Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients

IntroductionThere has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures.Patients and methodsHip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture.Results81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture.Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture.Discussion and conclusionSimultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.     

Incidence and outcome of osteoporotic fractures in 2004 in Sado City,Niigata Prefecture,Japan

Osteoporotic fracture in elderly populations is increasing worldwide, but there are few data on the incidence and outcome of osteoporotic fractures, including upper extremity and vertebral fracture, during a certain period in a defined geographic area. The purpose of this study was to determine the incidence of osteoporotic fractures in a particular area: Sado City, Niigata Prefecture, Japan. From January to December 2004, osteoporotic fractures of the vertebra, hip, distal radius, and proximal humerus in Sado City were recorded. The incidence, age, gender, type of fracture (for hip fracture), right or left side (for distal radius, proximal humerus, and hip fracture), place of injury, cause of injury, outcome, hospitalization period, and patient status regarding taking of drugs for osteoporosis treatment were checked for each fracture. The incidence was calculated based on the whole population of Sado City. The incidence per 100,000 population was 232.8, 121.4, 108.6, and 37.1 for fractures of the vertebra, hip, distal radius, and proximal humerus, respectively. The total incidence of these four kinds of fracture was 499.9 per 100,000 persons per year. The average age at the time of injury was 81.4, 77.7, 75.7, and 60.2 years old for fractures of the hip, vertebra, proximal humerus, and distal radius, respectively. As the average age increased, the percentage of fractures that occurred indoors also increased; that is, a higher percentage of hip fractures occurred indoors, followed by fractures of the vertebra, proximal humerus, and distal radius. Most patients were not taking anti-osteoporosis drugs before fractures of the hip or vertebra. We determined the incidence of major osteoporotic fractures in 1 year in a defined geographic area. Our data showed that 81% of hip fracture patients also had a vertebral fracture and that the average age at the time of injury was higher for hip fractures than for vertebral fractures. Therefore, these results suggest that vertebral fracture leads to hip fracture, indicating that early fracture prevention and continuous prevention strategies through positive treatment are of importance in osteoporotic elderly people.     

Radial and humeral fractures as predictors of subsequent hip,radial or humeral fractures in women,and their seasonal variation

Hip fractures are common in elderly women, and early risk assessment of future hip fractures is relevant in relation to prevention. We studied the predictive value of radial and humeral fractures in women. The influence of weather conditions on the risk was also studied. Women aged 20–99 years with a fracture of the distal radius (n=1162) or proximal humerus (n=406) were followed for 0 to 9 years. The relative risk (RR) and 95% confidence limits (CL) of subsequent fracture among women suffering radial or humeral fractures compared with the background population were calculated. Women 60–79 years of age who had suffered a fracture of the distal radius or proximal humerus had relative risks of sustaining a hip fracture of 1.9 (1.3–2.6, 95% CL) and 2.5 (1.3–3.6, 95% CL) respectively. The relative risk of hip fracture was highest within the first years following a fracture of the radius or the humerus. Women suffering an upper extremity fracture (radius or humerus) in snowy or icy weather had a marginally increased risk (RR=1.3, 0.4–2.3, 95% CL and RR=1.8, 0.3–3.4, 95% CL) for a later hip fracture. A woman 50 years old with a radial or a humeral fracture had an estimated residual lifetime risk of sustaining a subsequent hip fracture of 17% and 16% respectively compared with 11% for the background population. The moderately increased risk of hip fractures in peri- and postmenopausal women suffering upper extremity fractures may be caused by a greater propensity to fall and/or be related to a higher degree of osteoporosis compared with the background population. For individuals other indicators of hip fracture should also be considered to improve the risk estimation of a later hip fracture.     

Long-Term Risk of Osteoporotic Fracture in Malmö

The objectives of the present study were to estimate long-term risks of osteoporotic fractures. The incidence of hip, distal forearm, proximal humerus and vertebral fracture were obtained from patient records in Malmo¨, Sweden. Vertebral fractures were confined to those coming to clinical attention, either as an inpatient or an outpatient case. Patient records were examined to exclude individuals with prior fractures at the same site. Future mortality rates were computed for each year of age from Poisson models using the Swedish Patient Register and the Statistical Year Book. The incidence and lifetime risk of any fracture were determined from the proportion of individuals fracture-free from the age of 45 years. Lifetime risk of shoulder, forearm, hip and spine fracture were 13.3%, 21.5%, 23.3% and 15.4% respectively in women at the age of 45 years. Corresponding values for men at the age of 45 years were 4.4%, 5.2%, 11.2% and 8.6%. The risk of any of these fractures was 47.3% and 23.8% in women and men respectively. Remaining lifetime risk was stable with age for hip fracture, but decreased by 20–30% by the age of 70 years in the case of other fractures. Ten and 15 year risks for all types of fractures increased with age until the age of 80 years, when they approached lifetime risks because of the competing probabilities of fracture and death. We conclude that fractures of the hip and spine carry higher risks than fractures at other sites, and that lifetime risks of fracture of the hip in particular have been underestimated. Received: 9 November 1999 / Accepted: 2 February 2000     

Increased fragility in patients with fracture of the proximal humerus: a case control study

The aim of this study was to evaluate whether a fracture of the proximal humerus is associated with an increased prevalence of preceding fractures or a risk of subsequent fractures.

All patients who were treated at the Malmö General Hospital in 1987 for a fresh fracture of the proximal humerus were identified, representing practically all fractures of the proximal humerus in Malmö city (250,000) that year. Two hundred fifty-three adult patients, 54 men with an average age of 66 (24–90) and 199 women with a mean age of 74 (22–98) years, were included in the study together with 475 age- and gender-matched control persons. In 1999, fracture prevalence of patients and controls were rated by a survey at the Dept. of Radiology.

There was a significantly increased prevalence of previous fractures before 1987 in the humerus fracture group with an odds ratio (OR) of 3.5 [95% confidence interval (95% CI), 2.2–5.5] for a spinal fracture, OR 1.8 (95% CI, 1.3–2.6) for a previous fracture to the upper extremity, and OR 1.8 (95% CI, 1.2–2.6) for a preceding fracture of the lower limb.

The proximal humerus fracture also predicted a significantly increased risk of a subsequent fracture. The hazard ratio (HR) was 2.5 (95% CI, 1.7–3.7) for a forthcoming spinal fracture, HR 2.8 (95% CI, 2.0–3.7) for a future fracture of the upper extremity, and HR 2.0 (95% CI, 1.2–3.5) for a lower limb fracture. In a subgroup of male patients, an almost five times increased risk of sustaining subsequent extremity fractures was observed.

In summary, a fracture of the proximal humerus is associated both with increased prevalence of previous fractures of the spine and extremities and also predicting an increased risk of future fractures.     

Lifetime and Five-Year Age-Specific Risks of First and Subsequent Osteoporotic Fractures in Postmenopausal Women

We examined the incidence of fragility fractures in Australian women 50 years of age and over using a Markov process with Monte Carlo simulations. The lifetime risks and the risks of sustaining first and subsequent clinically diagnosed fractures at osteoporotic sites were estimated according to age, nursing home entry and mortality rates. Hip and spine fractures were evaluated individually and fractures of humerus, forearm, wrist, ribs, pelvis, upper leg (excluding proximal femur) and tibia/fibula were considered in combination. The model predicted that 42.1% of women aged 50 years will sustain at least one fracture in their remaining lifetime, of whom half are expected to sustain multiple fractures. The lifetime risks of sustaining hip, clinical spine and other fractures were 17.0%, 9.6% and 30.4%, with the risks of multiple fractures at these sites estimated at 19.5%, 39.7% and 35.7% respectively. The proportion of women expected to sustain their first fracture increased from 1.9% of the population under 55 years of age up to 49.1% of women over 89 years of age. The 5-year age-specific risks of sustaining any subsequent fractures increased from 2.8% of women under the age of 55 years to 61.6% for women age 89 years and over. The increased risks of new fractures following a first fracture lead to a considerable burden of multiple fractures. Received: 2 February 2000 / Accepted: 5 June 2000     

Mortality after low-energy fractures in patients aged at least 45 years old

BACKGROUND: Fractures sustained in low-energy injuries are recognized as a major public health issue, although, with the exception of proximal femoral fractures, little is known about the subsequent mortality rates. The aim of this study was to compare the survival rates of a population of individuals who sustained 3 types of low-energy fractures with age-matched cohorts from within the same population. METHODS: Between January 1988 and December 1999, data were prospectively gathered from all inpatient and outpatient fracture cases at a single trauma unit. During this time, 18,019 patients sustained low-energy fractures of the proximal femur, proximal humerus, or wrist. Survival analysis using the life table method was performed and hazard ratios calculated for risk of mortality when compared to general population controls within the first year postinjury, between the second and fifth years postinjury, and between the sixth and tenth years postinjury. The effects of various social, physical, and mental health parameters on survival were also analyzed using a Cox proportional hazards model. RESULTS: The patients who sustained proximal femoral fractures were older and significantly more physically and mentally impaired than the patients who sustained wrist fractures. The demographic features of the proximal humeral fracture cohort were intermediate between these 2 groups. The mortality was high in all age groups following proximal femoral and proximal humeral fractures, though the relative risk of death, when compared to age-matched population controls, decreased with increasing age at fracture. The risk of death in these groups was greatest in younger individuals and in the first year postinjury. The wrist fracture population had similar or enhanced survival when compared to age-matched population controls. The mortality after fracture was independently predicted by age at fracture, male gender, and use of walking aids, for all 3 fracture groups (P < 0.05), and additionally by level of social dependence in the proximal femoral fracture group (P < 0.05). Level of evidence: level one, prospective cohort study. CONCLUSIONS: There is prolonged risk of premature mortality seen in both proximal femoral and proximal humeral fracture groups in the younger age cohorts, possibly as a result of concomitant medical comorbidities contributing to their premature deaths. Elderly patients sustaining proximal femoral fractures, despite high risk of mortality in the first year after injury, have survival approaching those of the general population in the longer term. Elderly patients who sustain wrist fractures have consistently better survival rates than the general population. This group of patients may be physiologically more robust than their age-matched peers in the general population.     

Open lower limb fractures in the elderly

ObjectiveThe aim of this study was to assess the outcomes of open lower limb fractures in patients aged 65 and over. The primary outcome was mortality at 30 days, and the secondary outcome was reoperation.MethodsThis study retrospectively identified patients aged 65 and over, presenting with an open tibia or ankle fracture, over a two-year period. Patient demographics, injury characteristics and surgical interventions were documented. The 30-day and one-year mortality was recorded, as well as any complications encountered.ResultsThere were 88 patients included in the study, with a mean age of 78 years and 66% of patients were female. Of this cohort, 67 patients (76%) had low energy injuries and 64 patients (73%) had Gustillo-Anderson type IIIB injuries. Treatment consisted of a one-stage surgical procedure in 49 patients (56%) and a two-stage procedure in 37 patients (42%), with two patients dying before definitive treatment. Primary wound closure was performed in 23 patients (26%), four patients (5%) had a split skin graft alone, 35 patients (40%) had local flaps, 21 patients (24%) were managed with free flaps and three patients (3%) had primary below knee amputations. The 30-day mortality rate was 10%, the one-year mortality rate was 19% and the reoperation rate was 8%.ConclusionOpen lower limb fractures in the elderly are a life and limb threatening injury, with a similar demographic and mortality profile to hip fracture. This study demonstrates that limb salvage can be achieved in 93% of cases, with treatment performed as a one-stage procedure in 56% of cases.     

Refractures in patients at least forty-five years old. a prospective analysis of twenty-two thousand and sixty patients

BACKGROUND: Individuals who sustain a low-energy fracture are at increased risk of sustaining a subsequent low-energy fracture. The incidence of these refractures may be reduced by secondary preventative measures, although justifying such interventions and evaluating their impact is difficult without substantive evidence of the severity of the refracture risk. The aim of this study was to quantify the risk of sustaining another fracture following a low-energy fracture compared with the risk in an age and sex-matched reference population. METHODS: During the twelve-year period between January 1988 and December 1999, all inpatient and outpatient fracture-treatment events were prospectively audited in a trauma unit that is the sole source of fracture treatment for a well-defined local catchment population. During this time, 22,060 patients at least forty-five years of age who had sustained a total of 22,494 low-energy fractures of the hip, wrist, proximal part of the humerus, or ankle were identified. All refracture events were linked to the index fracture in the database during the twelve-year period. The incidence of refracture in the cohort of patients who had sustained a previous fracture was divided by the "background" incidence of index fractures within the same local population to obtain the relative risk of refracture. Person-years at-risk methodology was used to control for the effect of the expected increase in mortality with advancing age. RESULTS: Within the cohort, 2913 patients (13.2%) subsequently sustained a total of 3024 refractures during the twelve-year period. Patients with a previous low-energy fracture had a relative risk of 3.89 of sustaining a subsequent low-energy fracture. The relative risk was significantly increased for both sexes, but it was greater for men (relative risk = 5.55) than it was for women (relative risk = 2.94). The relative risk was 5.23 in the youngest age cohort (patients between forty-five and forty-nine years of age), and it decreased with increasing age to 1.20 in the oldest cohort (patients at least eighty-five years of age). CONCLUSIONS: Individuals who sustain a low-energy fracture between the ages of forty-five and eighty-four years have an increased relative risk of sustaining another low-energy fracture. This increased risk was greater when the index fracture occurred earlier in life; the risk decreased with advancing age. Secondary preventative measures designed to reduce the risk of refracture following a low-energy fracture are likely to have a greater impact on younger individuals.     

Fracture of the distal forearm as a forecaster of subsequent hip fracture: A population-based cohort study with 24 years of follow-up

Summary Objective: To determine the long-term risk of hip fracture following fracture of the distal forearm. Design: Registry-based cohort study comparing patients with a fracture of the distal forearm with a population-based cohort. Fracture cohort: All women and men above 40 years of age with a radiologically verified fracture of the distal forearm during a 5-year period. 1968–1972, in all 1,126 women and 212 men. Control cohort: An equal number of population-based, age-and sex-matched control persons selected from a population register. Measurements: All cohort members were followed up individually through record linkage until the first hip fracture, emigration, death, or the end of 1991. The cohort members contributed a total of 40,832 person-years of observation, and altogether 365 cases of hip fractures were observed. Results: Both women and men with a fracture of the distal forearm ran an increased risk of sustaining a subsequent hip fracture. The overall relative hazard for the women was 1.54 and for men 2.27. The increased risk in the women was independent of age at inclusion, but that in the men was more pronounced in the younger age groups. Conclusions: Patients with a fracture of the distal forearm run an increased risk of sustaining a subsequent hip fracture. They therefore appear to constitute a group in which appropriate prophylactic measures against osteoporosis and fractures should be considered.     

Mortality and pulmonary embolism after fracture in the elderly

Hip fracture has repeatedly been associated with increases in the risks of death and pulmonary embolism (PE), but few studies have considered whether other fractures are also associated with these adverse outcomes. The authors estimated the 90-day risks and relative risks of mortality and PE after fractures, and the longer-term relative risks of mortality, for each of ten fracture sites. Using the 5% US standard sample of the Medicare population, we identified 81,181 fractures of the pelvis, patella, and long bones occurring between July 1, 1986, and June 30, 1990, among beneficiaries aged 65 years or older. The fractures were randomly matched by sex, race, and year of birth with a beneficiary who did not suffer that particular fracture, to form ten control cohorts. All patients were followed up until December 31, 1990. The 90-day risk of death was greater than 9% after hip, nonhip femur, and pelvic fractures, with risks relative to their matched control cohorts of 4.7 to 6.7. For white patients with these three fracture types these relative risks decreased substantially with age. White patients who had a hospitalization in the 2 years before hip fracture were more likely to die in the first 90 days than those who had no hospitalization before the hip fracture, but this effect, too, decreased with age. Patients who survived 1 year after most fracture types had no clinically significant excess mortality compared with their surviving controls. For patients with hip, nonhip femur, and pelvis fractures, however, there remained an elevated risk of 1.6 to 1.8, and for patients with proximal humerus fractures the risk ratio was 1.4. All lower-limb fractures carried a higher risk of PE than any upper-limb fracture.     

Nonagenarian hip fractures: Morbidity and mortality at a single institution

ObjectivesThe incidence of hip fractures continues to rise dramatically, but few studies have examined these injuries in the population of individuals over 90 years of age, which is one of the fastest growing populations. We present the largest such study specifically examining hip fractures in the super-elderly.MethodsA review of 216 hip fracture patients over 90 years of age were examined for immediate postoperative complications and in-house, 30-day, and 1-year mortality.ResultsOverall 1-year mortality was 38.1%. Statistically-significant risk factors for 1-year mortality included oncologic fracture, dementia, and CHF. Fracture classification and hospital length of stay were associated with perioperative complications including anemia and pneumonia.ConclusionThe nonagenarian hip fracture is associated with a higher 1-year mortality than prior reported rates of mortality for elderly hip fractures. Factors previously reported to influence the risk of 1-year mortality in hip fractures are not observed in the super-elderly.     

Incidence and cost of osteoporotic fractures in France during 2001. A methodological approach by the national hospital database

The objective of this study was to describe the hospital incidence rate and the in-patient costs of three peripheral osteoporotic fractures (proximal humerus and hip, distal radius and/or ulna) in women and men aged over 45 in France during 2001. Each stay for fracture was selected from the dataset of the French national hospital database in 2001. The incidence rate (CI 95%) was standardized by age and gender according to the last census of the French population (1999). The effect of age and existence of geographical difference in incidence rates has been studied. For each fracture, we described the number of stays, rate of surgical procedure and in-patient costs according to the 2004 French list of cost per diagnosis-related group (2004 Euros); 118,839 fractures were registered during 2001 (61% hip, 28% distal radius and 11% proximal humerus; sex ratio 0.26). The incidence rate for all fracture was 7,567 (7,519–7,615) and 2,312 (2,283–2,341) for 10⁶ inhabitants in women and men aged over 45 years, respectively. The incidence increased significantly whatever type of fracture and gender. There were more fracture incidents in the east of France compared to the west and in the south compared to the north, whatever type of fracture in women and only for hip fracture in men. Surgical procedures were performed in 91% of proximal hip fractures, 83% of distal radius fractures and 53% of proximal humerus fractures. The median in-patient costs were 3,786 Euros for the humerus, from 2,363 to 2,574 Euros for the radius and from 8,048 to 8,727 Euros for the hip. The evaluation of the burden of peripheral fractures is possible using national hospital data in France. The incidence of fractures increased with age and is more common in women. Hip fracture with its higher occurrence, rate of procedure and in-patient costs could be used as a marker of osteoporosis for evaluating strategies of management.     

Remaining lifetime and absolute 10-year probabilities of osteoporotic fracture in Swiss men and women

Summary

Remaining lifetime and absolute 10-year probabilities for osteoporotic fractures were determined by gender, age, and BMD values. Remaining lifetime probability at age 50 years was 20.2% in men and 51.3% in women and increased with advancing age and decreasing BMD. The study validates the elements required to populate a Swiss-specific FRAX® model.

Introduction

Switzerland belongs to high-risk countries for osteoporosis. Based on demographic projections, burden will still increase. We assessed remaining lifetime and absolute 10-year probabilities for osteoporotic fractures by gender, age and BMD in order to populate FRAX® algorithm for Switzerland.

Methods

Osteoporotic fracture incidence was determined from national epidemiological data for hospitalised fractured patients from the Swiss Federal Office of Statistics in 2000 and results of a prospective Swiss cohort with almost 5,000 fractured patients in 2006. Validated BMD-associated fracture risk was used together with national death incidence and risk tables to determine remaining lifetime and absolute 10-year fracture probabilities for hip and major osteoporotic (hip, spine, distal radius, proximal humerus) fractures.

Results

Major osteoporotic fractures incidence was 773 and 2,078 per 100,000 men and women aged 50 and older. Corresponding remaining lifetime probabilities at age 50 were 20.2% and 51.3%. Hospitalisation for clinical spine, distal radius, and proximal humerus fractures reached 25%, 30% and 50%, respectively. Absolute 10-year probability of osteoporotic fracture increased with advancing age and decreasing BMD and was higher in women than in men.

Conclusion

This study validates the elements required to populate a Swiss-specific FRAX® model, a country at highest risk for osteoporotic fractures.     

Changing trends in the mortality rate at 1-year post hip fracture-a systematic review

BACKGROUND Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.AIM To address recent 1-year post hip fracture mortality rates in the literature.METHODS Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation(2013-2017), cohorts 100,studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.RESULTS Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.CONCLUSION There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.     

Variation in risk factors for fractures at different sites

Fractures in older people are important medical problems. Knowledge of risk factors is essential for successful preventive measures, but when fracture sites of diverse etiology are combined, risk factors for any one site are difficult to identify and may be missed entirely. Among older people, incidence rates of hip, proximal humerus, and vertebral fractures increase with age, but not rates of distal forearm and foot fractures. Low bone mineral density is strongly associated with hip, distal forearm, vertebral, and proximal humerus fractures, but not foot fracture. Most fractures of the hip, distal forearm, and proximal humerus result from a fall, whereas smaller proportions of fractures of the foot and vertebrae follow a fall. Frail people are likely to fracture their hip or proximal humerus, while healthy, active people tend to fracture their distal forearm. We strongly recommend that studies identify risk factors on a site-specific basis.     

Quantitative Ultrasound (QUS) of the Heel Predicts Wrist and Osteoporosis-Related Fractures in Women Age 45–75 Years

This study was designed to determine the ability of quantitative ultrasound (QUS) of the heel to predict fracture risk at different sites in postmenopausal women between the ages of 45 and 75 years. Heel QUS was measured at baseline using a Lunar Achilles scanner, and subsequent fractures were identified over 3 yr. The results were analyzed graphically after age adjustment and using Cox's proportional regression to estimate odds ratios for fracture risk; 3180 women were scanned (79% of sample). Sixty-three wrist, 12 hip, 4 vertebral, 7 proximal humerus, 3 pelvic, and 61 other fractures were identified over a mean followup of 31 mo. There was a fivefold difference in numbers of wrist and osteoporosis-related fractures (hip, vertebra, pelvis, and humerus combined) between the lowest and highest quartiles of QUS results adjusted for age. The odds ratios per 1 SD decline in QUS parameters adjusted for age were: wrist fractures BUA = 1.6, SOS = 1.5, stiffness = 1.8, osteoporosis-related fractures BUA = 1.9, speed of sound (SOS) = 1.6, stiffness = 2.2, and other fractures, BUA = 1.0, SOS = 1.1, stiffness = 1.1. When analyzed for each 10-yr age group, the odds ratios were generally higher in the 56-65 yr group than the other decades. In women between 45 and 75 yr, heel QUS can predict wrist and osteoporosis- related fractures at about the same level that dual-energy X-ray absorptiometry (DXA) of various sites can predict wrist fractures. This extends the current evidence that heel QUS can predict hip fracture risk in women over 75 yr to include other fracture sites in younger women. Heel QUS may be useful in the primary care assessment of osteoporotic fracture risk in women after the menopause.     

Hip fractures in centenarians

The centenarian population is increasing yet there is little about their morbidity and mortality rates following hip fracture. The aim was to review centenarians treated for proximal femoral fractures in Edinburgh describing treatment outcomes in relation to mortality, walking ability and residential status comparing centenarians with a the more typical hip fracture population. In this retrospective review, 18 centenarians sustaining hip fractures in Edinburgh between 1998 and 2002 were compared to 18 randomly selected "normal" hip fracture patients aged 75-83 years. Centenarian in-hospital, 1 and 4 month mortality was 11.1, 33.3 and 50%, respectively, versus 0, 0 and 5.6% in the normal group. Centenarian 4 month mortality was significantly greater than that of the normal group (Fisher's Exact Test, P = 0.00723). A total of 22.2% of centenarians regained pre-fracture walking ability compared to 58.8% of the normal patients. A total 28.6% of centenarians could continue living independently post-fracture compared to 69.2% of the normal group.     

The influence of local bone quality on fracture pattern in proximal humerus fractures

IntroductionBone mineral density and fracture morphology are widely discussed and relevant factors when considering the different treatment options for proximal humerus fractures. It was the aim of this study to investigate the influence of local bone quality on fracture patterns of the Neer classification as well as on fracture impaction angle in these injuries.Materials and methodsAll acute, isolated and non-pathological proximal humerus fractures admitted to our emergency department were included. The fractures were classified according to Neer and the humeral head impaction angle was measured. Local bone quality was assessed using the Deltoid Tuberosity Index (DTI). The distribution between DTI and fracture pattern was analysed.Results191 proximal humerus fractures were included (61 men, mean age 59 years; 130 women, mean age 69.5). 77 fractures (40%) were classified as one-part, 72 (38%) were two-part, 24 (13%) were three- and four-part and 18 (9%) were fracture dislocations. 30 fractures (16%) were varus impacted, whereas 45 fractures (24%) were classified as valgus impacted. The mean DTI was 1.48. Valgus impaction significantly correlated with good bone quality (DTI ≥ 1.4; p = 0.047) whereas no such statistical significance was found for the Neer fracture types.DiscussionWe found that valgus impaction significantly depended on good bone quality. However, neither varus impaction nor any of the Neer fracture types correlated with bone quality. We conclude that the better bone quality of valgus impacted fractures may be a reason for their historically benign amenability to ORIF. On the other hand, good local bone quality does not prevent fracture comminution.     

Influence of coincident distal radius fracture in patients with hip fracture: single-centre series and meta-analysis

BackgroundHip and wrist fractures are the most common orthopaedic injuries. Combined hip and distal radius fractures are an important clinical and public health problem, since mobilisation and rehabilitation is challenging and likely to be prolonged in this setting. Few studies have explored the influence of an associated wrist fracture in patients with hip fracture. We present the largest series of patients with concomitant hip and wrist fractures. We perform the first meta-analysis of the literature on patients with concurrent hip and wrist fractures.ResultsPatients with the combined fracture were of a similar age compared to those with isolated hip fracture. There were a significantly higher proportion of women in the cohort with both hip and wrist fractures (female:male ratio of 9:1 versus 4:1 p < 0.0001). The combination fracture group had a greater length of hospitalisation (18 vs 13 days p < 0.0001). The survivorship of both groups was not significantly different even after adjustment for age and gender. Meta-analysis of the literature showed female preponderance, increased length of stay but no significant difference in survival in patients with concomitant hip and wrist fractures.ConclusionThe combination fracture occurs much more commonly in women and patients require a greater length of hospitalisation. The patients who sustained simultaneous hip and wrist fractures experienced no statistically significant difference in survivorship when compared to those who suffer isolated hip fractures. This is not withstanding the presence of two fractures. This difference in mortality did not reach statistical significance.

Level of evidence

Level III (retrospective comparative study).