*Reprint req

Reconstructive

J Shoulder Elbow Surg (2011) 20, 795-801

1058-2746/$ - s

doi:10.1016/j.jse

www.elsevier.com/locate/ymse

Nondisplaced proximal humeral fractures: high incidenceamong outpatient-treated osteoporotic fractures andsevere impact on upper extremity function and patientsubjective health perception

Emilio Calvo, MD, PhD, MBAa,*, Diana Morcillo, MDa, Antonio M. Foruria, MD, PhDa,Enrique Redondo-Santamar�ıa, MDb, Fernando Osorio-Picorne, MDb,Jose R. Caeiro, MD, PhDc, in representation of the GEIOS-SECOT OutpatientOsteoporotic Fracture Study Group

aShoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Fundaci�onJim�enez D�ıazeCapio, Madrid, SpainbMedical Department, Merck Sharp & Dohme, Madrid, SpaincDepartment of Orthopedic Surgery and Traumatology, Complexo Hospitalario Universitario Santiago de Compostela,Santiago de Compostela, Spain

Background: Although most proximal humeral fractures are attributed to osteoporosis, they are usuallynot considered individually in osteoporotic studies because of their lower incidence. The purpose of thisstudy was to evaluate the incidence of nondisplaced proximal humeral fractures in comparison withother outpatient-treated osteoporotic fractures, as well as to assess their functional impact and effects onpatient-perceived quality of life.Materials and methods: In this multicenter, cross-sectional, prospective study, all osteoporotic fracturesin postmenopausal women aged 50 years or older treated nonoperatively in 358 trauma centers wererecorded during a 3-month period. Fractures were considered osteoporotic if caused by a low-energytrauma. Pathologic fractures were excluded. The incidence of proximal humeral fractures in relationto other osteoporotic fractures was calculated. Patients were interviewed by telephone 6 months afterthe fracture with the Disabilities of the Arm, Shoulder and Hand and EuroQoL 5D questionnaires.Results: This study comprised 5,147 women (mean age, 72.6 � 7.5 years) with 5,268 fractures. Of these, 912(17.5%) had had proximal humeral fractures. The mean Disabilities of the Arm, Shoulder and Hand score was26.6 � 25.7. Of the women, 67.3% had pain or discomfort and disclosed significant reductions in functionalcapacity, especiallywith regard to self-care (44.5%), daily life activities (56.5%), andanxietyordepression (32.7%).Conclusion: Nondisplaced proximal humeral fractures are among the most common fractures associatedwith osteoporosis, and they can be a major cause of functional disability and reduction in subjectivepatient-perceived health.

uests: Emilio Calvo, MD, PhD, MBA, Shoulder and Elbow

Surgery Unit, Department of Orthopedic Surgery and

Traumatology, Fundaci�on Jim�enez D�ıazeCapio, Avda Reyes Cat�olicos,

2, 28040 Madrid, Spain.

E-mail address: ecalvo@fjd.es (E. Calvo).

ee front matter � 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.

.2010.09.008

796 E. Calvo et al.

Level of evidence: Level IV, Case Series, Treatment Study.� 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Proximal humeral fractures; osteoporosis; health-related quality of life; upper extremity

function; prevalence

Osteoporosis is a major health concern affectinga growing number of individuals worldwide. It causes nosymptoms except for fractures and their complications. Theburden of osteoporotic fractures in terms of morbidity,mortality, disability, impact on health-related quality of life(HRQOL), and cost is substantial. Previous studies haveprimarily assessed the impact of hip, vertebral, and wristfractures on HRQOL.1,3,7,9,11,12,15,20,23,28,30-32 Althoughmost proximal humeral fractures occur in postmenopausalwomen and are attributed to osteoporosis, they are usuallynot considered individually in osteoporotic studies becauseof their lower incidence.5,12,18 However, the incidence ofproximal humeral fractures has been shown to be rising,and recent studies on their incidence in relation to otherosteoporotic fractures are lacking.16 In addition, mostproximal humeral fractures are minimally displaced, andare assumed to have a satisfactory functional outcome witha low impact on HRQOL, yet they have seldom beenstudied.2

We hypothesized that proximal humeral fractures areamong the most frequent fractures associated with osteo-porosis and may represent a major cause of functionaldisability, even if nondisplaced and treated conservatively.

The purpose of this study was to evaluate the incidenceof nondisplaced proximal humeral fractures in comparisonwith other osteoporotic fractures conservatively treated onan outpatient basis, as well as to assess their functionalimpact and effects on patient-perceived quality of life.

Materials and methods

Study population

In this multicenter, cross-sectional, prospective study, all acuteosteoporotic fractures in postmenopausal women aged 50 years orolder treated nonoperatively and on an outpatient basis in 358Spanish trauma centers were recorded during a 3-month period.Because conservatively treated fractures were analyzed, onlyvertebral, wrist, rib, and proximal humeral fractures among allosteoporotic fractures were assessed. The fractures were consid-ered osteoporotic if caused by low-energy trauma (ie, fracturesbeing the consequence of a fall from a standing height or less).Fractures were considered acute if they occurred less than 4 weeksearlier. All fractures were confirmed radiographically on at least2 perpendicular views.

Patients were excluded in the case of (1) fractures located inother sites different from the spine, wrist, ribs, or proximalhumerus; (2) fractures requiring surgical treatment or hospital

admission; (3) the presence of any condition causing skeletalfragility different from postmenopausal osteoporosis; (4) previousdiagnosis of any tumor; and (5) radiographic signs of pathologicfracture.

Epidemiologic study

The incidence of proximal humeral fractures in relation to otherosteoporotic fractures treated nonoperatively and on an outpatientbasis was calculated. Previous diagnosis and treatment for oste-oporosis, as well as the existence of previous low-energy fractures,were documented. The patient was considered to be under treat-ment for osteoporosis whenever she received at least 1 drugapproved for this condition. The number of fractures identified asosteoporotic in the emergency department was recorded.

Impact on HRQOL and functional status

To evaluate its impact onHRQOL and functional status, aswell as toassess the consequences for upper extremity function in the case ofwrist and proximal humeral fractures, a subpopulation of 301patients were interviewed by telephone 6 months after the fracture.The Spanish version of the EuroQoL 5D questionnaire was used toassess HRQOL after fracture.29 The Spanish version of theDisabilities of theArm, Shoulder andHand (DASH) questionnaire13

and the severity of symptoms and functional status questionnaire ofLevine et al19 were used to evaluate the impact of the fracture onupper extremity function. The EuroQoL 5D questionnaire isa standardized measure of health status developed to providea simple, generic measure of health for clinical and economicappraisal.29 The EuroQoL 5D questionnaire consists of 2 parts: theEuroQoL descriptive system and the EuroQoL visual analog scale(VAS). The EuroQoL descriptive system comprises 5 healthdomains: mobility, self-care, usual activities, pain/discomfort, andanxiety/depression. Each dimension is categorized into 1 of 3 levelsby the patient: no problems, some problems, or severe problems.The EuroQoL VAS records patient self-rated health on a verticalscale where the endpoints are labeled as ‘‘best imaginable healthstate’’ and ‘‘worst imaginable health state.’’ Levine et al reporteda self-administered questionnaire where the patient scores herability to perform 7 activities of daily living from 0 points (nodifficulty) to 5 points (unable to do). The final score obtained is themean of the scores for each individual activity. The DASH ques-tionnaire includes self-reporting questions aimed at rating thesymptoms and ability to perform certain daily activities with theupper extremity. Both the EuroQoL 5D and DASH questionnaireshave been extensively evaluated for reliability and validity underSpanish conditions and in many other countries, and they have beensuccessfully used in telephone interviews.10,19,21,29,33 All partici-pants were volunteers who agreed to participate in the study andsigned the informed consent document.

Figure 1 Graphic distribution of fractures studied. Data aregiven as absolute values.

Figure 2 Number of cases distributed by type of fracture andage.

Nondisplaced proximal humeral fractures 797

The Fundaci�on Jim�enez D�ıaz - Capio Ethics Committee ofClinical Research approved the human protocol for this investi-gation under no. 05/95.

Statistical analysis

A descriptive analysis of the sample was done. Continuous vari-ables were described by the mean, standard deviation, minimum,and maximum values. The discrete variables were presentedthrough the distribution of frequencies and percentages. The 95%confidence intervals were estimated when necessary. An Access2003 XP database (Microsoft, Redmond, WA) was createdincluding the patient data with margins of safety and standards ofinternal consistency. The categorical variables were comparedamong groups based on the c2 test. The risk analysis was con-ducted by providing the odds ratios and their 95% confidenceintervals. All differences were tested at a 2-sided significancelevel of P < .05. Statistical analyses were performed by use ofthe SPSS statistical package for Windows (version 14.0; SPSS,Chicago, IL).

Results

Epidemiologic study

A total of 5,506 patients were enrolled in the study,although 359 (6.5%) dropped out. We excluded 125patients in whom the fracture was suspected not to be acuteand 11 patients with an incomplete or suboptimal radio-graphic examination. A total of 223 patients with fractureslocated at sites different from the spine, rib, wrist, orproximal humerus were also excluded. Thus, a final total of5,147 women with a mean age of 72.6 � 7.5 years (range,50-98 years) were evaluated.

Fig. 1 shows the demographic data and distribution offractures in the sample evaluated. Of the patients, 121 had2 conservatively treated low-energy fractures; thus, 5,268fractures were studied overall. Proximal humeral fracturescomprised 17.9% (n ¼ 919) of all osteoporotic fracturesand were the most frequent after distal radius fractures(n ¼ 2,364 [45.9%]) and vertebral fractures (n ¼ 1,812[35.2%]). A total of 173 patients (3.4%) presentedrib fractures. Differences were statistically significant

regarding age distribution of the fractures analyzed forvertebral, distal radius, and proximal humeral fractures(P < .001). The incidence of these 3 types of fractureincreased with age during the index period, but whereas theincidence of distal radius and vertebral fractures decreasedafter age 70, proximal humeral fractures did not show thisreduction. The mean age of patients with proximal humeralfractures was significantly greater than that of patients withvertebral, distal radius, or rib fractures (P < .001) (Fig. 2).

Only 1,865 patients (35.4%) had been previously diag-nosed with postmenopausal osteoporosis, and 1,521(81.6%) were receiving treatment for this condition. A totalof 2,125 (40.3%) reported low-energy fractures before theindex fracture. The distribution of these previous fractureswas similar to that of the acute osteoporotic fractures: 901patients (42.4%) reported previous distal radius fractures,825 (38.8%) had vertebral fractures, 283 (13.3%) hadprevious proximal humeral fractures, 161 (7.6%) had ribfractures, and the remaining 220 (10.4%) had a clinicalhistory of fractures located at other sites. Previous osteo-porotic fractures were found to be predictive of anincreased risk of future fracture (Table I). In 2,913 cases(59.7%), the fracture was identified as osteoporotic in theemergency department, and treatment for this conditionwas recommended in addition to specific fracture care.Proximal humeral fractures were the fractures leastfrequently identified as osteoporotic in comparison tovertebral, distal radius, rib, or even other fractures (Fig. 3).

Impact on HRQOL and upper extremity function

A total of 301 patients with osteoporotic fractures (101vertebral, 154 distal radius, 46 proximal humerus, and 7 ribfractures) were contacted at 6 months to study the impact ofthe fracture on HRQOL. The latter was significantlyaffected by all fractures analyzed, according to the Euro-QoL questionnaire (Table II), and no significant differencescould be detected among the fracture groups overall.HRQOL values of the different domains included in theEuroQoL questionnaire for each fracture group are given in

Table I Risk of fracture in women with previous fracture

Index fracture Previous fracture

Vertebrae Distal radius Proximal humerus Rib Other

Vertebrae 1.49 (1.24-1.79) 0.75 (0.63-0.90) 0.90 (0.69-1.18) 0.98 (0.70-1.37) 0.58 (0.42-0.80)Distal radius 0.80 (0.67-0.96) 1.34 (1.12-1.59) 1.03 (0.80-1.32) 0.78 (0.56-1.08) 1.31 (0.99-1.73)Proximal humerus 0.93 (0.74-1.16) 0.97 (0.78-1.21) 1.12 (0.82-1.52) 1.25 (0.85-1.85) 1.25 (0.89-1.75)Rib 0.66 (0.40-1.09) 0.86 (0.54-1.38) 0.97 (0.49-1.91) 2.87 (1.58-5.25) 1.31 (0.66-2.58)Other 0.45 (0.15-1.36) 0.87 (0.33-2.24) 0.38 (0.05-2.87) 1.53 (0.35-6.72) 8.99 (3.53-22.89)

Figure 3 Percentage of cases identified as osteoporotic inemergency department in each fracture group.

798 E. Calvo et al.

Table III. The majority of patients reported problems.Whereas patients with vertebral fractures showed thelowest scores in most of the domains, differences reachedstatistical significance only for pain/discomfort (P ¼ .001).On the other hand, patients with proximal humeral fracturesreported significantly more severe difficulties regardingpersonal care (P ¼ .044). The subjective perception ofhealth based on the VAS was also lowest in patients withvertebral fractures, but differences did not reach signifi-cance when all fractures were compared (Table II).

Regarding upper extremity function, because the DASHscore cannot be calculated if more than 3 items are notanswered, the final score was obtained in only 108 patients(83 distal radius and 25 proximal humeral fractures).Although disability after proximal humeral fractures (26.4 �26.4) was greater when compared with distal radius fractures(21.2 � 21.8), the differences were not significant. Therewere also no significant differences when the Levine func-tional status scores achieved by the patients within thedifferent fracture groups were compared (Table II).

Discussion

Most investigations assessing the physical, psychological,social, and economic consequences of osteoporosis focuson vertebral fractures.1,3,9,11,20,23,30,32 A few studieshave evaluated the impact of non-vertebral osteoporoticfractures, but they usually address hip and distal radius

fractures, given their high prevalence and severe impact onpatient health.7,15,28,31,32 Proximal humeral fracture hasseldom been considered in osteoporosis studies, despite thefact that some authors have shown proximal humeralfractures in elderly patients to be associated with low bonemineral density and risk of falling, making clear that theyconstitute typical osteoporotic fractures.5,12,18 This is due inpart to the fact that proximal humeral fracture has beenconsidered to have a lower incidence. Nonetheless, epide-miologic studies have found proximal humeral fractures tobe the fourth most frequent type of osteoporotic fractureafter vertebral, hip, and distal radius fractures,21 and it isestimated that their incidence will increase sharply in thenear future, in view of their recent trend.26 Our study showsthat, to date, proximal humeral fractures account for almostone-fifth of all osteoporotic fractures treated conservativelyon an ambulatory basis, with important health, social, andeconomic implications.

Another interesting finding of these epidemiologicstudies concerns the mean age of the patients included.Several studies have made clear that proximal humeralfractures have a positive predictive value for hip fracture,which has been shown to be superior to that of distal radiusfracture.14,17,25 In our population, patients with proximalhumeral fractures were older, and the number of subjectsincluded in the study continued to increase after the age of70 years, whereas the number of other nonesurgicallymanaged osteoporotic fractures decreased. According to themean age of proximal humeral fracture associated withosteoporosis, younger than the mean ages reported for hipfracture in the literature, proximal humeral fracture shouldbe regarded as an important warning sign forecastingpotentially early hip fracture, permitting the application ofpreventive measures.17,25 On the other hand, prevalentvertebral fractures are also known to be strong predictors ofhip fracture, but because the majority remain undiagnosedand only 30% of patients seek medical attention in suchsituations, their final efficacy as a warning sign for hipfracture might be poorer.27

The key role of the orthopaedic surgeon in the diagnosisand treatment of osteoporosis, as well as in the prevention offragility fractures, has been repeatedly pointed out in theliterature.8 Despite these recommendations, orthopaedicsurgeons initially treating the patients in this study neglected

Table II Scores obtained by each fracture group at 6 months of follow-up based on 5 dimensions and VAS of EuroQoL and on Levinefunctional status scale

EuroQoL Functional status

EuroQoL 5D (mean � SD) VAS (mean � SD) n Score (mean � SD) n

Vertebrae 0.61 � 0.23 57.54 � 18.1 101 1.91 � 0.86 98Distal radius 0.70 � 0.24 62.81 � 20.6 154 1.85 � 0.92 151Proximal humerus 0.64 � 0.27 63.15 � 18.8 46 2.11 � 1.86 45Rib 0.54 � 0.33 60.00 � 22.4 7 2.09 � 1.86 7Overall 0.66 � 0.25 61.33 � 19.6 301 1.90 � 1.57 294

Table III Distribution (number and percentage of cases) according to each level and dimension considered in EuroQoL 5D ques-tionnaire for the four groups of fractures studied

Overall Vertebrae Distal radius Proximal humerus Rib

n % n % n % n % n %

MobilityNo problems 195 64.8 59 58.4 101 65.6 33 71.7 3 42.9Some problems 99 32.9 40 39.6 50 32.5 11 23.9 4 52.1Confined to bed 7 2.3 2 2.0 3 1.9 2 4.3 d dOverall 301 100 101 100 154 100 46 100 7 100

Self-careNo problems 215 71.4 71 70.3 117 76.0 26 56.5 3 42.9Some problems 76 25.2 29 28.7 33 21.4 16 34.8 2 28.6Unable to wash or dress 10 3.3 1 1.0 4 2.6 4 8.7 2 28.6Overall 301 100 101 100 154 100 46 100 7 100

Usual activitiesNo problems 138 45.8 37 36.6 79 51.3 20 43.5 3 49.2Some problems 139 46.2 57 56.4 65 42.2 20 43.5 2 28.6Unable to perform 24 8.0 7 6.9 10 6.5 6 13.0 2 28.6Overall 301 100 101 100 154 100 46 100 7 100

Pain/discomfortNo pain or discomfort 90 30.2 16 15.8 57 37.7 15 32.6 2 28.6Moderate pain or discomfort 168 56.4 65 64.4 80 53.0 25 54.3 4 57.1Extreme pain or discomfort 40 13.4 20 19.8 14 9.3 6 13.0 1 14.3Overall 298 100 101 100 151 100 46 100 7 100

Anxiety/depressionNot anxious or depressed 192 65.1 57 57.6 103 69.7 31 67.4 6 85.7Moderately anxious or

depressed80 27.1 35 35.4 34 22.7 12 26.1 1 14.3

Extremely anxious ordepressed

23 7.8 7 7.1 13 8.7 3 6.5 d d

Overall 295 100 99 100 150 100 46 100 7 100

Nondisplaced proximal humeral fractures 799

to identify the fracture as osteoporotic in 40% of the casesoverall. It is remarkable that the number of fractures notidentified as osteoporotic increased to 64.2% for proximalhumeral fractures, reflecting that these fractures are lesstypically associated with osteoporosis in the mind of generalorthopaedic surgeons. Therefore, additional awareness andgeneral education programs for orthopaedic surgeons andpatients need to be reinforced, also underlying the relevanceof proximal humeral fractures.

Another argument for the lack of inclusion of proximalhumeral fractures in osteoporosis studies in comparison to

vertebral, hip, or distal radius fractures is the general beliefthat most proximal humeral fractures are minimally dis-placed and can be managed nonoperatively with satisfac-tory functional outcome.16 However, recent epidemiologicstudies have shown that the proportion of minimally dis-placed fractures is significantly lower, accounting forapproximately half of all proximal humeral fractures.6

Previous reports have stated that displaced proximalhumeral fractures may require hospitalization and generallylead to long-term functional deficits.4,24 Our study focusedonly on minimally displaced proximal humeral fractures

800 E. Calvo et al.

and evaluated the impact on HRQOL and on upperextremity function in comparison to other prevalent nonesurgically treated osteoporotic fractures. The use of self-reported quality-of-life measures has gained increasingattention.1 We used the EuroQoL 5D because it is a vali-dated short questionnaire that assesses the major domainsrelated to HRQOL, including physical and psychologicaldisabilities, and has been extensively used to measure theimpact of osteoporotic fractures treated on an outpatientbasis.2 It is, moreover, short, thus minimizing patient timeand effort, increasing patient willingness to complete thequestionnaire, and it can be used in the context of a tele-phone interview.33 These characteristics made the EuroQoLespecially suited for telephone interview and made itpossible to obtain a sample of patients large enough tofacilitate statistical analysis. Proximal humeral fracturesshowed a significant impact on HRQOL in this study, as didvertebral or distal radius fractures. Interestingly, thepercentage of patients reporting problems in the domains ofthe EuroQoL was higher after vertebral fractures than afterproximal humeral or distal radius fractures, with theexception of self-care, where proximal humeral fractureshowed the poorest results, reflecting the importance ofshoulder function in personal care.

With regard to the impact of distal radius and proximalhumeral fractures on upper extremity function, we alsoused validated self-reported scales.2,13,19,29 Both osteopo-rotic fractures had a significant and quantitatively similarimpact on upper extremity function according to the2 questionnaires. However, the number of patients droppedfrom the functional evaluation when answering the DASHquestionnaire was important, because calculation of thefinal score is severely limited by the number of answerscompleted. According to these findings, we do not recom-mend the DASH score to be used for telephonic interviews,despite having been successfully used by other authors forthis purpose.10

To our knowledge, this is the first study to analyze bothHRQOL and functional ability after conservativelymanaging osteoporotic fractures on an outpatient basis.Another strength of the study is the large sample of patientsrecruited, permitting statistical analysis of non-vertebralfractures, as well as the prospective examination. Thisstudy is not without limitations, however. Conservativelytreated proximal humeral fractures were studied, and wecannot discard the possibility that some severely displacedfractures were included in patients in whom surgicaltreatment was considered not indicated because ofadvanced age or poor medical condition. However, themain limitation is that the impact on HRQOL and func-tional ability is analyzed at short-term follow-up (ie,6 months after fracture). Although the possibility ofHRQOL and upper extremity function normalization overlonger-term follow-up cannot be ruled out, outcome studieson proximal humeral fractures after very long-term follow-up reflect persistent shoulder dysfunction and substantial

mortality rates that can be predicted very early.24 Anotherdrawback is that patients were diagnosed with fragilityosteoporotic fractures without any assessment of bonemineral density. This implies that the diagnosis in the63.3% of patients included in the study who had not beenpreviously diagnosed with osteoporosis was only based onthe presence of low-energy trauma fracture after meno-pause, and no bone mineral density determinations wereperformed. However, Wilson et al34 showed that despite thefact that low-energy fractures of the proximal humerusindicate osteoporosis, bone mineral density measured at thehip or lumbar spine may underestimate the extent of oste-oporosis in the upper limb. In addition, the importance ofthe diagnosis of osteoporosis is based on fracture preven-tion, and the presence of a low-energy fracture aftermenopause is sufficient to establish an increased risk forsubsequent fragility fractures.22,34 Finally, no concomitantdiseases with a potential impact on HRQOL were recorded.

Conclusion

This study shows that proximal humeral fractures aretypical osteoporotic fractures with a high prevalence thatshould be strongly considered in osteoporosis investi-gations. Even when nondisplaced, these fractures can bea major cause of functional disability and result ina reduction in subjective patient-perceived health. Giventheir predictive value, these fractures should be regardedas an important warning sign forecasting potential hipfractures.

Disclaimer

This study was supported by a grant from Merck Sharp& Dohme, Spain.

The authors, their immediate families, and anyresearch foundations with which they are affiliated havenot received any financial payments or other benefitsfrom any commercial entity related to the subject of thisarticle.

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