Complications after ankle fracture in elderly patients.

BACKGROUND: Controversy exists regarding the risks and benefits of ankle fracture treatment in elderly patients. The purpose of this study was to use the United States Medicare database to determine the complication rate for ankle fractures in elderly patients treated operatively and to compare it to fractures treated nonoperatively. METHODS: We used the National Medicare Claims History System to study all enrollees who sustained ankle fractures between 1998 and 2001. A total of 33,704 patients were identified and their outcomes at numerous time points were evaluated. These outcomes included mortality, rate of repeat hospitalization, rate of medical and operative complications, and the rate of additional surgery. The predictor variables were either nonoperative or operative intervention. Covariates included patient age, gender, race, medical comorbidity status, and fracture type. RESULTS: Patients treated nonoperatively had significantly higher mortality (p < 0.05) than those treated operatively at all time periods except for 30 days. However, patients treated operatively had significantly higher rehospitalization rates (p < 0.05) at all time periods studied. The medical and operative complication rates at all time periods were less than or equal to 2% for patients who had either operative or nonoperative treatment. In the group that had operative management, a relatively small number of patients had additional procedures. Eleven percent had removal of hardware. Less than 1% of all patients had revision of the internal fixation, arthroplasty, arthrodesis, or amputation. CONCLUSION: In properly selected cases, the complication rates of both operatively and nonoperatively treated elderly patients are low.

Falling Down on the Job: Evaluation and Treatment of Fall Risk Among Older Adults With Upper Extremity Fragility Fractures.

Background: Clinical practice guidelines recommend fall risk assessment and intervention for older adults who sustain a fall-related injury to prevent future injury and mobility decline. Objective: The aim of this study was to describe how often Medicare beneficiaries with upper extremity fracture receive evaluation and treatment for fall risk. Design: Observational cohort. Methods: Participants were fee-for-service beneficiaries age 66 to 99 treated as outpatients for proximal humerus or distal radius/ulna ("wrist") fragility fractures. -Participants were studied using Carrier and Outpatient Hospital files. The proportion of patients evaluated or treated for fall risk up to 6 months after proximal humerus or wrist fracture from 2007-2009 was examined based on evaluation, treatment, and diagnosis codes. Time to evaluation and number of treatment sessions were calculated. Logistic regression was used to analyze patient characteristics that predicted receiving evaluation or treatment. Narrow (gait training) and broad (gait training or therapeutic exercise) definitions of service were used. Results: There were 309,947 beneficiaries who sustained proximal humerus (32%) or wrist fracture (68%); 10.7% received evaluation or treatment for fall risk or gait issues (humerus: 14.2%; wrist: 9.0%). Using the broader definition, the percentage increased to 18.5% (humerus: 23.4%; wrist: 16.3%). Factors associated with higher likelihood of services after fracture were: evaluation or treatment for falls or gait prior to fracture, more comorbidities, prior nursing home stay, older age, humerus fracture (vs wrist), female sex, and white race. Limitations: Claims analysis may underestimate physician and physical therapist fall assessments, but it is not likely to qualitatively change the results. Conclusions: A small proportion of older adults with upper extremity fracture received fall risk assessment and treatment. Providers and health systems must advance efforts to provide timely evidence-based management of fall risk in this population.

Ankle fractures in the elderly: what you get depends on where you live and who you see.

OBJECTIVES: This study was performed to determine 1) the rate of ankle fractures in the elderly in the United States stratified by hospital referral region, and 2) whether the percentage of ankle fractures treated surgically is affected by factors, such as fracture location, hospital referral region, concentration of orthopaedists, presence of a teaching hospital in that region, patient age, race, gender, or the number and type of specific medical comorbidities. DESIGN: A 20% sample of Medicare Part B claims from the years 1998 to 2000 was analyzed. PATIENTS/INTERVENTION: The CPT codes for operative and nonoperative treatment of isolated medial malleolar, isolated lateral malleolar, bimalleolar, and trimalleolar fractures were identified. These codes were used to determine the overall rate of ankle fractures and individual fracture types. MAIN OUTCOME MEASUREMENT: : The rate of ankle fractures was evaluated by hospital referral region, patient age (groups of 5 years, aged 65 years or older), gender, and race. The percentage of surgical treatment was determined for each fracture type as the number of surgically treated fractures over the total number of ankle fractures within each subtype and analyzed by fracture type, hospital referral region, and concentration of orthopaedists in that region, presence of a teaching hospital within the hospital service area, patient age, gender, race, and number and type of specific medical comorbidities. Regression was performed by using the above variables. RESULTS: We identified 33,704 ankle fractures: 7.6% were isolated medial malleolar, 50.8% were isolated lateral malleolar, 27.4% were bimalleolar, and 14.2% were trimalleolar fractures. The overall United States average was 4.2 ankle fractures per 1000 Medicare enrollees. The rate of ankle fractures varied by a factor of 8, from 1 per 1000 Medicare enrollees in San Francisco, CA, to 8.3 in Hickory, NC. The rate of ankle fractures was highest in white women at 5.8 and lowest in nonwhite men at 1.5 per 1000 Medicare enrollees. The overall rate of ankle fractures that underwent surgical stabilization was 33%, ranging from 14% in Binghampton, NY, to 72% in Napa, CA. The rate of surgical intervention was 22% for isolated medial malleolar fractures, 11% for isolated lateral malleolar fractures, 58% for bimalleolar fractures, and 74% for trimalleolar fractures. In regression analysis, the factors associated with nonoperative care after ankle fracture were: older age, female gender, increasing number of comorbidities as measured by the Charlson index, presence of diabetes or peripheral vascular disease, and living in a hospital service area that had a designated teaching hospital. Beneficiaries living in areas in which a hospital was a member of the Council of Teaching Hospitals were less likely to receive surgical treatment of their ankle fracture. Increasingly older age was strongly associated with decreased likelihood of having surgical intervention, with each 5 year age grouping progressively less likely to have surgical treatment. The concentration of orthopaedists in the region was not associated with the likelihood of having surgical treatment. CONCLUSIONS: The term ankle fracture involves a wide spectrum of injuries. We found a large variation through the United States in both the rate of ankle fractures and the percentage of those that undergo surgical intervention.

Management of midshaft clavicle fractures in adults.

Fractures of the clavicle are common injuries. The usual mechanism of clavicle fracture is a direct fall on the shoulder. There are 3 types of clavicle fractures, but type II or midshaft fractures make up the vast majority. Most clavicle fractures can be effectively treated nonoperatively. Rates of nonunion and poor functional outcome, however, may be higher than previously thought. Risk factors for nonunion include initial fracture displacement, comminution, shortening, and older age. The 2 main methods of operative management are plate-and-screws and intramedullary fixation. Study results for both methods have been good. Indications for operative management, however, remain controversial.

Current thinking: return to play and transient quadriplegia.

Athletes that participate in contact and collision sports assume risk of serious injury each time they take the field. For those athletes that have sustained an episode of transient quadriplegia, the decision of whether to return to competition can be a difficult one. Some athletes, realizing how close they may have come to permanent injury, may decide that further participation is not in their best interest. Others may be somewhat undecided, and some may want to return at all costs. As the treating physician, the goal is to identify those athletes who after a single episode of transient quadriplegia are at increased risk for further injury and consequently should discontinue participation in contact sports. Factors that may contribute to that determination include mechanism of injury, prior history of neurologic symptoms or injury, and anatomic features that may predispose to further injury such as disc herniation, fracture, or cervical stenosis.

Severe neurologic manifestations of fat embolism syndrome in a polytrauma patient.

Fat embolism syndrome (FES) is most commonly diagnosed when the classic triad of respiratory difficulty, neurologic abnormalities, and petechial rash are present in the appropriate clinical setting. Neurologic manifestations can range from headache, confusion, and agitation to stupor and, less commonly, coma. This article describes a case of FES with severe neurologic sequelae without typical pulmonary involvement in a polytrauma patient with proximal humerus and L1 compression fractures. The case highlights the importance of considering FES in the patient with deteriorating mental status in the setting of multiple fractures, particularly in the absence of other characteristic clinical findings. Early recognition allows for the anticipation of other complications, such as respiratory distress and the potential need for mechanical ventilation.

The magnetic attraction of lower extremity external fixators in an MRI suite.

OBJECTIVES: To determine the magnetic attraction of 10 currently available lower extremity external fixators in the MRI suite and to test fixators with minimal or no magnetic attraction for the presence of temperature elevation during a 30-minute MRI scan. DESIGN: Consecutive testing of selected tibial external fixation models in an identical manner. SETTING: Level 1 trauma center. CONSTRUCTS: Ten commercially available external fixators used for lower extremity injuries applied to saw bone tibia. INTERVENTION: External fixators suspended in testing apparatus were placed at three locations in the MRI suite for magnetic testing. Fixators with minimal attraction were scanned for 30 minutes. MAIN OUTCOME MEASUREMENTS: Magnetic attraction was measured with a digital scale, and temperature measurements were obtained with a digital thermometer and thermocouple. RESULTS: The Ilizarov with carbon fiber rings, Richards Hex-Fix, and Large Synthes External Fixator had <1 kg of magnetic attraction at all three locations. No component of these fixators experienced >2 degrees of temperature elevation after a 30-minute MRI scan. The EBI Dynafix with Ankle Clamp, EBI Dynafix, and EBI Dynafix Hybrid along with the Hoffman II, Hoffman II Hybrid, Ilizarov with stainless steel rings, and Synthes Hybrid had >1 kg of magnetic attraction at all three locations. CONCLUSIONS: Many commercially available external fixators have components and spring clamps that have significant magnetic attraction to the MRI scanner. Fixators that have <1 kg of attraction do not experience significant heating during MRI.

Orthopedic grand rounds can change resident practice.

This study sought to determine whether a grand rounds presentation could change resident practice. A 6-month review of all hip fracture patients 65 years and older at a single academic medical center was performed. The rate of addressing advanced directives and code status as documented in the medical record was noted. A grand rounds presentation was then given to the orthopedic department, and the medical records of hip fracture patients for the 12 months following the grand rounds were reviewed. In the 6 months prior to the grand rounds, orthopedic residents did not document code status or advanced directives in any of their admission or consultation notes. Following the grand rounds, orthopedic residents addressed advanced directives, code status, and contact person in 76% of their admission notes. There was a marked difference in the rate of documentation among residents who attended the grand rounds (88%), compared with residents who did not attend grand rounds (20%). Based on the results of this study, specifically whether residents attended grand rounds, this form of teaching can lead to changes in resident behavior.

Do seat belts and air bags reduce mortality and injury severity after car accidents?

We studied National Trauma Data Bank data to determine the effectiveness of car safety devices in reducing mortality and injury severity in 184,992 patients between 1988 and 2004. Safety device variables were seat belt used plus air bag deployed; only seat belt used; only air bag deployed; and, as explicitly coded, no device used. Overall mortality was 4.17%. Compared with the no-device group, the seat-belt-plus-air-bag group had a 67% reduction in mortality (adjusted odds ratio [AOR], 0.33; 99% confidence interval [CI], 0.28-0.39), the seatbelt- only group had a 51% mortality reduction (AOR, 0.49; 99% CI, 0.45-0.52), and the air-bag-only group had a 32% mortality reduction (AOR, 0.68, 99% CI, 0.57-0.80). Injury Severity Scores showed a similar pattern.

Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial.

OBJECTIVES: To determine the cost-effectiveness of open reduction internal fixation (ORIF) of displaced, midshaft clavicle fractures in adults. DESIGN: Formal cost-effectiveness analysis based on a prospective, randomized, controlled trial. SETTING: Eight hospitals in Canada (seven university-affiliated and one community hospital). PATIENTS/PARTICIPANTS: One hundred thirty-two adults with acute, completely displaced, midshaft clavicle fractures. INTERVENTION: Clavicle ORIF versus nonoperative treatment. MAIN OUTCOME MEASUREMENTS: Utilities derived from SF-6D. RESULTS: The base case cost per quality-adjusted life-year (QALY) gained for ORIF was $65,000. Cost-effectiveness improved to $28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $50,000 when the functional advantage persisted for 9.3 years or more. In other sensitivity analyses, the cost per QALY gained for ORIF fell below $50,000 when ORIF cost less than $10,465 (base case cost $13,668) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 (base case difference 0.014). Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 (base case utility 0.706) or when nonoperative treatment increased the time to union by 20 weeks (base case difference 12 weeks). CONCLUSIONS: The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions.

Does hospital surgical volume affect in-hospital outcomes in surgically treated pelvic and acetabular fractures?

A retrospective evaluation was done to determine the relationship between hospital volume and in-hospital mortality, complications, and length of stay in patients with operatively treated fractures of the pelvis or acetabulum. Patients were divided into three groups based on hospital volume. High volume centers had higher percentages of patients with one or more comorbidities, but who were less severely injured. Mortality rates were highest in small volume centers. Moderate volume centers had the lowest odds of death. Complication rates were similar between small and high volume hospitals. Length of stay was shortest in high volume centers. In-hospital outcomes associated with surgical fixation of the pelvis, acetabulum, or both were not uniformly associated with hospital volume.

The effects of alcohol on in-hospital mortality in drivers admitted after motor vehicle accidents.

BACKGROUND: The effects of alcohol on morbidity and mortality following motor vehicle accidents (MVAs) are controversial. This study was performed to address the effect of alcohol on in-hospital mortality for drivers in MVAs admitted to a trauma center before and after controlling for injury severity, safety device use, and patient demographics. METHODS: A retrospective study was performed using data from the National Trauma Data Bank, version 4.3. The cohort consisted of drivers in an MVA who were 15 years of age or older, had been admitted to the hospital on the same day as the accident, were screened for alcohol, and had no documentation of drugs in their system. Analyses were performed to explore the relationships between patient age, gender, race, presence of head injury, comorbid- ity status, injury severity score (ISS), and presence of alcohol and in-hospital mortality. RESULTS: The cohort consisted of 67,021 patients, 38.3% of whom were drivers involved in an MVA and, following screening, were found to have alcohol present in their system. Drivers who had alcohol present were more likely to be younger, male, White, not using a safety device, and to have sustained a head injury, than drivers who had no alcohol present in their system (alcohol absent driv- ers) at hospital presentation. After controlling for potential confounding variables, risk factors for in-hospital mortality included male sex, older age, and higher injury severity, while protective factors included the presence of alcohol and use of safety devices. The single strongest predictor of mortality was ISS. Sensitivity analyses to relect the impact of inlation in true ISS scores in the subgroup of patients who had alcohol present as well as a head injury revealed that the protective effect of alcohol diminished and became nonsignificant when the ISS was reduced by 9% and became a significant risk factor for in-patient mortality when the false elevation in ISS was estimated at 21%. CONCLUSIONS: These results suggest the importance of carefully considering the consequences that falsely inlated ISS scores might have for patients with alcohol present. Future work should evaluate the possible inlation of ISS and attempt to reconcile different interpreta- tions of the effects that the presence of alcohol may have on MVA mortality based by jointly considering crash site and in-hospital data.

Risk of injury associated with the use of seat belts and air bags in motor vehicle crashes.

Although air bags have been reported to reduce passenger mortality in frontal collisions, they have also been reported as a cause of injury in motor vehicle collisions(MVCs). The purpose of this study was to evaluate a large cohort of patients involved in MVCs to determine mortality and the pattern of injuries associated with seat belt use and air bag deployment. Information on patients involved in MVCs from 1988 to 2004 was obtained from the National Trauma Data Bank (NTDB). The data was evaluated based on four groups of safety devices: seat belt and deployed air bag (SBAB), seat belt only (SBO), deployed air bag only (ABO), and no safety devices (None). A total of 35,333 patients met study inclusion criteria. Air bags and seat belts used in combination decreased the risk of potentially fatal injuries, but increased the risk of lower extremity injuries (odds ratio, 1.35). The use of any type of restraint led to a decrease in the risk of injury or mortality in MVCs. Only half of all individuals in this study used any type of restraint device, which indicates the need for significant improvements in public health and safety seat belt utilization programs.