Musculoskeletal Trauma in the Elderly

Charles Court-Brown, Margaret McQueen, Marc F. Swiontkowski, David Ring, Susan M. Friedman, Andrew David Duckworth, Charles Court-Brown, Margaret McQueen, Marc F. Swiontkowski, David Ring, Susan M. Friedman, Andrew David Duckworth

• Publisher: CRC Press
• Year: 2016
• ISBN:
  9781315360690
• Edition: 1
• Topic: Medicina
• Subtopic: Geriatria

Trauma in older people aged over 65 is a rapidly growing field within orthopaedics. Up to two thirds of fractures occur as a result of a fall and about one third of all fractures occur in the over-65 population. The aim of this comprehensive new text is to present the epidemiology and management of all musculoskeletal trauma that occurs in the elderly. The book deals with the assessment and treatment of medical comorbidities, complications, and the role of orthogeriatric care.

The focus of the book is on the practical management of fractures although soft tissue injuries and dislocations are also discussed. Reflecting the multidisciplinary nature of the field, contributors are drawn from orthopaedics and orthogeriatrics on both sides of the Atlantic. The book is intended for all surgeons and physicians involved in the treatment of trauma in the elderly, and it will be relevant to trainees and as well as experienced practitioners.

1

Epidemiology of fractures in the elderly

Charles M. Court-Brown and Kate E. Bugler

History

Fracture incidence

Causes of fracture

Multiple fractures

Open fractures

Epidemiology of different fracture types

Fracture probability

The future

References

Fractures in the elderly are increasing in incidence very rapidly and are becoming a major socio-economic problem in most countries. A rapid rise in life expectancy has meant that there are many more patients aged ≥65 years in the population than there were only two generations ago. It is forecast that this increase in the proportion of elderly in the population will continue to increase and there is no doubt that fractures in the elderly will become a more important health issue in the next 20–30 years.

The scope of the problem is highlighted by reviewing life expectancy over the past century. In the United States, life expectancy in 1900 was 46.3 years for males and 48.3 years for females.¹ In the United Kingdom, the equivalent figures in 1911 were 49.4 and 53.1 years, respectively.² By 2010, the figures were 78.7 and 81.3, respectively, in the United States¹ and 78.5 and 82.5, respectively, in the United Kingdom,² and by 2030, it is projected that life expectancy in the United States will average 78.3 years in males and 84.2 years in females³ with the equivalent UK figures being 83.1 years and 86.4 years.⁴ It has been forecast that the population of the United States aged ≥65 years will rise from 35 million in 2000 to 71 million in 2030.⁵ In 2000, the population ≥65 years represented 12.4% of the whole population and this will rise to 19.6% by 2030.⁵ Table 1.1 gives figures for the proportion of the population aged ≥65 years in 1950 and 2000 in different parts of the world. It also shows projected figures for 2050.⁶ It can be seen that it is projected that there will be a significant rise in the elderly population throughout the world. The increase is projected to be highest in the less developed world. The analysis of the population aged ≥80 years in the United States shows an increase from 9.3 million in 2000 to 19.5 million in 2030. These figures emphasize the scope of the problem for the next 20–30 years.

History

The analysis of skeletons over the past seven millennia has shown signs of osteoporosis, particularly in females. Fractures which were possibly osteoporotic have been found in Egyptian mummies and in skeletons from the Middle Ages in England.⁷ These latter skeletons revealed healed rib and vertebral fractures, particularly in women with a lower femoral neck bone mineral density. There were no femoral neck fractures, probably due to the limited life expectancy in the Middle Ages.

Malgaigne analysed 2377 fractures in the Hȏtel-Dieu, Paris, between 1806–1808 and 1830–1839.⁸ He found that fractures were commonly seen in patients between 25 and 60 years of age and recorded that there were very few fractures in patients >60 years of age, but he noted that there were very few people of that age in the population. He did observe that diaphyseal fractures tended to occur in adulthood, whereas intra-articular fractures occurred in the elderly. He also stated that fractures of the ‘cervix femoris’ and ‘cervix humeri’ tended to occur in old age and that women often sustained fractures of ‘the carpal extremity of the radius’. Stimson in New York⁹ and Emmet and Breck in El Paso, Texas,¹⁰ analysed very large numbers of fractures in 1894–1903 and 1937–1956, respectively. They looked at fractures in children and adults of all ages and a comparison of their results with the prevalence of fractures in adults and children in the United Kingdom in 2000^11,12 is shown in Table 1.2. Allowing for differences in data collection, it is clear that the prevalence of fragility fractures of the proximal femur and distal radius has risen, whereas the prevalence of higher energy injuries such as fractures of the finger phalanges or the tibial and fibular diaphyses has fallen.

Table 1.1 Estimates of the prevalence of the population aged ≥65 years in different parts of the world between 1950 and 2050

Population aged >65 years	1950 %	2000 %	2050 %
World	5.2	6.9	15.9
North America	8.2	12.3	20.5
Europe	8.2	14.7	27.9
More developed world	7.9	14.3	25.9
Less developed world	3.9	5.1	14.3

The changing epidemiology of fractures is highlighted by a review of a study of fractures in the elderly undertaken in Dundee, Scotland, and Oxford, England, under the auspices of the Medical Research Council.¹³ The Medical Research Council held a conference to discuss fractures in the elderly in 1956 and undertook a 5-year study. The medical and social changes between the 1950s and now are highlighted by the fact that they chose to study fractures in the elderly by analysing patients >35 years of age. The results of this study were compared with a prospective study of fractures in patients aged >35 years in Edinburgh, Scotland, in 2010/2011.¹⁴ Edinburgh and Dundee are only 60 miles apart and have a very similar racial and social structure. The results highlighted the considerable changes in fracture epidemiology over a 60-year period. The overall prevalence of fractures increased by 50%, but the prevalence in males only increased by 5% compared with 85% in females. The analysis of the classic fragility fractures shows a 209% increase in the prevalence of proximal humeral fractures. This was mirrored in humeral diaphyseal fractures (129% increase), distal humeral fractures (267% increase), proximal ulnar fractures (220% increase), distal radial and ulnar fractures (39% increase), pelvic fractures (240% increase), proximal femoral fractures (186% increase), femoral diaphyseal fractures (92% increase) and distal femoral fractures (400% increase). There was an increased rate of fall related fractures in all age groups in both males and females. The study highlighted the considerable increase in fragility fractures in the last 60 years and the effect of socio-economic change on the incidence of fractures.¹⁴

Fracture Incidence

Accurate analyses of fracture incidence are surprisingly difficult to find in the literature for a number of reasons.¹⁵ In many parts of the world, there are no facilities to allow accurate analysis of what is a common medical condition. However, even in more affluent areas, little accurate information is available. In many countries, orthopaedic trauma is treated in different types of institutions, with severe trauma being treated in Level 1 trauma centres, or the equivalent, whereas less severe trauma is treated in community hospitals or by community surgeons in private practice. Thus very few large hospitals treat the whole range of orthopaedic trauma injuries and as there is very little communication between hospitals, accurate epidemiological information is hard to find. For this reason, a number of different methodologies have been used to try to assess fracture epidemiology. Not infrequently, information is gained from emergency department records. In many countries, emergency departments are mainly staffed by emergency doctors or surgeons in training who are very inexperienced in fracture diagnosis. This combined with the fact that information is not usually obtained from surgeons in private practice means that the epidemiological information is inaccurate. Surgeons have tried to obtain information by postal questionnaires asking patients if they have ever had a fracture. An analysis of the results of this method of obtaining fracture information has shown that reported fracture incidence is up to three times greater than the true incidence of fractures in the population.¹⁵ This is because many patients may be told by paramedical professionals or others that they may have had a fracture because they have unexplainable pain.

In countries with privatized medical systems, insurance records have been used to assess fracture incidence. Again this method relies not only on the accuracy of data input but also on the prevalence of insured people in the population. The same problem occurs if only inpatient information is used. This is easier to obtain, but the data tend to be inadequate and do not represent the whole population.

The epidemiology of fractures in the elderly has unfortunately been largely ignored by orthopaedic surgeons who have concentrated mainly on high energy injuries in younger patients. Thus much of the epidemiological information has been collected by rheumatologists and other physicians whose main interest is in the diagnosis and management of osteoporosis or in the other comorbidities associated with fractures in elderly patients. Much excellent research has been done,^16,17 but understandably little information about many different types of fracture has been obtained. This problem has been complicated by the assumption that is often made that fragility fractures are simply those of the thoracolumbar spine, proximal humerus, distal radius, proximal femur and pelvis. Some comparative epidemiological data are available for these fractures, but there are many other fragility fractures in the elderly that we have very little information about. In a number of studies, fractures of the lower limb and upper limb are simply combined together and therefore little useful information is provided about many fragility fractures.

In this chapter, information about fractures in the older population has been mainly derived from two 1-year prospective studies of fracture incidence carried out in the Royal Infirmary of Edinburgh 2 years apart.¹⁸ This is the only hospital treatin...