Charles M. Court-Brown

Age-related changes in the tensile properties of cortical bone. The relative importance of changes in porosity, mineralization, and microstructure.

Tensile testing to failure was done on 235 cortical specimens that had been machined from forty-seven femora from human cadavera. The donors had ranged in age from twenty to 102 years at the time of death. After mechanical testing, the porosity, mineralization, and microstructure were determined. Linear regression analysis showed that the mechanical properties deteriorated markedly with age. Ultimate stress, ultimate strain, and energy absorption decreased by 5, 9, and 12 per cent per decade, respectively. The porosity of bone increased significantly with age, while the mineral content was not affected. Microstructural analysis demonstrated that the amount of haversian bone increased with age. Both bivariate and multivariate analyses demonstrated the importance of age-related changes in porosity to the decline in mechanical properties. Changes in porosity accounted for 76 per cent of the reduction in strength. Microstructural changes were highly correlated with porosity and therefore had little independent effect. Mineral content did not play a major role. Thus, the quantitative changes in aging bone tissue, rather than the qualitative changes, influence the mechanical competence of the bone.

Intramedullary nailing of tibial diaphyseal fractures in adolescents with open physes

An analysis of 36 adolescent patients who presented with tibial diaphyseal fractures and open tibial physes has been undertaken. All patients were treated by reamed intramedullary nailing using a hollow, slotted nail. They were examined clinically and radiologically for late evidence of the effects of premature physeal closure secondary to nailing damage, but none were found. The speed of union in Tscherne C0 and C1 fractures in 13-16-year-old patients is highlighted and shown to be considerably faster than in adult patients. The speed of union in Tscherne C2 fractures is similar in adolescents and adults. The relatively high incidence of compartment syndrome in this age group is noted. Intramedullary nailing of tibial diaphyseal fractures in adolescents with open physes, using a slotted nail, appears to be safe and does not cause late growth problems.

Four score years and ten: An analysis of the epidemiology of fractures in the very elderly

UNLABELLEDnFragility fractures are becoming more common and with increasing longevity it seems likely that orthopaedic surgeons will see more such fractures in progressively older patients. We have examined the epidemiology of fractures in patients aged 90 years or more.nnnINTRODUCTIONnThe purpose of this study was to examine the epidemiology of fractures in the very elderly to see if it differed from the overall fracture epidemiology. The requirement for hospital admission and surgical treatment was assessed as was the patients domicile, length of hospital stay and discharge location.nnnMATERIALS AND METHODSnAll fractures presenting to the Royal Infirmary of Edinburgh and the Royal Hospital for Sick Children in 2000 were examined prospectively and recorded on databases. A retrospective examination of the clinical and social details of the 90+ age group was undertaken.nnnRESULTSnThe 90+ age group comprises 0.58% of the population but accounts for 3.02% of the fractures in the community, 8.7% of the in-patient admissions and 7.6% of the acute orthopaedic trauma surgery. About 56% of fractures in this age group are proximal femoral fractures but high prevalences were noted for all femoral fractures. About 65% of the fractures were in the lower limb. Over 86% of fractures occurred in falls and over 81% of patients were treated as in-patients. The average hospital stay was 9 days but only 23.9% were discharged to their domicile.nnnDISCUSSIONnIt is forecast that this age group will increase and become less fit. This has significant implications for hospital treatment and costs.

The relationship of fall-related fractures to social deprivation

SummaryThe relationship between fall-related fractures and social deprivation was studied in 3,843 patients. The incidence of fractures correlated with deprivation in all age groups although the spectrum of fractures was not affected by deprivation. The average age and the prevalence of hip fractures decreased with increasing deprivation.IntroductionThis study examines the relationship between social deprivation and fall-related fractures. Social deprivation has been shown to be a predisposing factor in a number of diseases. There is evidence that it is implicated in fractures in children and young adults, but the evidence that it is associated with fragility fractures in older adults is weak. As fragility fractures are becoming progressively more common and increasingly expensive to treat, the association between social deprivation and fractures is important to define.MethodsAll out-patient and in-patient fractures presenting to the Royal Infirmary of Edinburgh over a 1-year period were prospectively recorded. The fractures caused by falls from a standing height were analysed in all patients of at least 15xa0years of age. Social deprivation was assessed using the Carstairs score and social deprivation deciles, and the 2001 census was used to calculate fracture incidence. The data were used to analyse the relationship between social deprivation and fall-related fractures in all age groups.ResultsThe incidence of fall-related fractures correlated with social deprivation in all age groups including fragility fractures in the elderly. The overall spectrum of fractures was not affected by social deprivation although the prevalence of proximal femoral fractures decreased with increasing deprivation. The average age of patients with fall-related fractures also decreased with increasing social deprivation as did the requirement for in-patient treatment.ConclusionsThis is the first study to show the relationship between fall-related fractures and social deprivation in older patients. We believe that the decreased incidence of proximal femoral fractures, and the lower average age of patients with fall-related fractures, in the socially deprived relates to the relative life expectancies in the different deprivation deciles.

Changing epidemiology of adult fractures in Scotland

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

The changing epidemiology of fall-related fractures in adults

There has been very little analysis of the epidemiology of adult fall-related fractures outwith the osteoporotic population. We have analysed all in-patient and out-patient fall-related fractures in a one-year period in a defined population and documented their epidemiology. The overall prevalence of non-spinal fall-related fractures is 63.1% with 40.7% and 82.7% occurring in males and females respectively. In females aged 20-29 years >50% of fractures follow falls, the equivalent age range in males being 50-59 years. Analysis of fall-related fractures in two one-year periods in 2000 and 2010/11 shows a significant increase in almost all age ranges up to 60-69 years with a decreased incidence in 90+ patients. In males there is a significant increase in 30-39year males but also in males >80years. In females the greatest increase in incidence is in 16-19year females but all age ranges show a significant increase up to 60-69 years. There is a decreased incidence in 90+ females. The reasons for the increase in the incidence of fall-related are multifactorial but they are probably contributed to by the inherently weaker bone of younger females and by the increased incidence of conditions such as obesity and diabetes.

Outcome at 12 to 22 years of 1502 tibial shaft fractures

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome.

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

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

Global Forum: Fractures in the Elderly

Fractures in the elderly are increasing in incidence and becoming a major health issue in many countries. With an increasing number of the elderly living to an older age, the problems associated with fractures will continue to increase. We describe the epidemiology of fractures in the elderly and identify six fracture patterns in the population of patients who are sixty-five years of age or older. We also analyzed multiple fractures and open fractures in the elderly and we show that both increase in incidence with older age. The incidence of open fractures in elderly women is equivalent to that in young men. Many factors, including patient socioeconomic deprivation, increase the incidence of fractures in the elderly. More than 90% of fractures follow low-energy falls and the mortality is considerable. Mortality increases with older age and medical comorbidities, but there is also evidence that it relates to premature discharge from the hospital.

Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly

Aims The aim of this prospective randomised controlled trial was to compare non‐operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years. Patients and Methods Patients were randomised to either non‐operative management or operative management with either tension‐band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year. Results A total of 19 patients were randomised to non‐operative (n = 8) or operative (n = 11; tension‐band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non‐operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05). Conclusion These data further support the role of primary non‐operative management of isolated displaced fractures of the olecranon in the elderly. However, the non‐inferiority of non‐operative management cannot be proved as the trial was stopped prematurely.