humeral head. CONCLUSIONS: Glenohumeral dislocation is a rare entity associated with the proximal humerus fracture in children, with an overall incidence in our case series was 2.14%. Reduction and stabilization of such injury using an external fixator is a suitable choice for pediatric patients that failed closed reduction.

Proximal humeral fracture osteosynthesis in Belgium: a retrospective population-based epidemiologic study.

PURPOSE: Proximal humeral fractures (PHF) comprise approximately five percent of all fractures and this percentage will continue to increase due to the aging population with accompanying osteoporosis. Most PHF can be treated conservatively; however, in displaced fractures, surgical treatment is recommended. Retrospective analyses of large groups or even populations are important as they can contribute to the needs of the community. The aim of this study was to assess the epidemiology and management of PHF fixation in Belgium based on the most recently available data from the last 5 years. METHODS: The governmental organization National Institute of Health and Disability Insurance provided a population-based database with all PHF treated surgically or nonoperatively. This database was retrospectively assessed. The data included age, sex, region of residence, year and treatment strategy for every patient. Healthcare expenses were also provided. RESULTS: A total of 62,290 PHF were identified in Belgium between 2014 and 2018. The incidence was 111 per 100,000 persons/year. The highest incidence was observed in females and people older than 80 years. The average proportion of osteosynthesis was calculated at 21%. The Belgian government spent on average more than two million euros each year on PHF treatment. CONCLUSION: The overall incidence of PHF increased by 12% over the last 5 years. The majority were treated nonoperatively in Belgium.

Upper extremity fractures due to intimate partner violence versus accidental causes.

PURPOSE: The purpose of this study is to evaluate the prevalence of intimate partner violence (IPV)-related upper extremity fractures (UEF) in women presenting to US emergency departments (ED) and compare their anatomic location to those due to accidental falls or strikes. METHODS: An Institutional Review Board exempt, retrospective review of prospectively collected data was performed using the National Electronic Injury Surveillance System's All Injury Program data from 2005 through 2015 for all UEF sustained in women 15 to 54 years old. Injuries based on reported IPV versus accidental falls or strikes were analyzed accounting for the weighted, stratified nature of the data. RESULTS: IPV-related UEF represented 1.7% of all UEF and 27.2% of all IPV fractures. The finger was the most common fracture site in IPV (34.3%) and accidental striking (53.3%) but accounted for only 10% of fall-related UEF. There was a higher proportion of shoulder fractures in IPV (9.2%) compared to accidental falls (7.4%) or strikes (2.9%). The odds of a finger fracture were 4.32 times greater in IPV than falling and of a shoulder fracture were 3.65 greater in IPV than accidental striking (p < 0.0001). CONCLUSIONS: While the finger is the most common site for IPV UEF, it is also the most common location for accidental striking. A lower proportion of finger fractures in fall and of shoulder/forearm fractures in accidental striking should prompt the radiologist to discuss the possibility of IPV with the ED physician in any woman presenting with a finger fracture due to fall and a shoulder/forearm fracture with a vague history of accidental striking.

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

INTRODUCTION: This study aimed to investigate the influence of epidemiologic parameters on complications that needed operative revision of operatively treated proximal humerus fractures. METHODS: We performed a retrospective single-center study in a level 1 trauma center. We included all patients with operatively treated proximal humerus fractures from January 1 2005 to December 31 2015. We characterized our cohort and subgroup using descriptive statistics. The primary outcome was postoperative complications. For this purpose, postoperative complications were defined in advance, an operative revision was necessary on a general rule. The secondary outcome was a model of the risk factors for complications created with multiple logistic regression. RESULTS: We included 1109 patients. The average age was 67.2 years (± 16.4), and 71.4% of the fractures occurred in women. A total of 644 patients (58.1%) had between one to three comorbidities, and 27.8% had four or more. The fracture morphology was as follows: 3 part 41.8%, 4 part 26.9%, 2 part 24.3%, and dislocation fracture 6.7%. Complications occurred in 150 patients (13.5%). The number of comorbidities [odds ratio (OR) 2.85, p < 0.01], body weight (OR 1.15, p = 0.02), and substance abuse (OR 1.82, p = 0.04) significantly correlated with the risk of complications. We achieved a sensitivity of 48% and a specificity of 74% for the variables body weight, substance abuse, age, and comorbidities CONCLUSION: The epidemiologic parameters, comorbidities, substance abuse, weight, and age are independent risk factors for complications. If these factors are present, one can predict a postoperative complication requiring surgical revision with low sensitivity and moderate specificity. Therefore, concerning the high number of multi-morbid patients with proximal humerus fractures, an increased postoperative complication rate can be expected. LEVEL OF EVIDENCE: Level of evidence IV.

Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery. / Aktuelle Entwicklungen der Versorgungsrealität proximaler Humerusfrakturen ­ eine Auswertung von 1162 Fällen an einem Level-1-Traumazentrum mit schulterchirurgischem Schwerpunkt.

BACKGROUND: The management of proximal humeral fracture (PHF) is not only complex but ever changing. Published epidemiological data are often dated and do not factor in demographic changes or the latest developments in implant material and surgical techniques. AIMS: The primary aim of this study was to evaluate changes in the epidemiology and actual treatment of PHF at a level-1 trauma centre, with a special focus on shoulder surgery. HYPOTHESES: 1. Between 2009 to 2012 and 2014 to 2017, an increase in complex PHF entities can be observed. 2. In correlation with fracture complexity, an increasing number of comorbidities, especially osteoporosis, can be observed. METHODS: Between 2014 and 2017, a total of 589 patients (73% female; mean age: 68.96 ± 14.9 years) with 593 PHFs were treated. Patient records and imaging (XRs and CTs) of all patients were analysed. Fractures with ad latus displacement of a maximum of 0,5 cm and/or humeral head angulation of less than 20° were classified as non-displaced. Patients with displaced fractures were included in the analysis of the therapeutic algorithm. These results were compared to those of a cohort 2009 to 2012 (566 patients, 569 PHFs), which used the same inclusion criteria. RESULTS: The two cohorts showed comparable patient numbers, as well as gender and age distributions. Between 2009 to 2012 and 2014 to 2017, a decrease in 2-part fractures (13.9 to 8.6%) and a simultaneous increase in 4-part fractures (20.4 to 30%), and thus fracture complexity was observed. Further decreases were observed in conservative therapy (27.8 to 20.6%), nail osteosynthesis (10.7 to 2.7%) and anatomic shoulder arthroplasty (5,4 to 1%). Furthermore, there was an increase in the use of locking plate osteosynthesis (43.2 to 56.7%) and reverse shoulder arthroplasty (9 to 18.4%). The general trend shows an increase in surgical therapy between the years (72.2 to 79.4%), as well as an increase in osteoporosis incidence (13 to 20.6%). The greatest numbers of comorbidities were found in 3- and 4-part fractures. CONCLUSION: There is an increase in both the complexity of fractures and the number of surgically treated fractures between 2009 and 2012. Furthermore, an increase in osteoporosis numbers can be observed. New implants (PEEK, fenestrated screws for cement augmentation) and new surgical techniques (double plating osteosynthesis) were used as a result of increasing fracture complexity. Moreover, reverse total shoulder arthroplasty was used more commonly.

Proximal humeral fractures in Finland : trends in the incidence and methods of treatment between 1997 and 2019.

AIMS: Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland. METHODS: The study included all Finnish inhabitants aged ≥ 16 years between 1997 and 2019. All records, including diagnostic codes for PHFs and all surgical procedure codes for these fractures, were identified from two national registers. Data exclusion criteria were implemented in order to identify only acute PHFs, and the operations performed to treat them. RESULTS: During the 23-year study period, 79,676 PHFs were identified, and 14,941 operations were performed to treat them. The incidence of PHFs steadily increased. In 2019, the overall incidence was 105 per 100,000 person-years (105). The sex-adjusted incidence for females was 147.1 per 105, and the age-adjusted incidence for patients aged ≥ 80 years was 407.1 per 105. The incidence of operative treatment for PHFs rose during the first half of the study period and decreased during the second half. The use of plate osteosynthesis in particular decreased. In 2019, the incidence of operative treatment for PHFs was 13.2 per 105, with 604 operations. CONCLUSION: Although the incidence of PHFs is steadily increasing, particularly in elderly females, the incidence of operative treatment is now decreasing, which is in line with current literature regarding their treatment. Cite this article: Bone Joint J 2022;104-B(1):150-156.

Core set of unfavorable events of proximal humerus fracture treatment defined by an international Delphi consensus process.

BACKGROUND: Proximal humerus fracture (PHF) complications, whether following surgery or nonoperative management, require standardization of definitions and documentation for consistent reporting. We aimed to define an international consensus core event set (CES) of clinically-relevant unfavorable events of PHF to be documented in clinical routine practice and research. METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder trauma surgeons selected by survey invitation of AO Trauma members. An organized list of PHF events after nonoperative or operative management was developed and reviewed by panel members using on-line surveys. The proposed core set was revised regarding event groups along with definitions, specifications and timing of occurrence. Consensus was reached with at least a two-third agreement. RESULTS: The PHF consensus panel was composed of 231 clinicians worldwide who responded to at least one of two completed surveys. There was 93% final agreement about three intraoperative local event groups (device, osteochondral, soft tissue). Postoperative or nonoperative event terms and definitions organized into eight groups (device, osteochondral, shoulder instability, fracture-related infection, peripheral neurological, vascular, superficial soft tissue, deep soft tissue) were approved with 96 to 98% agreement. The time period for documentation ranged from 30 days to 24 months after PHF treatment depending on the event group and specification. The resulting consensus was presented on a paper-based PHF CES documentation form. CONCLUSIONS: International consensus was achieved on a core set of local unfavorable events of PHF to foster standardization of complication reporting in clinical research and register documentation. TRIAL REGISTRATION: Not applicable.