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Differences Across the U.S. in Treatment of Upper Arm Fractures

Posted on: 11/30/1999
There is some suspicion that common problems among older adults are treated differently depending on where you live. One way regional differences can be tracked for adults is through Medicare-Part B. Data from those records can be reviewed to get a picture of patient demographics (age, sex, race, education level, diagnosis, type of treatment).

In this study, trends in proximal humeral fractures among the elderly are reviewed. Using information compiled through Medicare Part-B, the number of these fractures that have been reported can be determined year-by-year. Surgical treatment and any repeat surgeries (e.g., remove hardware, perform a revision procedure) are recorded through billing codes used by surgeons.

Proximal humeral fractures refers to a break in the upper arm bone close to the top (but below the round head that fits into the shoulder socket). The reason this particular fracture was chosen is because treatment changed when locking plate technology was developed. These specially designed plates can be used with patients who have osteoporosis (brittle bones) that might not heal well without some extra support.

In order to compare treatment and results, data was collected for two one-year time periods (1999-2000 before locking plates were available and 2004-2005 after locking plates were developed). There are thousands of patients covered by Medicare -- too many to include in a single study. The authors selected a 20 per cent sample (all patients with a proximal humeral fracture treated surgically) from each time period.

That sounds all very simple but, in fact, there are some complicating factors to consider. First of all, proximal humeral fractures can't just be put in a cast like fractures in other locations. Hospitalization, surgery, and rehab are commonly required.

There is no research evidence to support one type of treatment over another for this problem. Treatment varies depending on whether the fracture has displaced (separated and shifted apart). And even when surgery is indicated, the type of surgery differs from case-to-case.

The basic surgical options include percutaneous fixation (inserting pins or screws through small incisions in the skin), open reduction and internal fixation (ORIF), and arthroplasty (shoulder replacement). ORIF involves an open incision and the use of various hardware devices such as plates (including the new locking plates), pins, and/or screws.

After gathering all the data and analyzing it for comparisons, the results of this study were placed in tables and on a map of all the states. One map showed differences in the number of fractures state-by-state. The second map showed the proportion of all proximal humeral fractures that were treated surgically by region.

Regional variations were further broken down by patient age, sex, and race. There were wide ranges across the country and differences between the two time periods. Here's a summary of what was found and reported:
  • The number of proximal humeral fractures has not changed from 1999 to 2005.
  • The group most likely to have this type of fragility fracture was 75 to 84 years old, female, and Caucasian.
  • More fractures occur in people living in the eastern United States compared to the western states. The reason(s) for this are unknown.
  • Most of the time, proximal humeral fractures in this age group are treated conservatively (without surgery), but over time, there has been a 25 per cent increase in the number of patients treated surgically.
  • Open reduction and internal fixation (ORIF) has gained in popularity over joint replacement.
  • The number of reoperations was much higher after locking plate technology (used with ORIFs) came on the scene.

  • References:
    John-Erik Bell, MD, MS, et al. Trends and Variation in Incidence, Surgical Treatment, and Repeat Surgery of Proximal Humeral Fractures in the Elderly. In The Journal of Bone and Joint Surgery. January 19, 2011. Vol. 93-A. No. 2. Pp. 121-131.

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