Introduction

Fragility fractures have become nearly epidemic in the United States among elderly adults with over 2 million fractures occurring each year—more than heart attacks, strokes, and breast cancer combined [1]. Forty-four million Americans are now affected by osteoporosis or low-bone density, with one of the most devastating complications of osteoporosis being fragility fracture. According to the National Osteoporosis Foundation, up to one-half of all women and up to one quarter of all men will suffer a fragility fracture in their lifetime. The economic impact of fragility fractures is staggering; the direct cost of care for these fractures on the United States health care system is estimated at 13–20 billion dollars annually, with costs projected to rise by almost 50 percent by 2025 [2–7]. The number of upper extremity fragility fractures will continue to increase as the US population continues to age, and the impact these fractures have on our health care system and patient quality of life will become a greater burden. Distal radius and proximal humerus fractures (PHF) are common among the elderly population as they are the second and third most common fractures in adults over the age of 65 [8]. It is estimated that proximal humerus fractures account for 20 % of all osteoporotic fractures, and it has been reported that more than 70 % of proximal humeral fractures occur in patients over 60 years old [9–11].

Several European countries have been able to use national claims databases from their single payer systems to evaluate the economic impact that upper extremity fragility fractures have on their aging population [12–14]. The lack of a national unified database in the US makes these studies more difficult. Additionally, while there has been extensive literature published in the US that focuses on social and financial consequences resulting from suffering a hip fracture, literature focused on functional and economic impact resulting from upper extremity fractures is limited [15–17]. These fractures account for one-third of the total incidence of fractures in the elderly, yet we do not fully understand the impact these fractures have on patient’s independence, quality of life, or families. In particular, as age increases so do the number of medical co-morbidities, leading to more complicated and costly hospital stays, poorer outcomes, and increased mortality [18–21]. We examined the relationship between age and treatment type for upper extremity fragility fractures. We also looked at the early social and economic impact that upper extremity fragility fractures have based on increased age at injury.

Methods

This was an Institutional Review Board approved retrospective review. The authors have no conflicts of interest for this study.

Patients who had an inpatient treatment at Bronson Methodist hospital with a diagnosis (ICD-9 codes) for a proximal humerus or a distal radius fracture from 2006 to 2012 were included in the study. A retrospective chart review was performed and patients were excluded if their fracture resulted from a high energy or traumatic injury such as motor vehicle accident or crush injury. Eighty-six patients who met all the criteria were included in this study. To better delineate effect of age on patients with these types of upper extremity fragility fractures, patients were divided into two groups; group 1 consisted of patients aged 50–79 years old and group 2 included patient’s ≥80 years old. The institutional EMR was used to collect relevant clinical, demographic, and discharge data for each participant ("Appendix").

Demographic data included age, gender, race, height, weight, smoking status, alcohol consumption, menopause status, history of fracture and location, and mechanism of injury for current fracture. The co-morbid conditions collected for both cohorts included histories of osteoporosis, osteopenia, diabetes mellitus, dementia, rheumatoid arthritis, and cancer. Medication history and discharge medication list were reviewed and data collected for oral steroids, Vitamin D, Calcium, and osteoporosis drugs including bisphosphonates.

Pre-fracture mobility levels were collected from patient charts. These were based on reported ambulatory status and pre-fracture place of residence [lived at home, in an assisted living facility (AL), or in a skilled nursing facility (SNF)]. Discharge levels of independence (residence status) were categorized into four groups: home, assisted living facility, skilled nursing or rehabilitation facility (Rehab), and hospice care or unknown. Additionally, inpatient data on treatment type: surgical or non-surgical and type of surgery, length of stay (LOS), complications or readmission were collected for each patient. Surgical treatments included open reduction and internal fixation (ORIF) of the humerus or distal radius or shoulder arthroplasty. Major complications included implant failure, loss of reduction, permanent neuropathy, deep infection, malunion, nonunion, while minor complications included delayed union, superficial infection, stiffness, symptomatic implant, transient neuropathy, or continued pain.

Total direct costs related to upper extremity fractures were computed for each group using standard charges from the admitting hospital for a general per diem inpatient stay and using CPT codes for fracture repair. Fixed standard charges for CPT codes were: CPT23470 hemiarthroplasty of the shoulder at $27,876.00, CPT23615 ORIF of the humerus at $29,523.00, CPT25607 for ORIF distal radius $19,195. The per diem inpatient charge for non-surgically treated patients was $2,428/day. Cost for non-operative treatment was calculated as inpatient days times standard daily charge, and the average was calculated by dividing by the total number of patients in each corresponding subset of a cohort (38 for cohort 1, and 48 for cohort 2). Total cost per group for treatment was calculated by combining total surgery costs and total non-operative treatment costs; the average was calculated using the total number of patients in each corresponding subset of a cohort.

Statistical analysis

The data were summarized using descriptive statistics. The R 3.01 (R Foundation for Statistical Computing, Vienna Austria) software was used for all statistical analyses. Comparisons between G1 and G2 were performed for each of the independent variables collected. The Chi-squared test was used to evaluate the association between 2 categorical variables including previous history of fracture, co-morbidities, comparison of patient living status or level of independence pre and post fracture, and pre- to post-fracture mobility. A Chi-squared test was also used to compare non-surgical and surgical treatments as they relate to age and co-morbidities. A student t test comparison was used to compare LOS between G1 and G2 and for non-operative and surgically treated patients. A p value ≤0.05 was considered statistically significant.

Results

Of the eighty-six patients who met our inclusion criteria; G1 consisted of 38 patients and G2 had 48 patients. The average ages for the groups were 66 years for G1 and 87 years for G2. The majority of our cohort was Caucasian (94 %) and over 70 % of patients had no prior diagnosis of osteoporosis. No difference was seen in the rate of previous fracture between G1 and G2 (34 and 35 %, respectively) (p = 0.13). There was a significantly higher rate of smoking among G1 patients compared to G2 (p < 0.0001). There were no other significant differences between group demographics (Table 1). Results of Chi-square analysis demonstrated no relationship between increased age and increased number of co-morbidities (p = 0.59).

Table 1 Summary of demographics and co-morbidities for G1 and G2
Full size table

Mobility and independence

The majority of both groups had a high level of independent pre-fracture mobility (Fig. 1). As expected, our younger cohort showed a higher level of baseline independent mobility with 76 % being ambulatory with no assisted devices and 24 % using a walker compared to 58.3 % of patients in the older cohort who were ambulatory with no assisted devices, 27 % using a walker, 8.3 % were in a wheelchair, and 6.3 % were considered immobile. Patients from both groups were discharged to either a skilled nursing facility or rehab at equal rates, 44.7 % for G1 compared to 45.8 % from G2 (p = 0.98). A similar trend was seen in the discharge of patients to assisted living facilities, 28.9 % for G1 compared to 31.3 % for G2 (p = 0.99). G2 patients were discharged home at a slightly higher rate 16.7 %, than their G1 counterparts 7.9 % but this was not statistically significant (p = 0.48). There was no significant difference in pre to post fracture independence between groups (p = 0.32) (Fig. 2).

Fig. 1
figure 1

Pre-fracture mobility status of patients in G1 and G2

Full size image
Fig. 2
figure 2

Pre- and post-fracture living status for patients in G1 (left) and G2 (right)

Full size image

Length of stay

The average LOS for all patients was not significantly different between the cohorts (p = 0.074). The overall average inpatient stay for the younger was 5.29 days compared to the average stay for the older cohort of 4.15 days (p = 0.074). Surgically treated patients within a group trended toward a shorter average LOS than the non-operative patients in that group. There was also no significant difference when comparing LOS for the surgically treated patients from G1 (4.93 days) to G2 (5.52 days), (p = 0.201) and LOS for non-operatively treated patients in G1 (3.6 days) to G2 (4.29 days) (p = 0.137). Chi-square analysis demonstrated no correlation between increased number of comorbidities and LOS (p = 0.159).

Treatment

Our study showed that patients in the older cohort (G2) were less likely to undergo elective surgical treatment for their fracture, 21 % compared to 39 % of patients in G1 (p = 0.06). In the younger cohort, 15 patients received surgical treatment for their fracture. Seven patients had an ORIF for a distal radius fracture, and eight patients had an ORIF for a proximal humerus fracture. Ten patients in G2 received surgical treatment for their fragility fracture; 4 patients were treated with ORIF for a proximal humerus fracture, 5 with ORIF for a distal radius fracture and 1 patient was treated with a hemiarthroplasty for their proximal humerus fracture. Chi-square analysis results showed no relationship between increased co-morbidities and selection for surgical treatment (>1 Co-morbidity p = 0.46 and >2 co-morbidities p = 0.96). Specifically, smokers did not have an increased rate of surgical treatment based on Chi-square analysis (p = 0.29) even though there was an uneven distribution of smokers in the younger cohort.

Post-fracture complications

The complication rate was similar for both groups, with 9 % of patients in G2 (4/43) and 5.5 % percent (2/36) of patients in G1 having post-fracture complications (p = 0.99). There were 2 major complications in G1 (1 loss of reduction and 1 deep infection). The minor complications in G1 included 3 patients with continuous pain and 1 patient with a superficial infection. There were 2 major complications in G2 (1 deep infection and 1 loss of reduction) and 2 minor complications: 1 delayed union and 1 patient with painful implant.

Cost

The average charge, based on per diem hospitalization charges, for non-operative treatment for patients in G1 was calculated to be $13,407 and $10,415 for G2. The average charges for surgically treating patients in G1 were $24,703 and $24,194 for patients in G2. The average cost for patients in G1 (combining both non-operative and operative treatment) was $17,866 compared with $13,286 per patient for G2 (p = 0.02) (Table 2).

Table 2 Cost analysis of upper extremity fragility fractures
Full size table

Discussion

In an aging population, upper extremity fragility fractures will continue to be a common and significant problem, particularly in osteoporotic patients. Controversy persists on whether non-operative or operative treatment is indicated in older individuals. There have been many studies that have analyzed patient quality of life following a specified treatment option for a PHF and distal radius fracture [22–26]. Olerud et al. [25] described the increase in functional outcome and quality of life following surgical intervention compared to non-operative treatment for PHF. Overall, operative treatment had earlier return to function, increased independence, and improved patient satisfaction/quality of life. Non-operative treatment however, has been reported equally beneficial, as there have been many authors that have found no significant benefits for operative treatment especially in the elderly population. Non-surgical treatment has less initial costs per patient and good functional outcomes.

Our results demonstrated age as the primary driver in selection for surgical treatment regardless of increased number of co-morbidities. In addition in our population increased number of co-morbidities was not associated with increased age or longer LOS [23]. These results illustrate the significant burden of upper extremity fractures in terms of loss of independence, inpatient hospitalizations, and prolonged nursing home or rehabilitation needs, accounting for considerable health care costs. The significant increased cost during the acute period for surgically treated patients did not produce more benefits than the non-operative group in terms of returning them home or allowing them to live independently. Non-elderly patients had surgery more often than elderly patients, increasing the overall cost in that group without a significant difference in independence post operatively (at the time of discharge). Although, not statistically significant, there was a trend to increase surgical treatment in the younger patients compared to the older cohort. This could be attributed to a selection bias by surgeons for more aggressive treatment in younger patients, in addition young patients being lower surgical risk and more better candidates for surgery based on higher functional requirements and expectations. Neither age nor treatment type had a statistically significant effect on LOS or discharge locations in these patients.

While hip fractures represent the most dramatic consequence of osteoporosis, fractures of the humerus, forearm and wrist account for one-third of the total incidence of fractures and can be a significant burden to individuals and the community [23]. The impact of these upper extremity fragility fractures may be more than predicted, and significant in terms of healthcare resources, social impact and loss of independence. Our results showed that all ages have decreased independence following these upper extremity fractures and this loss of independence can have a greater impact on older patients. Furthermore, regardless of treatment option, upper extremity fracture patients have problems with mobility, personal care, and are unable to perform their usual activities [26]. More research needs to be done regarding optimizing who we select for surgical versus non-surgical management and how treatment selection impacts not only patient satisfaction and function but also socio-economic impact.

More resources need to be dedicated to prevention of fragility fractures. These prevention programs could have a significant impact on patient-related outcomes, as well as healthcare costs. With 34.9 % of our patients having a history of previous fracture, prevention efforts can reduce the amount of fragility fractures, and thus improve patient quality of life. More focus on prevention of these types of injuries especially in the setting of a fragility fracture as a point of intervention which could reduce post-operative and post-fracture rehabilitation expenses.

In summary our results illustrate the significant impact upper extremity fragility fractures with inpatient hospitalizations, loss of independence and long-term rehabilitation needs. Increased age was not correlated with increased co-morbidities or LOS but did affect treatment selection. The need for better prevention efforts with a first time fragility fracture could clearly decrease incidence of repeated fragility fractures for this population. There is a large need for increased awareness and more studies specific to treatment of these upper extremity fractures, to optimize patient outcomes, function and reduced rehabilitation or long-term healthcare needs. In addition, more studies that focused on optimal treatment as it related to costs and healthcare impact, as has been done for lower extremity hip fractures, could prove to be beneficial in reducing the burden on the healthcare system with recurrent fractures and costly surgeries.