 TRAUMA

The outcome of proximal humeral fractures in the elderly PREDICTORS OF MORTALITY AND FUNCTION N. D. Clement, A. D. Duckworth, M. M. McQueen, C. M. Court-Brown From Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK

This study describes the epidemiology and outcome of 637 proximal humeral fractures in 629 elderly (≥ 65 years old) patients. Most were either minimally displaced (n = 278, 44%) or two-part fractures (n = 250, 39%) that predominantly occurred in women (n = 525, 82%) after a simple fall (n = 604, 95%), who lived independently in their own home (n = 560, 88%), and one in ten sustained a concomitant fracture (n = 76, 11.9%). The rate of mortality at one year was 10%, with the only independent predictor of survival being whether the patient lived in their own home (p = 0.025). Many factors associated with the patient’s social independence significantly influenced the age and gender adjusted Constant score one year after the fracture. More than a quarter of the patients had a poor functional outcome, with those patients not living in their own home (p = 0.04), participating in recreational activities (p = 0.01), able to perform their own shopping (p < 0.001), or able to dress themselves (p = 0.02) being at a significantly increased risk of a poor outcome, which was independent of the severity of the fracture (p = 0.001). A poor functional outcome after a proximal humeral fracture is not independently influenced by age in the elderly, and factors associated with social independence are more predictive of outcome. Cite this article: Bone Joint J 2014;96-B:970–7.

 N. D. Clement, MRCSEd, Specialty Registrar (StR) and Clinical Research Fellow  A. D. Duckworth, MSc, MRCSEd, Specialty Registrar (StR) and Clinical Research Fellow  M. M. McQueen, MD, FRCSEd, Professor of Orthopaedic Trauma Royal Infirmary of Edinburgh, Edinburgh Orthopaedic Trauma Unit, 51 Little France Crescent, Edinburgh, EH16 4SU, UK.  C. M. Court-Brown, MD, FRCSEd, Professor of Orthopaedic Trauma Royal Infirmary of Edinburgh, Edinburgh Orthopaedic Trauma Unit, 51 Little France Crescent, Edinburgh, EH16 4SU, UK. Correspondence should be sent to Mr N. D. Clement; e-mail: [email protected] ©2014 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.96B7. 32894 $2.00 Bone Joint J 2014;96-B:970–7. Received 25 July 2013; Accepted after revision 13 March 2014

970

The incidence of proximal humeral fractures has increased during the last 40 years in both Europe1 and the United States,2 and these are now amongst the most common fractures presented to orthopaedic surgeons.3 They are predominately present in older patients and are strongly associated with osteoporosis.3 The elderly population in the United Kingdom (UK) continues to rise,4 and these fractures will consequently be an increasing burden on trauma services. Recent epidemiological evidence shows that the incidence is particularly increasing in women aged > 80 years.5,6 This group of patients, representing the fastest growing sector of the population in the UK,7 has been termed ‘super-elderly’ as their outcomes are different to that of a relatively younger (65 to 79 years old) cohort, due to increasing frailty.8,9 Approximately 20% of patients, with more severe fractures according to Neer’s classification, may benefit from surgery.10,11 Thus, most proximal humeral fractures are managed nonoperatively. Despite this, most reports on the outcome of such fractures focuses on operative treatment.12-14 There is a paucity of literature reporting the outcome of the conservative management of proximal humeral fractures in

the elderly.15 In this study we describe the mortality and the function of the shoulder for elderly and super-elderly patients one year after a proximal humeral fracture. Our secondary aim was to identify independent predictors of a poor functional outcome after a proximal humeral in elderly patients.

Patients and Methods We identified patients with a proximal humeral fracture retrospectively from a prospectively compiled database between July 1992 and May 1996. Our centre is the only hospital receiving adult trauma for a predominately urban population of 615 000. The population aged ≥ 65 years accounted for 96 129 of the adult population.16 All patients from the catchment area and all resident patients receiving their initial management outside the catchment area were included, but patients residing outside the catchment population were excluded from the analysis. There were 637 proximal humeral fractures in 629 elderly patients recorded during the study period. The Carstairs score17 was used to assign the socioeconomic status of each patient. This score has been used to measure social deprivation for the Scottish population THE BONE & JOINT JOURNAL

THE OUTCOME OF PROXIMAL HUMERAL FRACTURES IN THE ELDERLY

971

Table I. The case-mix variables for the study cohort according to age group Case-mix variables Gender (n,%) Male Female Deprivation quintile (n,%) 1 (least) 2 3 4 5 (most) Unknown Live in own home (n,%) Yes No Unknown Live alone (n,%) Yes No Unknown Employed (n,%) Yes No Unknown Recreation (n,%) Yes No Unknown Shopping (n,%) Yes No Unknown Dressing (n,%) Yes No Unknown Housework (n,%) Yes No Unknown Home help (n,%) Yes No Unknown Multiple fractures (n,%) Yes No Parts (n,%) 0 2 3 4 Non-operative (n,%) Yes No

All patients n = 637

Elderly n = 394

Super-elderly n = 243 Odds ratio (95% CI) 1.25 (0.81 to 1.92)

112 (17.6) 525 (82.4)

74 (18.8) 320 (81.2)

38 (15.6) 205 (84.4)

149 (23.4) 134 (21.0) 104 (16.3) 192 (30.1) 52 (8.2) 6 (0.9)

85 (21.6) 74 (18.8) 66 (16.8) 126 (32.0) 39 (9.9) 4 (1.0)

64 (26.3) 60 (24.6) 38 (15.6) 66 (27.2) 13 (5.3) 2 (0.8)

-

560 (87.9) 70 (11.0) 7 (1.1)

368 (93.4) 22 (5.6) 4 (1.0)

192 (79.0) 48 (19.8) 3 (1.2)

4.18 (2.45 to 7.13)

297 (46.6) 329 (51.7) 11 (1.7)

164 (41.6) 223 (56.6) 7 (1.8)

133 (54.7) 106 (43.6) 4 (1.6)

1.71 (1.23 to 2.36)

24 (3.8) 558 (87.6) 55 (8.6)

18 (4.6) 343 (87.1) 33 (8.4)

6 (2.5) 215 (88.5) 22 (9.1)

323 (50.7) 293 (46.0) 21 (3.3)

235 (59.6) 146 (37.1) 13 (3.3)

88 (36.2) 147 (60.5) 8 (3.3)

2.68 (1.92 to 3.76)

466 (73.2) 146 (22.9) 25 (3.9)

332 (84.3) 50 (12.7) 12 (3.0)

134 (55.1) 96 (39.5) 13 (5.3)

4.76 (3.20 to 7.07)

576 (90.4) 36 (5.7) 25 (3.9)

366 (92.9) 15 (3.8) 13 (3.3)

210 (86.4) 21 (8.6) 12 (4.9)

2.44 (1.23 to 4.85)

467 (73.3) 142 (22.3) 28 (4.5)

333 (84.5) 48 (12.2) 13 (3.3)

134 (55.1) 94 (38.7) 15 (6.2)

4.87 (3.25 to 7.27)

138 (21.7) 469 (73.6) 30 (4.7)

55 (14.0) 323 (82.0) 16 (4.1)

83 (34.2) 146 (60.1) 14 (5.8)

3.34 (2.25 to 4.95)

76 (11.9) 561 (88.1)

39 (9.9) 355 (90.1)

37 (15.2) 206 (84.8)

1.63 (1.01 to 2.65

278 (43.6) 250 (39.2) 78 (12.2) 31 (4.9)

187 (47.5) 140 (35.5) 48 (12.2) 19 (4.8)

91 (37.4) 110 (45.3) 30 (12.3) 12 (4.9)

587 (92.2) 50 (7.8)

358 (90.9) 36 (9.1)

229 (94.2) 14 (5.8)

p-value* 0.31

0.06

< 0.001

0.002

0.26 1.88 (0.74 to 4.81) < 0.001

< 0.001

0.01

< 0.001

< 0.001

0.04

0.07

0.12 1.64 (0.87 to 3.12)

* Chi squared test

since 1981, with each postcode sector, of which there are 1010, within Scotland being assigned a standardised deprivation score.18 The patients were divided into five quintiles according to their postcode, with one being the most and VOL. 96-B, No. 7, JULY 2014

five the least affluent. Markers of physical and social independence were also recorded i.e. were they living in their own home, did they live alone, were they employed, did they participate in recreational activities, could they do

972

N. D. CLEMENT, A. D. DUCKWORTH, M. M. MCQUEEN, C. M. COURT-BROWN

Table II. Demographics of the elderly patients with nonunion of the fracture Gender

Age

Neer Subgroup

Female Female Female Female Female Male Female Female Female

68 69 75 75 75 81 83 83 86

Minimally displaced 3-part 2-part surgical neck 2-part surgical neck 2-part surgical neck 4-part 2-part surgical neck 2-part surgical neck 3-part

their own shopping, were they able to dress themselves, were they able to do their own housework, and did they need home help. The Neer classification10,11 for each fracture was assigned by the senior author (CMC-B). Other concomitant fractures were also recorded. Functional outcome was recorded using the Constant score19 by an independent physiotherapist at six, 13, 26, and 52 weeks, but for the purpose of this study only the one year score was used to assess functional outcome. The score for 29 patients who were discharged at six months, as their shoulder function was thought to be acceptable, was assumed to be their score at one year. A total of 483 (76%) Constant scores were available for the 637 proximal humeral fractures at one year. Of those without Constant scores at one year, 61 died before their one year follow-up, and the remaining 93 were either too frail to return to the clinic (n = 87) or declined to participate (n = 6). A Constant score of < 55 was defined as a poor outcome; this has previously been used by other authors assessing the outcome of proximal humeral fractures.20-22 The choice between operative and non-operative treatment was determined by the consultant caring for the patient, all of whom are experienced orthopaedic trauma surgeons. Operative management was undertaken for 50 patients, with the remaining 587 being managed conservatively. Statistical analysis. All data were analysed using Statistical Package for Social Sciences version 17.0 (SPSS Inc., Chicago, Illinois). Continuous variables (Constant score) were assessed using t-tests and analysis of variance (ANOVA) to identify significant differences between groups. Dichotomous variables were assessed using a Chisquared test. Standardised mortality rates (SMR), matched for age and gender, were calculated using the expected rates of mortality for the study population using data from the General Register Office for Scotland.23 Kaplan–Meier methodology24 was used to investigate patient survival. Cox regression analysis was used to identify independent predictors of mortality one year after the fracture. A multivariable linear regression analysis was used to assess the independent effect of case-mix variables on functional outcome, one year Constant score, using

‘Enter’ methodology. In addition logistic regression analysis was used to assess the independent predictors of a poor outcome (Constant score of 0 to 55).

Results The mean age of the patients was 76.9 years (65 to 98). There were 112 men with a mean age of 75.6 years (65 to 95) and 525 women with a mean age of 77.2 years (65 to 98). There were 394 elderly and 243 super-elderly patients. The incidence of proximal humeral fractures was 136/105/year in the elderly group and 260/105/year in the super-elderly cohort (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.56 to 2.36, chi square p < 0.001). The most common mode of injury was a simple fall from a standing height (n = 604, 94.8%), with the remainder being due to a fall from a height (n = 15, 2.4%), road traffic accident (n = 10, 1.6%), direct blow or assault (n = 6, 0.9%). and sport (n = 2, 0.3%), There was no significant difference in the mechanism of injury according to age group (p = 0.11, chi squared). Differences between the two groups are shown in Table I. There were more displaced fractures in the super-elderly (OR 1.51, 95% CI 1.09 to 2.09, chi square p = 0.017) without a significant associated difference in the rate of nonoperative management. In total, nine patients developed a nonunion (Table II) representing a rate of nonunion for all fractures of 1.4% (n = 9/637); increasing to 2.2% (n = 8/359) when analysing displaced fractures only. The rate of nonunion was not significantly different according to age, all fractures (p = 0.73) or for displaced fractures (p = 0.72). Within one year of the fracture, 61 patients had died giving a one year survival rate of 90.4% (95% CI 88.5 to 92.2) (Fig. 1). The standardised mortality ratio was 2.41 (95% CI 1.99 to 3.78, p < 0.001). Univariate analysis identified several risk factors associated with one year mortality (Table III). The only significant predictor of mortality however, after adjusting for confounding variables, was whether a patient lived in their own home; those patients not living in their own home had a greater risk of mortality at one year (OR 3.64, 95% CI 1.18 to 11.22, p = 0.025). THE BONE & JOINT JOURNAL

THE OUTCOME OF PROXIMAL HUMERAL FRACTURES IN THE ELDERLY

973

Table III. The case-mix variables for the study cohort according to their mortality at one year Case-mix variables Gender (n,%) Male Female Super-elderly (n,%) Yes No Deprivation (n,%) 1 (least) 2 3 4 5 (most) Unknown Live in own home (n,%) Yes No Unknown Live alone (n,%) Yes No Unknown Employed (n,%) Yes No Unknown Recreation (n,%) Yes No Unknown Shopping (n,%) Yes No Unknown Dressing (n,%) Yes No Unknown Housework (n,%) Yes No Unknown Home help (n,%) Yes No Unknown Multiple fractures (n,%) Yes No Parts (n,%) 0 2 3 4 Non-operative (n, %) Yes No

Alive n = 576

Deceased n = 61

99 (17.2) 477 (82.8)

13 (21.3) 48 (78.7)

201 (34.9) 375 (65.1)

42 (68.9) 19 (31.1)

132 (22.9) 118 (20.5) 96 (16.7) 175 (30.4) 50 (8.7) 5 (0.9)

17 (27.9) 16 (26.2) 8 (13.1) 17 (27.9) 2 (3.3) 1 (1.6)

521 (90.5) 51 (8.9) 4 (0.7)

39 (63.9) 19 (31.1) 3 (4.9)

266 (46.2) 304 (52.8) 6 (1.0)

31 (50.8) 25 (41.0) 5 (8.2)

24 (4.2) 507 (88.0) 45 (7.8)

0 51 (83.6) 10 (16.4)

313 (54.3) 250 (43.4) 45 (7.8)

10 (16.4) 43 (70.5) 10 (16.4)

450 (78.1) 113 (19.6) 13 (2.3)

16 (26.2) 33 (54.1) 12 (19.7)

538 (93.4) 24 (4.2) 14 (2.4)

38 (62.3) 12 (19.7) 11 (18.0)

451 (78.3) 109 (18.9) 16 (2.8)

16 (26.2) 33 (54.1) 12 (19.7)

115 (20.0) 441 (76.6) 20 (3.5)

23 (37.7) 28 (45.9) 10 (16.4)

65 (11.3) 511 (88.7)

11 (18.0) 50 (82.0)

260 (45.1) 214 (37.2) 74 (12.8) 28 (4.9)

18 (29.5) 36 (59.0) 4 (6.6) 3 (4.9)

528 (91.7) 48 (8.3)

59 (96.7) 2 (3.3)

Odds ratio (95% CI)

p-value*

0.77 (0.40 to 1.47)

0.65

4.12 (2.34 to 7.28)

< 0.001

-

0.41

4.98 (2.68 to 9.24)

< 0.001

1.42 (0.82 to 2.46)

0.26

1.10 (1.07 to 1.13)

0.12

5.38 (2.65 to 10.93)

< 0.001

8.21 (4.37 to 15.45)

< 0.001

7.08 (3.29 to 15.24)

< 0.001

8.53 (4.53 to 16.07)

< 0.001

0.32 (0.18 to 0.57)

< 0.001

0.58 (0.29 to 1.17)

0.12

0.009

0.37 (0.09 to 1.57)

0.16

* Chi squared test

The mean one year Constant score for the cohort was 64.2 (SD 16.4). Univariate analysis identified several factors that significantly influenced the Constant score at one year (Table IV). Multivariable regression analysis confirmed VOL. 96-B, No. 7, JULY 2014

that eight of the 14 factors assessed were independent predictors of the Constant score at one year (Table V). A total of 128 patients (26.5%) had a poor outcome according to the Constant score at one year. Multivariable

974

N. D. CLEMENT, A. D. DUCKWORTH, M. M. MCQUEEN, C. M. COURT-BROWN

1

Cumulative survival

0.98 0.96 0.94 0.92 0.9 0.88 0.86 0

50

100

150 200 250 Follow-up (days)

300

350

Fig. 1 Kaplan–Meier survivorship curve with 95% CI (dashed lines) for the study cohort illustrating mortality one year after sustaining a proximal humeral fracture.

logistic regression analysis identified five independent predictors of a poor outcome after adjusting for confounding variables (Table VI).

Discussion We have confirmed that most proximal humeral fractures in the elderly are either minimally-displaced or two-part fractures that predominantly occur in women after a simple fall; and we have shown that these patients live independently in their own home and that one in ten sustain another concomitant fracture. The incidence of proximal humeral fractures was significantly greater for super-elderly patients, who were less likely to live independently in their own home and more likely to sustain a displaced fracture and a concomitant facture. The mortality rate at one year was 10%, with the only independent predictor of survival being whether the patient lived in their own home. Many factors that related to the patients’ social independence influenced the Constant score, which was independent of the severity of the fracture and its management. More than a quarter of elderly patients sustaining proximal humeral fractures have a poor functional outcome. An original aspect of this study was the description of the many factors relating to each patient’s level of social independence, where 88% of elderly patients live independently in their own home, which is a similar proportion to all adults sustaining a proximal humeral fracture.25 However, the super-elderly patients were significantly less likely to live in their own home and were less independent, which is probably reflective of the increasing frailty.8,9 The overall rate of associated concomitant fractures (12%) is similar to that described previously,9 but this is significantly greater in

the super-elderly in whom the incidence of proximal humeral fractures is increasing.26 In addition, the severity of the fracture increased with age, with a greater rate of displaced fractures (56%) compared with that described in the general adult population,27 and more specifically in superelderly patients compared to elderly patients. This might relate to decreasing bone density with increasing age, which has been shown to correlate with increasing severity of distal radial fractures.27 The 10% mortality rate at one year and 2.4 SMR reported in this study is consistent with prior studies.7,28 Shortt and Robinson28 identified that older age, male gender, and the use of walking aids predicted mortality after proximal humeral fractures. Gender and age (elderly versus super-elderly) were not identified as independent predictors of one year mortality in our study. They also identified factors associated with social independence to be predictive of mortality, finding patients no longer living in their own home to have an increased risk of mortality. A recent systematic review of the outcome of proximal humeral fractures concluded that non-operative management is supported for minimally displaced and two part fractures.15 However, the review only demonstrated a ‘fair’ outcome overall and no predictors of outcome were identified. In our study of fractures in the elderly using the Constant score, adjusting for age, gender, the severity of the fracture and its management, factors associated with social independence affected the outcome. The choice as to whether operative management of a proximal humeral fracture is undertaken is influenced by many factors, with few absolute indications.13 It has been suggested13 that age is a relative contra-indication to surTHE BONE & JOINT JOURNAL

THE OUTCOME OF PROXIMAL HUMERAL FRACTURES IN THE ELDERLY

975

Table IV. Constant score according to patient case-mix variables. Case-mix variables Gender (n,%) Male Female Super-elderly (n,%) Yes No Deprivation (n,%) 1 (least) 2 3 4 5 (most) Live in own home (n,%) Yes No Live alone (n,%) Yes No Employed (n,%) Yes No Recreation (n,%) Yes No Shopping (n,%) Yes No Dressing (n,%) Yes No Housework (n,%) Yes No Home help (n,%) Yes No Multiple fractures (n,%) Yes No Parts (n,%) 0 2 3 4 Non-operative (n,%) Yes No

n

Mean Constant Score (SD)

69 414

67.4 (18.4) 63.7 (16.0)

156 327

59.2 (16.5) 66.6 (15.8)

112 98 87 140 41

64.2 (17.5) 63.2 (16.5) 64.6 (16.3) 65.4 (16.2) 62.3 (16.4)

442 41

65.6 (15.7) 49.6 (16.5)

226 256

63.8 (16.1) 64.7 (16.7)

19 427

70.8 (12.0) 64.2 (16.3)

290 191

67.9 (14.6) 58.7 (17.2)

397 83

66.6 (15.5) 53.2 (16.0)

461 18

65.2 (15.8) 41.9 (15.8)

399 80

66.5 (15.7) 53.3 (15.6)

86 388

57.5 (15.8) 65.9 (16.0)

51 432

58.1 (19.4) 65.0 (15.8)

211 183 67 22

68.8 (14.2) 61.6 (17.0) 61.1 (17.0) 52.6 (17.2)

448 35

65.2 (15.7) 52.5 (19.9)

Difference (95% CI)

p-value*

3.6 (-0.5 to 7.9)

0.09

7.4 (4.3 to 10.5)

< 0.001

-

0.80†

18.0 (10.1 to 21.0)

< 0.001

0.81 (-2.1 to 3.8)

0.59

6.7 (-0.8 to 14.1)

0.08

9.3 (6.4 to 12.1)

< 0.001

13.4 (9.7 to 17.1)

< 0.001

23.2 (15.8 to 30.8)

< 0.001

13.2 (9.4 to 16.9)

< 0.001

8.4 (4.7 to 12.2)

< 0.001

6.9 (2.2 to 11.6)

< 0.001

-

< 0.001†

12.6 (71 to 18.2)

< 0.001

*t-test unless otherwise stated † Analysis of variance (ANOVA)

gery, but it would seem, from our study, that indicators of social independence are of greater significance in regard to outcome. A recent simple literature review of studies reporting operative fixation of proximal humeral fractures demonstrated marked heterogeneity between studies with the mean age ranging from 42 to 78 years.29 Overall, the mean age of the patients undergoing fixation was younger than the mean age of the patients sustaining proximal VOL. 96-B, No. 7, JULY 2014

humeral fractures, suggesting an inclusion bias for younger patients. There have been two recent randomised control trials (RCTs) comparing the outcome of the fixation of three part fractures30 and hemi-arthroplasty for four part proximal humeral fractures31 with non-operative management in patients aged ≥ 55 years. No statistical difference in any of the outcome measures for three part fractures were

976

N. D. CLEMENT, A. D. DUCKWORTH, M. M. MCQUEEN, C. M. COURT-BROWN

Table V. Predictors of the Constant score at one year after sustaining a proximal humeral fracture on linear multivariable regression analysis using ’enter‘ methodology 95% Confidence Intervals Predictors in the model (R 2= 0.31)

B

Gender

Reference -8.67 Reference -6.58 Reference -1.31 Reference -17.98 Reference -3.26 Reference -12.23 Reference -7.99 Reference -8.66 Reference -25.31 Reference -5.36 Reference 0.80 Reference -0.69 Reference -3.44 Reference -14.23 102.03

Age group Deprivation Live in own home Live alone Employed Recreation Shopping Dressing Housework Home help Multiple fractures Parts Non-operative

Male Female Elderly Super-elderly Quintile 1 Each quintile Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Minimal Each part Yes No

(Constant)

Lower

Upper

p-value

-1.17

-4.92

0.01

-0.40

-3.49

0.03

0.71

-0.30

0.56

-5.72

-11.85

< 0.0001

2.40

-0.43

0.77

0.75

-5.74

0.08

-2.32

-5.15

< 0.0001

2.85

-2.90

0.32

-7.63

-16.47

< 0.0001

6.66

0.65

0.83

8.96

4.88

0.02

8.28

3.79

0.09

-1.31

-2.37

< 0.0001

-3.80 145.71

-9.01 123.87

0.001

Table VI. Independent case-mix variables associated with a poor outcome one year after sustaining a proximal humeral fracture using multivariable logistic regression analysis and ‘forward Wald’ methodology 95% Confidence Intervals Predictors in the model (R2=0.19) Live in own home Recreation Shopping Dressing Parts

(Constant)

Odds ratio Yes No Yes No Yes No Yes No Minimal Each part

Reference 2.62 Reference 1.85 Reference 2.22 Reference 6.93 Reference 1.37 0.002

demonstrated between those undergoing fixation and nonoperative management, and in the operative group there was a 33% rate of re-operation.30 In contrast, patients with a four-part proximal humeral fracture who were treated with a hemi-arthroplasty had a better mean EQ-5D32 at two years than those who were treated conservatively. This may, however, represent a type I error as there was no difference in the mean joint specific Constant score or the DASH score.12 The

Lower

Upper

1.04

6.57

1.15

2.98

1.1

4.29

1.33

36.10

1.14

1.65

-

-

p-value 0.04 0.01 0.02 0.02 0.001

< 0.0001

failure to demonstrate a difference in the Constant score between operative and non-operative forms of treatment in these studies may have been influenced by the case-mix variables of the cohorts, although both RCTs only included patients in ‘independent living conditions’. However, most patients with proximal humeral fractures live in their own home, as confirmed by our study, and factors that have a greater effect on the outcome, such as the ability to perform THE BONE & JOINT JOURNAL

THE OUTCOME OF PROXIMAL HUMERAL FRACTURES IN THE ELDERLY

recreational activities and to shop independently, may have influenced their findings. These factors should be considered when enrolling patients into clinical trials and contemplating operative intervention. The retrospective nature of this study is a limitation, and although no patient was lost to follow from the survival analysis, 93 patients (15%) did not have functional assessment available at one year. However, the prospectively compiled database used for this study was relatively complete, with few data points missing (Table I). It could be argued that the length of follow-up of one year is relatively short, but previous authors have demonstrated no further improvement after this time for elderly patients.30,31 This study has shown that age does not influence either the mortality or function after a proximal humeral fracture in the elderly. Factors associated with social independence, such as living in their own home, pursuing recreational activities, and being able to shop for themselves, were more influential upon outcome. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by D. Rowley and first proof edited by J. Scott.

References 1. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87–92. 2. Kim SH, Szabo RM, Marder RA. Epidemiology of humerus fractures in the United States: Nationwide emergency department sample, 2008. Arthritis Care Res (Hoboken) 2012;64:407–414. 3. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37:691–697. 4. No authors listed. Office for National Statistics. National Population Projections, 2010-Based Projections, 2011. http://www.ons.gov.uk/ons/rel/npp/national-population-projections/2010-based-projections/index.html (date last accessed 13 March 2014). 5. Kannus P, Palvanen M, Niemi S, et al. Osteoporotic fractures of the proximal humerus in elderly Finnish persons: sharp increase in 1970-1998 and alarming projections for the new millennium. Acta Orthop Scand 2000;71:465–470. 6. Clement ND, McQueen MM, Court-Brown CM. Social deprivation influences the epidemiology and outcome of proximal humeral fractures in adults for a defined urban population of Scotland. Eur J Orthop Surg Traumatol 2013;(Epub). 7. No authors listed. Office of National Statistics. Focus on Older People. http:// www.ons.gov.uk/ons/rel/mortality-ageing/focus-on-older-people/ (date last accessed 13 March 2014). 8. Clement ND, Aitken SA, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of fractures in very elderly patients. J Bone Joint Surg [Br] 2011;93B:806–810. 9. Clement ND, Aitken S, Duckworth AD, McQueen MM, Court-Brown CM. Multiple fractures in the elderly. J Bone Joint Surg [Br] 2012;94-B:231–236.

VOL. 96-B, No. 7, JULY 2014

977

10. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg [Am] 1970;52-A:1077–1089. 11. Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg [Am] 1970;52-A:1090–1103. 12. Robinson CM, Amin AK, Godley KC, Murray IR, White TO. Modern perspectives of open reduction and plate fixation of proximal humerus fractures. J Orthop Trauma 2011;25:618–629. 13. Murray IR, Amin AK, White TO, Robinson CM. Proximal humeral fractures: current concepts in classification, treatment and outcomes. J Bone Joint Surg [Br] 2011;93-B:1–11. 14. Robinson CM, Longino D, Murray IR, Duckworth AD. Proximal humerus fractures with valgus deformity of the humeral head: the spectrum of injury, clinical assessment and treatment. J Shoulder Elbow Surg 2010;19:1105–1114. 15. Iyengar JJ, Devcic Z, Sproul RC, Feeley BT. Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma. 2011;25:612–617. 16. No authors. General Register Office for Scotland. http://www.gro-scotland.gov.uk/ files2/stats/gros-mid-2008-population-estimates-scotland-population-estimates-bysex-age-and-administrative-area/j1075008.htm (date last accessed 13 March 2014). 17. Carstairs V, Morris R. Deprivation and Health in Scotland. Aberdeen: Aberdeen University Press, 1991. 18. No authors listed. Information services division Scotland. Deprivation, 2010. http:/ /showcc.nhsscotland.com/isd//3211.html (date last accessed 13 March 2014). 19. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160–164. 20. Bjorkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: a retrospective evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop Scand 2004;75:741–745. 21. Siwach R, Singh R, Rohilla RK, et al. Internal fixation of proximal humeral fractures with locking proximal humeral plate (LPHP) in elderly patients with osteoporosis. J Orthop Traumatol 2008;9:149–153. 22. Mattyasovszky SG, Burkhart KJ, Ahlers C, et al. Isolated fractures of the greater tuberosity of the proximal humerus: a long-term retrospective study of 30 patients. Acta Orthop 2011;82:714–720. 23. No Authors Listed. General Register Office for Scotland: Statistics. http:// www.gro-scotland.gov.uk/statistics/ (date last accessed 13 March 2014). 24. Kaplan EL, Meier P. Nonparametric estimation from incomplete observation. JASA 1958;53:457–481. 25. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001;72:365–371. 26. Kannus P, Palvanen M, Niemi S, Sievanen H, Parkkari J. Rate of proximal humeral fractures in older Finnish women between 1970 and 2007. Bone 2009;44:656–659. 27. Clayton RA, Gaston MS, Ralston SH, Court-Brown CM, McQueen MM. Association between decreased bone mineral density and severity of distal radial fractures. J Bone Joint Surg [Am] 2009;91-A:613–619. 28. Shortt NL, Robinson CM. Mortality after low-energy fractures in patients aged at least 45 years old. J Orthop Trauma 2005;19:396–403. 29. Clement ND. Can we decipher indications and outcomes of the PHILOS plate for fractures of the proximal humerus? Int Orthop 2013;37:1199–1200. 30. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011;20:747–755. 31. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011;20:1025–1033. 32. Brooks R. EuroQol: the current state of play. Health Policy. 1996;37:53–72.