Trauma in the elderly: determinants of outcome

Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS)

OBJECTIVE

Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries.

METHODS

This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays.

RESULTS

Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02-1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04-2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06-5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48-5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40-5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30-7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02-4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23-3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95-22.48, p < 0.001) were significant predictors of hospital mortality.

CONCLUSIONS

Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.

Management of Osteoporosis Medication after Osteoporotic Fracture

The aim of this study was to provide helpful information for use in selection of an appropriate medication after osteoporotic fractures through conduct of a literature review. In addition, a review of the recommendations of several societies for prevention of subsequent fractures was performed and the appropriate choice of medication for treatment of atypical femur fractures was examined. Clinical perspective was obtained and an updated search of literature was conducted across PubMed and MEDLINE and relevant articles were selected. The articles were selected manually according to relevance, and the references for identified articles and reviews were also evaluated for relevance. The following areas are reviewed: Commonly prescribed osteoporosis medications: BPs (bisphosphonates), denosumab, and SERMs (selective estrogen receptor modulators) in antiresorptive medications and recombinant human parathyroid hormone teriparatide, recently approved Romosuzumab in anabolic agents, clinical practice guidelines for the management of osteoporosis, osteoporotic fracture, and atypical femur fracture. Most medications for treatment of osteoporosis do not delay fracture healing and the positive effect of teriparatide on fracture healing has been confirmed. In cases where an osteoporotic fracture is diagnosed, risk assessment should be performed for selection of very high-risk patients in order to prevent subsequent fractures, and administration of anabolic agents is recommended.

Mortality related to and functional outcomes of upper cervical spine fractures in the elderly

BACKGROUND

Although the mortality related to hip fracture and osteoporotic vertebral fracture have been reported, few studies have examined the mortality related to atlas and/or axis fractures. The aim of this study was to assess the association between mortality and atlas and/or axis fractures retrospectively and to elucidate the efficacy of surgical treatment.

METHODS

A total of 33 elderly patients who were treated for atlas and/or axis fractures at our institution between January 2012 and December 2018 were included in this study. These patients were divided into two groups: surgical treatment and conservative treatment. Fracture types, comorbidities, neurological status, treatment types, and walking ability at follow-up were reviewed. Mortality was assessed using medical records or via phone interviews.

RESULTS

The mean age at injury was 79.9 ± 8.0 years, and the mean follow-up period was 2.3 years. The overall mortality rates at 1 and 5 years were 21.4% and 48.4%, respectively. During the observation period, 12 (36%) patients died. Twenty-two patients were treated conservatively (14 were treated with a cervical collar, 8 were treated with a halo vest). Surgical procedures included occipital-cervical fixation, osteosynthesis of C2 fractures, C1-2 fixation, and C1-4 fixation using a posterior approach. Surgical treatment correlated with better survival rates. There was no significant difference between the two groups in terms of ambulatory ability and functional recovery.

CONCLUSION

Upper cervical spine fractures appear to have a worse prognosis compared to hip and osteoporotic vertebral fractures. This study indicates the efficacy of surgical treatment for upper cervical spine fractures in the elderly for improving survival prognosis.

Predicting Mortality in Elderly Spine Trauma Patients

STUDY DESIGN

Retrospective analysis on prospectively collected data.

OBJECTIVE

The aim of this study was to construct a clinical prediction model for 90-day mortality in elderly patients with traumatic spine injuries.

SUMMARY OF BACKGROUND DATA

Spine trauma in the elderly population is increasing. Comparing elderly spine trauma patients to younger patients with similar injuries proves challenging due to the extensive comorbidities and frailty found in the elderly. There is a paucity of evidence to predict survival of elderly patients following traumatic spinal injuries.

METHODS

All patients 65+ with spine trauma presenting to a level I trauma center from 2010 to 2019 were reviewed from a prospectively maintained trauma registry. Retrospective chart review was performed to record injury, frailty scores, comorbidities, presence of spinal cord injury, imaging evidence of sarcopenia and osteopenia, mortality, and complications. We preselected 13 variables for our multivariable logistic regression model: hypotension on admission, gender, marital status, age, max Abbreviated Injury Scale, Modified Frailty Index, surgical treatment, hematocrit, white blood count, spinal cord injury, closed head injury, injury level and presence of high energy mechanism. The performance of the prediction model was evaluated using a concordance index and calibration plot. The model was internally validated via bootstrap approach.

RESULTS

Over the 9-year period, 1746 patients met inclusion criteria; 359 (20.6%) patients died within 90 days after presenting with spine trauma. The most important predictors for 90-day mortality were age, hypotension, closed head injury, max Abbreviated Injury Scale and hematocrit. There was an optimism-corrected C-index of 0.77. A calculator was created to predict a personalized mortality risk.

CONCLUSION

The incidence of spine trauma in elderly patients continues to increase. Previous publications described preexisting conditions that imply increased mortality, but ours is the first to develop a predictive calculator. Prospective research is planned to externally validate this model to better determine its predictive value and utility in the clinical setting.

Improved Prediction of Older Adult Discharge After Trauma Using a Novel Machine Learning Paradigm

BACKGROUND

The ability to reliably predict outcomes after trauma in older adults (age ≥ 65 y) is critical for clinical decision making. Using novel machine-learning techniques, we sought to design a nonlinear, competing risks paradigm for prediction of older adult discharge disposition following injury.

MATERIALS AND METHODS

The National Trauma Databank (NTDB) was used to identify patients 65+ y between 2007 and 2014. Training was performed on an enriched cohort of diverse patients. Factors included age, comorbidities, length of stay, and physiologic parameters to predict in-hospital mortality and discharge disposition (home versus skilled nursing/long-term care facility). Length of stay and discharge status were analyzed via competing risks survival analysis with Bayesian additive regression trees and a multinomial mixed model.

RESULTS

The resulting sample size was 47,037 patients. Admission GCS and age were important in predicting mortality and discharge disposition. As GCS decreased, patients were more likely to die (risk ratio increased by average of 1.4 per 2-point drop in GCS, P < 0.001). As GCS decreased, patients were also more likely to be discharged to a skilled nursing or long-term care facility (risk ratio decreased by 0.08 per 2-point decrease in GCS, P< 0.001). The area under curve for prediction of discharge home was improved in the competing risks model 0.73 versus 0.43 in the traditional multinomial mixed model.

CONCLUSIONS

Predicting older adult discharge disposition after trauma is improved using machine learning over traditional regression analysis. We confirmed that a nonlinear, competing risks paradigm enhances prediction on any given hospital day post injury.

Field-Triage, Hospital-Triage and Triage-Assessment: A Literature Review of the Current Phases of Adult Trauma Triage

ABSTRACT

Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.

Postmortem Analysis of Fall Victims According to Age Groups: A Comparative Study

Fall represents an important cause of death and its relation with the population aging evidences the need of a broad analysis considering different aspects associated with its occurrence. The objective of this study was to compare fatal victims due to unintentional fall among adults, young olds, olds, and oldest olds, according to sociodemographic data, characteristics, and severity of the trauma. This study is a cross-sectional, comparative study analyzing autopsy reports of fatal victims due to fall, admitted to the Medical Legal Institute of Sao Paulo, Sao Paulo, Brazil, in 2015. The following age groups were: adults (≥18 and <60 years), young olds (≥60 and <70 years), olds (≥70 and <80 years), and oldest olds (≥80 years). The Pearson's χ, Fisher's exact, Kruskal-Wallis, and Dunn tests were applied to compare the groups, with a significance level of 5%. Regarding the 469 fatalities analyzed (57.8% males, mean age: 71.3 ± 18.2 years), there was a higher frequency of oldest olds (43.5%), ground-level falls (70.1%), femoral fractures (35.0%), and delayed deaths (79.6%) due to posttraumatic complications (57.2%). Adults, young olds, olds, and oldest olds differed significantly (p ≤ .005) in relation to the total of analyzed variables, with a special remark on the differences between the age extremes. High frequencies of femoral fractures and delayed deaths due to complications of treatment in low-severity fall victims, especially those older than 70 years, make it necessary to improve fall prevention programs in the older adults and to create a line of care for this population.

Canadian Study of Health and Aging Clinical Frailty Scale: Does It Predict Adverse Outcomes among Geriatric Trauma Patients?

BACKGROUND

The Canadian Study of Health and Aging Clinical Frailty Scale (CFS) and the laboratory Frailty Index (FI-lab) are validated tools based on clinical and laboratory data, respectively. Their utility as predictors of geriatric trauma outcomes is unknown. Our primary objective was to determine whether pre-admission CFS is associated with adverse discharge destination. Secondary objectives were to evaluate the relationships between CFS and in-hospital complications and between admission FI-lab and discharge destination.

STUDY DESIGN

We performed a 4-year (2011 to 2014) retrospective cohort study with patients 65 years and older admitted to a level I trauma center. Admission FI-lab was calculated using 23 variables collected within 48 hours of presentation. The primary outcome was discharge destination, either adverse (death or discharge to a long-term, chronic, or acute care facility) or favorable (home or rehabilitation). The secondary outcome was in-hospital complications. Multivariable logistic regression was used to evaluate the relationship between CFS or FI-lab and outcomes.

RESULTS

There were 266 patients included. Mean age was 76.5 ± 7.8 years and median Injury Severity Score was 17 (interquartile range 13 to 24). There were 260 patients and 221 patients who had sufficient data to determine CFS and FI-lab scores, respectively. Pre-admission frailty as per the CFS (CFS 6 or 7) was independently associated with adverse discharge destination (odds ratio 5.1; 95% CI 2.0 to 13.2; p < 0.001). Severe frailty on admission, as determined by the FI-lab (FI-lab > 0.4), was not associated with adverse outcomes.

CONCLUSIONS

Pre-admission clinical frailty independently predicts adverse discharge destination in geriatric trauma patients. The CFS may be used to triage resources to mitigate adverse outcomes in this population. The FI-lab determined on admission for trauma may not be useful.

A Turbo Pascal Program to Convert Icd-9Cm Coded Injury Diagnoses into Injury Severity Scores: Icdtoais

Diagnoses of injuries as a result of trauma are commonly coded by means of the International Classification of Diseases (9th rev.) Clinical Modification (ICD-9CM). The Abbreviated Injury Scale (AIS) is frequently employed to assess the severity of injury per body region. The Injury Severity Score (ISS) is an over-all index or summary of the severity of injury. To compute one of these two types of scores the entire medical record of each patient must be examined. The program ICDTOAIS replaces the manual coding or translation between the two scores. The program converts the ICD-9CM coded diagnoses into AIS and ISS scores. The program also computes the maximum AIS (MAXAIS) per body region, enabling the researcher to assess the relative impact of the severity of trauma of different body regions in both morbidity and mortality studies. The program locates invalid ICD-9CM rubrics in the data file. ICDTOAIS may be employed as a program alone or as a procedure in database management systems (e.g., DBase III plus, DBase IV, or the different versions of FOXPRO). The program is written in Turbo Pascal, Version 6.

[Elderly victims of trauma: preexisting conditions, medications taken at home and indexes of trauma]

The objective was to identify the sociodemographic profile of the elderly victims of trauma, to characterize preexisting conditions and medications taken at home, and to calculate indices of trauma and clinical outcomes. This is a retrospective and exploratory analysis from a database of a general hospital between 2008 and 2010. There were studied 131 elderly, mean age 69.9 years, 73.3% male, 55.1% married, 54.7% retired, 65.6% had preexisting conditions and 48.9% used drugs at home. There was a representative number of falls (31.3%), followed by running over (28.2%), with the head/neck region being the most affected (59.5%). Moderate trauma prevailed (44.3%), with conditions of survival after the event (80.2%). There was an association between mechanism of trauma and preexisting disease (p=0.01) and between mechanism of trauma and sex (p=0.03). The knowledge of the variables involved with the elderly victims of trauma enables healthcare professionals to plan preventive measures aimed at improving the assistance.

CT screened arterial calcification as a risk factor for mortality after trauma

Background

Arterial calcification on Computerised Tomography (CT) is a marker of cardiovascular disease. It is predictive of future adverse cardiac events and mortality in many disease states. The incidence of arterial disease and its impact on outcomes of the injured is not known. The objectives of this study were to describe the incidence of arterial calcification in trauma patients, and establish its impact on mortality.

Methods

A retrospective cohort study of all injured patients aged over 45 years presenting to a major trauma centre over a 34-month period. The presence and quantity of coronary, aortic and abdominal arterial calcification on admission CT scans of the chest, abdomen and pelvis was established, and the association between cardiovascular disease and in-hospital mortality following trauma was determined.

Results

Five hundred ninety-one patients were included in the study. Cardiac calcium was visible on 432 (73 %) scans, and abdominal arterial calcification on 472 (79.9 %). Fifty (8.5 %) patients died. Patients with Superior Mesenteric (SMA) and Common Iliac Artery calcification had a significantly higher mortality than those without (p < 0.01).

In multivariarate analysis, only SMA calcification was independently associated with mortality (OR 2.462, 95 % CI 1.08–5.60, p = 0.032). Coronary calcium demonstrated no independent statistical relationship with death (Left Anterior Descending Artery OR 1.189, 95 % CI 0.51–2.78, Circumflex OR 1.290, 95 % CI 0.56–2.98, Right Coronary Artery OR 0.483, 95 % CI 0.21–1.10).

Discussion

This study has demonstrated that the identification of arterial calcification on admission CT scans of trauma patients is possible. Calcification was common, and present in around three-quarters of injured individuals over the age of 45 years. SMA calcium was an independent predictor of mortality. However, whilst the presence of arterial calcium demonstrated a tendency towards lower survival, this association was not significant in other territories, including the coronary arteries. Future studies should investigate further the association and pathophysiology linking SMA disease and mortality in trauma, in addition to the relationship between longer tem survival, adverse cardiac events and arterial calcification in injured patients.

Conclusions

Arterial calcification can be reliably identified on trauma CT scans, and is common in injured patients. Abdominal vascular calcification appears to be a better predictor of mortality than coronary artery disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0317-1) contains supplementary material, which is available to authorized users.

The Impact of Age upon Contingency Planning for Multiple-casualty Incidents Based on a Single Center's Experience

Introduction Trauma patients in the extremes of age may require a specialized approach during a multiple-casualty incident (MCI). Problem The aim of this study was to examine the type of injuries encountered in children and elderly patients and the implications of these injuries for treatment and organization.

METHODS

A review of medical record files of patients admitted in MCIs in one Level II trauma center was conducted. Patients were classified according to age: children (≤12 years), adults (between 12-65 years), and elders (≥65 years).

RESULTS

The files of 534 were screened: 31 (5.8%) children and 54 (10.1%) elderly patients. One-third of the elderly patients were either moderately or severely injured, compared to only 6.5% of the children and 11.1% of the adults (P<.001). Elderly patients required more blood transfusions (P=.0001), more computed tomography imaging (P=.0001), and underwent more surgery (P=.0004). Elders were hospitalized longer (P=.0003). There was no mortality among injured children, compared to nine (2.0%) of the adults and seven (13.0%) of the elderly patients (P<.0001). All the adult deaths occurred early and directly related to their injuries, whereas most of the deaths among the elderly patients (four out of seven) occurred late and were due to complications and multiple organ failure.

CONCLUSIONS

Injury at an older age confers an increased risk of complications and death in victims of MCIs. Ashkenazi I , Einav S , Olsha O , Turegano-Fuentes F , Krausz MM , Alfici R . The impact of age upon contingency planning for multiple-casualty incidents based on a single center's experience. Prehosp Disaster Med. 2016;31(5):492-497.

Comorbidity-Polypharmacy Score as Predictor of Outcomes in Older Trauma Patients: A Retrospective Validation Study

INTRODUCTION

Traditional injury severity assessment is insufficient in estimating the morbidity and mortality risk for older (≥45 years) trauma patients. Commonly used tools involve complex calculations or tables, do not consider all comorbidities, and often rely on data that are not available early in the trauma patient's hospitalization. The comorbidity-polypharmacy score (CPS), a sum of all pre-injury medications and comorbidities, was found in previous studies to independently predict morbidity and mortality in this older patient population. However, these studies are limited by relatively small sample sizes. Consequently, we sought to validate previous research findings in a large, administrative dataset.

METHODS

A retrospective study of patients ages≥45 years was performed using an administrative trauma database from St. Luke's University Hospital's Level I Trauma Center. The study period was from 1 January 2008 to 31 December 2013. Abstracted data included patient demographics, injury mechanism and severity [injury characteristics and severity score (ISS)], Glasgow coma scale (GCS), hospital and intensive care unit lengths of stay (HLOS and ILOS, respectively), morbidity, post-discharge destination, and in-hospital mortality. Univariate analyses were conducted with mortality, all-cause morbidity, and discharge destination as primary end-points. Variables reaching statistical significance (p≤0.20) were included in a multivariate logistic regression model. Data are presented as adjusted odds ratios (AORs), with p<0.05 denoting statistical significance.

RESULTS

A total of 5863 patient records were analyzed. Average patient age was 68.5±15.3 years (52% male, 89% blunt mechanism, mean GCS 14.3). Mean HLOS and ILOS increased significantly with increasing CPS (p<0.01). Independent predictors of mortality included age (AOR 1.05, p<0.01), CPS (per-unit AOR 1.08, p<0.02), GCS (AOR 1.43 per-unit decrease, p<0.01), and ISS (per-unit 1.08, p<0.01). Independent predictors of all-cause morbidity included age (AOR 1.02, p<0.01), GCS (AOR per-unit decrease 1.08, p<0.01), ISS (per-unit AOR 1.09, p<0.01), and CPS (per-unit AOR 1.04, p<0.01). CPS did not independently predict need for discharge to a facility.

CONCLUSIONS

This study confirms that CPS is an independent predictor of all-cause morbidity and mortality in older trauma patients. However, CPS was not independently associated with need for discharge to a facility. Prospective multicenter studies are needed to evaluate the use of CPS as a predictive and interventional tool, with special focus on correlations between specific pre-existing conditions, pharmacologic interactions, and morbidity/mortality patterns.

Role of trauma team activation in poor outcomes of elderly patients

INTRODUCTION

Elderly trauma patients suffer worse outcomes than younger patients. Trauma team activation (TTA) improves outcomes in younger patients. It is unclear whether decreased TTA effectiveness or under-activation in elderly patients could contribute to their poor outcomes.

MATERIAL AND METHODS

This retrospective registry study examined all adult trauma patients admitted to a level 1 trauma center over 2 y. Analyses tested (1) whether age modifies the effect of TTA on poor outcomes, (2) whether elderly patients with severe injury were less likely to receive TTA than younger patients, and (3) which early variables were associated with poor outcomes among elderly patients who did not receive TTA.

RESULTS

The study included 10,033 patients. The adjusted relative risk from TTA for all ages was 0.48 (95% confidence interval (CI) = 0.34-0.68, P < 0.001), and there was no effect modification by age (interaction term P value, 0.171). The adjusted odds ratio for the young was 0.49 (95% CI = 0.26-0.91, P = 0.024) and for the elderly was 0.80 (95% CI = 0.53-1.20, P = 0.282). The adjusted odds ratio for lack of TTA associated with old age was 1.37 (95% CI = 1.12-1.69, P = 0.003). The strongest associations with poor outcomes were seen with low heart rate, low minimum blood pressure, high injury severity score, and high Glasgow coma score.

CONCLUSIONS

Lack of TTA could contribute to elderly patients' poor outcomes. Clinicians should not be reassured by normal heart rates and should be wary of even transiently lower blood pressures in the elderly. A large cohort study is needed to identify which additional elderly patients could benefit from TTA.

Occupant and Crash Characteristics of Elderly Subjects With Thoracic and Lumbar Spine Injuries After Motor Vehicle Collisions

STUDY DESIGN

Retrospective study of a prospectively gathered database.

OBJECTIVE

To investigate the incidence and pattern of thoracic and lumbar (T and L) spine injuries among elderly subjects involved in motor vehicle collision (MVC).

SUMMARY OF BACKGROUND DATA

Adults age 65 and older currently constitute more than 16% of all licensed drivers. Despite driving less than the young, older drivers are involved in a higher proportion of crashes. Notwithstanding the safety features in modern vehicles, 15.8% to 51% of all T and L spine injuries result from MVCs.

METHODS

Crash Injury Research and Engineering Network database is a prospectively maintained, multicentered database that enrolls MVC occupants with moderate-to-severe injuries. It was queried for T and L spine injuries in subjects 65 and older. 142 Crash Injury Research and Engineering Network files for all elderly individuals were reviewed for demographic, injury, and crash data. Each occupant's T and L injury was categorized using a modified Denis classification.

RESULTS

Of 661 elderly subjects, 142 (21.48%) sustained T and L spine injuries. Of the 102 major injuries, there were 63 compression, 20 burst and 12 extension fractures. Seatbelt use predisposed elderly subjects to compression and burst fractures, whereas seatbelt and airbag use predisposed to burst fractures. Deployment of airbags without seatbelt use appeared to predispose elderly subjects to neurological injury, higher Injury Severity Score, and higher mortality. Occupants using 3-point belts who had airbags deployed during the collision had the lowest rates of fatality and neurological injury.

CONCLUSION

T and L spine injuries in the elderly are not uncommon despite restraint use. Whereas seatbelts used alone and in conjunction with airbag deployment reduced fatalities and neurological injuries in the elderly, deployment of airbags in occupants without seatbelts predisposed to more severe injury.

Impact of age on the clinical outcomes of major trauma

PURPOSE

In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients.

METHODS

Review of the literature.

RESULTS

Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality.

CONCLUSION

The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

Mortality in elderly patients following operative and nonoperative management of odontoid fractures

STUDY DESIGN

Retrospective matched cohort study.

OBJECTIVE

To compare mortality in elderly patients with odontoid fractures after operative and nonoperative treatment. In addition, to evaluate potential factors that may increase the risk of mortality in the geriatric population after odontoid fracture.

SUMMARY OF BACKGROUND DATA

Odontoid fractures represent the most common cervical spine fracture in patients over 70. In this population controversy exists as to the optimal treatment of odontoid fractures, especially type II fractures.

METHODS

A retrospective review of all odontoid fractures in patients 75 years of age or older at our institution from 1996 to 2010 was performed. Comorbidities were stratified using the Charlson comorbidity index. Mortality was determined at 3 months, 1, and 5 years.

RESULTS

A total of 96 patients were identified of which 75 met inclusion criteria. The average age of patients included was 82.3 years. The average Charlson comorbidity score for those operated on (2.37) was not significantly different from the nonoperative group (2.46), (P=0.45). At 3 months the operative group had a significantly lower mortality rate than the nonoperative group (P=0.024). There was no significant difference in 1-year (P=0.42) or 5-year (P=0.21) mortality between the operative and nonoperative cohorts. Of the patients treated nonoperatively, those who died within 3 months of treatment had a significantly higher Charlson score (3.98) than those who survived (2.14). Patients who survived at least 1 year after surgery had a significantly lower Charlson score (1.53) than those who died (3.22) within that time frame after surgery (P=0.05).

CONCLUSIONS

There was no significant difference between 1- and 5-year mortality in patients treated operatively or nonoperatively. Regardless of treatment Charlson score had a significant impact on mortality. Age significantly affected mortality in patients treated surgically.

Massive blood transfusions post trauma in the elderly compared to younger patients

INTRODUCTION

Older age and blood transfusion have both been independently associated with higher mortality post trauma and the combination is expected to be associated with catastrophic outcomes. Among patients who received a massive transfusion post trauma, we aimed to investigate mortality at hospital discharge of patients ≥65 years old and explore variables associated with poor outcomes.

METHODS

A retrospective review of registry data on all major trauma patients presenting to a level I trauma centre between 2006 and 2011 was conducted. Mortality at hospital discharge among patients ≥65 years old was compared to the younger cohort. A multivariable logistic regression model was constructed to determine independent risk-factors for mortality among older patients.

RESULTS

There were 51 (16.4%) patients of age ≥65 years who received a massive transfusion. There were 20 (39.2%) deaths, a proportion significantly higher than 55 (21.1%) deaths among younger patients (p<0.01). Pre-hospital GCS, the presence of acute traumatic coagulopathy and higher systolic blood pressure on presentation were independently associated with higher mortality. Age and volume of red cells transfused were not significantly associated with higher mortality.

CONCLUSIONS

Survival to hospital discharge was demonstrated in elderly patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality. Restrictive resuscitation or transfusion on the basis of age alone cannot be supported. Early aggressive resuscitation of elderly trauma patients along specific guidelines directed at the geriatric population is justified and may further improve outcomes.

High-energy femur fractures increase morbidity but not mortality in elderly patients

BACKGROUND

Trauma centers are projected to have an increase in the number of elderly patients with high-energy femur fractures. Greater morbidity and mortality have been observed in these patients. Further clarification regarding the impact of high-energy femur fractures is necessary in this population.

QUESTIONS/PURPOSES

Our purpose was to assess the influence of high-energy femur fractures on mortality and morbidity in patients 60 years and older. Specifically, we asked (1) if the presence of a high-energy femur fracture increases in-hospital, 6-month, and 1-year mortality in patients 60 years and older, and (2) if there is a difference in morbidity (number of complications, intensive care unit [ICU] and total hospital length of stay, discharge disposition, accompanying fractures, and surgical intervention) between patients 60 years and older with and without high-energy femur fractures.

METHODS

A retrospective review of 242 patients was performed. Patients with traumatic brain injury or spine injury with a neurologic deficit were excluded. A control group, including patients admitted secondary to high-energy trauma without femur fractures, was matched by gender and Injury Severity Score (ISS). In-hospital mortality, 6-month and 1-year mortality, complications, ICU and total hospital length of stay, discharge disposition, accompanying fractures, surgical intervention, and covariates were recorded. Statistical analyses using Fisher's exact test, ANOVA, Kaplan-Meier estimates, and Cox regression models were performed to show differences in mortality (in-hospital, 6-month, 1-year), complications, length of ICU and total hospital stay, discharge disposition, surgical intervention, and accompanying fractures between elderly patients with and without femur fractures. The average ages of the patients were 72.8 years (± 9 years) in the femur fracture group and 71.8 years (± 9 years) in the control group. Sex, age, ISS, and comorbidities were homogenous between groups.

RESULTS

In-hospital (p = 0.45), 6-month (p = 0.79), and 1-year mortality (p = 0.55) did not differ in patients with and without high-energy femur fractures. Elderly patients with high-energy femur fractures had an increased number of complications (p = 0.029), longer total hospital length of stay (p = 0.039), were discharged more commonly to rehabilitation centers (p < 0.005), had more accompanying long bone fractures (p = 0.002), and were more likely to have surgery (p < 0.001). Average ICU length of stay was similar between the two groups (p = 0.17).

CONCLUSIONS

High-energy femur fractures increased morbidity in patients 60 years and older; however, no increase in mortality was observed in our patients. Concomitant injuries may play a more critical role in this population. Additional studies are necessary to clarify the role of high-energy femur fracture mortality in this age group.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Predictors for mortality in elderly patients with cervical spine injury: a systematic methodological review

STUDY DESIGN

Systematic methodological review.

OBJECTIVE

Identify predictors for cervical spine injury (CSI) mortality in elderly patients by reviewing the available literature.

SUMMARY OF BACKGROUND DATA

The proportion of active elderly individuals in society is increasing. This population is at high risk for CSI mortality. The results of studies identifying predictors for CSI mortality in the elderly population are often inconclusive or even conflicting. Currently, there is no set of predictors that can adequately identify and describe CSI mortality risk for the elderly. Thus, we performed a systematic review to identify the predictors for mortality in elderly patients with CSI.

METHODS

We performed searches in the MEDLINE, EMBASE, ScienceDirect, and OVID databases (articles published prior to May 2012) for noninterventional studies that evaluated predictors for CSI mortality in the elderly. Only those observational studies with eligible data were included. Study quality was assessed using a modified quality assessment tool that was designed previously for an observational study. Study outcomes were combined with study quality scores using a best-evidence synthesis model.

RESULTS

Twenty-three observational studies involving 2325 patients were included. These studies were published between 1993 and 2011. According to the quality assessment criteria, 8 studies were of high quality, 11 studies were of moderate quality, and 4 studies were of low quality. We identified 3 strong evidence predictors for CSI mortality, including pre-existing comorbidities, spinal cord injury, and age. We also identified 3 moderate evidence predictors, 7 limited evidence predictors and 1 conflicting evidence predictor.

CONCLUSION

Although there is no conclusive evidence regarding the mortality of elderly patients with CSI, these data provide information that can help us to make recommendations and to counsel patients and their families. Special attention should be paid to the 3 strong predictors. Further studies will be required to validate these predictors.

Recommendations for Uniform Reporting of Data following Major Trauma — The Utstein Style: An Initiative

The document is published in collaboration with the following organisations: the European Society of Emergency Medicine (Leuven); the European Resuscitation Council (Antwerpen); the Air Medical Physician Association (Salt Lake City, US); the German Interdisciplinary Association of Critical Care Medicine; and the German Society of Anaesthesiology and Intensive Care. The document is to be published jointly in the following journals: 1) Trauma Care (ITACCS); 2) Resuscitation; 3) Prehospital and Disaster Medicine; 4) European Journal of Emergency Medicine; 5) Trauma and Emergency Medicine Journal (SA); 6) Emergency Medicine(Norway); 7) JEUR; and 8) Notfall und Rettungsmedizin (Germany).

Development of statewide geriatric patients trauma triage criteria

INTRODUCTION

The geriatric population is unique in the type of traumatic injuries sustained, physiological responses to those injuries, and an overall higher mortality when compared to younger adults. No published, evidence-based, geriatric-specific field destination criteria exist as part of a statewide trauma system. The Trauma Committee of the Ohio Emergency Medical Services (EMS) Board sought to develop specific criteria for geriatric trauma victims.

METHODS

A literature search was conducted for all relevant literature to determine potential, geriatric-specific, field-destination criteria. Data from the Ohio Trauma Registry were used to compare elderly patients, defined as age >70 years, to all patients between the ages of 16 to 69 years with regards to mortality risk in the following areas: (1) Glasgow Coma Scale (GCS) score; (2) systolic blood pressure (SBP); (3) falls associated with head, chest, abdominal or spinal injury; (4) mechanism of injury; (5) involvement of more than one body system as defined in the Barell matrix; and (6) co-morbidities and motor vehicle collision with one or more long bone fracture. For GCS score and SBP, those cut-off points with equal or greater risk of mortality as compared to current values were chosen as proposed triage criteria. For other measures, any criterion demonstrating a statistically significant increase in mortality risk was included in the proposed criteria.

RESULTS

The following criteria were identified as geriatric-specific criteria: (1) GCS score <14 in the presence of known or suspected traumatic brain trauma; (2) SBP <100 mmHg; (3) fall from any height with evidence of traumatic brain injury: (4) multiple body-system injuries; (5) struck by a moving vehicle; and (6) the presence of any proximal long bone fracture following motor vehicle trauma. In addition, these data suggested that elderly patients with specific co-morbidities be given strong consideration for evaluation in a trauma center.

CONCLUSIONS

The state of Ohio is the first state to develop evidence-based geriatric-specific field-destination criteria using data from its state-mandated trauma registry. Further analysis of these criteria will help determine their effects on over-triage and under-triage of geriatric victims of traumatic injuries and the impact on the overall mortality in the elderly.

Epidemiology of fractures in patients from small towns in Ceará treated by the SUS

Objective

To scientifically prove the high number of patients with fractures coming from the small towns of the State of Ceará treated with surgery by the SUS (the Brazilian State healthcare system) in Fortaleza.

Methods

A transversal, prospective, descriptive study was carried out involving 1694 patients treated by the SUS in Fortaleza, from August 2006 to March 2007, in four public hospitals and three private hospitals.

Results

38.78% of the patients came from small towns, and their ages ranged from 1 to 97 years old. The majority were single, male adults. The most common mechanism of injury was traffic accidents, accounting for 30.4% of all the cases. The forearm was the body segment most operated on, corresponding to 19%.

Conclusions

These results suggest there is a need for preventive measures, such as public traffic safety awareness campaigns, in order to reduce accidents. We have also verified the importance of investments aimed at developing the Traumatology Emergency services in the small towns of Ceará. Level of evidence II, Transversal, Prospective Study (Lower quality prospective study).

Obesity in trauma patients: correlations of body mass index with outcomes, injury patterns, and complications

Current understanding of the effects of obesity on trauma patients is incomplete. We hypothesized that among older trauma patients, obese patients differ from nonobese patients in injury patterns, complications, and mortality. Patients older than 45 years old presenting to a Level I trauma center were included in this retrospective database analysis (n = 461). Body mass index (BMI) groups were defined as underweight less than 18.5 kg/m(2), normal 18.5 to 24.9 kg/m(2), overweight 25.0 to 29.9 kg/m(2), or obese greater than 30 kg/m(2). Injury patterns, complications, and outcomes were analyzed using univariate analyses, multivariate logistic regression, and Kaplan-Meier survival analysis. Higher BMI is associated with a higher incidence of torso injury and proximal upper extremity injuries in blunt trauma (n = 410). All other injury patterns and complications (except anemia) were similar between BMI groups. The underweight (BMI less than 18.5 kg/m(2)) group had significantly lower 90-day survival than other groups (P < 0.05). BMI is not a predictor of morbidity or mortality in multivariate analysis. Among older blunt trauma patients, increasing BMI is associated with higher rates of torso and proximal upper extremity injuries. Our study suggests that obesity is not an independent risk factor for complications or mortality after trauma in older patients. Conversely, underweight trauma patients had a lower 90-day survival.

Type II odontoid fractures of the cervical spine: do treatment type and medical comorbidities affect mortality in elderly patients?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the influence of age, comorbidities, and treatment type on mortality in elderly patients with acute Type II odontoid fractures.

SUMMARY OF BACKGROUND DATA

Prior studies have documented increased morbidity and mortality among geriatric patients sustaining odontoid fractures. However, there is limited data regarding the effect of patient age, medical comorbidities, and treatment selection on mortality after Type II odontoid (C2) fractures in the elderly.

METHODS

An institutional registry was used to identify all Type II odontoid fractures sustained by patients aged 65 and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, and comorbidities were abstracted from medical records. Mortality was ascertained using the National Death Index. Risks of mortality and their associated 95% confidence intervals (CIs) were calculated at 3 months, 1 year, 2 years, and 3 years. Multivariable Cox proportional hazard regression was used to evaluate independent factors affecting mortality stratified by age (65-74 years, 75-84 years, ≥ 85 years) and treatment type (operative or nonoperative treatment, and halo or collar immobilization).

RESULTS

Of 156 patients identified with Type II odontoid fracture, the average age was 82 years (SD = 7.8; Range: 65-101). One hundred and twelve patients (72%) were treated nonoperatively. At 3 years postinjury, there was a 39% (95% CI: 32-47) mortality rate for the entire cohort. Mortality for the operative group was 11% (95% CI: 2-21) at 3 months and 21% (95% CI: 9-32) at 1 year compared with 25% (95% CI: 17-33) at 3 months and 36% (95% CI: 27-45) at 1 year in the nonoperative group. The Cox regression model showed that the protective effect of surgery was seen in patients aged 65 to 74 years, in whom the hazard ratio associated with surgery for mortality after odontoid fracture was 0.4 (95% CI: 0.1-1.5). Those aged 75 to 84 years had a hazard ratio of 0.8 (95% CI: 0.3-2.3), and patients 85 years or older had a hazard ratio of 1.9 (95% CI: 0.6-6.1; P value for interaction between age and treatment = 0.09) with operative treatment having a protective effect in patients aged 65 to 74 years.

CONCLUSION

In a cohort of elderly patients, Type II odontoid fractures were associated with a high rate of mortality, regardless of intervention.

Mortality in elderly patients with hyperostotic disease of the cervical spine after fracture: an age- and sex-matched study

BACKGROUND CONTEXT

Several reports indicate that patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) have increased mortality after cervical spine fractures. However, outcomes of the fractured hyperostotic cervical spine are incompletely described, and there are limited data regarding the covariable effects of patient age and medical comorbidities on mortality.

PURPOSE

To determine mortality associated with cervical fractures in patients with hyperostotic disease.

STUDY DESIGN

Retrospective case-control study.

PATIENT SAMPLE

Forty-three patients identified through a registry as having fractures of the cervical spine in the setting of hyperostotic disease. These patients were matched to 43 controls who did not carry the diagnosis of hyperostotic disease.

OUTCOME MEASURES

Mortality at 3 months and 1, 2, and 3 years after fracture.

METHODS

An institutional database was used to identify all cervical fractures sustained by patients aged 65 years and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, presence of AS or DISH, and comorbidities were abstracted from medical records and radiographs. Mortality was ascertained using the National Death Index. Patients with AS or DISH were matched to controls who did not carry the diagnosis of hyperostotic disease. Risks of mortality were calculated at 3 months, 1 year, 2 years, and 3 years. Kaplan-Meier methods, logistic regression analysis, the two independent sample t test, and the Fisher exact test were used to compare mortalities between the two groups. Statistical significance was determined as p values <.05.

RESULTS

Forty-three patients were identified as having fractures in the setting of hyperostotic disease of the cervical spine. Twenty-seven individuals had DISH, and 16 had AS. The average age of both the study group and controls was 80 years, with an age range of 68 to 94. There was no significantly increased risk of mortality between the overall study group and control group at 3 months (p=.20), 1 (p=.22), 2 (p=.15), or 3 years (p=.50) after injury. Compared with controls, subgroup analysis of patients with AS showed a statistically increased risk of mortality at 3 months (p<.01) and at 1 and 2 years (p<.01 at both time points). When compared with individuals with DISH, those with AS had an increased risk of mortality at time points up to 2 years after fracture. Patients with DISH did not have an increased mortality risk at any time point when compared with controls.

CONCLUSIONS

The effect of fracture on mortality appears to be greatest in those with AS. Patients with DISH did not demonstrate an increased risk of mortality compared with age- and sex-matched controls. Future studies of patients with hyperostotic disease should analyze patients with DISH and AS separately instead of as a single homogenous group.

LEVEL OF EVIDENCE

Level IV.

The effect of bone morphogenetic protein-2, bone morphogenetic protein-7, parathyroid hormone, and platelet-derived growth factor on the proliferation and osteogenic differentiation of mesenchymal stem cells derived from osteoporotic bone

INTRODUCTION

It has been previously shown that in patients with osteoporosis, mesenchymal stem cell (MSC) growth rate and osteogenic potential is decreased contributing to inferior fracture consolidation. The aim of this study was to investigate the effect of bone morphogenetic protein-2 (BMP-2), BMP-7, parathyroid hormone (PTH), and platelet-derived growth factor (PDGF) on proliferation and osteogenic differentiation of MSCs derived from patients with osteoporosis.

MATERIALS AND METHODS

Trabecular bone was obtained from 10 patients (four males, mean age 76 years) with lower extremity osteoporotic fractures. MSCs were isolated by enzymatic digestion. Functional assays of proliferation and osteogenic differentiation were performed under the influence of a wide range of concentrations of BMP-2, BMP-7, PTH, and PDGF-BB. Proliferation was assessed using CFU-F and XTT assays. Osteogenic differentiation was assessed by alkaline phosphatase activity and total calcium production.

RESULTS

MSC proliferation was found to be stimulated by supplementation with BMP-7 and PDGF-BB, whereas BMP-2 and PTH had little effect. The largest increase in proliferation rate was observed after administration 100 ng/mL of BMP-7. All four molecules induced alkaline phosphatase activity and calcium production in growing osteoblasts with a dose-dependent effect noted. BMP-2 and BMP-7 at their highest studied concentration (100 ng/mL) produced a threefold increase in the osteogenic potential of MSCs.

CONCLUSION

BMP-7, BMP-2, PTH, and PDGF-BB were observed to have a positive effect on osteogenic differentiation of MSCs. BMP-7 and PDGF-BB (in high doses) could be considered most potentially advantageous because they enhance both proliferation and osteogenic differentiation of MSCs derived from elderly osteoporotic bone.

Characteristics of elderly Japanese patients with severe burns

In this study, we report the clinical characteristics of elderly Japanese patients with severe burns. We studied the clinical features of 76 adult patients with severe burns, 35 of whom (46.1%) were ≥65 years old. We evaluated the characteristics of patients with respect to each type of burn. In addition, we studied the rate of death and survival in the elderly and also between the elderly and non-elderly patients. The following parameters were either assessed or compared between the elderly and non-elderly: gender, average age, vital signs (Glasgow Coma Scale, systolic blood pressure, heart rate and respiratory rate) and PaO(2)/FiO(2) (P/F) ratio at admission, cause of burn and a history of physical or psychiatric disease. Further, we investigated whether the burn was caused by attempting suicide and determined the percent total body surface area (%TBSA), second- and third-degree burn area, burn index (BI), prognostic burn index (PBI), presence of tracheal burns, presence of alcohol intoxication and overdose poisoning, presence of tracheal intubation, outcome and cause of death. The male:female ratio of the elderly patients was 17:18 (average age, 78.1 (8.2) years). Burns were mostly caused by flame (26/35), followed by scalding (8/35). Ten patients had attempted suicide. The %TBSA, second-degree burn area, third-degree burn area, BI and PBI, respectively were 46.6% (26.7%), 15.3% (19.0%), 35.6% (26.0%), 41.1 (25.2) and 119.2 (25.9). Of the 35 patients, 23 died. The notable characteristics of the elderly patients who died were flame as the cause of the burns: high %TBSA, BI and PBI, and a high rate of tracheal intubation. Elderly patients constituted approximately 45% of our study population. Most burns were caused by flames. The incidence of accidental bathtub-related burns was higher and that of suicide attempts was lower in the elderly patients, as compared with the non-elderly patients. Severe burns were fatal for elderly patients. Therefore, elderly Japanese people should be educated on how to prevent non-intentional burns.

Mortality in elderly patients after cervical spine fractures

BACKGROUND

Despite an increased risk of cervical spine fractures in older patients, little is known about the mortality associated with these fractures and there is no consensus on the optimal treatment. The purposes of this study were to determine the three-month and one-year mortality associated with cervical spine fractures in patients sixty-five years of age or older and to evaluate potential factors that may influence mortality.

METHODS

We performed a retrospective review of all cervical spine fractures in patients sixty-five years of age or older from 1991 to 2006 at two institutions. Information regarding age, sex, race, treatment type, neurological involvement, injury mechanism, comorbidity, and mortality were collected. Overall risk of mortality and mortality stratified by the above factors were calculated at three months and one year. Cox proportional-hazard regression was performed to identify independent correlates of mortality.

RESULTS

Six hundred and forty patients were included in our analysis. The mean age was eighty years (range, sixty-five to 101 years). Two hundred and ninety-four patients (46%) were male, and 116 (18%) were nonwhite. The risk of mortality was 19% at three months and 28% at one year. The effect of treatment on mortality varied with age at three months (p for interaction = 0.03) but not at one year (p for interaction = 0.08), with operative treatment being associated with less mortality for those between the ages of sixty-five and seventy-four years. A higher Charlson comorbidity score, male sex, and neurological involvement were all associated with increased risk of mortality.

CONCLUSIONS

Operative treatment of cervical spine fractures is associated with a lower mortality rate at three months but not at one year postoperatively for patients between sixty-five and seventy-four years old at the time of fracture.

Fractures of the hip and osteoporosis: the role of bone substitutes

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised. Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.

Increased Fatalities and Cost of Traumatic Injuries in Elderly Pedestrians in Hawaii: A Challenge for Prevention and Outreach

This study was carried out to evaluate and quantify risk factors, mechanisms, and cost of traumatic injuries in Hawaii's elderly and to identify potential preventive strategies. A retrospective review of a prospective database of patients admitted to the only Trauma Center in the Pacific Basin, between January 2000 and December 2001, was conducted. Of 2634 trauma admissions, 11% were ≥65 years of age. Mechanisms of injury included falls, motor vehicle crashes (MVCs), pedestrians hit by automobiles, and miscellaneous causes. The incidence of elderly pedestrians hit by automobiles in Hawaii is higher than previously reported. Hospital mortality rate was highest for the pedestrian hit group, followed by falls, and then MVCs. The pedestrian hit group consumed the largest quantity of resources and MVCs the least. Given the high mortality rate and associated resource consumption in the pedestrian hit group, it would be appropriate to give priority to this group while developing preventive measures for this age group.

The use of calcium sulfate and calcium phosphate composite graft to augment screw purchase in osteoporotic ankles

BACKGROUND

Screws placed in the distal fibula may not have satisfactory purchase during internal fixation of an osteoporotic ankle fracture. Tibia-pro-fibula screws that extend from the fibula into the distal tibial metaphysis provide additional purchase. The purpose of this study was to investigate if purchase of these screws can be enhanced further by injecting calcium sulfate and calcium phosphate composite graft into the drill holes prior to insertion of the screws.

MATERIALS AND METHODS

Bone density was quantified using a DEXA scan in paired cadaver legs. One leg from each pair was randomly selected for injection of composite graft into the screw holes before insertion of the screws. Two screws were inserted through the fibula into the distal tibial metaphysis in each leg, at the level of the syndesmosis under fluoroscopy in a standardized fashion in an MTS machine.

RESULTS

After testing 4 pairs of cadaver legs, a statistically significant difference was noted in displacement (p = 0.018 distal, p = 0.0093 proximal), failure load, (p = 0.0185 distal, p = 0.0238 proximal), and failure energy (p = 0.0071 distal, p = 0.0115 proximal) between augmented and non-augmented screws, with the augmented screws being considerably stronger.

CONCLUSION

Screws augmented with composite graft provide significantly greater purchase in an osteoporotic fibular fracture model.

CLINICAL RELEVANCE

Composite graft augmented screws inserted into the distal tibia from the fibula may enhance the stability of internal fixation of an osteoporotic ankle fracture. This may enable earlier weightbearing and return to function which is important in elderly patients.

Epidemiologia das lesões traumáticas de alta energia em idosos

O aumento proporcional de idosos na população mundial associado à melhoria nas condições de saúde e suporte preventivo para essa faixa etária, permite forma de vida mais ativa, expondo-os a risco mais elevado de acidentes e traumas de alta energia. Esses pacientes têm características fisiológicas, doenças associadas, padrão comportamental e complicações pós-operatórias que levam a resposta sistêmica diferente dos demais grupos etários. Esse trabalho avaliou prospectivamente 28 pacientes com idade superior a 65 anos - 16 mulheres e 12 homens. O mecanismo de trauma mais prevalente foi atropelamento, resultando principalmente, em fraturas dos membros inferiores. O tempo de internação foi superior ao de pacientes de faixas etárias inferiores e 90% dos casos apresentaram algum tipo de complicação clínica após a osteossíntese. A idade age isoladamente como fator preditivo positivo para tais complicações no paciente politraumatizado. As doenças prévias e a idade dos doentes não influenciaram o desenvolvimento de complicações ortopédicas. As lesões associadas às fraturas apresentaram correlação com o mecanismo de trauma. Estes pacientes normalmente precisam ser operados para tratamento definitivo de suas fraturas. O fato de serem mais idosos e apresentarem doenças anteriormente ao acidente não aumenta o período pré-cirúrgico.

Mortality rates in geriatric patients with spinal cord injuries

OBJECT

The authors undertook this study to evaluate the incidence of spinal cord injury (SCI) in geriatric patients (> or = 70 years of age) and examine the impact of patient age, extent of neurological injury, and spinal level of injury on the mortality rate associated with traumatic SCI.

METHODS

A prospectively maintained SCI database (3481 patients) at a single institution was retrospectively studied for the period from 1978 through 2005. Parameters analyzed included patient age, admission American Spinal Injury Association (ASIA) motor score, level of SCI, mechanism of injury, and mortality data. The data pertaining to the 412 patients 70 years of age and older were compared with those pertaining to the younger cohort using a chi-square analysis.

RESULTS

Since 1980, the number of SCI-related hospital admissions per year have increased fivefold in geriatric patients and the percentage of geriatric patients within the SCI population has increased from 4.2 to 15.4%. In comparison with younger patients, geriatric patients were found to be less likely to have severe neurological deficits (greater percentage of ASIA Grades C and D injuries), but the mortality rates were higher in the older age group both for the period of hospitalization (27.7% compared with 3.2%, p < 0.001) and during 1-year follow-up. The mortality rates in this older population directly correlate with the severity of neurological injury (1-year mortality rate, ASIA Grade A 66%, Grade D 23%, p < 0.001). The mortality rate in elderly patients with SCI has not changed significantly over the last two decades, and the 1-year mortality rate was greater than 40% in all periods analyzed.

CONCLUSIONS

Spinal cord injuries in older patients are becoming more prevalent. The mortality rate in this patient group is much greater than in younger patients and should be taken into account when aggressive interventions are considered and in counseling families regarding prognosis.

Treatment options of pelvic and acetabular fractures in patients with osteoporotic bone

The incidence of pelvic ring and acetabular fractures in the elderly is climbing relentlessly. This increase is attributed to a greater longevity and a decrease in the incidence of alcohol-related trauma in younger adults. Often, the elderly trauma patient has compromised physiological reserve and healing capacity due to concomitant morbidities, resulting in a less favourable clinical outcome. The presence of osteopenic or osteoporotic bone and other treatments for existing comorbidities hamper some treatment alternatives, especially those designed for younger patients. Diverse clinical presentations include minor trauma, major polytrauma and insufficiency fractures. An assessment of the general health and functional status of the patient is of utmost importance to determine the optimal treatment. The different treatment options of pelvic and acetabular fractures in the presence of osteoporosis vary mainly according to the clinical presentation and include: conservative methods, percutaneous or minimally invasive procedures, open reduction and fixation, and primary total hip arthroplasty. Whichever treatment is chosen, even for elderly people, the aim is a rapid mobilisation of the patient in order to reduce complications to some extent inherent to this age group.

Predictive effect of out-of-hospital time in outcomes of severely injured young adult and elderly patients

INTRODUCTION

The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients.

METHODS

This is a cross-sectional, observational study. All adults (> or = 18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Student's t-test were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three independent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level.

RESULTS

Of 41,041 cases, 37,276 were > or = 18 years of age. Of the 1,866 with an Injury Severity Score (ISS) > 15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group pre-hospital time had no significant predictive effect for length of stay, complications, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively).

CONCLUSION

This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

Fracture healing in osteoporotic fractures: is it really different? A basic science perspective

Osteoporosis is a major health problem characterized by compromised bone strength that predisposes patients to an increased risk of fracture. Osteoporotic patients differ from normal subjects in bone mineral composition, bone mineral content, and crystallinity. Poor bone quality in patients with osteoporosis presents the surgeon with difficult treatment decisions. Much effort has been expended on improving therapies that are expected to preserve bone mass and thus decrease fracture risk. Manipulation of both the local fracture environment in terms of application of growth factors, scaffolds and mesenchymal cells, and systemic administration of agents promoting bone formation and bone strength has been considered as a treatment option from which promising results have recently been reported. Surprisingly, less importance has been given to investigating fracture healing in osteoporosis. Fracture healing is a complex process of bone regeneration, involving a well-orchestrated series of biological events that follow a definable temporal and spatial sequence that may be affected by both biological factors, such as age and osteoporosis, and mechanical factors such as stability of the osteosynthesis. Current studies mainly focus on preventing osteoporotic fractures. In recent years, the literature has provided evidence of altered fracture healing in osteoporotic bone, which may have important implications in evaluating the effects of new osteoporosis treatments on fracture healing. However, the mechanics of this influence of osteoporosis on fracture healing have not yet been clarified and clinical evidence is still lacking.

Injury in the Elderly and End-of-Life Decisions

The elderly constitute the fastest growing sector of the population of the United Stated and geriatric trauma patients are presenting for care with increasing frequency. These patients are challenging particularly because of their vulnerability to severe injury, limited physiologic response to stress, and frequent presence of comorbid medical conditions complicating care. Many elderly trauma victims require prolonged intensive care and some fail to improve or succumb despite the best efforts because of the extent of their injuries and their underlying disease. These patients may present profound ethical challenges for trauma surgeons as the goals of care shift from salvage to end-of-life care.

Long-Term Survival of Medicare Patients With Head Injury

BACKGROUND

An increasing number of older patients are being hospitalized with traumatic brain injury (TBI). Knowledge of their expected long-term survival may be useful in making clinical decisions.

METHODS

Patients age 65 or older admitted for the first time with head injury (ICD-9 800-804 or 850-854) during 1999 were identified in a complete national sample of fee-for-service Medicare hospitalization and denominator data. Cases were categorized by age, sex, maximum Abbreviated Injury Score (AISmax), and Charlson comorbidity score. Survival was determined at hospital discharge, and (using the denominator file) at 1, 6, 12, and 24 months after the initial hospital admission.

RESULTS

For all cases (n = 30,684), the hospital mortality was 14.3%, but was cumulatively 19.75%, 30.5%, 36.1%, and 44.9% at successive times up to 24 months. Long-term mortality was higher with increased age, comorbidity, or AISmax, and higher in men. These effects persisted with multivariate logistic regression analysis and were used to construct a simplified prediction score for clinical use.

CONCLUSIONS

The mortality for older patients with TBI is much higher than for an uninjured control population. The relative risk for death remains elevated after hospital discharge and for at least 2 years. Awareness of the expected prognosis may help family members and health care providers make appropriate clinical decisions during acute hospitalization.

The effect of pre-existing medical conditions and age on mortality after injury

BACKGROUND

Pre-existing medical conditions (PMCs) have been shown to increase mortality after trauma even after adjustment for the effect of chronological aging. It has been suggested that there is an interaction between injury severity and physiologic reserve, such that diminished physiologic reserve will have an adverse effect on survival at lower injury severity, but that at higher levels of injury severity, physiologic reserve will have much less of an impact.

METHODS

Records of 65,743 patients, admitted after trauma, were extracted from the database of the United Kingdom Trauma Network to explore the impacts of age, gender and PMCs on mortality, and modification of these effects by severity of injury.

RESULTS

PMCs were categorized as absent (23%), present (23%), or unrecorded (54%). There was an increase in mortality with increasing age at all levels of injury severity. Presence of a PMC was associated with a marked increase in mortality of patients with minor injuries (odds ratio [OR] = 5.9, 95% confidence interval [CI] 4.4, 8.0) or moderate injuries (OR = 2.0, 95% CI 1.4, 2.9), but not in those with more severe injuries (OR = 1.1, 95% CI 0.9, 1.4). The impact of age and male gender were also somewhat more pronounced for patients with less severe injuries.

CONCLUSION

These findings support the hypothesis of an interaction between physiologic reserve and injury severity, where PMCs are associated with increased mortality when combined with low to moderate severity injuries, but not when combined with more severe injuries.

Principles of fixation of osteoporotic fractures

Despite advances in the prevention and treatment of osteoporotic fractures, their prevalence continues to increase. Their operative treatment remains a challenge for the surgeon, often with unpredictable outcomes. This review highlights the current aspects of management of these fractures and focuses on advances in implant design and surgical technique.