Broken Bones of the Upper Limb in People over 50
About this PSP
This PSP looked at broken bones (fractures) in the shoulder (collarbone and shoulder girdle), arm, elbow (humerus), forearm and wrist in people over 50. Fractures involving the upper limb are very common and often have long-lasting effects. Wrist fractures alone affect 100,000 people per year in the UK.
Injuries affecting these parts of the body, either temporarily or permanently, can lead to significant disability. The treatment received is very important in minimising this.
These fractures often occur as a result of low energy injuries such as falls from a standing height. This is often the case with patients over 50. They can also occur as a result of high-energy injuries such as those related to sports, as well as those involved in road traffic accidents.
The treatment for these injuries may involve surgery or not (often called “operative” or “non-operative”). Non-operative treatments include analgesia (pain relief), casting (i.e., placing the affected part into a plaster cast for some weeks) and rehabilitation (such as physiotherapy or occupational therapy). Operative procedures may involve fixing a fracture with the insertion of metal plates and screws, rods passed on the inside of the bone, or even, perhaps, bone replacement using an artificial joint.
There is a lack of research evidence to guide the care and treatment of patients with upper limb fractures. The period immediately after the fracture (initial treatment), the active treatment phase (non-operative or operative) and rehabilitation (restoring limb function and confidence) are three distinct phases in the patient journey. The PSP set out to identify key research questions in each of these areas.
The PSP Top 10 was published in December 2019.
Impact of Top 10s
Top 10 priorities
- What are the most important outcomes after an upper limb fracture in people over 50 including physical, psychological and financial effects? (e.g. time for the bone to heal / return to normal activities / time to achieve a good recovery / cosmetic appearance)
- What type of information should patients over 50 with an upper limb fracture be given and how should this be provided? (e.g. nutrition, pain relief, rehabilitation, return to work, driving, sport / exercise)
- What is the best physical rehabilitation programme for people over 50 with an upper limb fracture (with or without surgery) when it NO LONGER needs to be kept still?
- In people over 50, what is the patient experience of an upper limb fracture management and how does it influence outcomes?
- What is the best alternative to medication / drugs to manage pain following an upper limb fracture in people over 50? (e.g. splints / casts / lining the fracture back up / ice)?
- What is the best physical rehabilitation programme for people over 50 with an upper limb fracture (with or without surgery) whilst it needs to be kept still (e.g. in a cast or sling)?
- Which are the most important factors which decide whether a patient over 50 with an upper limb fracture is treated with or without surgery?
- What is the best surgical management for an upper limb fracture in people over 50? (e.g. incision, technique, metalwork, technology)
- What is the best way of treating people over 50 who are at risk of developing psychological issues following an upper limb fracture?
- For people over 50, how well does a wrist fracture need to be reduced (put back into its normal position) to ensure a good long-term functional outcome?
The following questions were also discussed and put in order of priority at the workshop:
- What is the best way to manage an upper limb fracture in people over 50 that does not need surgery?
- Does a delay in physical rehabilitation of an upper limb fracture in people over 50 affect outcomes?
- When is the best time to operate on an upper limb fracture in people over 50 and does a delay in surgery influence outcomes?
- Does when, how and who manipulates an upper limb fracture (returns the fractured bone to its normal position) influence outcome in people over 50?
- Does the way in which rehabilitation is delivered (e.g. individual sessions, group sessions, hydrotherapy) to people over 50 with an upper limb fracture affect outcomes?
- What are the best pain-relieving drugs to use at each phase of treatment of an upper limb fracture in people over 50?
- Can we predict who will do well with rehabilitation after an upper limb fracture in people over 50?
- Does compliance with rehabilitation following an upper limb fracture affect outcomes in people over 50 and if so, how can we improve this?
- What is the best way to treat a nerve injury that happens at the same time as an upper limb fracture in people over 50?
- What is the best way to manage upper limb fractures in people over 50 that have not healed properly?
- What is the best form of anaesthetic (medication to stop patients feeling pain) to reduce an upper limb fracture (put it back into its normal position) in people over 50?
- Is day surgery (no overnight hospital stay) for upper limb fractures in people over 50 possible and what are the benefits for the patient and the hospital service?
- Does showing people over 50 with an upper limb fracture their x-rays lead to better outcomes and better patient satisfaction / experience?
- What information should be provided about casts / splints to ensure they work correctly and do not cause any problems to people over 50 with an upper limb fracture? Who should provide this information and how?
Key documents
Broken Bones of the Upper Limb in People over 50 PSP Steering Group Terms of Reference
Broken Bones of the Upper Limb in People over 50 PSP Protocol
Broken Bones of the Upper Limb in People over 50 PSP Engagement Summary
Broken Bones of the Upper Limb in People over 50 PSP Question Verification Form