Disclosure Statement:

There was no external funding for this study

Epidemiology of Humerus Fractures in the United States:

Nationwide Emergency Department Sample (NEDS), 2008

We wish to disclose that we have NO conflict of interest

Sunny H. Kim, PhD Robert M. Szabo, MD MPH Richard A. Marder, MD

Fractures

Humerus Fracture

Mostly caused by trauma (falls, struck by or against, traffic accident) In a fall, low BMD increases a persons likelihood of sustaining a fracture.

A humerus fracture is often caused by: - a fall directly on the shoulder or arm - a fall onto an outstretched hand

Epidemiologic studies reports:

Knowledge Gap
To date, there has been no published study on humerus fractures based on a representative sample in the U.S. Consequently, the annual cases (and incidence rates) of humerus fractures remain largely unknown. Without such data, it is difficult to plan and monitor the effectiveness of measures to prevent humerus fractures.

Widely diverse incidence rates of humerus fracture.

Conflicting results in these studies likely reflect a wide variation among samples.

Objectives
The objective of this study was To evaluate the occurrence of humerus fractures in the United States (U.S.).

Nationwide Emergency Department Sample (NEDS)

The objective of NEDS is to document national estimates of ED visits in the U.S.

To identify the demographic characteristics of people at

higher risk for these fractures as well as elucidate the mechanism of injury.

To provided the future demands of care for humerus

fractures in the U.S. relevant for aging baby boomers.

1st stage of sampling: Stratification

2nd stage of sampling: cluster

A random sample of hospitals (clusters) is drawn and then all discharges are included from each selected hospital. This type of sampling design is referred to as a stratified, single-stage cluster sample.

Region of the U.S. Hospital ownership Teaching hospital Urban-rural location Trauma-level

NEDS- 2008
In 2008, probability samples of 980 EDs were selected All visits within the selected EDs were included in the database. As a result, probability samples of 28 million ED visits were selected from a total of 125 million ED visits.

Humerus fracture cases

We identified the cases of interest using diagnostic codes for proximal, shaft, and distal humerus fractures. ICD-9-CM diagnostic codes; 812.0 and 812.1 for proximal humerus fracture 812.2 and 812.3 for humeral shaft fracture 812.4 and 812.5 for distal humerus fracture

ED visits for humerus fractures in 2008

Finding #1: Frequency (occurrence)

In 2008, approximately 370,000 ED visits occurred in the U.S. as a result of patients with humerus fractures

40,000

35,000

30,000

25,000

Shaft , 15% Proximal , 50%

20,000

Proximal Distal Shaft

15,000

Distal , 35%

10,000

5,000

0 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 90-94 90-94
85-89

Proximal Humerus Fractures

Humerus fracture site by gender

Frequency
140,000 120,000 100,000 80,000
Female

Often resulting from low-energy falls Commonly encountered in patients with osteoporosis

60,000
Male

40,000
Male

20,000
Female

Male

Female

0 Distal Shaft Proximal

Finding #2: Risk of fracture

700 650 600 550

Risk of fractures (per 100,000 persons)

The annual incidence rate indicates the risk of an individual sustaining a humerus fracture within a one-year period.

500 450 400 350 300 250 200 150 100 50 0 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 70-74 75-79 80-84 85-89 5-9
65-69

Proximal, Females Distal, Females Shaft, Females

Proximal, Males Distal, Males Shaft, Males

95+
Age Age

<5

95+
Age

<5

5-9

Exponential growth

In comparison with Japan and European countries

The rate of proximal humerus fractures followed the shape of

an exponential function in the age group - 40 to 84 for women (R2=97.9%) - 60 to 89 for men (R2=98.2%). - the rate of fracture increased by 46% for every five-year increase in age. That is, compared with 40-44 year old women, the risk of sustaining a proximal humerus fracture was: - 5 times greater for 60-64 year old women; - 21 times greater for 80-84 year old women.

Proximal humerus
Epidemiologic studies suggest that the annual incidence rates of humerus fractures in the U.S. are higher than those of Japan and European countries. Why? 1) low bone mineral density? 2) falling? 3) Differences in data accuracy?

Distal fractures

The rate of fractures also showed the highest peak in children

aged 5-9 years old

Improved playground safety (Jungle Gym)

- lowering the monkey bar height, - installing an impact-absorbing surface underneath the bars, - adult supervision, etc.

The degree of implementation and success rates are unknown,

yet nearly 69,000 children 9 years old or younger are still visiting the ED with distal humerus fractures every year.

3. Projection & Baby Boomers

We projected the number of humerus fractures in 2030, when the youngest of the baby boomers will turn 65. On January 1st, 2011, the oldest baby boomers turn 65 years old, including the first two baby boomer presidents, Bill Clinton and George Bush. More than 10,000 baby boomers will turn 65 every day for the next 19 years.
55,000 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 10-14 15-19

Projection, year 2030

Humerus fractures observed in the year 2008

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

90-94

20-24

85-89

95+

5-9

<5

Age

Limitations of study

Conclusion

The accuracy of ICD-9-CM codes submitted by each hospital is

unknown.

In 2008, approximately 370,000 ED visits occurred in the U.S.

as a result of patients with humerus fractures.

The NEDS database contains event-level records but no

patient-level records. A patient-level analysis of humerus fracture injuries is not allowed in this dataset.

The rate of fracture increased by 50% for every five-year

increase in age 40 - 84 yrs for women; 60- 89 yrs for men.

Projection: future improvement in preventing fractures is

another important factor that may decrease the occurrence of humerus fractures but is not reflected in the projection.

The risk of humerus fractures in the US were considerably

higher compared with those of other countries.

Assuming no change in age- and gender-specific incidence,

greater than 490,000 ED visits due to humerus fractures can be expected.