JSES International 6 (2022) 137e143

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JSES International
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Trending a decade of proximal humerus fracture management in older

adults
Akshar H. Patel, MDa, J. Heath Wilder, MDa, Sione A. Ofa, BSa, Olivia C. Lee, MDa,b,c,
Felix H. Savoie III, MDa, Michael J. O’Brien, MDa, William F. Sherman, MD, MBAa,*
a
Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
b
Department of Orthopaedic Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
c
Southeast Louisiana, Veterans Health Care System, New Orleans, LA, USA

a r t i c l e i n f o Background: Proximal humerus fractures are the third most common fracture in older adults. Because
of the aging population, the incidence of these fractures and their impact will continue to grow. With
Keywords: advancement in treatment options for proximal humeral fractures, the aim of this study was to evaluate
Proximal humerus fracture the trends in acute management of proximal humerus fractures to determine how definitive treatment
Hemiarthroplasty has changed over the past decade in patients older than 65 years.
Reverse shoulder arthroplasty
Methods: Using a commercially available database, patient records were queried from 2010 to 2019 for
Total shoulder arthroplasty
the incidence of proximal humerus fractures. For each individual year, data were queried to identify the
Internal fixation
Elderly incidence of closed reduction percutaneous pinning (CRPP), hemiarthroplasty (HA), intramedullary
nailing (IMN), open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), reverse total
Level of evidence: Level IV; Case Series; shoulder arthroplasty (RSA), or nonoperative treatment for acute proximal humeral fractures. A Cochran-
Descriptive Epidemiology Study Armitage trend test was used to determine significant changes in the trends of proximal humerus
fracture management. Logistic regression analyses were performed to generate odds ratios (OR) with
associated 95% confidence intervals comparing each individual procedure performed in 2019 to 2010.
Results: A total of 160,836 patients at least 65 years of age and older were diagnosed with a proximal
humerus fracture. Of this total, 28,503 (17.72%) patients received operative treatment and 132,333
(82.28%) received nonoperative treatment. From 2010 to 2019, operative treatment trends of proximal
humerus fractures changed such that CRPP decreased by 60.0%, HA decreased by 81.4%, IMN decreased by
81.9%, ORIF decreased by 25.7%, TSA decreased by 80.5%, and RSA increased by 1841.4% (all P < .0001).
Overall, nonsurgical management increased from 80% to 85% during the examined study period
(P < .0001). Patients in 2019 were significantly more likely to receive an RSA (OR 22.65) and were
significantly less likely to receive CRPP (OR 0.45), HA (OR 0.20), IMN (OR 0.20), ORIF (OR 0.82), and TSA
(OR 0.22) than patients in 2010. In addition, patients in 2019 were significantly more likely to receive
nonoperative treatment than patients in 2010 (OR 1.10).
Conclusion: Over the past decade, most of older adults who sustain proximal humerus fractures
continue to receive nonoperative treatment. Although CRPP, IMN, HA, ORIF, and TSA have decreased, RSA
has recently become more widely utilized, which is consistent with what has been noted in other
countries. Continued examination of the mid- and long-term outcomes of the increasing percentages in
RSA should be performed in this population.
© 2021 The Author(s). Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Accounting for 5%-6% of all adult fractures, proximal humerus distribution and typically involve young patients with high-energy
fractures occur in the United States at an annual incidence of 600 trauma or older patients who experience low-energy falls. Proximal
cases per 1,000,000 people.5,13 These fractures have a bimodal humerus fracture treatments vary based on myriad factors
including fracture displacement, activity level, concurrent injuries,
age, fracture type, and bone quality.26 Although proximal humerus
Institutional review board exemption was granted by Tulane University Biomed- fracture management in patients older than 65 years is debated,
ical IRB (study #: 2021-632). most of these fractures have historically been treated non-
*Corresponding author: William F. Sherman, MD, MBA, Department of Ortho-
paedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New
operatively.16,17 When indicated, operative treatment options
Orleans, LA 70112, USA. include open reduction internal fixation (ORIF), closed reduction
E-mail address: [email protected] (W.F. Sherman). percutaneous pinning (CRPP), intramedullary nailing (IMN),

https://doi.org/10.1016/j.jseint.2021.08.006
2666-6383/© 2021 The Author(s). Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.H. Patel, J.H. Wilder, S.A. Ofa et al. JSES International 6 (2022) 137e143

hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and this data set included Current Procedural Technology (CPT) and
reverse total shoulder arthroplasty (RSA).7 International Classification of Diseases (ICD), Ninth Revision and
As the third most common fracture type in the elderly following Tenth Revision (ICD-9/ICD 10). Institutional review board exemp-
hip fractures and distal radius fractures, proximal humerus fracture tion was granted through the Tulane University Human Research
cases are expected to rise with the aging U.S. population.2,12 With and Protection Program as the provided data were deidentified and
perceived increasing popularity of RSA and increasing prevalence of compliant with the Health Insurance Portability and Accountability
proximal humerus fractures in older adults, this study aimed to Act.
evaluate the trends in acute management of proximal humerus
fractures to determine how treatment selection has changed over Patient selection
the last decade. It was hypothesized that RSA has increased relative
to other surgical treatment options. Using both ICD-9 and ICD-10 diagnostic codes, patient data
consisting of a diagnosis of proximal humerus fracture were first
Materials and methods queried. Patients who received either operative or nonoperative
treatment of the proximal humerus fracture within 1 month of
Data source initial trauma were included in this study to best represent acute
decision-making management. These data were queried each year
A large nationwide commercially available administrative from 2010 through 2019. Only patients aged 65 years and older
claims database, PearlDiver (PearlDiver, Inc, Fort Wayne, IN, USA), were included. Patients with prior history of malignancy and
was utilized to retrospectively review deidentified patient records. infection were excluded. Records regarding fractures of the isolated
This study used the “MUExtr” data set, a subedata set of the 144 greater tuberosity, shaft, or distal humerus were not included. Pa-
million patients within PearlDiver. Specifically, this data set con- tients who passed away during the examined study period or did
tains patient records pertaining to procedures or diagnoses of the not have active follow-up during this time were also excluded.
upper extremity from multiple insurance providers across U.S. Given that both RSA and TSA are coded using the same CPT code
territories and states including commercial insurance groups, (CPT-23472), these operations were identified with ICD-9 and ICD-
Medicare, and Medicaid from 2010 to Q1 of 2020. Codes used from 10 procedural codes as these codes allow for specificity. Similar to

Figure 1 The flow diagram of patients included in the study. Fx, fracture; Hx, history.

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Table I Table I (continued )

Comprehensive breakdown of treatments provided to patients with proximal hu-
merus fractures by year. Procedure Number of patients %

2019 (n ¼ 15,078)
Procedure Number of patients %
CRPP 90 0.60%
2010 (n ¼ 16,961) Hemiarthroplasty 90 0.60%
CRPP 225 1.33% Intramedullary nailing 148 0.98%
Hemiarthroplasty 483 2.85% ORIF 1326 8.79%
Intramedullary nailing 816 4.81% Total shoulder arthroplasty 15 0.10%
ORIF 1784 10.52% Reverse total shoulder arthroplasty 563 3.73%
Total shoulder arthroplasty 77 0.45% Nonoperative management 12,846 85.20%
Reverse total shoulder arthroplasty 29 0.17%
CRPP, closed reduction percutaneous pinning; ORIF, open reduction internal fixation.
Nonoperative management 13,547 79.87%
2011 (n ¼ 16,301)
CRPP 186 1.14%
Hemiarthroplasty 434 2.66%
Intramedullary nailing 733 4.50%
ORIF 1792 10.99%
previous studies, the use of ICD procedural codes for the procedures
Total shoulder arthroplasty 11 0.07% instead of CPT-23472 allowed accuracy in identifying TSA versus
Reverse total shoulder arthroplasty 112 0.69% RSA during the studied time period.8,21,22 A comprehensive list of
Nonoperative management 13,033 79.95% all ICD and CPT codes used in this study are included in
2012 (n ¼ 16,656)
Supplementary Table S1.
CRPP 170 1.02%
Hemiarthroplasty 371 2.23%
Intramedullary nailing 757 4.54% Outcomes
ORIF 1841 11.05%
Total shoulder arthroplasty 8 0.05%
For each individual year of this study, data were queried for
Reverse total shoulder arthroplasty 155 0.93%
Nonoperative management 13,354 80.18% patients undergoing operative or nonoperative treatment within 1
2013 (n ¼ 18,110) month of their initial proximal humerus fracture. The procedures
CRPP 237 1.31% analyzed included CRPP, HA, ORIF, IMN, TSA, and RSA. Patients who
Hemiarthroplasty 363 2.00%
received nonoperative treatment were identified if they did not
Intramedullary nailing 808 4.46%
ORIF 2068 11.42% have any surgical procedures or procedures requiring anesthesia
Total shoulder arthroplasty 21 0.12% within 1 month after initial proximal humerus fracture. One month
Reverse total shoulder arthroplasty 220 1.21% was chosen for the operative cohort to define a period of acute
Nonoperative management 14,393 79.48% treatment such that fractures fixed after this time period would be
2014 (n ¼ 18,492)
considered due to failure of nonoperative management.20
CRPP 203 1.10%
Hemiarthroplasty 330 1.78%
Intramedullary nailing 724 3.92% Statistical analysis
ORIF 2051 11.09%
Total shoulder arthroplasty 16 0.09%
Reverse total shoulder arthroplasty 357 1.93%
All data analyses were performed using the R statistical software
Nonoperative management 14,811 80.09% (R Project for Statistical Computing, Vienna, Austria) integrated
2015 (n ¼ 16,335) within PearlDiver and Microsoft Excel (Microsoft Corp., Redmond,
CRPP 151 0.92% WA, USA) with the XLStat statistical package add-on (Addinsoft
Hemiarthroplasty 226 1.38%
Inc., New York, NY, USA) with an a level set to 0.05. A Cochran-
Intramedullary nailing 536 3.28%
ORIF 1638 10.03% Armitage trend test was performed to analyze operative manage-
Total shoulder arthroplasty 15 0.09% ment trends by evaluating the two-tailed null hypothesis that each
Reverse total shoulder arthroplasty 329 2.01% treatment remained constant over the decade. Logistic regression
Nonoperative management 13,440 82.29% analyses were conducted to generate odds ratios (ORs) with asso-
2016 (n ¼ 14,420)
ciated 95% confidence intervals (CIs) that compared each individual
CRPP 122 0.85%
Hemiarthroplasty 162 1.12% procedure in 2019 versus 2010.
Intramedullary nailing 152 1.05%
ORIF 1223 8.48% Results
Total shoulder arthroplasty 11 0.08%
Reverse total shoulder arthroplasty 351 2.43%
Nonoperative management 12,399 85.99% From 2010 to 2019, a total of 160,836 patients aged 65 years and
2017 (n ¼ 14,042) older were diagnosed with a proximal humerus fracture, and of this
CRPP 90 0.64% total, 28,503 (17.72%) patients received operative treatment and
Hemiarthroplasty 93 0.66%
132,333 (82.28%) received nonoperative treatment (Fig. 1). The
Intramedullary nailing 119 0.85%
ORIF 1237 8.81% comprehensive breakdown of individual treatments provided to
Total shoulder arthroplasty 11 0.08% patients with a proximal humerus fracture by year is listed in
Reverse total shoulder arthroplasty 405 2.88% Table I.
Nonoperative management 12,087 86.08% When evaluating the decade trends for each individual treat-
2018 (n ¼ 14,441)
CRPP 75 0.52%
ment utilizing the Cochran-Armitage trend test, the rates of CRPP
Hemiarthroplasty 89 0.62% decreased by 60.0%, HA decreased by 81.4%, IMN decreased by
Intramedullary nailing 158 1.09% 81.9%, ORIF decreased by 25.7%, and TSA decreased by 80.5%,
ORIF 1239 8.58% whereas the rate of RSA increased by 1841.4% (all P < .0001) as seen
Total shoulder arthroplasty 13 0.09%
in Table II. The rate of nonoperative management increased during
Reverse total shoulder arthroplasty 444 3.07%
Nonoperative management 12,423 86.03% the study period from 80% to 85% (P < .0001). When the rates of
(continued on next column)
operative procedures for proximal humerus fractures were
compared between 2010 and 2019, patients in 2019 were more
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A.H. Patel, J.H. Wilder, S.A. Ofa et al. JSES International 6 (2022) 137e143

Table II When examining international treatment trends, Klug et al

Operative treatment trends for 65-year-old patients and older over the decade. tracked proximal humerus management from 2007 to 2016 in a
Treatment trends from 2010 to 2019 Total % change P value national German registry and reported ORIF to be the most com-
for patients aged 65 years and older mon operative treatment method, although RSA had the greatest
CRPP e60.0 <.0001 proportional increase in utility over that period supporting its
Hemiarthroplasty e81.4 <.0001 growing popularity.15 Evaluating the 9-year surgical trend of the
Intramedullary nailing e81.9 <.0001 South Korean population from 2008 to 2016, Jo et al documented
ORIF <.0001
ORIF rates increasing in this cohort.11 However, this study did
e25.7
Total shoulder arthroplasty e80.5 <.0001
Reverse total shoulder arthroplasty 1841.4 <.0001 highlight a proportionate increase in the overall rate of RSA over
this time period, accounting for greater than 50% of all arthroplasty
CRPP, closed reduction percutaneous pinning; ORIF, open reduction internal fixation.
procedures in the final year of the study period.11 Sumrein et al
reported a rise in ORIF treatment of proximal humerus fractures for
Table III the Swedish population from 2001 to 2012 with the rate of
An odds ratio comparison of proximal humerus treatments in 2019 versus 2010. arthroplasty doubling.27 While studying the 23-year long-term
2019 versus 2010 treatments ORs (95% CI) trends of surgical treatment for proximal humerus fractures in
the Finnish population, Huttunen et al documented a similar rise in
CRPP 0.45 (0.35-0.57)
Hemiarthroplasty 0.20 (0.16-0.26)
ORIF treatment as the most common operative procedure, whereas
Intramedullary nailing 0.20 (0.16-0.23) there was a 6-fold increase in arthroplasty rates from 1987 to
ORIF 0.82 (0.76-0.88) 2009.10 Data in the present study are aligned with other global
Total shoulder arthroplasty 0.22 (0.13-0.38) population treatment trends such that there continues to be an
Reverse total shoulder arthroplasty 22.65 (15.58-32.91)
increase in RSA performed in this cohort.
Nonoperative treatment 1.10 (1.06-1.15)
After initial approval by the Food and Drug Administration in
OR, odds ratio; CI, confidence interval; CRPP, closed reduction percutaneous pinning; 2003, RSA has gained popularity as a treatment option in the United
ORIF, open reduction internal fixation.
States for elderly patients with severe proximal humerus fractures.23
When used for treatment of proximal humerus fractures, RSA
likely to receive an RSA than those in 2010 (OR 22.65, 95% CI: 15.58- prosthesis survival has been reported to be as high as 91% after 20
32.91). Conversely, patients in 2019 were less likely to receive CRPP, years with satisfactory functional outcomes.6 As poor functional
HA, IMN, ORIF, and TSA than those in 2010 (CRPP, OR 0.45, 95% CI: outcomes have been reported with HA in the setting of rotator cuff
0.35-0.57; HA, OR 0.20, 95% CI: 0.16-0.26; IMN, OR 0.20, 95% CI: deficiencies, Mata-Fink et al demonstrated RSA to have superior
0.16-0.23; ORIF, OR 0.82, 95% CI: 0.76-0.88; TSA, OR 0.22, 95% CI functional outcomes in a 2013 systematic review of proximal hu-
0.13-0.38). Patients in 2019 were also more likely to receive merus management in older adults.18 Because of ORIF and HA having
nonoperative treatment than patients in 2010 (OR 1.10, 95% CI 1.06- the potential for complications including nonunion and poor tu-
1.15) (Table III). berosity healing, RSA may be a viable option in the aging population
The number of surgeries performed for proximal humerus for patients with complex multiple-part proximal humerus fracture
fractures over the past decade by percentage of all treated proximal patterns as it allows for greater tolerance in tuberosity positioning
humerus fractures can be seen in Figure 2. Graphic representation and healing.1,3,4 If ORIF fails in the elderly, salvage RSA may remain as
of the relative treatment proportions of 2010 versus 2019 can be an option for proximal humerus fractures. However, RSA after failed
seen in Figure 3. ORIF has been reported to have higher complication rates than acute
RSA treatment after a proximal humerus fracture with primary RSA
Discussion having significantly better range of motion, better patient-reported
outcomes, and fewer complications than patients with RSA per-
With improvements in health care, life expectancy in the United formed as a revision salvage procedure and may also contribute to
States has increased from 69.9 to 78.9 years from 1959 to 2016.28 In surgeons choosing primary RSA over ORIF.19,25
addition, Khatib et al reported a 28% increase in population- This study has several limitations inherent to database studies.
adjusted incidence of proximal humerus fractures from 1990 to Both ICD-9 and ICD-10 codes were manually examined and queried
2010 in patients aged 65 years and older and attributed this overall for this study. As code descriptions differ between ICD-9 and ICD-10
increase to the aging population as patients younger than 65 years for given diagnoses and procedures, there is a possibility of coding
had no significant increase in proximal humerus fracture inci- discrepancies. To reduce this potential limitation, a coding trans-
dence.14 Although cases of proximal humerus fractures in the lator was used to ensure that relevant ICD-9 and ICD-10 codes were
elderly increase, there is still no consensus in selecting between used and that chosen ICD-9 codes corresponded with chosen ICD-
different treatment options.24 10 codes. Given this study only reported on trends of proximal
In a 2016 study of U.S. epidemiological trends, Han et al reported humerus fractures and rates of operative versus nonoperative
nonoperative treatment to be the mainstay proximal humerus management using retrospective data, outcome and complication
fracture management in the elderly with an increasing rate of RSA information cannot be attained. In addition, this study was inclu-
despite ORIF being the most common operative procedure over an sive of all proximal humerus fractures to show an overview of the
8-year span.8 Hasty et al in 2017 demonstrated nonoperative last decade’s trends as a whole. Therefore, diverse fracture patterns
treatment to similarly be the treatment of choice for proximal ranging from nondisplaced to 4-part fractures were examined
humerus fractures over an 8-year span in the United States despite together, and analysis did not evaluate differing treatments for each
rates of operative management rising with ORIF as the most com- pattern. An inherent limitation of a claims study is human error
mon procedure performed and a decreasing rate of HA while RSA created from errors in medical billing code input. However, a study
increased.9 In 2016, when examining only operative treatments for from the Centers for Medicare and Medicaid Services reported such
proximal humerus fractures, Rosas et al determined HA to be the instances make up only 1.0% of overall payments and thus would
most common operative treatment in the United States despite a have minimal impact on the outcomes seen.29 These data are from a
decreasing trend in use over a 3-year span with RSA rates U.S. database, so the trends may not accurately reflect global trends
increasing and ORIF rates remaining constant.21 in proximal humerus fracture management. Additionally, the
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A.H. Patel, J.H. Wilder, S.A. Ofa et al. JSES International 6 (2022) 137e143

Figure 2 The proportional trend of acute operative treatments given to elderly patients in 2010-2019 after sustaining a proximal humerus fracture. CRPP, closed reduction
percutaneous pinning; Hemi, hemiarthroplasty; IMN, intramedullary nailing; ORIF, open reduction internal fixation; TSA, total shoulder arthroplasty; RSA, reverse total shoulder
arthroplasty.

decision to use only ICD procedural codes in identifying procedures examination of the mid- and long-term outcomes of RSA should be
such as TSA and RSA may have undercounted the procedures per- performed in this population.
formed. However, this decision was necessary, given TSA and RSA
have the same CPT code (CPT-23472). In addition, certain CPT codes
aggregate multiple procedures under the same code such as HA,
Disclaimers:
TSA, and RSA for prosthetic replacement (CPT-23616). This CPT code
was therefore excluded to maintain specificity; however, the total
Funding: No funding was disclosed by the authors.
number of patients with this CPT was comparable with the total
Conflicts of interest: F.H.S. has received royalties from Smith and
number of patients identified through ICD procedural codes. By
Nephew, Exactech, CONMED, and Zimmer Biomet and is affiliated
solely using ICD codes to identify these operations, this study was
with and currently serves as the 1st Vice President of the American
able to more accurately distinguish procedures such as TSA and RSA
Academy of Orthopaedic Surgery. These royalties and affiliation are
as there are specific ICD codes for each. Finally, the switch from ICD-
not related to the subject of this work. M.J.O.B. has received
9 to ICD-10 in October of 2015 likely accounts for the drop in total
consultant payments from Smith and Nephew, Exactech, Wright
proximal humerus fracture patients seen in the following data.
Medical, and Aevumed. These payments are not related to the
However, any coding issues due to the transition would be expected
subject of this work. The other authors, their immediate families,
in all treatment groups and would be unlikely to affect percentages.
and any research foundation with which they are affiliated have not
received any financial payments or other benefits from any com-
mercial entity related to the subject of this article.
Conclusion

Over the past decade, most of older adults who sustain proximal
humerus fractures are treated nonoperatively at an increasing rate. Supplementary data
RSA has continued to increase in comparison with CRPP, HA, IMN,
ORIF, and TSA as the first-line surgical treatment option consistent Supplementary data to this article can be found online at
with what has been seen in other countries. Continued https://doi.org/10.1016/j.jseint.2021.08.006.
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A.H. Patel, J.H. Wilder, S.A. Ofa et al. JSES International 6 (2022) 137e143

Figure 3 Proportional changes in treatments from 2010 to 2019. (A) Breakdown of treatments in 2010. (B) Breakdown of treatments in 2019.

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