High mortality in younger patients with major osteoporotic fractures.

Data were gathered with regard to mortality after fractures in 1006 younger patients. Results revealed that major osteoporotic fractures of the hip and humerus and drinking alcohol to excess were related to an increased risk of mortality. INTRODUCTION: Major osteoporotic fractures are known to be associated with increased mortality in older individuals. It is less clear whether this also applies to younger patients. METHODS: Date were gathered regarding patient demographics, fracture pattern, mechanism of injury, as well as smoking and alcohol intake at the time of injury in consecutive patients aged between 40 and 55 who presented to a UK trauma centre over a 12-month period. Mortality data was taken from the electronic patient records and was cross referenced with data from the General Registrar Office of Scotland. Cox regression analysis was used to identify independent predictors of mortality after adjusting for confounding factors. RESULTS: The study cohort consisted of 1006 patients, of which 53% were male. The commonest mechanism of injury was a fall. We obtained complete data regarding mortality for all patients at a median of 5.4 years (inter-quartile range 5.1 to 5.6). During this period, 46 patients were identified as being deceased. The overall standardised mortality ratio for the cohort was substantially increased relative to the age and sex matched general population with a ratio of 3.89 (95% confidence intervals (CI) 1.59 to 6.19). Alcohol excess and fractures involving the humerus and the neck of femur were independent predictors of mortality. CONCLUSIONS: Young individuals with hip and humerus fractures have a significantly increased mortality risk after their injury relative to the general population. The results of our study suggest that this may be in part due to a high prevalence of alcohol excess.

Revisiting the 'bag of bones': functional outcome after the conservative management of a fracture of the distal humerus.

The best method of managing a fracture of the distal humerus in a frail low-demand patient with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for patients in whom open reduction and internal fixation (ORIF) is not possible. Conservative methods of treatment, including the 'bag of bones' technique (acceptance of displacement of the bony fragments and early mobilisation), are now rarely considered as they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with a fracture of the distal humerus who had been treated conservatively at our hospital between March 2008 and December 2013, and assessed their short- and medium-term functional outcome. In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to 80) at six weeks after injury to 67 points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30 points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of fracture union at one year was 53%. The mortality at five years approached 40%. Conservative management of a fracture of the distal humerus in a low-demand patient only gives a modest functional result, but avoids the substantial surgical risks associated with primary ORIF or TEA.

The importance of epidemiological fracture data: injury epidemiology for the non-epidemiologist.

Epidemiological studies enhance clinical practice in a number of ways. However, there are many methodological difficulties that need to be addressed in designing a study aimed at the collection and analysis of data concerning fractures and other injuries. Most can be managed and errors minimised if careful attention is given to the design and implementation of the research.

When does hip fracture surgery fail?

INTRODUCTION: Hip fractures remain the most common orthopaedic injury requiring hospital admission. Failed surgery for any cause carries a higher morbidity, mortality, and healthcare-related cost. The aims of this study were to determine risk factors for surgical complications of hip fracture surgery, when they occurred and their effect on mortality. PATIENTS AND METHODS: From a prospectively collected consecutive database of 795 hip fractures admitted between July 2007 and June 2008, all surgical and non-surgical complications were identified as well as re-operation for any cause and mortality in the 4 years since surgery. RESULTS: Fifty-five (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age, smoking and cannulated screw fixation. Cannulated screw fixation was associated with a 30.9% rate of re-operation. Post-operative medical complication occurred in 21.8%. It was associated with a 78.5% mortality at 4 years with a median time to mortality of 58 days (95% CI 0-120 days). CONCLUSIONS: Mechanical failure was the most common reason for cannulated screw re-operation. Hip hemiarthroplasty most commonly failed by infection. Inter-trochanteric and sub-trochanteric fracture fixation had very low failure rates. Post-operative medical complications, but not surgical complications, were associated with a higher mortality rate.

The suspected scaphoid injury: resource implications in the absence of magnetic resonance imaging.

INTRODUCTION: Undiagnosed and untreated scaphoid fractures have poorer outcomes and many patients are unnecessarily immobilised for prolonged periods of time to avoid missing occult injuries. Magnetic resonance imaging has a high sensitivity and specificity in detecting occult scaphoid fractures, but many units do not routinely use this imaging modality in the diagnostic pathway. We aimed to determine the patterns of suspected scaphoid injuries, report the process of care, and calculate the costs involved in their management. METHODS: We prospectively identified all adult patients referred to fracture clinic at the Royal Infirmary of Edinburgh with a scaphoid-related injury, between October 2007 and September 2008. Clinical notes were examined retrospectively. We defined three injury groups: true fractures, occult fractures, and suspected scaphoid injuries. We analysed patient demographics, treatment timelines, and the treatment costs involved. RESULTS: Fracture clinic received 537 scaphoid-related referrals. There were 87 true fractures, 43 occult fractures, and 407 suspected injuries, incurring average treatment costs of £1,173, £773, and £384 respectively. Occult fractures accounted for 33% of all confirmed scaphoid fractures. The majority of scaphoid-related referrals (76%) were never proven to have a scaphoid fracture, and many were unnecessarily immobilised. The costs involved in the treatment of suspected scaphoid injuries were found to be higher than the cost of magnetic resonance imaging (£97). CONCLUSION: In this group of suspected scaphoid injury, we believe the introduction of an early magnetic resonance imaging protocol would lead to an earlier definitive diagnosis and potentially a more cost-effective service.

The outcome of fractures in very elderly patients.

We compared case-mix and outcome variables in 1310 patients who sustained an acute fracture at the age of 80 years or over. A group of 318 very elderly patients (≥ 90 years) was compared with a group of 992 elderly patients (80 to 89 years), all of whom presented to a single trauma unit between July 2007 and June 2008. The very elderly group represented only 0.6% of the overall population, but accounted for 4.1% of all fractures and 9.3% of all orthopaedic trauma admissions. Patients in this group were more likely to require hospital admission (odds ratio 1.4), less likely to return to independent living (odds ratio 3.1), and to have a significantly longer hospital stay (ten days, p = 0.01). The 30- and 120-day unadjusted mortality was greater in the very elderly group. The 120-day mortality associated with non-hip fractures of the lower limb was equal to that of proximal femoral fractures, and was significantly increased with a delay to surgery > 48 hours for both age groups (p = 0.04). This suggests that the principle of early surgery and mobilisation of elderly patients with hip fractures should be extended to include all those in this vulnerable age group.

The epidemiology of fractures of the hand and the influence of social deprivation.

This study investigates the relationship between the epidemiology of hand fractures and social deprivation. Data were collected prospectively in a single trauma unit serving a well-defined population. The 1382 patients treated for 1569 fractures of the metacarpals or phalanges represented an incidence of hand fracture of 3.7 per 1000 per year for men and 1.3 per 1000 per year for women. Deprivation was not directly associated with the incidence of hand fracture. Common mechanisms of injury are gender specific. Fractures of the little finger metacarpal were common (27% of the total) and were associated with social deprivation in men (P = 0.017). For women, fractures where the mechanism of injury was unclear or the patient was intoxicated and could not recall the mechanism showed a clear association with deprivation. Affluent patients were more likely to receive operative treatment. Social deprivation influences both the pattern and management of hand fractures.

Recreational mountain biking injuries.

Mountain biking is increasing in popularity worldwide. The injury patterns associated with elite level and competitive mountain biking are known. This study analysed the incidence, spectrum and risk factors for injuries sustained during recreational mountain biking. The injury rate was 1.54 injuries per 1000 biker exposures. Men were more commonly injured than women, with those aged 30-39 years at highest risk. The commonest types of injury were wounding, skeletal fracture and musculoskeletal soft tissue injury. Joint dislocations occurred more commonly in older mountain bikers. The limbs were more commonly injured than the axial skeleton. The highest hospital admission rates were observed with head, neck and torso injuries. Protective body armour, clip-in pedals and the use of a full-suspension bicycle may confer a protective effect.

The relationship of fall-related fractures to social deprivation.

UNLABELLED: The relationship between fall-related fractures and social deprivation was studied in 3,843 patients. The incidence of fractures correlated with deprivation in all age groups although the spectrum of fractures was not affected by deprivation. The average age and the prevalence of hip fractures decreased with increasing deprivation. INTRODUCTION: This study examines the relationship between social deprivation and fall-related fractures. Social deprivation has been shown to be a predisposing factor in a number of diseases. There is evidence that it is implicated in fractures in children and young adults, but the evidence that it is associated with fragility fractures in older adults is weak. As fragility fractures are becoming progressively more common and increasingly expensive to treat, the association between social deprivation and fractures is important to define. METHODS: All out-patient and in-patient fractures presenting to the Royal Infirmary of Edinburgh over a 1-year period were prospectively recorded. The fractures caused by falls from a standing height were analysed in all patients of at least 15 years of age. Social deprivation was assessed using the Carstairs score and social deprivation deciles, and the 2001 census was used to calculate fracture incidence. The data were used to analyse the relationship between social deprivation and fall-related fractures in all age groups. RESULTS: The incidence of fall-related fractures correlated with social deprivation in all age groups including fragility fractures in the elderly. The overall spectrum of fractures was not affected by social deprivation although the prevalence of proximal femoral fractures decreased with increasing deprivation. The average age of patients with fall-related fractures also decreased with increasing social deprivation as did the requirement for in-patient treatment. CONCLUSIONS: This is the first study to show the relationship between fall-related fractures and social deprivation in older patients. We believe that the decreased incidence of proximal femoral fractures, and the lower average age of patients with fall-related fractures, in the socially deprived relates to the relative life expectancies in the different deprivation deciles.

Osteoporotic periprosthetic fractures of the femur in elderly patients: outcome after fixation with the LISS plate.

Longer patient survival and the extension of joint arthroplasty to older patients means that osteoporotic fractures of the femur are often associated with joint implants. This poses a significant trauma work load. This problem is likely to increase over time. The management of these periprosthetic fractures may be difficult and strategies are not universally agreed. Revision arthroplasty, single or double plate fixation with or without augmentation with methylmethacrylate or bone grafting, are all variously advocated in the literature for different indications. We retrospectively identified 28 elderly patients consecutively treated in our institution with Less Invasive Stabilisation System (LISS) plate fixation for osteoporotic and periprosthetic fractures of the femur. We present prospectively collected data for clinical and radiographic follow-up and patient outcomes. Patients had a mean age of 86.7 years. A fall from a standing height was the most common mechanism of injury. No cases of non-union were seen in survivors. Mortality in the first year was a major complication (5 patients). Rates of revision surgery were low (2 patients). Most patients required a formal period of rehabilitation, however, only half of the patients were successfully discharged to their own homes. The LISS plate provides good fixation in osteoporotic periprosthetic fractures of the femur. It restores a stable limb allowing early weight bearing as well as achieving clinical and radiographic union. Patients return to mobility levels approaching their pre-injury status although most benefit from a formal period of rehabilitation. In this patient group, the LISS plate often outlives the patient.

A method for detecting DNA polymorphism in large populations.

Molecular markers linked to loci of interest can be used for fine mapping a particular area of a genome or for marker-assisted selection. We present an approach for screening individual plants with polymorphic markers that facilitates phenotyping in large populations. Polymorphic DNA fragments, amplified by PCR, are labelled with digoxigenin and used as probes on slot blots of amplified DNA from the individual plants to be tested. DNA is obtained by a simple two-tube purification method. The colorimetric detection of alleles on the blots is more reliable, and more amenable to automation, than conventional staining of electrophoresis gels.