Global Forum: Fractures in the Elderly Court-Brown, Charles M; McQueen, Margaret M
Journal of bone and joint surgery. American volume,
2016-May-04, Letnik:
98, Številka:
9
Journal Article
Recenzirano
Fractures in the elderly are increasing in incidence and becoming a major health issue in many countries. With an increasing number of the elderly living to an older age, the problems associated with ...fractures will continue to increase. We describe the epidemiology of fractures in the elderly and identify six fracture patterns in the population of patients who are sixty-five years of age or older. We also analyzed multiple fractures and open fractures in the elderly and we show that both increase in incidence with older age. The incidence of open fractures in elderly women is equivalent to that in young men. Many factors, including patient socioeconomic deprivation, increase the incidence of fractures in the elderly. More than 90% of fractures follow low-energy falls and the mortality is considerable. Mortality increases with older age and medical comorbidities, but there is also evidence that it relates to premature discharge from the hospital.
The aim of our study was to document the estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome.
From our ...prospective trauma database, we identified all patients who had sustained a tibial diaphyseal fracture over a ten-year period. A retrospective analysis of 1184 patients was performed to record and analyze the documented use of continuous intracompartmental pressure monitoring and the use of fasciotomy. A diagnosis of acute compartment syndrome was made if there was escape of muscles at fasciotomy and/or color change in the muscles or muscle necrosis intraoperatively. A diagnosis of acute compartment syndrome was considered incorrect if it was possible to close the fasciotomy wounds primarily at forty-eight hours. The absence of acute compartment syndrome was confirmed by the absence of neurological abnormality or contracture at the time of the latest follow-up.
Of 979 monitored patients identified, 850 fit the inclusion criteria with a mean age of thirty-eight years (range, twelve to ninety-four years), and 598 (70.4%) were male (p < 0.001). A total of 152 patients (17.9%) underwent fasciotomy for the treatment of acute compartment syndrome: 141 had acute compartment syndrome (true positives), six did not have it (false positives), and five underwent fasciotomy despite having a normal differential pressure reading, with subsequent operative findings consistent with acute compartment syndrome (false negatives). Of the 698 patients (82.1%) who did not undergo fasciotomy, 689 had no evidence of any late sequelae of acute compartment syndrome (true negatives) at a mean follow-up time of fifty-nine weeks. The estimated sensitivity of intracompartmental pressure monitoring for suspected acute compartment syndrome was 94%, with an estimated specificity of 98%, an estimated positive predictive value of 93%, and an estimated negative predictive value of 99%.
The estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome following tibial diaphyseal fracture are high; continuous intracompartmental pressure monitoring should be considered for patients at risk for acute compartment syndrome.
Fractures in older adults. A view of the future? Court-Brown, Charles M.; Duckworth, Andrew D.; Clement, Nicholas D. ...
Injury,
December 2018, 2018-Dec, 2018-12-00, 20181201, Letnik:
49, Številka:
12
Journal Article
Recenzirano
It is accepted that the incidence of fractures in patients aged ≥ 65 years is increasing but little is known about which fractures are becoming more common in this group of patients. Virtually all ...research has concentrated on the classic fragility fractures of the proximal femur, proximal humerus, pelvis, spine and distal radius but it is likely that other fractures are becoming more common.
We have examined two prospectively collected databases 10 years apart to see which fractures are becoming more common in ≥ 65 year old patients. We compared the fractures to look for epidemiological differences over the 10-year period and we compared the epidemiology of the fractures that had increased in incidence with equivalent fractures in the < 65 year old population.
Analysis shows that in older female patients fractures of the clavicle, finger phalanges, ankle and metatarsus are increasing in incidence. In males there is an increasing incidence of fractures of the proximal humerus, distal humerus, metacarpus, pelvis, femoral diaphysis, distal tibia and ankle. In females the basic epidemiology of fractures in the ≥ 65 year old population was very similar to the fractures seen in younger females and we believe that the increasing incidence of fractures in the future will mainly be low velocity fractures following falls. In older males however, it is apparent that there is a much wider variation in the causes of fracture.
We believe that the changes in fracture epidemiology in older patients relate to improved health and longevity and analysis of our population during the study period shows significant social changes which are associated with increased longevity and improved health. It is probable that fractures in older patients will continue to increase in incidence and that other fractures that are now commonly seen in middle-aged patients will be seen in older patients. Surgeons will have to treat more complex fractures in older males than in older females and it is likely that there will be a higher incidence of open and multiple fractures. Appropriate management techniques will need to be established.
The aim of this single-center, single-blinded, prospective randomized trial was to compare the outcomes of tension-band wire (TBW) and plate fixation for simple isolated, displaced fractures of the ...olecranon.
We performed a prospective randomized trial involving 67 patients who were ≥16 to <75 years of age and had an acute isolated, displaced fracture of the olecranon. Patients were randomized to either TBW (n = 34) or plate fixation (n = 33) and were evaluated at 6 weeks, 3 months, 6 months, and 1 year following surgery. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year.
The baseline demographic and fracture characteristics of the 2 groups were comparable, except for age, which was lower in the TBW group. The 1-year follow-up rate was 85% (n = 57), with 84% (n = 56) completing the DASH. There was a significant improvement in the DASH score over the 1-year period following surgery (p < 0.001). At 1 year, the DASH score for the TBW group (12.8) did not differ significantly from that of the plate group (8.5) (p = 0.315). The groups also did not differ significantly in terms of range of motion, the Broberg and Morrey score, the Mayo Elbow Score, or the DASH at all assessment points over the 1 year (all p ≥ 0.05). Complication rates were significantly higher in the TBW group (63% compared with 38%; p = 0.042), predominantly because of a significantly higher rate of metalwork removal in symptomatic patients (50.0% compared with 22%; p = 0.021). Four infections occurred, all in the plate group (0% versus 13%; p = 0.114), as did 3 revision surgeries (0% versus 9.4%; p = 0.238).
Among active patients with a simple isolated, displaced fracture of the olecranon, no difference was found between TBW and plate fixation in the patient-reported outcome at 1 year following surgery. The complication rate was higher following TBW fixation and was due to a higher rate of implant removal in symptomatic patients. However, the more serious complications of infection and the need for revision surgery occurred exclusively following plate fixation in this trial.
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Nonunion is a rare complication of a fracture of the clavicle, but its occurrence can compromise shoulder function. The aim of this study was to evaluate the prevalence of and risk factors for ...nonunion in a cohort of patients who were treated nonoperatively after a clavicular fracture.
Over a fifty-one-month period, we performed a prospective, observational cohort study of a consecutive series of 868 patients (638 men and 230 women with a median age of 29.5 years; interquartile range, 19.25 to 46.75 years) with a radiographically confirmed fracture of the clavicle, which was treated nonoperatively. Eight patients were excluded from the study, as they received immediate surgery. Patients were evaluated clinically and radiographically at six, twelve, and twenty-four weeks after the injury. There were 581 fractures in the diaphysis, 263 fractures in the lateral fifth of the clavicle, and twenty-four fractures in the medial fifth.
On survivorship analysis, the overall prevalence of nonunion at twenty-four weeks after the fracture was 6.2%, with 8.3% of the medial end fractures, 4.5% of the diaphyseal fractures, and 11.5% of the lateral end fractures remaining ununited. Following a diaphyseal fracture, the risk of nonunion was significantly increased by advancing age, female gender, displacement of the fracture, and the presence of comminution (p < 0.05 for all). On multivariate analysis, all of these factors remained independently predictive of nonunion, and, in the final model, the risk of nonunion was increased by lack of cortical apposition (relative risk = 0.43; 95% confidence interval = 0.34 to 0.54), female gender (relative risk = 0.70; 95% confidence interval = 0.55 to 0.89), the presence of comminution (relative risk = 0.69; 95% confidence interval = 0.52 to 0.91), and advancing age (relative risk = 0.99; 95% confidence interval = 0.99 to 1.00). Following a lateral end fracture, the risk of nonunion was significantly increased only by advancing age and displacement of the fracture (p < 0.05 for both). On multivariate analysis, both of these factors remained independently predictive of nonunion (p < 0.05), and, in the final model, the risk of nonunion was increased by a lack of cortical apposition (relative risk = 0.38; 95% confidence interval = 0.25 to 0.57) and advancing age (relative risk = 0.98; 95% confidence interval = 0.97 to 0.99).
Nonunion at twenty-four weeks after a clavicular fracture is an uncommon occurrence, although the prevalence is higher than previously reported. There are subgroups of individuals who appear to be predisposed to the development of this complication, either from intrinsic factors, such as age or gender, or from the type of injury sustained. The predictive models that we developed may be used clinically to counsel patients about the risk for the development of this complication immediately after the injury.
The Epidemiology of Radial Head and Neck Fractures Duckworth, Andrew D., MSc; Clement, Nicholas D., MBBS; Jenkins, Paul J., MBBS ...
The Journal of hand surgery (American ed.),
2012, 2012-Jan, 2012-1-00, 20120101, Letnik:
37, Številka:
1
Journal Article
Recenzirano
Purpose The aim of this study was to define the epidemiological characteristics of proximal radial fractures. Methods Using a prospective trauma database of 6,872 patients, we identified all patients ...who sustained a fracture of the radial head or neck over a 1-year period. Age, sex, socioeconomic status, mechanism of injury, fracture classification, and associated injuries were recorded and analyzed. Results We identified 285 radial head (n = 199) and neck (n = 86) fractures, with a patient median age of 43 years (range, 13–94 y). The mean age of male patients was younger when compared to female patients for radial head and neck fractures, with no gender predominance seen. Gender did influence the mechanism of injury, with female patients commonly sustaining their fracture following a low-energy fall. Radial head fractures were associated more commonly with complex injuries according to the Mason classification, while associated injuries were related to age, the mechanism of injury, and increasing fracture complexity. Conclusions Radial head and neck fractures have distinct epidemiological characteristics, and consideration for osteoporosis in a subset of patients is recommended. Type of study/level of evidence Prognostic IV.
Abstract There is little information available about the epidemiology of open fractures. We examined 2386 open fractures over a 15-year period analysing the incidence and severity of the fractures. ...The majority of open fractures are low energy injuries with only 22.3% of open fractures being caused by road traffic accidents or falls from a height. The distribution curves of many open fractures are different to the overall fracture distribution curves with high-energy open fractures being commoner in younger males and low energy open fractures in older females. The mode of injury and the different demographic characteristics between isolated and multiple open fractures are also discussed.
Background
When treating complex radial head fractures, important goals include prevention of elbow or forearm instability, with restoration of radiocapitellar contact essential. When open reduction ...and internal fixation cannot achieve this, radial head replacement is routinely employed, but the frequency of and risk factors for prosthesis revision or removal are not well defined.
Questions/purposes
We determined (1) the frequency of prosthesis revision or removal after radial head replacement for acute complex unstable radial head fractures, (2) risk factors for revision or removal, and (3) functional outcomes after radial head replacement.
Methods
We identified from our prospective trauma database all patients over a 16-year period managed acutely for unstable complex radial head fractures with primary radial head replacement. Of the 119 patients identified, 105 (88%) met our inclusion criteria; mean age was 50 years (range, 16–93 years) and 57 (54%) were female. All implants were uncemented monopolar prostheses, of which 86% were metallic and 14% silastic. We recorded further procedures for prosthesis revision or removal for any cause, with a minimum followup of 1 year (n = 105). Cox regression analysis was used to determine independent factors associated with revision or removal when controlling for baseline patient (age, sex, comorbidities) and fracture (location, classification, associated injury) characteristics. Short-term functional outcomes (Broberg and Morrey score, ROM) were determined from retrospective review of clinic followup (n = 74), with a minimum followup of 3 months.
Results
Twenty-nine patients (28%) underwent prosthesis revision (n = 3) or removal (n = 26) at a mean of 6.7 years (range, 1.8–18 years) after injury. Independent risk factors for removal or revision were silastic implant type and lower age. At a mean of 1.1 years (range, 0.3–5.5 years) after surgery, mean Broberg and Morrey score was 80 out of 100 (range, 40–99). Mean elbow flexion was 133° (range, 90°–159°; SD, 13°), extension 21° (range, 0°–80°; SD, 17°), flexion arc 112° (range, 10°–140°; SD, 25°), pronation 84° (range, 0°–90°; SD, 18°), supination 73° (range, 0°–90°; SD, 28°), and forearm rotation arc 156° (range, 0°–180°; SD, 38°).
Conclusions
We demonstrated a high removal or revision rate after radial head replacement for acute unstable complex fractures, with lower age and silastic implants independent risk factors. Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement. Future work should focus on long-term patient-reported outcomes after these injuries.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
The evidence for treating acute, unreconstructable radial head fractures in unstable elbows with radial head replacement predominantly consists of short- to mid-term follow-up studies with a ...heterogenous mix of implants and operative techniques. Data on longer-term patient-reported outcomes after radial head replacement is lacking.
(1) What proportion of patients undergo revision or implant removal after radial head replacement? (2) At a minimum of 8 years follow-up, what are the patient-reported outcomes (QuickDASH, Oxford Elbow Score, and EuroQol-5D)? (3) What factors are associated with a superior long-term patient-reported outcome, according to the QuickDASH?
Between September 1994 and September 2010, we surgically treated 157 patients for acute radial head fractures. We excluded patients where the radial head was excised (n = 21), internally fixed (n = 15), or replaced as a secondary procedure after failed internal fixation (n = 2). A total of 119 patients who underwent radial head replacement surgery for an acute unreconstructable fracture were included, with a mean age of 50 years (range 15 to 93 ± 19 years), and 53% of patients (63) were women. All but two implants were uncemented, loose-fitting, monopolar prostheses, of which 86% (102) were metallic and 14% (17) were silastic. Implants were only cemented if they appeared unstable within the proximal radius. Silastic implants were used in the earlier series and replaced by metallic implants starting in 2000. We reviewed electronic records to document postoperative complications and prosthesis revision and removal. A member of the local research team (THC, CDC) who was not previously involved in patient care contacted patients to confirm complications, reoperations and to obtain long-term patient-reported outcomes scores. Nineteen patients had died at the point of outcome score collection. Of the remaining 100 patients, 80 were contacted (67% of total cohort), at a median of 11 years (range 8 to 24 years) after injury. The primary outcome measure was the QuickDASH score.
Of 119 patients, 25% (30) underwent reoperation, with three patients undergoing revision and 27 patients undergoing prosthesis removal at a median of 7 months (range 0 to 125 months). Twenty-one of 30 procedures (70%) occurred within 1 year after implantation. Kaplan-Meier survivorship analysis demonstrated a cumulative implant survival rate of 71%. In the 80 patients contacted, the mean QuickDASH score was 13 ± 14, the mean Oxford Elbow Score was 43 ± 6, and the median EuroQol-5D score was 0.8 (-0.3 to 1.0). After controlling for covariates, we found that prothesis revision or removal (p = 0.466) and prosthesis type (p = 0.553) were not associated with patient-reported outcome, according to the QuickDASH.
The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperation. Patients must be counselled regarding this risk of secondary intervention, of which the peak risk appears to be within 1 year after implantation. Despite this, patients report low disability according to the QuickDASH at a minimum follow-up of 8 years.
Level IV, therapeutic study.
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