Epidemiology and outcome of fractures in elderly and super-elderly patients

Abstract

Introduction Over the next decade it is predicted that there will be an increase in the elderly (≥65 years old) population within Western society especially those aged 80 years or more (super-elderly). Associated with this there is an anticipated increase in the number of patients presenting with fractures in these age groups. There is a paucity of literature describing the outcome of fractures in the elderly and super-elderly, other than those affecting the hip. Aims To describe the epidemiology and outcome of common fractures in the elderly and super-elderly patients. Methods Two prospective fractures databases were used to describe the epidemiology and change in incidence of fractures sustained by elderly and super-elderly patients over a decade for the same patient population. Case-mix and outcome variables for 1310 super-elderly patients sustaining acute fractures were recorded. A cohort of 318 veryelderly (90+ years) patients was compared with a group of 992 elderly (80-89 years) patients. During a three-year period, a prospective consecutive series of 162 elderly patients that underwent internal fixation for an undisplaced intracapsular hip fracture was collected. An established database of proximal humeral fractures was used to describe epidemiology and outcome of these fractures in the elderly. Two hundred and twenty-eight displaced distal radial fractures in super-elderly patients were retrospectively identified from a prospective database of 4024 distal radial fractures. 937 elderly patients with pelvic fractures presenting to the study centre over a 15-year period were identified. Two hundred and thirty-three tibial diaphyseal fractures were prospectively compiled for 225 elderly patients over a ten-year period. One hundred and nineteen (5.1% of all elderly fractures) elderly patients presented with multiple fractures during a one-year period were used to describe the epidemiology and outcome. Results More than a third of all fractures occur in elderly (≥65 years) patients, of which half occur in super-elderly (≥80 years) patients. The risk of sustaining a fracture was significantly increased for elderly (odds ratio (OR) 2.3) and super-elderly patients (OR 2.7) relative to those aged 15 to 64 years old. More than 90% of fractures in the elderly were sustained after a fall from standing height. There was a significant increase in the incidence for the elderly (2025 vs 2318/105/yr, p<0.0001) and super-elderly (3733 vs 4045/105/yr, p=0.0003) fractures between the years 2000 and 2010. The elderly and super-elderly population increased during this time but so did the number of fractures which increased disproportionally. There was an increased incidence in distal radial, proximal humeral and ankle fractures for the elderly and super-elderly populations. The very-elderly (≥90 years) group accounted for only 0.6% of the overall population, but they represented 4.1% of all fractures and 9.3% of all orthopaedic admissions. Patients in the very-elderly cohort were more likely to require hospital admission, were less likely to return to independent living. Lower American Society of Anesthesiologists (ASA) grade and the presence of posterior tilt (p<0.0001) were significant independent predictors of fixation failure of undisplaced intracapsular hip fracture. More than a quarter of elderly patients sustaining proximal humeral fractures had a poor functional outcome, with those patients not living in their own home (p=0.04), participating in recreational activities (p=0.01), able to perform their own shopping (p<0.001) or ability to dress themselves (p=0.02) being at an increased risk of a poor outcome which was independent of fracture severity (p=0.001). The premanipulation dorsal angulation of distal radial fractures was a significant independent predictor of the degree of improvement in the final dorsal angulation (p<0.001) and ulnar variance (p=0.01). No significant difference was observed in activities of daily living (p=0.28), wrist pain (p=0.14), whether the wrist had returned to its normal level function (p=0.25), grip strength (p=0.31) or range of movement (p=0.41) between the malunion group and the non-malunion group. The incidence of pelvic fractures increased from 7.9/105/yr to 13.1/105/yr, of which the majority were fragility fractures of the pubic rami (84%). 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 one-year mortality. Tibial diaphyseal fractures in the elderly (≥65 years) predominantly occurred in females (73%) after a fall (61%). The overall standardised mortality ratio (SMR) was significantly increased (4.4 p<0.0001) relative to the population at risk and was greatest for elderly female patients (8.1 p<0.0001). These frailer patients had more severe injuries with an increased rate of open fractures (30%) and suffered a greater non-union rate (10%). Distal radial, proximal humeral and pelvic fractures were associated with a significantly (p<0.0001) increased risk of sustaining associated fractures. 4.5% of patients after a simple fall sustained multiple fractures, but due to the frequency of falls in the elderly this mechanism resulted in 80.7% of all multiple fractures. The SMR at one year was significantly greater after sustaining multiple fractures which included fractures of the pelvis, proximal humerus and proximal femur (p<0.001). Conclusion The incidence of elderly and super-elderly fractures increased over the last decade. This increase in incidence was specifically observed for fractures involving the distal radius, proximal humerus, and ankle in the elderly and super-elderly populations. The very-elderly group form a small proportion of the population but are more likely to require hospital admission and are less likely to return to independent living with a longer hospital stay. Lower ASA grade and posterior tilt of the femoral neck were independent predictors of fixation failure of undisplaced intracapsular hip fractures. A poor functional outcome after a proximal humeral fracture was not independently influenced by age and factors associated with social independence were more predictive of outcome. Patients with a high risk of distal radial malunion or poor improvement in the fracture position can be identified pre-manipulation, however malunion does not seem to influence the functional outcome of independent superelderly patients. The incidence of elderly pelvic fractures is increasing, and patient demographics could be used to predict length of stay, return to domicile, and oneyear mortality after a pubic rami fracture. Tibial diaphyseal fractures in the elderly are more common in females after a fall, which are more likely to be open and are associated with a higher prevalence of non-union. There will be financial repercussions associated with the management and ongoing care for these frail elderly patients especially those sustaining multiple fractures, with high admission rates, prolonged length of stay, and the increased level of care needed upon discharge.