Multiple trauma in the elderly: new management perspectives

Which Factors Influence the Need for Inpatient Aftercare of Elderly Patients After Hospital Treatment for Proximal Humerus Fractures?

Introduction

While epidemiology and treatment strategies of proximal humerus fractures have been well studied, post-hospital care is poorly analysed. Corresponding data is available in the context of hip fractures, but the evidence regarding proximal humerus fractures is weak. Aim of this study is to identify risk factors for institutionalisation required after discharge into inpatient aftercare for elderly patients treated for proximal humerus fractures.

Materials and Methods

For this retrospective single-centre investigation, n = 295 patients (age 70 (58,79) years, 63.7% female) admitted to hospital from home due to proximal humerus fractures were included and divided into two study groups: Patients being discharged home ('Home') vs being discharged into aftercare ('Aftercare'). Differences regarding demographic and clinical data were analysed. Odds ratios (OR) of influencing factors (adjusted for age) were calculated by logistic regression analysis.

Results

Increased age notably increased the likelihood for discharge of patients into 'Aftercare' (OR 1.09 [1.06;1.12] per year of life). Age-independent indicators for 'Aftercare' were higher ASA score (OR 2.16 per ASA point [1.37;3.49]; P < .001), anterior surgical approach (OR 6.05 [1.93,27.1]; P < .006), duration of surgery (OR 1.01 per min [1.00,1.02]; P < .012), non-surgical complications (OR 3.82 [1.60,9.49]; P < .003), length of stay (OR 1.12 per day [1.04,1.22]; P < .005), ICU stay (OR 3.15 [1.71,6.00]; P < .001) and reversely surgery (OR 0.39 [0.19,0.80]; P < .010).

Conclusion

Increased Age and higher ASA score notably increase the likelihood for post-hospital discharge to an inpatient aftercare facility. Available literature in the context of hip fractures is confirmed. The results of this study may assist in identifying patients at risk and may serve as a stepstone in establishing a scoring system for elderly patients with proximal humerus fractures.

A high hospital frailty risk score indicates an increased risk for complications following surgical treatment of proximal humerus fractures

BACKGROUND

Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment.

METHODS

Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios.

RESULTS

In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay.

CONCLUSION

Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.

Does tranexamic acid have a positive effect on the outcome of older multiple trauma patients on antithrombotic drugs? An analysis using the TraumaRegister DGU®

Background

Acute hemorrhage is one of the most common causes of death in multiple trauma patients. Due to physiological changes, pre-existing conditions, and medication, older trauma patients are more prone to poor prognosis. Tranexamic acid (TXA) has been shown to be beneficial in multiple trauma patients with acute hemorrhage in general. The relation of tranexamic acid administration on survival in elderly trauma patients with pre-existing anticoagulation is the objective of this study. Therefore, we used the database of the TraumaRegister DGU® (TR-DGU), which documents data on severely injured trauma patients.

Methods

In this retrospective analysis, we evaluated the TR-DGU data from 16,713 primary admitted patients with multiple trauma and age &gt; =50 years from 2015 to 2019. Patients with pre-existing anticoagulation and TXA administration (996 patients, 6%), pre-existing anticoagulation without TXA administration (4,807 patients, 28.8%), without anticoagulation as premedication but TXA administration (1,957 patients, 11.7%), and without anticoagulation and TXA administration (8,953 patients, 53.6%) were identified. A regression analysis was performed to investigate the influence of pre-existing antithrombotic drugs and TXA on mortality. A propensity score was created in patients with pre-existing anticoagulation, and matching was performed for better comparability of patients with and without TXA administration.

Results

Retrospective trauma patients who underwent tranexamic acid administration were older and had a higher ISS than patients without tranexamic acid donation. Predicted mortality (according to the RISC II Score) and observed mortality were higher in the group with tranexamic acid administration. The regression analysis showed that TXA administration was associated with lower mortality rates within the first 24 h in older patients with anticoagulation as premedication. The propensity score analysis referred to higher fluid requirement, higher requirement of blood transfusion, and longer hospital stay in the group with tranexamic acid administration. There was no increase in complications. Despite higher transfusion volumes, the tranexamic acid group had a comparable all-cause mortality rate.

Conclusion

TXA administration in older trauma patients is associated with a reduced 24-h mortality rate after trauma, without increased risk of thromboembolic events. There is no relationship between tranexamic acid and overall mortality in patients with anticoagulation as premedication. Considering pre-existing anticoagulation, tranexamic acid may be recommended in elderly trauma patients with acute bleeding.

Reality of treatment for severely injured patients: are there age-specific differences?

BACKGROUND

Major trauma and its consequences are one of the leading causes of death worldwide across all age groups. Few studies have conducted comparative age-specific investigations. It is well known that children respond differently to major trauma than elderly patients due to physiological differences. The aim of this study was to analyze the actual reality of treatment and outcomes by using a matched triplet analysis of severely injured patients of different age groups.

METHODS

Data from the TraumaRegister DGU® were analyzed. A total of 56,115 patients met the following inclusion criteria: individuals with Maximum Abbreviated Injury Scale > 2 and < 6, primary admission, from German-speaking countries, and treated from 2011-2020. Furthermore, three age groups were defined (child: 3-15 years; adult: 20-50 years; and elderly: 70-90 years). The matched triplets were defined based on the following criteria: 1. exact injury severity of the body regions according to the Abbreviated Injury Scale (head, thorax, abdomen, extremities [including pelvis], and spine) and 2. level of the receiving hospital.

RESULTS

A total of 2,590 matched triplets could be defined. Traffic accidents were the main cause of severe injury in younger patients (child: 59.2%; adult: 57.9%). In contrast, low falls (from < 3 m) were the most frequent cause of accidents in the elderly group (47.2%). Elderly patients were least likely to be resuscitated at the scene. Both children and elderly patients received fewer therapeutic interventions on average than adults. More elderly patients died during the clinical course, and their outcome was worse overall, whereas the children had the lowest mortality rate.

CONCLUSIONS

For the first time, a large patient population was used to demonstrate that both elderly patients and children may have received less invasive treatment compared with adults who were injured with exactly the same severity (with the outcomes of these two groups being opposite to each other). Future studies and recommendations should urgently consider the different age groups.

Polytrauma in the Geriatric Population: Analysis of Outcomes for Surgically Treated Multiple Fractures with a Minimum 2 Years of Follow-Up

INTRODUCTION

This study analyzed the clinical and radiological outcomes of geriatric polytrauma patients who had multiple fractures surgically treated and a minimum of 2 years of follow-up.

METHODS

Eighty-six geriatric patients with polytrauma and multiple fractures which were surgically treated in orthopedics and who had a minimum of 2 years of follow-up were retrospectively analyzed. Patients' demographic characteristics, comorbidities, and follow-up time were recorded. The mechanism of injury, fracture type and location, Injury Severity Score (ISS), American Society of Anesthesiologists (ASA) score, duration of hospital stay, complications, and 1-year mortality were also recorded. Fracture union, implant failure, and refractures/misalignment were analyzed from radiographs.

RESULTS

There were 34 (39.5%) male and 52 (60.5%) female patients. Mean age was 73.5 years with an average follow-up time of 32.9 months. Patients had more low-energy traumas and more lower extremity, comminuted fractures. On the contrary, high-energy traumas and femur/pelvic fracture surgeries had higher associated mortality. The mean ISS score was 26.3. The most common ASA score was ASA 3 (75.8%). The most common clinical and radiological complications were prolonged wound drainage and implant failure. The total 1-year mortality rate was 22.1%. Patients with high ASA scores and patients with lower extremity fractures (femoral/pelvic fractures) also had significantly increased mortality rates. No significant relation was detected between mortality and ISS, fracture type, number of fractures, and duration of hospital stay.

CONCLUSION

Orthopedic surgeons must be alert about the possible complications of femoral fractures and comminuted fractures including pelvic girdle. Surgically treated, multifractured patients with high-energy trauma, advanced age, and high ASA scores are also at risk for mortality regardless of the ISS, comorbidities, and duration of hospital stay. Pulmonary thromboemboli must be kept in mind as a significant complication for mortality.

The Surgical Treatment of Proximal Humeral Fractures in Elderly Patients—An Analysis of the Long-Term Course of Locked Plate Fixation and Reverse Total Shoulder Arthroplasty Based on Health Insurance Data

BACKGROUND

The goal of this study is to compare mortality, the frequency of major adverse events, and complication rates after the surgical treatment of proximal humeral fractures with locked plate fixation (LPF) and reverse total shoulder arthroplasty (RTSA) in elderly patients.

METHODS

Health insurance data from patients aged 65 and above over the period January 2010 to September 2018 were retrospectively evaluated. The median follow-up duration after locked plate fixation (40 419 patients) or reverse total shoulder arthroplasty (13 552 patients) was 52 months. Hazard ratios adapted to the patients' risk profiles were determined with the aid of multivariate Cox regression models. The p-values were adjusted with the Bonferroni- Holm method.

RESULTS

After adaptation to the patients' risk profiles, reverse total shoulder arthroplasty was found to be associated with statistically significantly lower mortality (HR: 0.92; 95% confidence interval: [0.88; 0.95]; p <0.001) and fewer major adverse events (HR: 0.92 [0.89; 0.95]; p <0.001) than locked plate fixation. Eight years after surgery, the risk of surgical complications was twice as high for LPF (12.2% [11.9; 12.7]; HR for RTSA versus LPF: 0.5 [0.46; 0.55]; p <0.001 for both), with 3.8% [3.6; 4.0] of the patients receiving a secondary RTSA. Surgical complications were more common (p <0.05) in patients carrying a diagnosis of osteoporosis, obesity, alcohol abuse, chronic polyarthritis, or frozen shoulder.

CONCLUSION

The long-term findings accord with clinical short-term findings from other studies and support the current trend toward more liberal use of inverse shoulder endoprosthesis in elderly patients.

[Influence of complications and comorbidities on length of hospital stay and costs for surgical treatment of proximal humeral fractures]

Nach proximaler Humerusfraktur beim alten Patienten stellen die winkelstabile Plattenosteosynthese und die inverse Schulterendoprothese zwei konkurrierende Operationsverfahren dar. Auch wenn erste klinische Studien auf eine funktionelle Überlegenheit der inversen Schulterendoprothese hindeuten, fehlt ein gesundheitsökonomischer Vergleich in der Literatur. Krankenkassendaten von 55.070 Patienten ab einem Alter von 65 Jahren, welche nach proximaler Humerusfraktur mittels inverser Schulterendoprothese oder winkelstabiler Plattenosteosynthese versorgt worden sind, wurden auf Kosten und Liegedauer untersucht. Multivariable lineare Regressionsmodelle wurden zur Beurteilung von Komplikationen und Komorbiditäten gerechnet. Die Liegedauer nach inverser Schulterendoprothese war mit 20,0 (±13,5) Tagen statistisch auffällig länger als nach winkelstabiler Plattenosteosynthese mit 14,6 (±11,4) Tagen (p < 0,001). Die Kosten pro Fall unterschieden sich mit 11.165,70 (±5884,36) EUR für die inverser Prothese und 7030,11 (±5532,02) EUR für die Plattenosteosynthese deutlich (p < 0,001). Statistisch auffällige Kostensteigerungen durch Komplikationen und Komorbiditäten unterstreichen den Bedarf an spezialisierten geriatrischen Traumazentren.

Retrospective Analysis of Geriatric Major Trauma Patients Admitted in the Shock Room of a Swiss Academic Hospital: Characteristics and Prognosis

Increased life expectancy exposes a great number of elderly people to serious accidents, thus increasing the amount of major geriatric trauma cases. The aim of our study was to determine the profile of elderly patients undergoing major trauma, and the contributing factors predicting mortality in this specific patient group, compared to the younger population. Retrospective analysis of 1051 patients with major trauma admitted over ten years in a Level-1 trauma center was performed. Data collected were: history, nature and type of trauma; age and sex; vital signs on admission; injury severity score; shock index; comorbidities; coagulation diathesis; injury patterns; emergency measures taken; main diagnosis; mortality; and length of hospital and intensive care unit (ICU) stay. Geriatric patients admitted for major trauma have a mortality rate almost four times greater (47%) than their younger counterparts (14%) with the same ISS. According to statistical regression analysis, anti-platelet therapy (OR 3.21), NACA (National Advisory Committee for Aeronautics) score (OR 2.23), GCS (OR 0.83), ISS (OR 1.07) and age (OR 1.06) are the main factors predicting mortality. Conclusion: Geriatric major trauma patients admitted to our trauma resuscitation area have a high mortality rate. Age, GCS, ISS and NACA scores as well as anti-platelet therapy are the main factors predicting mortality.

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

INTRODUCTION

Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making.

METHODS

This study included patients aged 65 years and older that were treated at one Level 1 trauma center between 2007 and 2018. Inclusion criteria: Proximal humerus fracture treated with or without allograft, conclusive data-sets. Exclusion criteria: prior surgical treatment of the proximal humerus, open fracture with bone loss, neurological damage. Patients were stratified according to the use of allograft augmentation in two groups: Group NA (no allograft augmented PHILOS) and Group A (PHILOS with allograft augmentation). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Fractures were graded according to the classification by Neer. Radiographic union was analyzed at 6 weeks, 12 weeks, and at year follow up. Complications include surgical site infection, implant failure, humeral head necrosis, or delayed union. Allograft was used in cases of 1inch/3cm3 bone-loss or an egg-shell situation, where the patient refused arthroplasty.

RESULTS

This study included 167 patients, with 143 (85%) in the Group NA, and 24 (15%) in the Group A. There were no significant differences in age, gender, injury distribution, and distribution of Neer classification or CCI. Patients in Group A had significantly lower T-scores preoperatively (-2.87 ± 1.08 versus -0.9 ± 2.12, p = 0.003). No difference occurred in any of the complications. At one-year follow-up, the range of motion was comparable in both groups.

CONCLUSION

In patients with allograft augmentation and severe osteopenia, similar clinical and radiological results were obtained when compared with patients with better preoperative bone density scores (T-scores, DEXA). In view of a lack of guidelines indicating the indication for the use of allograft, this difference may be worth further study.

[Polytrauma in old age-Knowledge from the TraumaRegister DGU®]

The geriatric fracture patient is becoming more and more in the forefront due to the demographic development. It is expected that the number of polytraumatized geriatric patients in the coming years will rise in line with demographic trends. The TraumaRegister DGU® of the German Trauma Society (DGU) provides interesting insights into the age structure and patient outcome. In 2017 in total 26.2% of the patients included were over 70 years old. Geriatric polytraumatized patients show significant differences in the injury patterns as well as in the treatment strategy compared to younger patients. This is often due to the pre-existing diseases and various drugs that alter the physiology. With respect to the injury patterns an increase in severe head injuries and a decrease in severe abdominal injuries can be seen with increasing age. Hospitals and professional societies are currently dealing with numerous challenges. The implementation of the General Data Protection Regulation leads to conflicts and uncertainties. The further development of the TraumaRegister DGU® is important in order to collect more outcome-relevant data from patients because more than ever the objective should be the survival of an accident with a high quality of life. To measure this, a structured survey of patients is necessary. The TraumaRegister DGU® is one of the most important tools to make treatment comparable and to measure structural changes.

Whole-body computed tomography as a factor associated with lower mortality in severe geriatric trauma with thoracic-abdominal-pelvic injury

OBJECTIVE

To determine the relationship between the use of whole-body computed tomography (WB-CT) and hospital mortality in elderly patients with thoracic-abdominal-pelvic injury requiring admission to an intensive care unit.

PATIENTS AND METHOD

An observational, descriptive and retrospective study was conducted on 140 patients aged 65 years and older admitted to the intensive care unit after a thoracic-abdominal-pelvic injury. Two groups were established, depending on whether a WB-CT was performed as a routine part of the study or the diagnosis was established by conventional radiography or ultrasound. A comparative analysis was performed on both groups, as well as an analysis of mortality through logistic regression.

RESULTS

The mean age of the patients was 75.16±8.89 years. The mean score on the APACHE II scale was 16.25±8.4 points, and on the Injury Severity Score scale, 22.38±15.45 points. WB-CT was performed on 102 patients (72.9%). In these patients, there was a lower mortality rate (15.7 vs. 52.6%, P˂.001), a lower need for mechanical ventilation (47.1 vs. 65.8%, P=.049), and a lower score on the APACHE II scale (14.75±7.19 vs. 20.26±10.06 points, P=.003). The multivariate analysis showed a lower mortality in the patients in whom WB-CT was performed, with an OR of 0.21 (95% CI 0.07-0.68; (P=.010), after adjusting for the APACHE II and ISS scores.

CONCLUSIONS

Performing a WB-CT scan as part of the trauma study could improve the management of elderly patients with thoracic-abdominal-pelvic involvement admitted to the intensive care unit.

Is prescribed lower extremity weight-bearing status after geriatric lower extremity trauma associated with increased mortality?

OBJECTIVES

Evaluate whether mortality after discharge is elevated in geriatric fracture patients whose lower extremity weight-bearing is restricted.

DESIGN

Retrospective cohort study SETTING: Urban Level 1 trauma center PATIENTS/PARTICIPANTS: 1746 patients >65 years of age INTERVENTION: Post-operative lower extremity weight-bearing status MAIN OUTCOME MEASURE: Mortality, as determined by the Social Security Death Index RESULTS: Univariate analysis demonstrated that patients who were weight-bearing as tolerated on bilateral lower extremities (BLE) had significantly higher 5-year mortality compared to patients with restricted weight-bearing on one lower extremity and restricted weight-bearing on BLE (30%, 21% and 22% respectively, p < 0.001). Cox regression analysis controlling for variables including age, Charlson Comorbidity Index, Injury Severity Scale, combined UE/LE injury, injury mechanism (high vs low), sex, BMI and GCS demonstrated that, in comparison to patients who were weight bearing as tolerated on BLE, restricted weight-bearing on one lower extremity had a hazard ratio (HR) of 0.97 (95% confidence interval 0.78 to 1.20, p = 0.76) and restricted weight-bearing in BLE had a HR of 0.91 (95% confidence interval 0.60 to 1.36, p = 0.73).

CONCLUSIONS

In geriatric patients, prescribed weight-bearing status did not have a statistically significant association with mortality after discharge, when controlling for age, sex, body mass index, medical comorbidities, Injury Severity Scale (ISS), mechanism of injury, nonoperative treatment and admission GCS. This remained true in when the analysis was restricted to operative injuries only.

Survivorship After High-Energy Geriatric Trauma

OBJECTIVES

To evaluate in-hospital, 1-year, and 5-year survivorship of geriatric patients after high-energy trauma, to compare survivorship of geriatric patients who sustained high-energy trauma with that of those who sustained low-energy trauma, and to identify predictors for mortality.

DESIGN

Retrospective.

SETTING

Urban Level I trauma center.

PATIENTS

Study group of 1849 patients with high-energy trauma and comparison group of 761 patients with low-energy trauma.

INTERVENTION

Each patient was observed from the time of index admission through the end of the study period or until death or readmission.

MAIN OUTCOME MEASUREMENT

Long-term survivorship based on the Social Security Death Index.

RESULTS

Survivorship between patients with high-energy and low-energy injuries was statistically significant. Among patients who sustained high-energy injuries, in-hospital mortality was 8%, 1-year mortality was 15%, and 5-year mortality was 25%. Among patients who sustained low-energy injuries, in-hospital mortality was 3%, 1-year mortality was 23%, and 5-year mortality was 40%. Low-energy mechanism of injury was an independent predictor for 1-year and 5-year mortality, even when controlling for Charlson Comorbidity Index (CCI), Injury Severity Score (ISS), age, sex, body mass index (BMI), and admission Glasgow Coma Scale (GCS) score.

CONCLUSIONS

Geriatric patients with high-energy injuries and those with low-energy injuries seem to represent different patient populations, and low-energy mechanism seems to be a marker for frailty. High-energy mechanism was associated with lower long-term mortality rates, even when controlling for CCI, ISS, age, sex, BMI and admission GCS score.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Base excess, a useful marker in the prognosis of chest trauma in the geriatric population

OBJECTIVE

To determine the usefulness of the determination of base excess in a cohort of elderly patients admitted to an intensive care unit (ICU) with a diagnosis of chest trauma.

MATERIAL AND METHOD

Two hundred and forty-nine patients were included aged 65 years and over with a diagnosis of thoracic trauma who required admission to the ICU. We made a statistical analysis in order to determine the association of the first base excess levels with mortality during the unit stay.

RESULTS

Two hundred and forty-nine patients, with a mean APACHE II score of 16.21±7.87 and 24.45±14.16 ISS. Mean ICU stay was 12.74±16.85 days and the mean hospital stay was 26.55±30.1 days. Statistical analysis showed an association with mortality in patients whose blood pressure was lower than 110mmHg on admission, with an OR=4.11 (95% CI 1.91 to 8.85) compared to patients with blood pressure between 110 and 140mmHg. Those patients who had base excess levels on admission of less than -6mmol/L also showed increased mortality compared to patients with higher levels, with an OR=3.12 (95% CI 1.51 to 6.42).

CONCLUSIONS

The presence of a base excess level of less than -6 is associated with increased mortality in elderly patients with initial blood pressure between 110 and 140mmHg, diagnosed with thoracic trauma and who require admission to ICU. Routine measurement of this parameter in this population may show the clinical usefulness of assessing possible hidden hypoperfusion.

Polytrauma in the elderly: a review

Although the field of geriatric trauma is – ironically – young, care for the elderly trauma patient is increasingly recognised as an important challenge, considering the worldwide trend towards increasing longevity.

Increasing age is associated with physiological changes and resulting comorbidities that present multiple challenges to the treating physician.

Even though polytrauma is less likely with increasing age, lower-energy trauma can also result in life-threatening injuries due to the reduced physiological reserve.

Mechanisms of injury and resulting injury patterns are markedly changed in the elderly population and new management strategies are needed. From initial triage to long-term rehabilitation, these patients require care that differs from the everyday standard.

In the current review, the special requirements of this increasing patient population are reviewed and management options discussed. With the increase in orthogeriatrics as a speciality, the current status quo will almost certainly shift towards a more tailored treatment approach for the elderly patient. Further research expanding our current knowledge is needed to reduce the high morbidity and mortality rate.

Cite this article: Braun BJ, Holstein J, Fritz T, Veith NT, Herath S, Mörsdorf P, Pohlemann T. Polytrauma in the elderly: a review. EFORT Open Rev 2016;1:146-151. DOI: 10.1302/2058-5241.1.160002.

Pain relief management following proximal femoral fractures: Options, issues and controversies

The majority of proximal femoral fractures occur in the elderly population. Safe and adequate pain relief is an integral part of the overall management of hip fractures. Inherent difficulties in the assessment of pain in elderly need to be taken into account and unique considerations should be made regarding the effective analgesia due to different elderly physiology, and their response to trauma and subsequent surgery. The pain management should start as soon as possible and special emphasis should be paid to contemporary methods of regional anaesthesia whilst a multimodal approach should be adopted in the perioperative period. The present review summarises the contemporary treatment options and controversies pertaining to the management of pain in elderly patients with proximal femoral fractures.

Open Reduction and Internal Fixation of Scapula Fractures in a Geriatric Series

The purpose of this small descriptive series was to report patient and injury characteristics, as well as, surgical and functional outcomes in patients aged 70 years or older, with operative scapular fracture. A retrospective review of 214 scapula fractures identified 6 consecutive geriatric patients aged 70 years or older and formed the basis for this study. Outcomes reported include surgical complications; disabilities of the arm, shoulder, and hand (DASH); range of motion (ROM); and strength assessment at the 6-month postoperative interval and final follow-up. All patients were community ambulators and 5 of the 6 patients routinely performed recreational activities that required shoulder strength and/or motion. Outcomes were attained on all patients at greater than 1 year with a mean of 23.2 months. There were no surgical complications and all fractures united. The mean ROM expressed as a percentage of contralateral ROM ranged from 82% to 100% at both 6-month and final follow-up. The mean strength expressed as a percentage of contralateral strength ranged from 63% to 82% at the 6-month follow-up and 94% to 100% at the final follow-up. The mean DASH score was 12.3 at final follow-up. Our conclusion is that operative treatment for displaced scapula fractures appears to be safe and can yield good functional results in patients aged 70 years and older.

Low Energy Trauma in Older Persons: Where to Next?

The global population is increasing rapidly with older persons accounting for the greatest proportion. Associated with this rise is an increased rate of injury, including polytrauma, for which low energy falls has become the main cause. The resultant growing impact on trauma resources represents a major burden to the health system. Frailty, with its related issues of cognitive dysfunction and sarcopenia, is emerging as the unifying concept that relates both to the initial event and subsequent outcomes. Strategies to better assess and manage frailty are key to both preventing injury and improving trauma outcomes in the older population and research that links measures of frailty to trauma outcomes will be critical to informing future directions and health policy. The introduction of "Geriatric Emergency Departments" and the development of "Fracture Units" for frail older people will facilitate increased involvement of Geriatricians in trauma care and aid in the education of other health disciplines in the core principles of geriatric assessment and management. Collectively these should lead to improved care and outcomes for both survivors and those requiring end of life decisions and palliation.

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.

The injury profile and acute treatment costs of major trauma in older people in New South Wales

AIMS

To Describe injury profile and costs of older person trauma in New South Wales; quantify variations with peer group costs; and identify predictors of higher costs.

METHODS

Nine level 1 New South Wales trauma centres provided data on major traumas (aged ≥ 55 years) during 2008-2009 financial year. Trauma register and financial data of each institution were linked. Treatment costs were compared with peer group Australian Refined Diagnostic Related Groups costs, on which hospital funding is based. Variables examined through multivariate analyses.

RESULTS

Six thousand two hundred and eighty-nine patients were admitted for trauma. Most common injury mechanism was falls (74.8%) then road trauma (14.9%). Median patient cost was $7044 (Q1-3: $3405-13 930) and total treatment costs $76 694 252. Treatment costs were $5 813 975 above peer group average. Intensive care unit admission, age, injury severity score, length of stay and traumatic brain injury were independent predictors of increased costs.

CONCLUSION

Older person trauma attracts greater costs and length of stay. Cost increases with age and injury severity. Hospital financial information and trauma registry data provides accurate cost information that may inform future funding.

Management of high-energy foot and ankle injuries in the geriatric population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.