Fractures of the wrist and shoulder are increasingly operated on with metal plates, which are more expensive than other methods. But moderate dislocations may respond just as well to the alternatives. The SBU assessment points the way to an approach that would reverse the trend and ensure equal quality of care at lower costs.
Individuals who suffer a fracture of the arm in late middle age or older do not appear to obtain significant extra benefit from surgery. Moderate dislocations may respond just as well to non-invasive options. Scarce resources can be used more efficiently.
SBU systematically reviewed all available trials concerning the treatment of fractures in populations where the average age was 60 or more, an age where brittleness of the bones is common.
For instance, people who have a shoulder fracture without major dislocation can enjoy the same mobility and quality of life after conservative treatment with a simple sling. By the same token, a cast for a moderately dislocated wrist appears to ensure the same mobility as surgery with a metal plate, or percutaneous fixation. Pins and metal rods (percutaneous fixation) are equally or more effective than casts when it comes to quality of life, whereas grip strength is about the same either way.
SBU also reviewed current practice and resource utilisation in the Swedish healthcare system. According to the analysis, less frequent surgery would free up resources for potentially better use.
The latest available statistics indicate that 27% of wrist fractures and 14% of shoulder fractures are operated on within one month. Some of these resources could be allocated differently, according to the assessment.
The SBU report presents a calculation: A three-quarter reduction of surgical procedures for various types of arm fractures in favour of casts or slings could save a total of SEK 66 million annually without compromising quality. The magnitude of the amount is due to a substantial variation for different kinds of fractures. Wrist fractures can cost as little as SEK 1,200 for a cast and as much as SEK 15,000 for surgery with a plate. Shoulder fractures can cost as little as SEK 345 for a sling and as much as SEK 68,000 for reverse prosthesis, which replaces and switches the position of the ball and socket.
Another scientifically documented area for improvement concerns the information and solicitude given to people who have osteoporosis. Qualitative studies indicate that these patients report getting insufficient, erroneous and contradictory information such that they don’t know what treatment or preventive measures they need.
The post-fracture repercussions may be extensive. Patients may be so worried about the risk for more fractures that they stay home all the time and become isolated. Lack of knowledge and information can delay intervention and cause unnecessary suffering. [RL]
About the report: Treatment options of arm fractures in the elderly – A systematic review and assessment of the medical, economic, social and ethical aspects (2017). Executive summary and conclusions in English
Medical and Social Science & Practice The SBU newsletter presents and disseminates the results of the SBU reports, describes ongoing projects at the agency, informs about assessment projects at sister organisations, and promotes interest in scientific assessments and critical reviews of methods in health care and social services.