Fractures in older adults. A view of the future?

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. DISCUSSION: 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.

Tibial Fracture Nonunion and Time to Healing After Reamed Intramedullary Nailing: Risk Factors Based on a Single-Center Review of 1003 Patients.

OBJECTIVE: To determine factors associated with nonunion of adult tibial fractures. DESIGN: Retrospective review with data collection for logistic regression and survival analysis. SETTING: Scottish Level I trauma center, 1985-2007. PATIENTS: During this period, 1590 adult tibial fractures were treated by reamed nailing and 1003 fractures met all inclusion criteria for the chosen analysis. INTERVENTION: Reamed intramedullary nailing. MAIN OUTCOME MEASURES: Record of nonunion diagnosis and final union time with characteristics, including age, gender, closed or open injury, OTA/AO classification, Gustilo classification, fasciotomy, infection, polytrauma, smoking, and injury severity score. RESULTS: The overall nonunion rate was 12%, and median time to healing was 18 weeks. Age significantly influenced nonunion, with middle-aged patients at highest risk. Both fracture type (closed/open) and morphology (OTA/AO classification) significantly influenced nonunion risk and time to union. Among closed injuries, the highest nonunion rate was for OTA/AO type B fractures (15%). Among open injuries, the highest nonunion rate was for OTA/AO type C (61%). Both compartment syndrome and smoking did not significantly influence nonunion risk but did significantly extend time to union. CONCLUSIONS: Injury characteristics including fracture morphology and severity of soft tissue injury were strong predictors of compromised fracture healing. Age also influenced nonunion risk in an unexpected way, with highest rates in the middle decades of adulthood. Future studies should consider the possibility of similar age-related effects and clinical studies should seek to identify explanations for why this may arise, including both physiological and socio-behavioral factors. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists.

AIMS: To investigate the changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists. MATERIALS AND METHODS: Data on all non-spinal open fractures admitted to the Royal Infirmary of Edinburgh after a road traffic accident between 1988 and 2010 were collected and analysed to provide information about the changing epidemiology in different patient groups. Demographic information was collected on all patients with the severity of injury being analysed with the Injury Severity Score (ISS), Musculoskeletal Index (MSI) and the number of open fractures. The severity of the open fractures was analysed using the Gustilo classification. The 23-year study period was divided into four shorter periods and the results were compared. RESULTS: There were 696 patients treated in 23 years. Analysis showed that the incidence of RTA open fractures initially fell in both males and females and continued to fall in females during the 23 years. In males it levelled off about 2000. The age of the female patients also fell during the study period but it did not change in males. The only patient group to show an increased incidence of open fractures were cyclists. In vehicle occupants the incidence fell throughout the study period but it levelled off in pedestrians and motorcyclists. There was no difference in the severity of injury in any group during the study period. The most severe open fractures were those of the distal femur and femoral diaphysis although open tibial diaphyseal fractures were the most common fracture in all patient groups. CONCLUSIONS: Improved car design and road safety legislation has resulted in a reduction in the incidence of open fractures in vehicle occupants, pedestrians and motorcyclists. The most obvious group to have benefitted from this are older female pedestrians. The only group to show an increase in age during the study period were male motorcyclists.

Plate Versus Tension-Band Wire Fixation for Olecranon Fractures: A Prospective Randomized Trial.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology of open fractures in sport: One centre's 15-year retrospective study.

AIM: To describe the epidemiology of sport-related open fractures from one centre's adult patient population over a 15-year period. METHODS: A retrospective review of a prospectively-collected database was performed: The database contained information all sport-related open fractures, sustained from 1995 to 2009 in the Edinburgh, Mid and East Lothian Populations. RESULTS: Over the 15-year period, there were 85 fractures recorded in 84 patients. The annual incidence of open sport-related fractures was 0.01 per 1000 population. The mean age at injury was 29.2 years (range 15-67). There were 70 (83%) males and 14 females (17%). The 6 most common sports were soccer (n = 19, 22%), rugby (n = 9, 11%), cycling (n = 8, 9%), hockey (n = 8, 9%); horse riding (n = 6, 7%) and skiing (n = 6, 7%). The five most common anatomical locations were finger phalanges (n = 30, 35%); tibial diaphysis (n = 19, 23%); forearm (n = 12, 14%); ankle (n = 7, 8%) and metacarpals (n = 5, 6%). The mean injury severity score was 7.02. According to the Gustilo-Anderson classification system, 45 (53%) fractures were grade 1; 28 (33%) fractures were grade 2; 8 (9%) fractures were grade 3a; and 4 (5%) fractures were grade 3b. Out of the total number of fractures, 7 (8%) required plastic surgical intervention as part of management. The types of flaps used were split skin graft (n = 4), fasciocutaneous flaps (n = 2); and adipofascial flap (n = 1). CONCLUSION: We analysed the epidemiology of open fractures secondary to sport in one centre over a 15-year period. Soccer and rugby were the most common causative sports while fractures of the finger phalanx and of the tibial diaphysis were the most common sites. Open fractures are uncommon in sport; however, when they are sustained they usually occur on muddy sport fields or forest tracks and therefore must be treated appropriately. It is important that clinicians and sports therapists have knowledge of these injuries, in order to ensure they are managed optimally.

Incidence and Epidemiology of Patellar Fractures.

The literature lacks large-scale, up-to-date, population-based epidemiology studies on the incidence of patellar fractures based on complete populations. The purpose of this study was to provide up-to-date information concerning the incidence of patellar fractures in a large and complete population spanning a decade and to report on the distribution of fracture classification, trauma mechanisms, and patient baseline demographics. A retrospective review of clinical and radiological records of 756 patellar fractures treated between 2005 and 2014 was conducted. Mean age at the time of fracture was 54±21 years. Mean age was 46±22 years for males and 61±18 years for females. The sex distribution was 425 (56%) females and 331 (44%) males. The incidence of patellar fractures between 2005 and 2014 was 13.1/100,000/ year with a year-to-year variation between 10.5 and 16.5/100,000/year during the 10-year observation period. The distribution of incidence shows an increase with increasing age. Males have the highest incidence of fracture in the 10-to-19-year age group, approximately 15.4/100,000/year. Females in the 60-to-80-year age group have the highest incidence, approximately 36/100,000/year. AO type 34-C3 was the most common fracture type, representing 25% of all patellar fractures, followed by AO type 34-C1, representing 23%. [Orthopedics. 2016; 39(6):e1154-e1158.].

Global Forum: Fractures in the Elderly.

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 role of primary plastic surgery in the management of open fractures.

A study was undertaken to determine the requirement for primary plastic surgery in the treatment of open fractures. We reviewed 3297 consecutive open fractures in a 22-year period in a defined population. Analysis showed that 12.6% of patients required primary plastic surgery with 5.6% being treated with split skin grafting and 7.2% with a flap. Only 3.5% of open upper limb fractures required primary plastic surgery compared to 27.9% of open lower limb fractures. The fractures that required most primary plastic surgery were those of the femoral diaphysis and all fractures between the proximal tibia and the midfoot. The incidence of open fractures that require primary plastic surgery was 28/10(6)/year. The incidence in open upper and lower limb fractures was 5.3/10(6)/year and 22.7/10(6)/year respectively. Using these figures it is possible to estimate the numbers of open fractures that will require primary plastic surgery each year in the United Kingdom.

Predictors of Compartment Syndrome After Tibial Fracture.

OBJECTIVES: The aim of our study was to identify the risk factors associated with the development of acute compartment syndrome (ACS) after a fracture of the tibia. DESIGN: Retrospective cohort study. SETTING: Orthopaedic trauma unit, university teaching hospital. PATIENTS: From our trauma database, we identified all patients who sustained an acute tibial diaphyseal fracture over a 13-year period. A retrospective analysis of 1407 patients was performed to record and analyze the OTA fracture classification, open fracture grade according to Gustilo, soft tissue injury classification according to Tscherne, treatment, development of ACS, and other patient demographics including smoking, occupation, and socioeconomic deprivation. MAIN OUTCOME MEASURE: A diagnosis of ACS was made using clinical signs, compartment pressure monitoring, or a combination of the 2. RESULTS: One thousand three hundred eighty-eight patients were included with a mean age of 39 (12-98) years, and 957 (69%) were male. One hundred sixty patients (11.5%) were diagnosed with ACS. On initial analysis, age, male gender, blue-collar occupation, sporting injury, fracture classification, and treatment with intramedullary nails were predictive of ACS (all P < 0.05). Age was the strongest predictor of developing ACS (P < 0.001), with the highest prevalence between 12-19 years and 20-29 years. Occupation (P = 0.01) and implant type (P = 0.004) were the only factors that remained significant after adjusting for age. On further subanalysis, implant type was not predictive when stratified by Tscherne class (P = 0.11). CONCLUSIONS: We have documented the risk factors for the development of ACS after an acute tibial diaphyseal fracture, with youth the strongest predictor. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Open ankle fractures: who gets them and why?

Open ankle fractures present a significant clinical challenge. The management and outcome of these injuries has been extensively reported, but there have been no reports of the epidemiology and how this has changed over time. We report 178 adult patients with open ankle fractures presenting to our unit over a twenty-three year period. The study centre is the only hospital receiving adult orthopaedic trauma in the region and has a defined population. The incidence of open ankle fractures was 1.5/10(5)/year, representing 1.5 % of all ankle fractures. The mean age was 55 years (range 16-96), with the highest incidence occurring in women over the age of 90. The most common mechanism was a simple fall with only 26 % of cases due to a motor vehicle collision (MVC). 82 % of cases were isolated injuries. Social deprivation had no significant influence on the incidence, but there was a difference in the mechanism with the majority of injuries in the most deprived quintile caused by MVCs and significantly fewer due to simple falls (p = 0.047). Over the twenty-three years, there was a significant increase in the mean age from 44 to 64 years (p = 0.03). The overall incidence remained constant over the two decades. In common with many traumatic injuries, open ankle fractures are increasingly low-energy insufficiency fractures affecting elderly patients, particularly older women. This has implications for service planning and training as well as the surgical intervention in these patients.

Predictors of poor clinical outcome following hip fracture in middle aged-patients.

The aim of this study was to investigate morbidity and mortality following hip fractures in middle aged patients. In addition, we aimed to identify risk factors which could be used to predict postoperative complications. All patients aged 40-55 who sustained a hip fracture in Lothian from 2007 to 2008 were identified from a prospective trauma database. The main outcomes were complications and 5-year mortality. Thirty hip fractures were included in the study. Complications occurred in nine (30%) cases. Deep infection was seen in three cases (10%). Mortality was 20% at 5 years, 26 times higher than for the general population. All surviving patients were contacted for risk factor analysis (24). Low energy fractures, alcohol excess, smoking and history of previous fractures were significantly associated with complications (p<0.05). Complications only occurred amongst low energy fractures. Risk factors were further analysed using the WHO FRAX algorithm. No patient with a FRAX score of less than 10 suffered a complication, whereas 50% of patients who had a FRAX score of more than 10 suffered a complication. The results of our study suggest that low energy hip fractures in middle age are due to underlying morbidity and are associated with a high incidence of postoperative complications and mortality. The FRAX score could be used as a simple method of identifying patients in this age group who are at risk of a poor outcome.

Open fractures in the elderly. The importance of skin ageing.

Open fractures in the elderly are rare and there is little information about them. We have reviewed 484 open fractures in patients aged ≥65 years over a 15-year period and compared them with 1902 open fractures in patients <65 years treated in the same period. The incidence of open fractures increased significantly with age. The incidence of open fractures in patients aged <65 years was 296.6/10(6)/year compared which increased to 332.3/10(6)/year in patients aged ≥65 years and further still to 446.7/10(6)/year in the super-elderly aged ≥80 years The fracture distribution curves show that males aged 15-19 years and females aged ≥90 years have a very similar incidence of open fractures. In males the incidence declines almost linearly, whereas in females there is a steady increase in fracture incidence with age until the 7th decade of life when the incidence rises sharply. About 60% of open fractures in the elderly follow a fall and most fractures are caused by low energy injuries. Despite this there is a high incidence of Gustilo Type III fractures, particularly in females. The commonest open fractures in females are those of the distal radius and ulna, fingers, tibia and fibula and ankle, all fractures with subcutaneous locations. It has been shown that ageing alters the mechanical properties of skin and we believe that this accounts for the increased incidence of open fractures in elderly females which occurs about 1 decade after the post-menopausal increase in fracture incidence.

Long-term outcomes of isolated stable radial head fractures.

BACKGROUND: There is evidence to support primary nonoperative management of isolated stable fractures of the radial head, although minimal data exist regarding long-term outcomes. The aim of this study was to report subjective long-term outcomes of isolated stable fractures of the radial head and neck following primary nonoperative management. METHODS: From a prospective database of proximal radial fractures, we identified all skeletally mature patients who sustained an isolated stable Mason type-1 or type-2 fracture of the radial head or neck during an eighteen-month period. Inclusion criteria were a confirmed isolated stable fracture of the proximal aspect of the radius, primarily managed nonoperatively. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: The study cohort comprised 100 patients with a mean age of forty-six years (range, seventeen to seventy-nine years). A fall from a standing height accounted for 69% of all injuries. Thirty-five percent of the patients had one or more comorbidities. There were fifty-seven Mason type-1 fractures and forty-three Mason type-2 fractures. At a mean of ten years post injury (range, 8.8 to 10.2 years), the mean DASH score was 5.8 (range, 0 to 67.2) and the mean Oxford Elbow Score (OES) was 46 (range, 14 to 48). Fourteen (14%) of the patients reported stiffness and twenty-four (24%) reported some degree of pain. A worse DASH score was associated with older age (p = 0.002), one or more comorbidities (p = 0.008), increasing socioeconomic deprivation by Index of Multiple Deprivation quintile (p = 0.026), increasing amount of fracture displacement (p = 0.041), and involvement in compensation proceedings (p = 0.006). CONCLUSIONS: Long-term patient-reported outcomes were excellent following the nonoperative management of isolated stable fractures of the radial head or neck. We suggest that routine primary nonoperative management of these fractures provides a satisfactory outcome for the majority of patients, with few patients in our study requiring further intervention for persisting complaints. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The influence of vitamin C on the outcome of distal radial fractures: a double-blind, randomized controlled trial.

BACKGROUND: Vitamin C has been proposed to improve outcomes after a distal radial fracture by promotion of bone and soft-tissue healing and reduction of the prevalence of complex regional pain syndrome (CRPS). Our primary aim was to examine the effect of vitamin C on functional outcome after a distal radial fracture. METHODS: A total of 336 adult patients with an acute fracture of the distal aspect of the radius were recruited over a one-year period and randomized to receive 500 mg of vitamin C or placebo daily for fifty days after the fracture. The primary outcomes were the DASH (Disabilities of the Arm, Shoulder and Hand) score at six weeks and at one year. Secondary variables included complications, wrist and finger motion, grip and pinch strength, pain, and a CRPS score. RESULTS: There were no significant differences in patient or fracture characteristics between the treatment groups. There was no significant effect of vitamin C on the DASH score throughout the study period. At six weeks, patients in the vitamin C group with a nondisplaced fracture had a significantly greater wrist flexion deficit (p = 0.008) and pinch strength deficit (p = 0.020) and a greater rate of CRPS (p = 0.022), but there was no difference in the CRPS rate at any other time point. At twenty-six weeks, there was a higher rate of complications (p = 0.043) and greater pain with use (p = 0.045) in the patients with a displaced fracture treated with vitamin C. There was no significant difference in the time to fracture-healing. CONCLUSIONS: This study demonstrated no significant difference at one year in the DASH score, other functional outcomes, the rate of CRPS, or osseous healing of nondisplaced or displaced distal radial fractures treated with vitamin C compared with placebo. We conclude that administration of vitamin C confers no benefit to patients with a displaced or nondisplaced fracture of the distal aspect of the radius. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology, management, and outcome of sport-related ankle fractures in a standard UK population.

BACKGROUND: The literature on the outcome of sport-related ankle fractures has focused on operatively managed fractures, despite a large proportion being treated nonoperatively. We describe the epidemiology, management, and outcome of acute sport-related ankle fractures in a UK population. METHODS: All sport-related ankle fractures sustained during 2007 to 2008 in the Lothian Population were prospectively collected when patients attended the only adult orthopaedic service in Lothian. Fractures were classified using the Lauge Hansen and the Pott's Classification. The presence of fracture displacement was also recorded. Patients were contacted in February 2011 to ascertain their progress in return to sport. RESULTS: Ninety-six sport-related ankle fractures were recorded in 96 patients. Eighty-four fractures (88%) were followed up at a mean interval of 36 months (range, 30-42). Most common associated sports were soccer (n = 49), rugby (n = 15), running (n = 5), and ice skating (n = 3). The mean time for return to sport was 26 weeks (range, 4-104), the return rate to sport 94%, and the persisting symptom rate 42%. Fifty-two fractures (all nondisplaced) were managed nonoperatively-43 isolated lateral malleolar (30 Weber B, 13 Weber A), 2 isolated medial malleolar, 7 bimalleolar. Forty-four fractures were managed operatively-42 were displaced (2 isolated lateral malleolar, 3 isolated medial malleolar, 18 bimalleolar equivalent, 9 bimalleolar, 3 trimalleolar equivalent, 7 trimalleolar), 2 were un-displaced (2 trimalleolar). The mean times for return to sport were 20 weeks (range, 4-52) for the nonoperative cohort (NOC) and 35 weeks (range, 8-104) for the operative cohort (OC) (P < .001), the return rates to sport were 100% for NOC and 87% for OC (P < .016), and the persisting symptom rates were 17% for NOC and 71% for OC (P < .001). CONCLUSIONS: Nondisplaced ankle fractures in athletes were successfully managed with nonoperative care. They had greater return rates to sport, quicker return times, and lower persisting symptom rates but had less severe injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Oxford shoulder score in a normal population.

BACKGROUND: The function of the asymptomatic normal shoulder may differ according to gender and could also deteriorate with age. This may result in a disparity in the normal Oxford shoulder score (OSS) according to these variables. If a difference were to exist an adjusted OSS, for age and gender, could be calculated from the raw score using the expected normal score. AIM: The aim of this study was to define a normal OSS in an asymptomatic population according to age and gender. MATERIALS AND METHODS: During the study period 202 patients aged from 20 years to 99 years with subjectively asymptomatic shoulders completed an OSS. These patients presented to the study center during a 1 week period for management of disorders out with their shoulder girdle. Patients with a known prior shoulder pathology, injury, or polyarthropathy were excluded. RESULTS: The mean OSS varied according age and gender. There was a significant correlation between age and the OSS, with an increasing score (worse) being associated with older age (r = 0.62, P < 0.0001). The mean OSS for females was 18.8 (12-42, SD 5.4) and for males was 16.3 (12-30, SD 4.5), this difference was significant (P = 0.0001). We propose that a normalized OSS could be calculated as a percentage by the using the expected normal for that patient's age and gender as demonstrated in this study ((raw score/normal score) × 100). CONCLUSION: Our study provides normal data for an urban population presenting to orthopedic services and allows for a relative OSS to be calculated from the raw score.

Elderly pelvic fractures: the incidence is increasing and patient demographics can be used to predict the outcome.

OBJECTIVES: To (1) to determine the incidence of elderly pelvic fractures over the last decade, (2) describe the epidemiology and outcome of patients with pubic rami fractures and compare these to those patients sustaining all other pelvic fractures, and (3) identify independent predictors of length of stay, return to domicile, and 1-year mortality for patients with pubic rami fractures. METHODS: We retrospectively identified 937 elderly patients (≥65 years) with pelvic fractures presenting to the study centre over a 15-year period. Patient demographics, mechanism of injury, and associated fractures were recorded for a defined 2-year period. Outcomes assessed were length of stay, return to original place of domicile, and 1-year mortality. RESULTS: The incidence increased from 7.9 per 100,000 to 13.1 per 100,000. The majority were fragility fractures of the pubic rami (84%). Patients sustaining a pubic rami fracture were older, more likely to be female, less deprived and have sustained an isolated injury by a low-energy mechanism. Patients sustaining a pubic rami fracture were less likely to return to their original place of domicile. Pre-injury independence and mobility, socioeconomic status, associated fractures, energy of injury, and male gender were independent predictors of length of stay, return to original place of domicile, and 1-year mortality. CONCLUSION: The incidence of elderly pelvic fractures is increasing, and fractures of the pubic ramus have different patient demographics compared to other pelvic fractures. Patient demographics could be used to predict: length of stay, return to domicile, and 1-year mortality after a pubic rami fracture. LEVEL OF EVIDENCE: Retrospective prognostic study, Level IV.

Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal?

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.

Nonoperative management of displaced olecranon fractures in low-demand elderly patients.

BACKGROUND: The aim of this study was to document both the short and the long-term outcomes following primary nonoperative management of isolated displaced fractures of the olecranon. METHODS: We identified, from our prospective trauma database, all patients who had been managed nonoperatively for a displaced olecranon fracture over a thirteen-year period. Inclusion criteria included all isolated fractures of the olecranon with >2-mm displacement of the articular surface. The primary short-term outcome measure was the Broberg and Morrey Elbow Score. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: There were forty-three patients with a mean age of seventy-six years (range, forty to ninety-eight years) in the study cohort. A low-energy fall from a standing height accounted for 84% of all injuries, and one or more comorbidities were documented in thirty-eight patients (88%). At a mean of four months (range, 1.5 to ten months) following injury, the mean Broberg and Morrey score was 83 points (range, 48 to 100 points), with 72% of the patients having an excellent or good short-term outcome. No patient underwent surgery for a symptomatic nonunion. At a mean of six years (range, two to fifteen years) postinjury, the mean DASH score was 2.9 points (range, 0 to 33.9 points) and the mean Oxford Elbow Score was 47 points (range, 42 to 48 points); 91% (twenty-one) of twenty-three patients available for follow-up expressed satisfaction with the result of the procedure. CONCLUSIONS: We found satisfactory short-term and long-term outcomes following the nonoperative management of isolated displaced olecranon fractures in older, lower-demand patients.

Changing epidemiology of adult fractures in Scotland.

BACKGROUND: Fracture epidemiology in adults is changing but there is very little information about the rate of change or whether the change affects males and females equally. METHODS: We have compared fracture incidence in two similar populations 50-60 years apart. A study of fractures in Dundee, Scotland and Oxford, England, in 1954-1958, was compared with a similar cohort of fractures in Edinburgh, Scotland, in 2010-2011. Fracture incidence in patients >35 years was recorded in both time periods. RESULTS: The incidence of fractures increased by 50% between the two time periods, although the increase in males was only 5% compared with 85% in females. The spectrum of fractures has changed considerably, and there has been an increase in the incidence of both fragility and non-fragility fractures. Analysis showed an increased incidence of fall-related fractures in all age groups in both males and females. INTERPRETATION: There has been a substantial change in the incidence of fractures in the last 50-60 years. These have been caused by greater longevity and by considerable social and economic changes.