Iatrogenic open humeral shaft fractures following functional bracing.

INTRODUCTION: The treatment of closed humeral shaft fractures tends to be successful with functional bracing. Treatment failure due to iatrogenic conversion to an open fracture has not been described in the literature. We present a case series of patients that experienced open humeral shaft fractures after initially being treated with functional bracing for closed humeral shaft fractures and describe what factors are associated with this complication. MATERIALS AND METHODS: This was a retrospective case series performed at three level 1 trauma centers across North America. All nonoperatively treated humeral shaft fractures were reviewed from 2001 to 2023. Patients were included if they sustained a humeral shaft fracture, > 18 years old, were initially treated non-operatively with functional bracing which subsequently converted to an open fracture. Eight patients met inclusion criteria. All included patients were eventually treated with irrigation, debridement, and open reduction and internal fixation. Outcomes assessed included mortality rate, time until the fracture converted from closed to open, need for further surgery, and bony union. Descriptive statistics were used in analysis. RESULTS: The eight included patients on average were 65 ± 21.4 years old and had a body mass index (BMI) of 25.6 ± 5.2. Six patients were initially injured due to a fall. Time until the fractures became open on average was 5.2 ± 3.6 weeks. Three patients (37.5%) died within 1.8 ± 0.6 years after initial injury. The average Charlson Comorbidity Index (CCI) score was 4.5 ± 3.4. Three patients (37.5%) had dementia. Common characteristics among this cohort included a history of visual disturbances (50.0%), cerebrovascular accident (50.0%), smoking (50.0%), and alcohol abuse (50.0%). CONCLUSION: Conversion from a closed to open humeral shaft fracture after functional bracing is a potentially devastating complication. Physicians should be especially cognizant of patients with a low BMI, history of falling or visual disturbance, dementia, age ≥ 65, decreased sensorimotor protection, and significant smoking or alcohol history when choosing to use functional bracing as the final treatment modality. LEVEL OF EVIDENCE: IV.

Exposing the Care Conundrum of Low-Energy Pelvic Ring Fractures in Older Adults: A Review of 322 Patients.

Introduction: A care conundrum for low-energy pelvic ring fracture patients in which they face financial burden after not qualifying for an inpatient stay of 3 days or more has been noted in the literature. The purpose of this study was to identify factors that lead to inpatient length of stay (IP LOS) ≥3 days in older adults with nonoperative pelvic ring fragility fractures and to highlight the challenging financial decision-making of those with IP LOS <3 days in the context of the Medicare 3-day rule. Methods: This was a retrospective review of 322 patients aged ≥65 presenting from March 2016 and February 2019 to either of 2 emergency departments (EDs) after a ground-level fall resulting in a pelvic ring fracture. Patient demographic, IP LOS, and mortality data were extracted. Case management notes were analyzed to summarize financial decision-making for patients with IP LOS <3 days. Multivariate logistic regression analysis was conducted to identify factors that predicted IP LOS ≥3 days and mortality. Results: IP LOS ≥3 days was associated with presentation to level I hospital (OR .30 [.19, 0.50]) and being single (OR 2.50 [1.10, 5.68]). 70.3% required a post-acute skilled nursing facility (SNF) stay. Of patients with LOS <3 days, 25.0% were financially responsible for their SNF stay, while 7.9% elected home care due to financial reasons. Overall 30-day, 90-day, and 1-year mortality were 2.5%, 8.1%, and 20.8%, respectively. For patients with LOS <3 days, returning to assisted living compared to discharging to a SNF increased 90-day mortality risk (HR 8.529, P = .0451). Having Medicare trended towards increased 90-day mortality risk compared to commercial insurance (HR 4.556, P = .0544). Conclusion: The current system is failing older adult patients who sustain nonoperative low-energy pelvic ring fractures in terms of financial coverage of necessary post-acute treatment. This care conundrum has yet to be solved.

Elder abuse: an update on prevalence, identification, and reporting for the orthopaedic surgeon.

Elder abuse is an underestimated mechanism of musculoskeletal injury and is of significant concern in geriatric and rapidly aging populations of the United States. Abuse can occur in a home or institutional setting and may include physical, sexual, emotional, or financial abuse as well as neglect or abandonment. Elderly persons with shared living arrangements, those with a history of domestic violence, and those with cognitive impairment are at high risk of abuse. Prevalence studies in the United States estimate that more than 1 million elderly persons are victims of abuse annually, and up to 25% have been physically abused. Multiple fractures, inconsistent histories, bruising, dehydration, and malnutrition are indications of abuse that can be identified by the orthopaedic surgeon. Elder abuse is often overlooked and is severely underreported. Because physicians are required to report abuse to agencies such as Adult Protective Services, awareness of its prevalence is essential, and the orthopaedic surgeon must know how best to identify, treat, and report elder abuse.

AAOS Clinical Practice Guideline Summary: Management of Hip Fractures in Older Adults.

Fragility hip fractures are a major public health problem with a notable effect on quality of life for patients and their families. Management of Hip Fractures in Older Adults: Evidence-Based Clinical Practice Guideline serves as current evidence-based practice guidelines for orthopaedic surgeons in the management of this common fracture and is based on a systematic review of published studies examining the surgical treatment of hip fractures in adults aged 55 years and older (older adults). The lower age limit for the patient population was set at 55 years but was also required to have a median age of 65 years. All aspects of care for older patients at risk of hip fracture or who have sustained a hip fracture could not be addressed within the scope of this guideline, including important topics of prevention of primary or secondary hip fractures or posthospital rehabilitation. This guideline contains 16 recommendations and three options to assist orthopaedic surgeons and all qualified physicians managing patients older than 55 years with hip fractures based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

Medial femoral circumflex artery pseudoaneurysm following intramedullary nailing for intertrochanteric fracture.

CASE: We present the case of a 92-year-old woman who developed a medial femoral circumflex artery (MFCA) pseudoaneurysm intraoperatively while obtaining reduction during intramedullary nailing (IMN) for intertrochanteric fracture. CONCLUSIONS: Pseudoaneurysms are rare vascular complications in hip fracture surgery. Early recognition of signs and symptoms of this phenomenon are essential for diagnosis and treatment. Close post-operative monitoring and serial hemoglobin should be considered for unexplained intra-operative bleeding. A low threshold for angiography should be entertained if active bleeding and clinical decompensation occur during instrumented percutaneous pertrochanteric fracture reduction. This patient underwent conventional angiography with successful coil embolization and exclusion of the MFCA pseudoaneurysm.

Low-energy suspiciously open proximal humerus fracture management in older adult patient: A case report.

Although fractures of the proximal humerus are common among older adults, open fractures following low-energy trauma are exceptionally rare. Prior studies have alluded to the existence of this injury, but there are no detailed reports on its presentation, management, or long-term follow-up. We present the case of a 78-year-old man that sustained a suspiciously open proximal humerus fracture of the dominant hand following a fall down a few stairs. Management consisted of early intravenous antibiotics followed by open reduction and internal fixation with irrigation and debridement. Intraoperative soft tissue assessment revealed a wound extending from bone to skin. The patient suffered no complications, regained full function of his arm, and is pain free. Considering the rarity of this injury and its potential for highly morbid complications, this case serves as a reminder that we should continue to have a low suspicion threshold for open fracture when punctures or lesions are present around proximal humerus fractures, even for low-energy injuries. Prompt and thorough examination, initiation of antibiotics, and surgical intervention are keys to providing best care for this uncommon injury.

Hip Fracture Care in Parkinson Disease: A Retrospective Analysis of 1,239 Patients.

Introduction: Compared to other patients, Parkinson disease (PD) patients may experience suboptimal outcomes after hip fracture. The purpose of this study was to describe and compare characteristics and outcomes of hip fracture patients with PD to those without PD. Methods: This retrospective cohort study included all patients admitted for hip fracture within a large healthcare system between July 1, 2017 and June 30, 2019. Demographics, injury characteristics, Charlson Comorbidity Index (CCI), treatment characteristics, and outcomes including complications, readmissions, and mortality were extracted. Patients with PD were compared to those without PD. Chi-square tests, two-sample t-tests, and Fisher exact tests were conducted to identify group differences. Results: A total of 1239 patients were included (4.0% PD and 96.0% non-PD). PD patients were mostly male (59.2%) compared to mostly female non-PD patients 69.4%, P < .001). PD patients on average had a higher CCI (2.3 vs 1.7, P = .040) and more frequently had dementia (42.9% vs 26.7%, P = .013). No PD patients were discharged home without additional assistance compared to 8.1% of patients without PD. More PD patients were discharged to a skilled nursing facility (SNF) than non-PD patients (65.3% vs 48.2%, P = .021). Only 22.4% of PD patients were previously prescribed osteoporosis medication, and only 16.3% were referred for osteoporosis follow-up after fracture. In-house complications, readmissions, and mortality up to 1 year were comparable between groups (P>.191). Conclusions: Outcomes between PD patients and non-PD patients were mostly equivalent, but more PD patients required discharge to a higher-level care environment compared to non-PD patients. Although PD seems to be a risk factor for hip fracture regardless of age and sex, most patients had not undergone proper screening or preventative treatment for osteoporosis. These results emphasize the need for early bone health evaluation, multidisciplinary collaboration, and care coordination in preventing and treating hip fractures in PD.

Creative bracing: A descriptive overview of an alternative technique for non-operative fracture management of frail older adults.

As the world population ages, a higher proportion of older and frailer patients will sustain fragility fractures. Considering their depleted physiologic reserve and potentially different goals of care at their stage in life, these patients; especially those enrolled in hospice care, with profound dementia, or at end-of-life care; may not benefit from traditional surgical methods of fracture care. Non-operative treatment using standard immobilization or casting techniques in older and frailer patients can still render them susceptible to complications and adverse events. Here we describe our alternative non-operative treatment method of creative bracing to address the needs of this specific population. Creative bracing can be done with simple supplies available in almost all healthcare settings. Through patient-specific pre-treatment assessment, a creative brace tailored to the patient's risk factors and goals of care can be designed to provide sufficient fracture immobilization and comfort. Creative bracing is a low-cost, low-technical demand modality for non-operative treatment of some fragility fractures. Its benefit can be appreciated to greatest effect in the frailest patients for whom standard, surgical treatment does not represent best care.

Hip fracture care during the COVID-19 pandemic: retrospective cohort and literature review.

OBJECTIVES: The goal of this study was to investigate whether the COVID-19 pandemic has affected hip fracture care at a Level I Trauma hospital. The secondary goal was to summarize the published hip fracture reports during the pandemic. DESIGN: A retrospective cohort study. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: Eighty-six operatively treated hip fracture patients age ≥65 years, occurring from January 17 to July 2, 2020. INTERVENTION IF ANY: N/A. MAIN OUTCOME MEASUREMENTS: We defined 3 phases of healthcare system response: pre-COVID-19 (period A), acute phase (period B), and subacute phase (period C). The primary outcome was 30-day mortality. Clinical outcomes including time to surgery (TTS) and length of stay (LOS) were extracted from the electronic medical record. RESULTS: Twenty-seven patients from Period A, 27 patients from Period B, and 32 patients from Period C were included. The 30-day mortality was not statistically different. The mean TTS was 20.0 +/- 14.3 hours and was the longest in Period C (22.1 +/- 9.8 hours), but the difference was not statistically significant. The mean LOS was 113.0 +/- 66.2 hours and was longest in Period B (120.9 +/- 100.6 hours). However, the difference was not statistically significant. CONCLUSIONS: The 30-day mortality, TTS, and LOS were not statistically different across multiple phases of pandemic at a level 1 trauma center. Our results suggest that we successfully adapted new protocol changes and continued to provide evidence-based care for hip fracture patients. Our results were comparable with that of other authors around the world.

Outcomes After Revision Fixation With Cement Augmentation for Failed Intertrochanteric Fracture Fixation in Older Adult Patients.

Introduction: Intertrochanteric (IT) fractures that fail fixation are traditionally treated with arthroplasty, introducing significant risk of morbidity and mortality in frail older adult patients. Revision fixation with cement augmentation is a relatively novel technique that has been reported in several small scale international studies. Here we report a clinical series of 22 patients that underwent revision fixation with cement augmentation for IT fracture fixation failure. Methods: This retrospective case series identified all patients that underwent revision intramedullary nailing from 2018 to 2021 at two institutions within a large metropolitan healthcare system. Demographics, injury characteristics, Charlson Comorbidity Index score, and surgical characteristics were extracted from the electronic medical record. Outcomes were extracted from the electronic medical record and included radiographic findings, pain, functional outcomes, complications, and mortality. Results: Average follow-up after revision surgery was 15.2 ± 10.6 months. Twenty patients (90.9%) reported improved pain and achieved union or progressive healing after surgery. Most of these patients regained some degree of independent ambulation (19 patients, 86.4%), with only 5 patients (22.7%) requiring increased assistance for their activities of daily living (ADLs). One-year mortality was 13.6% (3 patients). Of the 5 patients (22.7%) that experienced complications, 2 patients (9.1%) required revision hemiarthroplasty for subsequent fixation failure. The other 3 patients did well when complications resolved. Conclusions: Revision fixation with cement augmentation can be an effective, safe, cost-effective alternative to arthroplasty for the management of cases involving non-infected failed IT fracture fixation with implant cut-out or cut-through limited to the femoral head in older adult patients that have appropriate acetabular bone stock.

A quality improvement project addressing the underreporting of delirium in hip fracture patients.

INTRODUCTION: After discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred. METHODS: Hip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations. RESULTS: The incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001). CONCLUSIONS: Our institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.

Management of Geriatric Elbow Injury.

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Fracture Risk Assessment: An Update.

➤: Our ability to accurately identify high fracture risk in individuals has improved as the volume of clinical data has expanded and fracture risk assessment tools have been developed. ➤: Given its accessibility, affordability, and low radiation exposure, dual x-ray absorptiometry (DXA) remains the standard for osteoporosis screening and monitoring response to treatment. ➤: The trabecular bone score (TBS) is a DXA software add-on that uses lumbar spine DXA imaging to produce an output that correlates with bone microarchitecture. It has been identified as an independent fracture risk factor and may prove useful in further stratifying fracture risk among those with a bone mineral density (BMD) in the osteopenic range (-1.0 to -2.4 standard deviations), in those with low-energy fractures but normal or only mildly low BMD, or in those with conditions known to impair bone microarchitecture. ➤: Fracture risk assessment tools, including the Fracture Risk Assessment Tool (FRAX), Garvan fracture risk calculator, and QFracture, evaluate the impact of multiple clinical factors on fracture risk, even in the absence of BMD data. Each produces an absolute fracture risk output over a defined interval of time. When used appropriately, these enhance our ability to identify high-risk patients and allow us to differentiate fracture risk among patients who present with similar BMDs. ➤: For challenging clinical cases, a combined approach is likely to improve accuracy in the identification of high-risk patients who would benefit from the available osteoporosis therapies.

Outcomes of COVID-19 Negative Hip Fracture Patients During the Acute and Subacute Pandemic.

OBJECTIVES: To better elucidate how the COVID-19 pandemic has affected the operatively treated geriatric hip fracture population and how the health care system adapted to pandemic dictated procedures. DESIGN: Retrospective cohort study. SETTING: A community hospital. PARTICIPANTS: Individuals ≥65 years of age presented with a proximal femoral fracture from a low-energy mechanism undergoing operative treatment from January 17, 2020 to July 2, 2020 (N = 125). MEASUREMENTS: We defined 3 phases of healthcare system response: pre-COVID-19, acute phase, and subacute phase. Thirty-day mortality, time to operating room (OR), length of stay, time to start physical therapy, perioperative complications, delirium rate, hospice admission rate, discharge dispositions, readmission rate, and the reason of surgery delay were assessed. RESULTS: The number of hip fractures has remained constant during the pandemic. The 30-day mortality rate, time to OR, and length of stay were higher in the pandemic compared to the pre-pandemic. Those who had a longer wait time to OR (≥ 24 hours) had more complications and increased 30-day mortality rates. Some of the surgery delays were related to OR unavailability as a consequence of the COVID-19 pandemic. Surgery was delayed in 3 patients who were on direct oral anticoagulants (DOACs) in pandemic but none for pre-pandemic period. CONCLUSION: This is the first study to compare the effect of the acute and subacute phases of the pandemic on uninfected hip fracture patients. In the age of COVID-19, to provide the best care for the vulnerable geriatric orthopedic populations, the healthcare system must adopt new protocols. We should still aim to promote prompt surgical care when indicated. It is important to ensure adequate resource availability, such as OR time and staff so that hip fracture patients may continue to receive rapid access to surgery. A multidisciplinary approach remains the key to the management of fragility hip fracture patients during the pandemic.

Own the Fall: AOA Critical Issues.

ABSTRACT: Falls are the most common cause of injury to older patients, resulting in >3 million emergency room visits per year and 290,000 hip fractures annually in the United States. Orthopaedic surgeons care for the majority of these patients; however, they are rarely involved in the assessment of fall risk and providing prevention strategies. Falls also occur perioperatively (e.g., in patients with arthritis and those undergoing arthroplasty). Preoperatively, up to 40% of patients awaiting joint arthroplasty sustain a fall, and 20% to 40% have a fall postoperatively. Risk factors for falls include intrinsic factors such as age and comorbidities that are not modifiable as well as extrinsic factors, including medication reconciliation, improvement in the environment, and the management of modifiable comorbidities that can be optimized. Simple in-office fall assessment tools are available that can be adapted for the orthopaedic practice and be used to identify patients who would benefit from rehabilitation. Orthopaedic surgeons should incorporate these strategies to improve care and to reduce fall risk and associated adverse events.

Low-Energy Pelvic Ring Fractures: A Care Conundrum.

INTRODUCTION: A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services' (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care. RESULTS: Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population. CONCLUSIONS: Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

Minimizing Nonessential Follow-up for Hip Fracture Patients.

INTRODUCTION: Hip fractures pose a significant burden to patients and care providers. The optimal protocol for postoperative care across all surgically treated hip fracture patients is unknown. The purpose of this study was to investigate the effect that routine follow-up had on changing the clinical course. METHODS: This was a retrospective review of all low-energy hip fractures (ie, femoral neck fractures, pertrochanteric hip fractures, and subtrochanteric fractures) treated surgically from January 2018 through December 2019. Charts were reviewed for demographic information; the procedure performed; the number of postoperative follow-up visits each patient had with the orthopaedic surgery team; the number of sets of postoperative radiographic images obtained; and postoperative complications. RESULTS: Eight hundred eleven patients with 835 hip fractures were included in the study. The overall number of patient visits was 1,788, and the number of radiograph sets was 1,537. The median number of follow-up visits was two visits/fracture (interquartile range: 1 to 3 visits, maximum = 9 visits), with the median follow-up length of 54 days (interquartile range: 33 to 97 days) with the treating orthopaedic surgeons. Sixty-two (7.6%) patients had 81 (4.5%) postoperative visits and 26 (1.7%) sets of images that led to treatment changes. Among them, 48 (77.4%) patients had concerns that were initiated by the patients and/or care provider. Fourteen standard patient visits led to treatment changes that were not initiated as concerns by the patient and/or care provider. DISCUSSION: Most clinic visits and radiographs did not lead to a change in the care plan. We recommend that emphasis be placed on comprehensive orthogeriatric care of these patients, and we believe that these data provide the impetus to work toward improving the care pathways for elderly patients with hip fractures.

Development of a Questionnaire to Assess Patient Priorities in Hip Fracture Care.

BACKGROUND: Patient reported outcome measures (PROMs) are becoming well recognized as an important component of health care outcomes and determinants of value in patient-centered care. Yet, there is emerging recognition that guidance is lacking in the utilization of PROMs in hip fracture patients. The aim of this study was to collect input from hip fracture patients and their health care advocates as proxies to identify outcomes that are important and to gain insight into which ones are of greatest importance. METHODS: A cross-section of patients aged 65 and older treated for hip fractures at a single level 1 trauma center within the previous 3 to 9 months was identified. Semistructured telephone interviews of patients and/or health care proxies were performed in 2 phases: (1) concept identification and conceptual framework development and (2) item generation and assessment of relative importance of health care outcomes. Each phase was completed by separate patient cohorts. RESULTS: Sixty-four interviews were completed. Eighteen interviews with 13 patients and 5 proxies were completed for framework development. Forty-six interviews with 33 patients and 13 proxies were completed for the assessment of relative importance. Care team and communication were reported as important in hip fracture patients. Physical outcomes were ranked as most important by only 9% of respondents. "Having confidence that I/my loved one received the best care possible" was perceived as very important by 98% of respondents and "Having access to the surgeon" was perceived as very important by 76% of the respondents. CONCLUSIONS: In our study, communication between patients and care providers as well as collaboration among patients' care providers ranked as the most important postoperative preferences in our cohort. Notably, physical outcomes were ranked as most important by only 9% of respondents.

Mobile Outreach: An Innovative Program for Older Orthopedic Patients in Care Facilities.

INTRODUCTION: The worldwide incidence of fragility fractures is increasing and the greatest burden is borne by the oldest population. Mobile Outreach, an innovative orthopedic-based program providing on-site musculoskeletal care for individuals in nursing care facilities, was implemented as part of our Geriatric Orthopaedic Trauma Program. The objectives of this report are to describe characteristics of patients cared for through Mobile Outreach and to report specific services provided. PROGRAM DESCRIPTION: Based from a nonprofit, private hospital that serves as the community's level 1 trauma center and teaching hospital, the Mobile Outreach Program is directed by an orthopedic surgeon with geriatric subspecialization and staffed by a full-time geriatric nurse practitioner. Patients receive care for musculoskeletal concerns and fracture assessments at their nursing care facilities by a Mobile Outreach care provider. Referral for care is from nursing care facilities or as scheduled postoperative follow-up. RESULTS: In 2016, the program treated 458 patients (76% female) in the patients' care settings for a total of 689 visits. The mean age was 81 years (standard deviation = 14; range 25-107). Care of patients included nonoperative fracture care in 100 (22%), postoperative fracture follow-up in 149 (33%), injections for pain management in 184 (40%), and other orthopedic care in 25 (5%). Visits occurred at 88 facilities, mean 7 visits per site (range 1-57). CONCLUSIONS: Mobile Outreach was implemented to improve postoperative fracture care in the elderly patients. The program also provides on-site nonoperative fracture care and care of frail elderly individuals with chronic musculoskeletal conditions. This report aims to establish the feasibility of a program focused on the provision of appropriate, coordinated care for older fracture patients in their care facility. Level of Evidence: Level V.

Predictors of Mortality in Elder Patients With Proximal Humeral Fracture.

BACKGROUND: Known possible consequences of proximal humerus fractures include impaired shoulder function, decreased independence, and increased risk for mortality. The purpose of this report is to describe the survival and independence of elderly patients with fractures of the proximal humerus, treated in our institution, relative to patient characteristics and treatment method. METHODS: Retrospective cohort study from 2006 to 2012. SETTING: Community-based hospital with level 1 designation. PATIENTS/PARTICIPANTS: Three hundred nineteen patients ≥60 years who presented to the emergency department with an isolated fracture of the proximal humerus were either admitted to the inpatient ward for the organization and provision of immediate definitive care or discharged with the expectation of coordination of their care as an outpatient. Treatment was nonoperative or operative. OUTCOME MEASURES: One- and 2-year mortality. RESULTS: Significant predictors of mortality at 1 year included Charlson Comorbidity Index (CCI; continuous, hazard ratio [HR] = 1.40; 95% confidence interval [CI]: 1.06-1.86), body mass index (BMI; <25 vs ≥25; HR = 3.43; 95% CI: 1.45-8.14), and American Society of Anesthesiologists (ASA) disease severity score (3-4 vs 1-2; HR = 4.48; 95% CI: 1.21-16.55). In addition to CCI and BMI, reliance on a cane/walker/wheelchair at the time of fracture predicted mortality at 2 years (vs unassisted ambulation; HR = 3.13; 95% CI: 1.59-5.88). Although the Neer classification of fracture severity significantly correlated with inpatient admission (P < .001), it was not significantly associated with mortality or with loss of living or ambulatory independence. Among admitted patients, 64% were discharged to a facility with a higher level of care than their prefracture living facility. Twenty percent of study patients experienced a loss in ambulatory status by at least 1 level at 1 year postfracture. CONCLUSION: In a cohort of elderly patients with fractures of the proximal humerus, patient characteristics including comorbidities, ASA classification, and lower BMI were associated with increased mortality. Specifically, those admitted at the time of fracture and treated nonoperatively had the highest mortality rate and, likely, represent the frailest cohort. Those initially treated as outpatients and later treated operatively had the lowest mortality and, likely, represent the healthiest cohort. These data are inherently biased by prefracture comorbidities but help stratify our patients' mortality risk at the time of injury.