Chapter 20: Fractures in The Elderly Patient

Nicholas D. Clement, Leela C. Biant

Chapter Outline

Introduction

An “elderly” person is generally defined by age, with those aged 65 years and older being assigned “elderly” status. This chronologic definition is related to policies and social norms related to retirement and legislation.152 In contrast, a physiologic definition of aging is more complex, and would vary depending on individual well-being, relative to the society in which the person lives. 
In the United States of America the retirement age was introduced in the 1930s as a way of encouraging people to leave the labor force to be replaced by younger people, thereby lowering the unemployment rate. Such legislation made it “customary” to “finish working,” thus giving people an expectation of retirement at 65 years. A survey in Manitoba, Canada revealed that nearly 80% of people aged 65 and over, who considered themselves retired, stated that they had done so voluntarily, although health also entered into the equation for about a third of the patients.159 
The elderly population is commonly subdivided into three groups that show marked physiologic variation. Thus, young–old (65 to 69), middle–old (70 to 74), and old–old (over 75) cohorts are often identified. Sometimes the age divisions vary and being over 80 or over 85 years may define the “oldest–old” category. The terminology also changes with oldest–old and super-elderly being used to define the oldest patients. The term “super-elderly” has been used in orthopedics for both elective and trauma patients. The definition, however, varies from those patients greater than 80 years old to those greater than 90 years old.18,37 For the purpose of this chapter, we will define the super-elderly population as those patients 80 years old or more. This group of patients is thought to be more vulnerable to the physical and social challenges that we associate with old age, such as widowhood, worsening health, and an increasing difficulty completing the activities of daily life without assistance.159 

Incidence and Epidemiology of Fractures in the Elderly

Aging Population

The elderly population is on the threshold of a boom. According to the United States Census Bureau75 projections, a substantial increase in the number of older people will occur during the 2010 to 2030 period, after the first “baby boomers” have turned 65. The older population in 2030 is projected to be twice as large as it was in 2000, growing from 35 million to 72 million, which will represent nearly 20% of the total United States population. The median age rose from 22.9 years in 1900 to 35.3 years in 2000 and is projected to increase to 39 years by 2030. In 2000, the oldest–old, defined as those 85 years and older, was 34 times greater than that recorded in 1900, whereas the elderly population aged between 65 and 84 years was only 10 times as large. In 2000, 420 million people in the world were at least 65 years of age, this constituting 7% of the world’s population. However, this number is projected to more than double by 2030, reaching 974 million. This changing population demographic is affecting developing countries at a rapid rate; in the year 2000, 60% of the world’s elderly population lived in developing countries. This is projected to increase to 70% by 2030. 
People in developed countries are not only living longer but they are enjoying increasingly healthier lifestyles than ever before. The effect of the obesity epidemic on longevity is yet to peak. The average life expectancy in the United States at birth rose from 47.3 years in 1900 to 76.9 years in 2000. Furthermore, disability among the older population is declining, with studies over the past two decades demonstrating a substantial decline in the rate of disability and functional limitation. The growth of this more active and physically fitter elderly population is challenging policy makers, families, businesses, and health-care providers to meet the needs of aging individuals. This will have major repercussions upon the type and severity of fragility fractures presenting to orthopedic surgeons. Fracture management in the elderly and super-elderly patients will consume a greater proportion of the trauma workload and expense in the future with an ever-increasing population being at risk. 

Life Expectancy of the Super-Elderly

There is evidence that increases in the population of centenarians over the 20th century were largely a result of increases in survival between 80 and 100 years and at birth, as well as increases in the size of the birth cohorts available to survive.141 The increases in survival from birth to 80 years, combined with the increases in survival from 80 to 100 years seen over the second half of the 20th century, are expected to continue. This suggests that considerable extension to the length of life has been, and will continue to be, achieved in very old age. Table 20-1 presents the life expectancy at age 80 for cohorts born between 1901 and 1961 in England and Wales and the estimated and projected population aged 80 between 1981 and 2041. Life expectancy at age 80 for females born in England and Wales at the beginning of the 20th century was about 8 years. The estimated mid-year population of females aged 80 years in 1981 was 152,000. The cohort of females born in England and Wales in 1961 is expected to live, on an average, for a further 13 years after their 80th birthday in 2041. The population of females aged 80 in 2041 is projected to be twice the size of that of the same age in 1901. The remaining life expectancy, at age 80, for men born during the 20th century has increased and is expected to increase at a greater pace than that of women. Life expectancy at age 80 for the cohort of men born in 1901 was 6 years but will be 12 years for those born in 1961. The population of men aged 80 in 1901 was 74,000, half that of women of the same age. The population of men aged 80 years projected to be alive in 2041 is 3.5 times larger than that in 1901. The super-elderly population is growing and is projected to continue to grow. In addition, expectation of life at older ages is expected to continue to increase. 
Table 20-1
The Life Expectancy at 80 Years and the Estimated Mid-Year Population for Males and Females Aged ≥80 Years Born Between 1901 and 1961
Birth Cohort Year Aged 80 Life Expectancy at 80 (yrs) Population ≥80 yrs (1000s)
Male Female Male Female
1901 1981 6 8 74 152
1911 1991 7 8 96 172
1921 2001 8 9 127 202
1931 2011 9 11 136 180
1941 2021 11 12 157 187
1951 2031 12 13 207 244
1961 2041 12 13 252 295
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Trends in Fracture Incidence

A simple fall from standing height is the commonest cause of injury in the elderly population.99,167 Out of all fall-related injuries needing medical attention in older people, every second injury is reported to be a fracture.90 In 2000, the worldwide occurrence of fragility fractures in adults aged 50 years or older was estimated to be approximately 9 million.91 In Finland, the annual number of hip fractures has remained static at approximately 7,000 fractures per year in patients aged 50 years or older between 1997 and 2004.95 However, due to increasing longevity and a growing elderly population the number of fractures presenting to orthopedic surgeons is estimated to double150 and the number of hip fractures to double or even triple by the year 2030.95 
The cost of fracture care in the elderly is relatively high compared with younger patients.22,140 In Finland, the average total cost of a patient with a hip fracture during the first postoperative year was $17,750 in 2003.140 More recently, Nikitovic et al.139 demonstrated the costs to be far greater reaching nearly $40,000 in the first year. This continued into the second postoperative year with a further $10,000 of costs being recorded. This was mainly due to the cost of institutional care after injury, with 24% of females and 19% of males who were living independently in the community before their fracture needing long-term postoperative care. In the United States, medical expenditure has been reported to be two to three times greater for women compared with men.167 It is predicted, however, that in the future the number and the costs of fall-related injuries will rise more rapidly in older men relative to women.150,151 The insult of the fracture upon the functional status of elderly patients can be serious91 and can lead to excess morbidity and mortality and foreshorten the frailty trajectory.21 In addition to altering physical performance and the management of activities of daily living tasks, hip fractures may seriously affect health-related quality of life.22,180 Thus, fracture prevention is an important public health issue. 
Falls and fractures can be prevented.68,101 There is inconsistency regarding the role of fall-related factors and bone fragility in predicting whether a person will sustain a fracture.100 Factors associated with an increased risk of falls differ according to gender.26 Thus, more detailed information about the gender-specific predictors of fractures are needed to make prevention of fractures more effective. 

Fragility Fracture Burden

Elderly Fractures over the Last Decade

Three analyses of fracture epidemiology have been undertaken in Edinburgh since 2000 with the third analysis, undertaken over a period of 1 year in 2010/11, being analyzed in Chapter 3. The previous two studies were undertaken in 200048 and 2007/08.46 Each study has analyzed all adult fractures from a defined population in a developed country. This data from Scotland has been used to assess the change in fracture epidemiology during the last decade with regard to the elderly and super-elderly population, and in relation to common fragility fractures. Spinal fractures were excluded because of the fact that not all spinal fractures in the elderly are admitted to the hospital and analysis would underestimate the exact incidence. 
The overall incidence of all adult fractures during the last decade has significantly increased from 1,113/105/year in 2000 to 1,352/105/year in 2010/11 (odds ratio 1.2, p < 0.0001). The age group in which fracture incidence has increased most rapidly during this time period is the elderly, and more specifically, the super-elderly (Tables 20-2 and 20-3). The incidence of fractures in the elderly increased from 2,028/105/year in the year 2000 to 2,318/105/year in 2010/11 (odds ratio 1.2, p < 0.001). A similar rate of increase was also observed for the super-elderly group which increased from 3,733/105/year in the year 2000 to 4,045/105/year in 2010/11 (odds ratio 1.1, p < 0.001). This was the greatest increase in any age group. Hence, elderly patients are the fastest-growing age group that are currently presenting with fractures. This will have significant repercussions upon the provision of future trauma services. Not only are the absolute numbers in the elderly age group increasing but also it would seem that the fracture incidence is also increasing. If the incidence of fractures continues to increase at the same rate, by 2050, the incidence of fractures in the elderly will be 4,079/105/year which is double that observed in the year 2000. This, combined with the increasing elderly population at risk, will result in a considerable change in the delivery of orthopedic trauma services, where the majority of the workload will involve fragility fractures in frail patients. 
Table 20-2
Epidemiology of Fractures Treated in a 1-Year Period. The Numbers, Prevalence, Incidence, and Gender Ratios are Shown Together with the Average Ages and Percentages of Patients ≥65 Years and ≥80 Years of Age
All Fractures n % n/105/yr Average Age (yrs) ≥65 yrs (%) ≥80 yrs (%) Male/Female
Distal radius/ulna 1,221 17.5 235.9 58.4 41.8 18.1 28/72
Metacarpus 781 11.2 150.9 33.6 8.2 3.1 80/20
Proximal femur 753 10.8 145.5 80.7 90.6 63.7 27/73
Ankle 720 10.3 139.1 48.8 23.6 6 47/53
Finger phalanges 696 9.9 134.5 41.6 13.6 5.8 60/40
Proximal humerus 478 6.8 92.4 66.3 55.6 23 31/69
Metatarsus 465 6.6 89.8 44.6 17 5.2 37/63
Proximal forearm 378 5.4 73 45.6 17.2 5.8 46/54
Clavicle 257 3.7 49.7 44.5 21 9.7 70/30
Toe phalanges 248 3.5 47.9 35.7 3.9 1 59/41
Carpus 194 2.8 37.5 38 7.7 1.5 64/36
Pelvis 119 1.7 23 75.6 74.8 58.8 30/70
Femoral diaphysis 82 1.2 15.8 70.2 67.1 39 48/52
Tibial diaphysis 69 1 13.3 42.3 8.7 0 71/29
Calcaneus 65 0.9 12.6 41 9.2 3.1 74/26
Humeral diaphysis 62 0.9 12 59.5 46.8 22.6 47/53
Proximal tibia 59 0.8 11.4 54.5 30.5 11.9 52/48
Distal humerus 56 0.8 10.8 56.4 50 25 43/57
Forearm diaphysis 55 0.8 10.6 48 27.3 16.4 69/31
Patella 49 0.7 9.5 64.8 55.1 28.6 41/59
Scapula 37 0.5 7.1 54.8 32.4 16.2 76/24
Fibula 41 0.5 7.9 46.8 14.6 2.4 46/54
Distal femur 36 0.5 7 67.3 52.8 38.9 17/83
Distal tibia 35 0.5 6.8 44.6 22.9 5.7 63/27
Mid-foot 28 0.4 5,4 39.4 7.1 0 61/39
Talus 12 0.2 2.3 30.1 0 0 83/17
All fractures 6,996 100 1,351.7 53.2 34 17.3 47/53
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Table 20-3
The Numbers of Fractures in Younger Patients and in the Elderly. The Odds Ratios for Each Fracture are Given
Fracture Number Odds Ratio
All 15–64 65+
Proximal femur 753 70 683 45.36
Pelvis 119 30 89 13.71
Femoral diaphysis 82 27 55 9.41
Proximal humerus 478 211 267 5.86
Patella 49 22 27 5.67
Distal femur 36 17 19 5.16
Distal humerus 56 28 28 4.62
Humeral diaphysis 62 33 29 4.06
Distal radius/ulna 1,221 711 510 3.32
Scapula 37 25 12 2.22
Proximal tibia 59 41 18 2.03
Forearm diaphysis 55 40 15 1.73
Ankle 720 550 170 1.43
Distal tibia 35 27 8 1.37
Clavicle 257 203 54 1.23
Proximal forearm 378 313 65 0.96
Metatarsus 465 386 79 0.95
Fibula 41 35 6 0.79
Finger phalanges 696 602 94 0.72
Calcaneus 65 59 6 0.47
Tibial diaphysis 69 63 6 0.44
Metacarpus 781 717 64 0.41
Carpus 194 179 15 0.39
Mid-foot 28 26 2 0.36
Toe phalanges 248 238 10 0.19
Talus 12 12 0 0
All fractures 6,996 4,665 2,331 2.34
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Fracture epidemiology varies widely according to the demographics, socioeconomic status, and health and safety standards in a particular country. However, data from Scotland should be representative of the fracture incidence of the Western world.93 Figures from both Europe and America affirm the increasing rate of fragility fractures. 
In developed and developing countries the incidence of osteoporosis is increasing at a rate faster than would be predicted simply by the increasing longevity of the population.109 The increasing rate of osteoporosis may be one aspect of the increasing rate of fragility fractures we have observed in Scotland. Osteoporosis is a metabolic bone disease leading to microarchitectural deterioration, which results in bone fragility and increased fracture risk.42 The estimated prevalence of osteoporosis in Europe varies; in Denmark approximately 20% of men and 40% of women aged 50 years or more have osteoporosis,175 whereas in southern European countries such as Spain, the prevalence is lower but still significant, the condition affecting one in four Spanish women who are at least 50 years of age.55 Over two million people are affected by osteoporosis in Australia,160 with 1 in 10 men and 1 in 4 women aged over 60 years being diagnosed with osteoporosis.138 In China, osteoporosis affects almost 70 million people over the age of 50 years, whereas, in India, bone mineral density at all the skeletal sites showed a high prevalence of osteopenia (52%) and osteoporosis (29%).162 The prevalence of osteoporosis in the Japanese female population aged 50 to 79 years has been estimated to be about 35% in the spine and 9.5% in the hip.86 This considerable global rate of osteoporosis, which seems to be accelerating, may explain the increasing incidence of fractures we have observed in our elderly population over the last decade. This makes elderly fractures one of the most important groups to understand as this growing group of patients will constitute more of the orthopedic trauma workload of the future. 

Epidemiology of Elderly Fractures

More than a third of all fractures presenting to orthopedic trauma services are sustained by elderly patients, of which half occur in the super-elderly age group. It is not surprising that more than half of proximal femoral and proximal humeral fractures occur in elderly patients (Table 20-2), as these are generally accepted as fragility fractures of the elderly. However, it is interesting to note that Table 20-2 shows that more than half of pelvic, distal femoral, and femoral diaphyseal fractures occur in this elderly group. These fractures may not be as readily accepted as fragility fractures by all surgeons. Each of these fractures, except femoral diaphyseal fractures, are associated with an approximate 70/30 female to male ratio, which is likely to be caused by the effect of osteoporosis in this elderly population. In contrast, femoral diaphyseal fractures demonstrate a 50/50 female to male ratio. This difference may be due to the fracture distribution curve which formerly demonstrated a type A curve, this being a unimodal distribution in younger males and older females. However it is likely that the distribution curve is now a type G curve (see Chapter 3). 
The definition of what constitutes a fragility fracture lies in the pattern of presentation and relates to age and the low-energy mechanism of injury. It is discussed further in Chapters 3 and 19. However, if we accept that these are fractures that are more likely to occur in the elderly population, then more than half of all fractures are fragility fractures (Table 20-3). Overall, the elderly population is more likely to sustain a fracture relative to the population aged between 15 and 64 years of age (odds ratio 2.3). Fractures of the femur, humerus, pelvis, patella, and distal radius were all at least three times more likely to occur in the elderly age group (Table 20-3). Interestingly, fractures affecting the scapula, proximal tibia, forearm diaphysis, ankle, distal tibia, and clavicle were also more likely to occur in the elderly age group; however, the risk was not as great as the fractures mentioned above. In contrast, fractures less likely to occur in the elderly were those involving the foot and the hand. This difference probably relates to the mechanism by which these fractures are sustained. Younger patients are more likely to sustain their fracture by a fall from height, a direct blow, sport, or a motor vehicle accident which are the typical mechanisms by which foot and hand fractures occur. These fractures are less likely, even in the presence of osteoporosis, to occur after a simple fall from standing height. 
The incidence of proximal femoral fractures in the elderly (≥65 years) is 679/105/year (Table 20-4). If the elderly population of the United States continues to increase as predicted and reach an estimated 71 million in 2030 this would double the number of proximal femoral fractures presenting to orthopedic trauma services resulting in half a million hip fractures per year.129 Similar figures would also be observed for fractures of the distal radius and proximal humerus, with 360,000 and 190,000 presenting to orthopedic services in the United States alone. This will have considerable repercussions upon trauma services and the management of these frail patients. Currently proximal humeral fractures are the sixth most common fracture in the population. However, the overall incidence will increase because of the growing elderly population who are more likely to sustain a proximal humerus fracture. 
Table 20-4
The Prevalence and Incidence of Each Fracture Type in the Younger-Elderly and the Super-Elderly Groups
≥65 yrs ≥80 yrs
Number % Incidence (x/105/year) Number % Incidence (x/105/year)
Ankle 170 7.3 169 43 3.7 147.8
Calcaneus 6 0.3 6 2 0.2 6.9
Carpus 15 0.6 14.9 3 0.3 10.3
Clavicle 54 2.3 53.7 25 2.1 85.9
Distal femur 19 0.8 18.9 14 1.2 48.1
Distal humerus 28 1.2 27.8 14 1.2 48.1
Distal radius/ulna 510 21.9 507.1 221 18.8 759.6
Distal tibia 8 0.3 8 2 0.2 6.9
Femoral diaphysis 55 2.4 54.7 32 2.7 110
Fibula 6 0.3 6 1 0.1 3.4
Finger phalanges 94 4 93.5 39 3.3 134
Forearm diaphysis 15 0.6 14.9 9 0.8 30.9
Humeral diaphysis 29 1.2 28.8 14 1.2 48.1
Metacarpus 64 2.7 63.6 24 2 82.5
Metatarsus 79 3.4 78.6 24 2 82.5
Mid-foot 2 0.1 2 0 0 0
Patella 27 1.2 26.8 14 1.2 48.1
Pelvis 89 3.8 88.5 70 5.9 240.6
Proximal femur 683 29.3 679.2 479 40.7 1,646.3
Proximal forearm 65 2.8 64.6 22 1.9 75.6
Proximal humerus 267 11.5 265.5 111 9.4 381.5
Proximal tibia 18 0.8 17.9 7 0.6 24.1
Scapula 12 0.5 11.9 6 0.5 20.6
Talus 0 0 0 0 0 0
Tibial diaphysis 6 0.3 6 0 0 0
Toe phalanges 10 0.4 9.9 1 0.1 3.4
Total 2,331 100 2,318 1,177 100 4,045.2
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Table 20-5 shows the modes of injury that caused fractures in the 2010/11 study. The commonest mode of injury for all ages is falls from a standing height and almost 40% of fractures that followed a standing fall occurred in patients ≥65 years. If one simply examines the elderly age group between 65 and 79 years, 91.2% of all fractures followed a standing fall. Falls from a standing height were more common in females, whereas all other modes of injury were equally distributed between the genders or were male-predominant. There is marked difference in the fracture incidence between males and females in the elderly. The incidence of fractures in elderly males is 1,301/105/year, and in females is 3,055/105/year. Hence, female gender is associated with an increased risk of fracture in this elderly age group (odds ratio 2.4, p < 0.001). 
 
Table 20-5
Epidemiology of the Different Modes of Injury
View Large
Table 20-5
Epidemiology of the Different Modes of Injury
% Average Age (yrs) ≥65 yrs ≥80 yrs Male/Female
All Males Females
Falls (standing height) 62.5 62.3 54.3 65.7 38.9 20.6 30/70
Falls (stairs/low height) 4.2 51.7 48.2 55.2 27.1 10.8 51/49
Falls (height) 2.3 36 37.5 30 8.1 2.5 88/12
Direct blow/assault/crush 13.6 33.3 31.1 40.1 3.6 1 75/25
Sport 11.1 31.3 30.4 35.5 3 0.3 82/18
Motor vehicle accident 5.2 42.6 41.7 45.8 10.2 3 78/22
Pathologic 0.4 67.3 63.5 70.3 60 24 44/56
Stress/Spontaneous 0.3 49.9 44.5 54 21.4 21.4 43/57
The prevalence and gender ratios are shown. The average ages and prevalence of patients ≥65 years and ≥80 years are also shown. Low falls include falls down stairs and slopes. Direct blows/assaults include crush injuries.
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Despite the marked difference in fracture incidence between elderly males and females, the prevalence of each fracture according to anatomical location is similar. Tables 20-6 and 20-7 show the incidence of fractures in males (Table 20-6) and females (Table 20-7) aged ≥65 years. Approximately 30% of fractures in both males and females involve the proximal femur and 10% of fractures involve the proximal humerus. However, fractures involving the distal radius were less prevalent in males, accounting for 10% of fractures, compared with about 25% in females. The reason for this difference is not clear. The rate of multiple fractures varied with the anatomical site of the fracture but the overall incidence was about 5%. Fractures of the proximal humerus were associated with other fractures in about 10% of patients. The rate of open fractures was low, but was greater in elderly females (Tables 20-6 and 20-7). 
 
Table 20-6
Epidemiology of Fractures in Males Aged ≥65 Years
View Large
Table 20-6
Epidemiology of Fractures in Males Aged ≥65 Years
Males ≥65 yrs Number % Multiple Fractures (%) Open (%) Causes
Proximal femur 180 32.7 3.9 0 92.2% falls, 3.9% low fall
Proximal humerus 59 10.7 13.6 0 94.9% falls, 1.7% low fall
Distal radius/ulna 54 9.8 9.3 0 94.4% falls, 3.7% MVA
Ankle 47 8.5 4.3 0 83% falls, 6.4% sport
Finger phalanges 35 6.4 13.8 3.1 59.4% falls, 18.7% db/assault
Metacarpus 25 4.5 41.2 0 72% falls, 12% sport
Pelvis 20 3.6 10 0 90% falls, 10% MVA
Femoral diaphysis 20 3.6 5 0 80% falls, 15% pathologic
Clavicle 19 3.5 10.5 0 63.2% falls, 10.5% MVA
Proximal forearm 15 2.7 20 0 80% falls, 6.6% MVA
Metatarsus 11 2 18.2 0 63.6% falls, 18.2% db/assault
Humeral diaphysis 9 1.6 11.1 0 100% falls
Proximal tibia 8 1.5 37.5 12.5 50% falls, 12.5% fall height
Distal humerus 7 1.3 28.6 0 71.4% falls, 14.3% fall height
Carpus 6 1.1 0 0 100% falls
Patella 6 1.1 0 0 83.3% falls, 16.6% low fall
Scapula 5 0.9 20 0 40% falls, 20% fall height
Toe phalanges 5 0.9 0 0 80% db/assault, 20% falls
Tibial diaphysis 5 0.9 20 40 60% falls, 40% MVA
Forearm diaphysis 4 0.7 0 0 75% falls, 25% sport
Fibula 3 0.5 0 0 33.3% fall, 33.3% db/assault
Distal femur 3 0.5 0 0 100% falls
Calcaneus 2 0.4 50 0 50% fall height, 50% low fall
Distal tibia 2 0.4 0 0 100% falls
Mid-foot 0 0 0 0
Talus 0 0 0 0
550 100 5.7 0.7 83.8% falls, 4% MVA
The numbers and prevalence of the different fractures are shown as are the prevalence of open fractures and patients with multiple fractures. The two commonest causes of each fracture are shown. (db = direct blow).
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Table 20-7
Epidemiology of Fractures in Females Aged ≥65 Years
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Table 20-7
Epidemiology of Fractures in Females Aged ≥65 Years
Females ≥65 yrs Number % Multiple Fractures (%) Open (%) Causes
Proximal femur 503 28.2 6.2 0 96.8% falls, 1.8% low fall
Distal radius/ulna 456 25.6 7.1 1.5 95.6% falls, 2.9% low fall
Proximal humerus 208 11.7 9.2 0 93.8% falls, 5.3% low fall
Ankle 123 6.9 5.7 2.4 95.1% falls, 2.4% low fall
Pelvis 69 3.9 8.7 0 97.1% falls, 2.9% low fall
Metatarsus 68 3.8 20 0 91.2% falls, 4.4% low fall
Finger phalanges 59 3.3 18 3.6 72.9% falls, 15.3% db/assault
Proximal forearm 50 2.8 16 4 94% falls, 4% MVA
Metacarpus 39 2.2 17.6 2.6 92.3% falls, 2.4% low fall
Clavicle 35 2 5.7 0 91.4% falls, 5.7% MVA
Femoral diaphysis 35 2 2.9 0 88.6% falls, 5.7% pathologic
Distal humerus 21 1.2 14.3 0 100% falls
Patella 21 1.2 0 4.8 95.2% falls, 4.8% db/assault
Humeral diaphysis 20 1.1 0 5 85% falls, 10% pathologic
Distal femur 16 0.9 12.5 6.2 81.2% falls, 12.5% low fall
Forearm diaphysis 11 0.6 9.1 0 90.9%falls, 9.1% pathologic
Proximal tibia 10 0.6 20 0 70% falls, 20% low fall
Carpus 9 0.5 11.1 0 88.9% falls, 11.1% db/assault
Scapula 7 0.4 14.3 0 100% falls
Distal tibia 6 0.3 0 0 83.3% falls, 16.6% low fall
Toe phalanges 5 0.3 0 0 80% falls, 20% db/assault
Calcaneus 4 0.2 25 0 100% falls
Fibula 3 0.2 63.3 0 66.6% falls, 33.3% MVA
Mid-foot 2 0.1 0 0 50% fall height, 50% sport
Tibial Diaphysis 1 0.06 0 100 100% falls
Talus 0 0 0 0
1,781 100 5 1.2 94.3% falls, 2.9% low fall
The numbers and prevalence of the different fractures are shown as are the prevalence of open fractures and patients with multiple fractures. The two commonest causes of each fracture are shown. (db = direct blow).
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Epidemiology of Super-Elderly Fractures

Knowledge and understanding of the fracture epidemiology of the super-elderly age group forms an important aspect of what the future may hold for orthopedic trauma services. The super-elderly population, comprising patients over the age of 80 years, has doubled during the last 25 years and will probably double again in the next 25 years.181 Approximately half of all fragility fractures occur in this super-elderly subgroup although they constitute only 29% of the elderly population. More than half of all proximal femur and pelvic fractures, and approximately a quarter of all humeral fractures, occur in the super-elderly age group (Table 20-2). Interestingly, 40% of femoral diaphyseal and distal femoral fractures occur in this age group, these being fractures that are traditionally associated with high-energy trauma. 
The fracture risk is significantly increased for elderly patients relative to those aged between 15 and 64 years of age (Table 20-3). However, the risk of a super-elderly patient sustaining a fracture is also greater relative to the younger-elderly population. A comparison of the numbers of the different fractures presenting in the younger-elderly and the super-elderly populations is shown in Table 20-8 which shows that fractures of the pelvis, distal femur, proximal femur, forearm diaphysis, and femoral diaphysis are at least three times more common in the super-elderly group. It also shows that hand and foot fractures are less common in the super-elderly. Super-elderly patients are nearly three times more likely to sustain a fracture compared with younger-elderly patients (odds ratio 2.6, p < 0.001). Table 20-4 gives the prevalences and incidences of each fracture in the younger-elderly and super-elderly groups in 2010/11. The overall incidence of fractures in the super-elderly was 4,045/105/year, which is nearly double that observed for the younger-elderly patients which was 2,318/105/year. Fractures involving the proximal femur, distal radius, and proximal humerus have the greatest incidence in the super-elderly population (Table 20-4). This is also true of the younger-elderly population. However, the incidence for these fractures is significantly greater with increasing age. This is particularly obvious in proximal femoral fractures where the overall incidence is 145/105/year. This increases to 679/105/year in the younger-elderly population and increases further to 1,646/105/year in the super-elderly population. Fractures of the femur, humerus, pelvis, patella, distal radius, scapula, proximal tibia, forearm diaphysis, and clavicle are all more likely to occur in the super-elderly age group relative to the younger-elderly group (Table 20-4). This confirms that a number of these fractures should be regarded as fragility fractures (see Table 3-19) and also suggests that other fractures, which are not currently regarded as fragility fractures, may be so regarded in the future. However, the increased risk of ankle and distal tibial fractures in the elderly group, was not demonstrated in the super-elderly group. The reason for this is not clear but it may be related to the mechanism of the fall in older patients. 
Table 20-8
The Numbers of Fractures in Younger-Elderly Patients and in the Super-Elderly. The Odds Ratios for Each Fracture are Given
Fracture Number Odds Ratio
65+ yrs 65–79 yrs 80+ yrs
Pelvis 89 19 70 9.07
Distal femur 19 5 14 6.88
Proximal femur 683 204 479 5.85
Forearm diaphysis 15 6 9 3.69
Femoral diaphysis 55 23 32 3.42
Patella 27 13 14 2.65
Distal humerus 28 14 14 2.46
Scapula 12 6 6 2.46
Humeral diaphysis 29 15 14 2.29
Clavicle 54 29 25 2.12
Distal radius/ulna 510 289 221 1.89
Proximal humerus 267 156 111 1.75
Finger phalanges 94 55 39 1.74
Proximal tibia 18 11 7 1.56
Metacarpus 64 40 24 1.47
Proximal forearm 65 43 22 1.26
Calcaneus 6 4 2 1.23
Metatarsus 79 55 24 1.07
Ankle 170 127 43 0.83
Distal tibia 8 6 2 0.82
Carpus 15 12 3 0.61
Fibula 6 5 1 0.49
Toe phalanges 10 9 1 0.27
Talus 0 0 0 0
Mid-foot 2 2 0 0
Tibial diaphysis 6 6 0 0
Total 2,331 1,154 1,177 2.57
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The commonest mode of injury for all ages is falls from standing height (Table 20-5). The prevalence of simple fall-related fractures in the elderly age group was 91.2%; however, this increased to 94.3% in the super-elderly. The super-elderly age group was significantly more likely to sustain fractures from a fall compared with both the adult population, aged between 15 and 64 years of age (odds ratio 2.4, p < 0.001), and the younger-elderly population, aged between 65 and 79 years of age (odds ratio 1.2, p = 0.02). 
There is a marked difference in the fracture incidence between males and females in the super-elderly group. The incidence of fractures in super-elderly males is 2,880/105/year, and in females is 4,870/105/year (odds ratio 1.7, p < 0.001). This would imply that super-elderly females, like their elderly counterparts, are twice as likely to sustain a fracture after a fall from standing height when compared with males if we assume the rate of falls is equal. 
Tables 20-9 and 20-10 show the epidemiology of fractures in super-elderly males and females in 2010/11. Despite the gender difference in fracture incidence, the prevalence of a number of fractures is very similar. For example, approximately 40% of fractures involve the proximal femur and 10% involve the proximal humerus. However, fractures involving the distal radius demonstrated a similar pattern to that observed in the elderly group (Tables 20-6 and 20-7). They only accounted for 7% of fractures in super-elderly males compared with 22% of fractures in super-elderly females. The prevalences of pelvic fractures were very similar but it is interesting to observe that there was a higher prevalence of femoral diaphyseal fractures in super-elderly males. The rate of multiple fractures varied according to the fracture site for both genders. The overall rate of multiple fractures was 5%, but this varied between fracture types. One in ten patients who sustained a proximal humerus or distal radius fracture had an associated fracture. 
 
Table 20-9
Epidemiology of Fractures in Males Aged ≥80 Years
View Large
Table 20-9
Epidemiology of Fractures in Males Aged ≥80 Years
Males 80+ yrs Number % Multiple Fractures (%) Open (%) Causes
Proximal femur 112 44.4 4.5 0 92.8% falls, 4.5% fall height
Proximal humerus 25 9.9 24 0 100% falls
Distal radius/ulna 18 7.1 16.7 0 94.4% falls, 5.6% MVA
Pelvis 13 5.2 0 0 100% falls
Finger phalanges 13 5.2 30 0 84.6% falls, 15.4% MVA
Femoral diaphysis 12 4.8 0 0 91.7% falls, 8.3% pathologic
Metacarpus 11 4.4 25 0 72.7% falls, 18.2% fall height
Ankle 10 4 0 0 90% falls, 10% MVA
Clavicle 6 2.4 0 0 83.3% falls, 16.6% low fall
Humeral diaphysis 6 2.4 16.6 0 100% falls
Proximal forearm 5 2 40 0 100% falls
Distal humerus 4 1.6 25 0 50% falls, 25% fall height
Metatarsus 3 1.2 0 0 77.7% falls, 18.2% fall height
Patella 3 1.2 0 0 100% falls
Distal femur 3 1.2 0 0 100% falls
Forearm diaphysis 3 1.2 0 0 66.6% falls, 33.3% sport
Proximal tibia 3 1.2 33.3 0 66.6% falls, 33.3% fall height
Carpus 1 0.4 0 0 100% falls
Toe phalanges 1 0.4 0 0 100% db/assault
Scapula 0 0 0 0
Distal tibia 0 0 0 0
Calcaneus 0 0 0 0
Fibula 0 0 0 0
Mid-foot 0 0 0 0
Tibial diaphysis 0 0 0 0
Talus 0 0 0 0
252 100 5.8 0 90.5% falls, 2.4% low fall
The numbers and prevalence of the different fractures are shown as are the prevalence of open fractures and patients with multiple fractures. The two commonest causes of each fracture are shown. (db = direct blow).
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Table 20-10
Epidemiology of Fractures in Females Aged ≥80 Years
View Large
Table 20-10
Epidemiology of Fractures in Females Aged ≥80 Years
Females 80+ yrs Number % Multiple Fractures (%) Open (%) Causes
Proximal femur 367 39.7 5.4 0 97% falls, 1.9% low fall
Distal radius/ulna 203 21.9 10.5 1 98.5% falls, 1.5% low fall
Proximal humerus 86 9.3 12.8 0 96.5% falls, 3.5% low falls
Pelvis 57 6.2 8.8 0 96.5% falls, 3.5% low falls
Ankle 33 3.6 12.1 6.1 93.9% falls, 3% low falls
Finger phalanges 26 2.8 25 7.7 88.5% falls, 7.7% db/assaults
Metatarsus 21 2.3 36.4 0 76.2% falls, 14.3% MVA
Femoral diaphysis 20 2.2 5 0 95% falls, 5% low fall
Clavicle 19 2.1 5.3 0 94.7% falls, 5.3% MVA
Proximal forearm 17 1.8 11.8 5.9 100% falls
Metacarpus 13 1.4 36.4 0 92.3% falls, 7.7% db/assaults
Patella 11 1.2 0 0 100% falls
Distal femur 11 1.2 9.1 0 90.9% falls, 9.1% low falls
Distal humerus 10 1.1 0 0 100% falls
Humeral diaphysis 8 0.9 0 0 87.5% falls, 12.5% pathologic
Forearm diaphysis 6 0.6 0 0 100% falls
Scapula 6 0.6 16.6 0 100% falls
Proximal tibia 4 0.4 25 0 75% falls, 25% MVA
Carpus 2 0.2 0 0 100% falls
Distal tibia 2 0.2 0 50 100% falls
Calcaneus 2 0.2 0 0 100% falls
Fibula 1 0.1 100 0 100% falls
Toe phalanges 0 0 0 0
Mid-foot 0 0 0 0
Tibial diaphysis 0 0 0 0
Talus 0 0 0 0
925 100 5.4 0.9 96.1% falls, 2.1% low fall
The numbers and prevalence of the different fractures are shown as are the prevalence of open fractures and patients with multiple fractures. The two commonest causes of each fracture are shown. (db = direct blow).
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Pattern of Changing Fracture Incidence in the Elderly

We have already documented that the overall incidence of all adult fractures increased during the last decade, from 1,113/105/year in 2000 to 1,352/105/year in 2010/11 (odds ratio 1.2, p < 0.0001). This is shown diagrammatically in Figure 20-1 with the comparative figures for 2000 and 2010/11 being shown in Table 20-11. Table 20-11 shows that this was because of a significant increase in elderly fractures. Fractures affecting the proximal femur, distal radius, proximal humerus, ankle, and pelvis are the most common fractures of the elderly and their changing incidence will be examined in more detail. 
Figure 20-1
Fracture incidence, according to age, comparing the year 2000 with 2010/11.
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Table 20-11
The Patient Numbers and Fracture Incidences in 2000 and 2010/11. The Odds Ratios and p Values are Shown
Patients 2000 2010/11 Odds Ratio p Value
Number Incidence Number Incidence
All 6,562 1,267.9 6,996 1,238.4 0.98 0.55
15–64 yrs 4,606 1,094.7 4,665 1,004.6 0.92 0.051
≥65 yrs 1,963 2,028.2 2,331 2,318 1.15 <0.0001
≥80 yrs 930 3,733.4 1,177 4,045.2 1.09 0.0003
Incidence, x/105/yr.
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The changing incidence of proximal femoral fractures between 2000 and 2010/11 is shown in Table 20-12. The overall incidence of proximal femoral fractures in the year 2000 was 129/105/year. This increased to 146/105/year in the 2010/11 study (odds ratio 1.1, p = 0.33). This increase in the incidence of proximal femoral fractures was not observed across all age groups There was an increase from 77/105/year in 2000 to 101/105/year in 2010/11 for patients aged between 60 and 69 years (Table 20-12). Otherwise the general trend was similar between these two time points. This is shown diagrammatically in Figure 20-2. However, there was a significant decrease in the incidence of proximal femoral fractures in those patients aged 90 years and older, although the absolute number increased from 132 patients in 2000 to 142 patients in 2010/11. The population in this age group increased in number, hence the decreased incidence. 
Figure 20-2
Incidence of proximal femoral fractures for the year 2000 and 2010/11, according to patient age.
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Table 20-12
The Incidence of Proximal Femoral Fractures in Different Age Groups in 2000 and 2010/11. The Odds Ratios, 95% Confidence Limits, and p Values are Shown
Proximal Femoral Fractures
Age Group Incidence (x/105/year) Odds Ratio 95% CI p Value
2000 2010
15–29 4.5 1.3 0.2 0.02–1.7 0.9
30–39 3 3.1 1 0.2–5 0.9
40–49 10.6 4.2 0.4 0.1–1.1 0.12
50–59 38.5 35.2 0.9 0.6–1.5 0.82
60–69 76.9 100.5 1.3 0.9–1.8 0.08
70–79 380 349.4 0.9 0.8–1.1 0.26
80–89 1,439.9 1,445.3 1 0.9–1.1 0.9
90+ 3,353.7 2,994.5 0.9 0.8–0.9 <0.001
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The changing incidence of distal radial fractures between 2000 and 2010/11 is shown in Table 20-13. The overall incidence of distal radial fractures significantly increased from 195/105/year in the year 2000 to 236/105/year in 2010/11 (odds ratio 1.2, p = 0.048). Overall, the general trend was toward an increase in incidence for all age categories. This is shown diagrammatically in Figure 20-3. This increase, however, was more marked, and only became significant, from the age of 40 years (Table 20-13). The greatest increase in incidence was observed in the 40- to 60-year age group which suggests that younger patients are sustaining distal radial fractures. If this is the case and the predominant mode of injury remains a fall from standing height, then it is possible that the bone quality of the population at risk may be worsening. 
Figure 20-3
Incidence of distal radial fractures for the year 2000 and 2010/11, according to patient age.
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Table 20-13
The Incidence of Distal Radial Fractures in Different Age Groups in 2000 and 2010/11. The Odds Ratios, 95% Confidence Limits, and p Values are Shown
Distal Radial Fractures
Age Group Incidence (x/105/year) Odds Ratio 95% CI p Value
2000 2010
15–29 144.2 155.8 1.1 0.9–1.4 0.49
30–39 85.3 109.9 1.3 0.97–1.7 0.07
40–49 76.8 125.5 1.6 1.2–2.2 0.0006
50–59 149.8 231.5 1.5 1.3–1.9 <0.001
60–69 273.6 339.1 1.2 1.1–1.5 0.009
70–79 500.7 430.6 0.9 0.7–0.97 0.02
80–89 677 788.4 1.2 1.1–1.3 0.003
90+ 813 970.1 1.2 1.1–1.3 0.0002
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The changing incidence of proximal humeral fractures between 2000 and 2010/11 is shown in Table 20-14. The overall incidence of proximal humeral fractures in the year 2000 was 63/105/year. This increased to 92/105/year in 2010/11 (odds ratio 1.5, p = 0.02). There was no difference in the incidence in patients below the age of 50 years. After the age of 50 years, there was a significant increased risk of sustaining a fracture of the proximal humerus (Table 20-14). This is shown diagrammatically in Figure 20-4. Excluding those patients over 90 years, the risk seems to accelerate with increasing age. 
Figure 20-4
Incidence of proximal humeral fractures for the year 2000 and 2010/11, according to patient age.
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Table 20-14
The Incidence of Proximal Humeral Fractures in Different Age Groups in 2000 and 2010/11. The Odds Ratios, 95% Confidence Limits and p Values are Shown
Proximal Humeral Fractures
Age Group Incidence (x/105/year) Odds Ratio 95% CI p Value
2000 2010
15–29 9.7 5.8 0.6 0.2–1.7 0.45
30–39 23.8 21.6 0.9 0.5–1.6 0.76
40–49 37.8 47.1 1.2 0.8–1.9 0.33
50–59 66 93.1 1.4 1.02–1.9 0.03
60–69 118 169.6 1.4 1.1–1.8 0.002
70–79 172.1 225.4 1.3 1.1–1.6 0.008
80–89 271.8 398.3 1.5 1.3–1.7 <0.001
90+ 482.7 442.9 0.9 0.8–1.04 0.19
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The changing incidence of ankle fractures between 2000 and 2010/11 is shown in Table 20-15. The overall incidence of ankle fractures has significantly increased over the last decade from 101/105/year in 2000 to 139/105/year in 2010/11 (odds ratio 1.4, p = 0.02). A similar pattern to that of distal radial and proximal femoral fractures was observed for the change in incidence of ankle fractures with a trend from increased incidence in younger patients to a significant increase in older patients (Table 20-15). This is shown diagrammatically in Figure 20-5. The greatest increased incidence of ankle fractures was observed in patients aged 90 years or more. 
Figure 20-5
Incidence of ankle fractures for the year 2000 and 2010/11, according to patient age.
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Table 20-15
The Incidence of Ankle Fractures in Different Age Groups in 2000 and 2010/11. The Odds Ratios, 95% Confidence Limits, and p Values are Shown
Ankle Fractures
Age Group Incidence (x/105/year) Odds Ratio 95% CI p Value
2000 2010
15–29 97.9 113.3 1.2 0.9–1.5 0.33
30–39 79.4 92.4 1.2 0.9–1.6 0.35
40–49 92.2 118.2 1.3 0.97–1.7 0.08
50–59 103.1 159.8 1.6 1.2–2 0.0005
60–69 144.8 186.8 1.3 1.03–1.6 0.02
70–79 105.1 151 1.4 1.1–1.8 0.005
80–89 138.3 176.6 1.3 1.02–1.6 0.02
90+ 76.2 147.6 2 1.5–2.7 <0.001
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The changing incidence of pelvic fractures between 2000 and 2010/11 is shown in Table 20-16. The overall incidence of pelvic fractures in 2000 was 17/105/year, compared with 23/105/year in 2010/11 (odds ratio 1.4, p = 0.42). The increase in incidence was only significant in very elderly patients, aged 90 years or older (Table 20-16). This is shown diagrammatically in Figure 20-6. This increase in the incidence in the very elderly suggests that fragility fractures of the pelvis are fractures of extreme old age, and may explain the decrease in proximal femoral fractures observed for this age group. A simple fall in this age group may cause a pelvic fracture instead of a proximal femoral fracture. 
Figure 20-6
Incidence of pelvic fractures for the year 2000 and 2010/11, according to patient age.
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Table 20-16
The Incidence of Pelvic Fractures for the Different Age Groups in 2000 and 2010/11. The Odds Ratios, 95% Confidence Limits, and p Values are Shown
Pelvic Fractures
Age Group Incidence (x/105/year) Odds Ratio 95% CI p Value
2000 2010
15–29 3 4.5 1 0.5–1.7 0.9
30–39 4 2.1 0.5 0.1–2.7 0.9
40–49 3.5 4.2 1 0.3–4 0.9
50–59 4.1 10.1 2.5 0.8–8 0.18
60–69 17.9 25.1 1.4 0.8–2.5 0.35
70–79 40.2 24.8 0.6 0.4–1.03 0.08
80–89 157.3 180.7 1.2 0.9–1.4 0.21
90+ 228.7 611.6 2.7 2.3–3.1 <0.001
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Open Fractures in the Elderly and Super-Elderly

Table 20-17 shows the incidence of open fractures in the different age groups. The data comes from a 15-year study of open fractures and the overall data from the study is shown in Table 3-17 which gives the prevalences of different open fractures in the elderly and super-elderly groups. The overall incidence of open fractures is 30/105/year, and the most common fractures involved are the hand, tibia, distal radius, toes, and ankle (Table 20-17). The incidence in younger patients and elderly patients is similar but it rises to 46/105/year in the super-elderly aged 80 years or more. The incidence of open fractures associated with finger, metacarpal, and tibial fractures remains relatively constant across all age groups (Table 20-17). However, the reason for the increasing incidence of open fractures with age is because of a significant increase in the incidence of open distal radius and ankle fractures with age. The incidence of open distal radius fractures increases from 1/105/year for adults aged between 15 and 64 years of age to 6/105/year for elderly patients (odds ratio 4.5, p = 0.03), and increases further still to 15/105/year for super-elderly patients (odds ratio 7.5, p = 0.002). This is also true for open ankle fractures where the incidence increases from 1/105/year for adults aged between 15 and 64 years of age to 3/105/year for elderly patients, and again increases further still to 5/105/year for super-elderly patients (Table 20-17). 
Table 20-17
The Number and Incidence of Open Fractures in Younger Patients, the Elderly, and the Super-Elderly
15–64 yrs 65–79 yrs 80+ yrs
Number Incidence Number Incidence Number Incidence
Finger phalanges 944 14.9 100 9.3 46 12.2
Tibial diaphysis 219 3.5 30 2.8 18 4.8
Distal radius 60 0.9 68 6.3 56 14.9
Toe phalanges 150 2.4 17 1.6 3 0.8
Ankle 72 1.1 36 3.3 18 4.8
Metacarpus 96 1.5 3 0.3 5 1.3
Proximal ulna 36 0.6 11 1 4 1.1
Metatarsus 42 0.7 5 0.5 2 0.5
Patella 41 0.6 3 0.3 2 0.5
Radius and ulna 35 0.6 6 0.6 3 0.8
Femoral diaphysis 40 0.6 1 0.1 1 0.3
Distal tibia 24 0.4 6 0.6 1 0.3
Proximal tibia 22 0.3 4 0.4 3 0.8
Distal femur 21 0.3 2 0.2 3 0.8
Ulna diaphysis 21 0.3 4 0.4
Calcaneus 14 0.2 4 0.4
Distal humerus 12 0.2 4 0.4 2 0.5
Humeral diaphysis 10 0.2 4 0.4 2 0.5
Proximal humerus 9 0.1 2 0.2
Clavicle 8 0.1 1 0.3
Pelvis 6 0.1 1 0.1
Talus 6 0.1
Radial diaphysis 4 0.06 1 0.1
Mid-foot 5 0.08
Scapula 2 0.03
Proximal radius/ulna 1 0.02 1 0.3
Proximal femur 1 0.02
Carpus 1 0.02
Total 1,902 30.1 312 28.9 172 45.7
Incidence, x/105/yr.
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Although as a group the incidence of open fractures increases with age, analysis by gender demonstrates that the incidence of open fractures in male patients actually decreases with age whereas the incidence of open fractures in females increases with age (Fig. 20-7). The incidence in males peaks in the 15- to 29-year age group and then gradually decreases with age to 24/105/year in patients aged more than 90 years. However, the incidence of open fractures in females is relatively low from 15 to 60 years, at which point the incidence doubles to reach a peak of 52/105/year in the super-elderly patients. This significant difference in the incidence of open fractures by age and gender is related to the increase in open distal radius and ankle fractures (Table 20-17), which are more common in super-elderly females (Tables 20-9 and 20-10). The reason why super-elderly females have a significantly increased risk of sustaining an open fracture (odds ratio 1.7, p = 0.03) relative to males is not clear. Assuming the mechanism of these open fractures is similar, with the majority occurring after a fall from standing height, then this suggests that the soft tissues in females may be more vulnerable to trauma. 
Figure 20-7
Incidence of open fractures, according to patient age and gender.
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The Future Effect on Trauma Services

There are few studies analyzing the outcome of all fractures in super-elderly patients.49 The majority of the literature focuses upon proximal femoral fractures in this age group, as they are acknowledged to have major repercussions for the patient, their family, social services, and health-care services. These patients have an increased age- and gender-adjusted mortality rate when compared with the general population.80 The outcome deteriorates with increasing age, mortality increases, and the patient is less likely to return to independent living and mobility after the fracture.84 
The super-elderly account for 17% of all fractures presenting to orthopedic surgeons. However they account for 34% of all acute orthopedic trauma admissions. There are significant case-mix and comorbidity considerations in admissions of the super-elderly. Table 20-18 shows a comparison of the case-mix variables in the elderly and super-elderly patients admitted to the Royal Infirmary of Edinburgh.36 These patients are less likely (odds ratio 3) to live in their own home and are less likely (odds ratio 4.5) to be independently mobile. Dementia is also significantly more common in the super-elderly group. Excluding hip fractures, the oldest patients are more likely to be admitted to hospital after injury even after upper limb fractures where the patient may otherwise be ambulant. This reflects their frailty and failure to cope unaided. 
Table 20-18
Case-Mix Variables in Elderly and Super-Elderly Patients. See Text for Details
Case-mix Variables Age Group
Elderly Super-elderly
Gender
 Male 18% (189) 18.2% (58)
 Female 82% (808) 81.8% (260)
Prefracture Residence of Inpatients
 Own homea 82.6% 68.8%
 Residential carea 5.9% 8.6%
 Nursing homea 11.2% 22.3%
 Hospital 0.4% 0.4%
Prefracture Mobility
 No aidsa 49% 17.6%
 One stick 33.7% 38.5%
 Two sticksa 11.1% 14.6%
 Zimmer framea 4.4% 23.9%
 Unable to walka 1.8% 5.4%
Comorbidities
 Nil 6.1% 4.1%
 One 23% 20.6%
 Two 39.5% 40.2%
 Three 22.3% 23.7%
 Four or more 10.1% 11.4%
 Dementiaa 5.1% 11.6%
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Increasing age is associated with a higher rate of mortality after hip fracture.80 However, a recent study also affirmed that in elderly patients this increased risk extends across all common fractures. When survival outcome was analyzed, patients in the super-elderly group were less likely to survive 120 days in all fracture subgroups (Fig. 20-8).36 
Figure 20-8
120-day patient survival for upper and lower limbs, pelvis and proximal femoral fractures for the elderly (80 to 90 years) and very elderly (90 years and older).
aSignificant difference between the two groups (p < 0.02).
aSignificant difference between the two groups (p < 0.02).
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Several studies have demonstrated that advancing age is associated with increased length of hospital stay after surgery for the treatment of hip fractures.88,89 The median length of hospital stay is significantly longer for the super-elderly group when compared with the elderly group.36 Assuming that the cost of stay per day in an acute ward is similar to that of a fractured hip ($664119), then this would result in an increased cost of $6,640 per patient. This will have major implications for future resource allocation and service provision in the face of an aging population. 
Those patients admitted from their own home form an important group. The aim of treatment should be to return the patient to independent living. Only 58.4% of the super-elderly patients documented in Table 20-18, who were living independently, returned to their original domicile (Table 20-19). Failure to discharge these patients directly to their domicile may reflect their worsening mobility when compared with elderly patients (Table 20-18), with their fracture finally initiating the need for increased care. It is difficult to analyze the cost implications of future care packages in all fractures in the super-elderly, but this financial burden is well recognized in hip fracture studies.95,99 
Table 20-19
The Outcome of Elderly and Super-Elderly Patients Admitted to Hospital with a Fracture
Outcome Age Group
Elderly Very-elderly
30-day survival for all inpatients
 Alive 94.6% 91.1%
 Dead 5.4% 8.9%
120-day survival for all inpatients
 Alive 85.5% 74%
 Dead 14.4% 26%
Residence at 120 days if patient lived at home prior to fracture
 Own home 81.3% 58.4%
 Residential care 9.3% 15.7%
 Nursing home 6.6% 18.9%
 Rehabilitation ward 3% 6.5%
 Hospital 0% 1.1%
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The super-elderly patients are more likely to sustain a proximal femoral or pelvic fracture than a distal radius fracture.36 This may be because of decreasing cognition with age and diminished protective reflexes.6,153 
Table 20-20 presents an analysis of the management of elderly and super-elderly patients in Edinburgh, Scotland.36 It shows that super-elderly patients are more likely to be managed nonoperatively for upper limb fractures. This is particularly true if they had more than two comorbidities or a diagnosis of dementia. This is because of their diminished functional demand, with nearly a third of patients residing in care homes. For those living at home at the time of admission, the rate of operative intervention increased. 
Table 20-20
An Analysis of the Requirement for Surgery for Various Upper and Lower Limb Fractures and Pelvic Fractures in the Elderly and Super-Elderly
Fracture Group Elderly Super-elderly Risk of Surgery p Value
Patients Number (%) Surgery (%) Patients Number (%) Surgery (%)
Lower Limb
 Ankle 30 (3) 8 (26.7) 10 (3.1) 3 (30) OR 1.1 p = 0.6
 Distal femur 8 (0.8) 6 (75) 6 (1.9) 5 (83.3) OR 1.7 p = 0.6
 Femoral diaphysis 29 (2.9) 27 (93.1) 12 (3.8) 11 (91.7) OR 1.2 p = 0.7
 Proximal tibia 10 (1) 7 (70) 6 (1.9) 4 (66.7) OR 1.2 p = 0.7
Total 77 48 (62.3) 34 23 (67.6) OR 1.3 p = 0.4
Upper Limb
 Distal radius 180 (18.2) 41 (22.8) 35 (11.1) 2 (5.7) OR 4 p = 0.04
 Proximal humerus 110 (11) 11 (10) 34 (10.8) 1 (2.9) OR 3.4 p = 0.2
Total 290 52 69 3 OR 4.1 p = 0.006
Pelvis 43 (4.3) 0 23 (7.3) 0 OR 1.9 p = 0.6
Proximal femur 421 (42.5) 409 (97.1) 160 (50.6) 149 (93.1) OR 2.4 p = 0.03
OR, Odds ratio.
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Evidence demonstrates that operating on proximal femoral fractures within 48 hours of admission improves patient outcome, with decreased perioperative complication rates and shorter length of stay.32 It would seem logical to apply this principle to all lower limb fractures requiring surgery in the elderly to aid early rehabilitation. A single study has demonstrated a significantly increased mortality risk for super-elderly patients with lower limb fractures who had delayed surgery (>48 hours).36 However, this delay may also be because of optimization of the most physically unwell patients who may carry an increased mortality risk. 
Due to the complex issues surrounding the inclusive care of these very-elderly patients, a multidisciplinary team approach has been shown to improve 1-year survival in hip fracture patients,2 and may benefit all elderly patients with a fragility fracture.72 The acute orthopedic trauma ward may also be a suboptimal location to manage such patients who may need an environment that will address their multifaceted needs. 

Specific Common Fractures in the Elderly

The management of specific fractures is comprehensively covered within the appropriate chapters of Rockwood and Green. This section offers a review of specific issues relating to super-elderly patients presenting with fragility fractures. 

Proximal Femur

Hip fractures account for 12% of all adult fractures presenting to orthopedic trauma surgeons,48 and are a major cause of morbidity and mortality for elderly patients.82 Although the reported annual incidence of hip fractures during the last decade has declined,81,95 the population at risk continues to increase.147 Hence, these elderly patients will form an increasing proportion of the orthopedic trauma workload in the future. The mean age of patients with proximal femoral fractures is 80 years. The management of proximal femoral fractures is covered in Chapters 49 and 50. However, a question that particularly pertains to the super-elderly patient group is whether undisplaced intracapsular hip fractures should be managed with internal fixation or with an arthroplasty? 
Approximately 50% of hip fractures are intracapsular,83 of which 32% to 38% are undisplaced.69,70 The conventional management of an undisplaced intracapsular hip fracture is by internal fixation. However, there is a reported revision rate of 12% to 30% at 1 year.41,117 Recently, Gjertsen et al.70 demonstrated that the outcome of displaced intracapsular hip fractures managed with a hemiarthroplasty was better than in patients with an undisplaced intracapsular hip fracture managed with internal fixation. If patients with a high risk of revision surgery could be identified prior to fixation of their undisplaced intracapsular hip fracture, they might benefit from a primary hemiarthroplasty or potentially a total hip replacement.104 Conn and Parker41 identified age, mobility, and the lateral Garden angle to be risk factors for nonunion after fixation of undisplaced intracapsular hip fractures. 
The 1-year mortality after a hip fracture is approximately 30%.179 Independent patients surviving beyond this time may benefit from a total hip replacement when compared with a hemiarthroplasty.12,27,104 Isolated independent predictors of survival have been identified for both intra- and extracapsular fractures hip fractures.169,179 Holt et al.82 specifically identified intracapsular fractures to be associated with a decreased early mortality rate relative to other hip fracture patterns. 
Varying survival rates 52,117 have been reported for cannulated screw fixation of undisplaced intracapsular fractured neck of femur, with the largest series in the literature reporting 88% survival.41 Increasing age has been associated with nonunion of femoral neck fractures,14,33,41 and hence would result in a lower survivorship rate in the super-elderly cohort. Posterior tilt (anterior angulation) on the lateral radiograph of the hip is an independent predictor of fixation failure (Fig. 20-9). This was identified to be a risk factor by Conn and Parker.41 The presence of posterior tilt probably relates to comminution of the posterior aspect of the femoral neck. This is associated with an inferior biomechanical construction when using cannulated screws.53 Those patients with posterior tilt may benefit from the biomechanical advantage of either four screws or a fixed angle device, such as an extramedullary sliding hip screw, which could potentially improve their survival rate.53,103 Recent evidence, however, from the Norwegian hip fracture register found patients with displaced intracapsular hip fractures managed with hemiarthroplasty experienced greater patient satisfaction and pain relief and better functional results when compared with patients who had sustained undisplaced intracapsular hip fractures managed with internal fixation.70 Gjertsen et al.70 hypothesize that this difference in outcome may relate to the higher re-operation rate associated with internal fixation compared to hemiarthroplasty. 
Figure 20-9
Lateral radiograph of the hip demonstrating posterior tilt (A) with a Garden lateral angle of 145 degrees (B).
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The 1-year unadjusted mortality rate reported after undisplaced femoral neck fractures is approximately 20%,41 which is about 10% less than other hip fracture patterns.179 The patient’s age and gender have previously been shown to be independent predictors of mortality for hip fracture patients.82,169 The American Society of Anesthesiologists (ASA) grade was designed to predict perioperative mortality,11 and has been shown to be an independent predictor of early mortality for hip fracture patients.82 Patients with a lower ASA grade, predicting longevity, but with risk factors for failure of internal fixation, may benefit from a primary total hip replacement if we apply the rationale that has already been discussed.104 
The management of super-elderly patients with an undisplaced fractured neck of femur with a high risk of fixation failure is difficult, and randomized controlled trials are required to compare the outcome of the alternative methods of internal fixation and arthroplasty for these patients. 

Distal Radius

Fractures of the distal radius account for 16% of all fractures, making it the commonest fracture that presents to orthopedic surgeons.43 Undisplaced stable fractures can be managed conservatively with the expectation of a good functional outcome.45,126 However the management of unstable fractures of the distal radius remains controversial.73 The functional outcome of displaced fractures is generally accepted to correlate with the anatomical reduction of the fracture,126 although some authors suggest that this may not be the case.10 This disparity may be because of the size of the reported cohorts, lack of standardized reporting, and the combination of both intra- and extra-articular fractures within a series. In addition, multiple studies have reported cohorts with a wide age range with one series including patients 18 to 86 years old.168 Because age has been demonstrated to influence the outcome of distal radial fractures,164 this may have influenced the outcome of these studies hence the differing functional results observed with and without anatomical restoration. 
The effect of a distal radial malunion upon functional outcome has been demonstrated to diminish with increasing age.56 Most studies reporting the outcome of distal radial fractures in the elderly, being defined as greater than 60 or 65 years of age, include low-demand patients only. The question remains whether malunion results in an inferior outcome in super-elderly patients who have a lower physical demand, because of their advanced age. Furthermore, manipulation and reduction of distal radial fractures has been shown to be of minimal benefit in frail elderly patients.19 
Colles,39 some 200 years ago, when describing his fracture, stated that “one consolation only remains, that the limb at some remote period will again enjoy perfect freedom in all its motions, and be completely exempt from pain: the deformity, however, will remain undiminished through life.” This statement may not be applicable to all patients, but as functional demand decreases with age it may display a degree of insight into the problem. Even if there is a malunion in the elderly population the associated diminished grip strength and range of movement may not hinder limb function. 
There is no association of malunion with poor functional outcome for low-demand patients. Beumer and McQueen19 questioned whether attempted reduction of displaced distal radial fractures should be attempted in very elderly, frail, dependent, or demented patients after finding that 88.3% lost reduction and went on to malunion. Young and Rayan182 and Chang et al.30 showed that malunion did not correlate with poor functional outcome. These studies only included elderly patients with low physical demands. More recently, Grewal and MacDermid71 included all patients, with no exclusions according to physical demands, and found no difference in the outcome of extra-articular fractures of the distal radius after malunion in patients greater than 65 years old. They did however demonstrate an increased risk of a poor functional outcome in younger patients. They assessed the outcome using the Disabilities of the Arm, Shoulder and Hand (DASH) score. The DASH score is not validated for patients at the extremes of age. To state that a DASH score of 20 points or more is a poor outcome for very elderly patients is difficult to support, as this score may be normal for them. In fact, one study found the mean DASH score to be 22 points for a group of patients with a mean age of 78 years after sustaining a distal radial fracture.8 
The management of distal radial fractures, the most prevalent fracture of the super-elderly,36 will form the greatest proportion of the emergency room and orthopedic trauma workload. If a conservative protocol was followed for all distal radial fractures in the super-elderly group in view of the limited disability incurred, a potential risk would be the development of a symptomatic malunion in some patients. A distal radial osteotomy is indicated in fit patients with a symptomatic malunion which interferes with function irrespective of age. Patients generally achieve a good functional outcome, but the rate of metalwork removal varies from 25% to 54% when plates are used to stabilize the osteotomy. However, more recently, the use of a nonbridging external fixator has been described to stabilize the osteotomy, offering a minimally invasive technique and good functional results without the subsequent need to remove internal metalwork.127 

Proximal Humerus

Fractures of the proximal humerus account for about 7% of all adult fractures presenting to orthopedic surgeons, the prevalence being recorded as 7.3% in the seventh edition of Rockwood and Green18 and 6.8% in this edition (Table 20-2). It is the third commonest fracture sustained by elderly patients. Proximal humeral fractures have a type F fracture distribution, being unimodal for both older males and females (Table 3-13). Table 20-2 shows that the average age of patients with proximal humeral fractures is about 66 years, hence more than half of these injuries occur in the elderly, and it is regarded as an osteoporotic fracture.48 Proximal humeral fractures, like those of the proximal femur, are associated with an increased mortality, relative to a standardized population.163 Modification in the management of proximal humeral fractures may address this excess mortality, as previously demonstrated for proximal femoral fractures.72 
The incidence of proximal humeral fractures is increasing although the reason for this is not clear.144 In Sweden, the incidence of proximal humeral fractures in females doubled between 1950 and 1980.17 Kannus et al.97 and Palvanen et al.,144 reporting the epidemiology of proximal humeral fractures from Finland, demonstrated that the incidence in elderly patients tripled from 32/105/year in 1970 to 105/105/year in 2002. The most recent update of this study from Finland, reporting the incidence of proximal humeral fractures in super-elderly female patients, shows results that are nearly identical to the incidence and the rate of change observed in the Scottish super-elderly population. If the incidence of proximal humeral fractures in the super-elderly population continues to increase at the rate predicted by our results and those of Kannus et al.,97 it will reach 1,000 to 1,600/105/year by 2030. In addition, if this same population also doubles, as it is predicted to do,141 then we will be managing four times as many proximal humeral fractures in the super-elderly than orthopedic trauma surgeons manage currently. 
Proximal humeral fractures are regarded as fragility fractures.48 The incidence of all fragility fractures in the elderly is increasing, with most occurring as the result of low-energy falls, which usually occurs in the patients’ place of domicile.46,98 Approximately one-third of the elderly population who live at home fall each year. This increases to two-thirds in those who live in residential homes.125 One in ten of these falls results in a serious injury172 and a recent Swedish study has suggested that 7% of falls in the elderly result in fracture.178 It is likely that the incidence of fall-related fractures, including those affecting the proximal humerus, will increase in the future resulting in considerable expense for all healthcare systems. The Center for Disease Control and Protection in the United States has suggested that the cost of falls in 2020 may reach $35 billion.28 
Fragility fractures are more likely to occur in patients with poor gait, festinant gait or who fall sideways, or are unable to break their fall with an outstretched arm.105 Allum et al.6 studied age-dependent balance correction and arm movements for falls in different age groups, and showed that compensatory movements to facilitate protection from falls were less effective with increasing age. Frailer patients are more likely to incur proximal limb girdle fractures because of diminished protective reflexes.6,153 
The level of social deprivation of patients sustaining proximal humeral fractures has increased. A greater proportion of elderly patients sustaining such fractures suffer an increased level of comorbidity, which is associated with social deprivation,38,47 and in turn is an independent risk factor for sustaining a proximal humeral fracture.105 We have observed increasing fracture severity in the last 20 years and this may be, at least partially, due to increasing social deprivation (Table 3-12). Diminishing bone mineral density has been demonstrated to result in more severe fractures of the distal radius34 and the same may be true for the proximal humerus. The increasing proportion of elderly patients sustaining proximal humeral fractures, in addition to their increased deprivation, with its associated comorbidities, may also have reduced bone mineral density149 and hence more severe fractures. 
The overall unadjusted mortality rate at 1 year is approximately 10%. Shortt and Robinson163 demonstrated a significantly increased mortality associated with these fractures relative to the standard population in all age groups older than 45 years. The highest 1-year mortality rate that they observed was approximately 30% for patients 85 years or more, this being the same as the unadjusted mortality rate we observed for our super-elderly patients. They did not analyze the standardized mortality by gender, but they did identify male gender as an independent predictor of outcome. Morin et al.131 more recently demonstrated that both female and male genders suffered a significantly increased standardized mortality rate at 1 year after a “nontraumatic” fracture of the proximal humerus. 
It is not clear whether super-elderly patients benefit from operative intervention. Again, the functional demands of this patient population need to be acknowledged. Most studies reporting the outcome of operative intervention, open reduction and internal fixation, and hemiarthroplasty consist of cohorts of a younger mean age than that of the average for proximal humeral fractures. Hence, outcomes reported by these authors may not reflect that of the older low-demand patient. It can be expected that a good functional result will be obtained by nonoperative management for minimally displaced and two-part proximal humeral fractures, which is acknowledged for all age groups. However, for three- and four-part fractures of the proximal humerus the evidence is not as clear for elderly patients. 
During the course of the last decade there has been over 60 studies published describing the outcome of proximal humeral fractures fixed using the proximal humeral internal locking system (PHILOS) plate. There has been an exponential rise in the published literature during this time period, from a single study in 200420 to 13 in 2012. The claimed advantages of the PHILOS plate are improved screw fixation in osteoporotic bone which facilitates fixation with minimal soft tissue dissection. The plate is precontoured for the proximal humerus, and direct compression of the plate against the bone is not required, which is thought to preserve the blood supply to the bone. The locking screws offer angular as well as axial stability and may reduce the risk of loss of reduction.66 
Despite the escalation in the use of the PHILOS plate and in publications regarding its outcome the evidence as to whether this device is beneficial to the patients it was designed for remains difficult to decipher. It is not clear in which patients these plates should be used and whether they offer a functional advantage over nonoperative management. There have been 29 studies, of the 63 cited on PubMed, that have used the Constant score as their outcome assessment tool (Table 20-21). There is, however, marked heterogeneity between these studies, with the mean age ranging from 42 to 78 years old, and the size of the reported cohorts varying from 9 to 294 fractures. The mean age of the patients in those studies reporting the outcome of the PHILOS plate is 62 years old but it should be remembered that while the average age of patients with proximal humeral fractures is 66 years,97 the average age of patients who present with three- and four-part proximal humeral fractures is 72 years.98 This suggests that there is an inclusion bias in some studies, which may reserve such an intervention for younger patients. However, this does seem to be at odds with the design and intention of the PHILOS plate. 
Table 20-21
Studies Reporting the Outcome of Proximal Humeral Fractures Treated with the Philos Plate
Author Year Number Age (yrs) Constant Score
Reported Predicted* Difference
Brunner et al.24 2012 16 61 81 77 4
Zhao et al.183 2012 74 57 86 82 4
Aksu et al.5 2012 9 75 87 72 15
Spross et al.166 2012 294 73 89 72 17
Acklin and Sommer1 2012 29 64 78 77 1
Kuhlmann et al.116 2012 30 69 62 77 –15
Spross et al.165 2012 44 75 65 72 –7
Konrad et al.110 2012 153 65 75 77 –2
El-Sayed61 2010 59 42 65 86 –21
Hirschmann et al.78 2011 57 65 81 77 4
Parmaksizogˇlu et al.148 2010 12 56 88 82 6
Parmaksizogˇlu et al.148 2010 19 67 74 77 –3
Aksu et al.4 2010 103 62 68 77 –9
Thyagarajan et al.171 2009 30 58 58 82 –24
Geiger et al.67 2010 28 61 68 77 –9
Liu et al.121 2010 17 71 87 72 15
Papadopoulos et al.145 2009 29 62 86 77 9
Brunner et al.25 2009 158 65 72 77 –5
Fazal and Haddad63 2009 27 56 70 82 –12
Martinez et al.124 2009 58 61 80 77 3
Kilic et al.107 2008 22 57 76 82 –6
Krivohlavek et al.115 2008 49 57 75 82 –7
Korkmaz et al.111 2008 24 47 95 86 9
Korkmaz et al.111 2008 17 78 93 72 21
Handschin et al.74 2008 31 62 80 77 3
Moonot et al.130 2007 32 60 67 82 –15
Kettler et al.106 2006 225 66 70 77 –7
Koukakis et al.112 2006 20 62 76 77 –1
Bjorkenheim et al.20 2004 72 67 77 77 0
 

From Constant CR, Gerber C, Emery RJ, et al. A review of the Constant score: Modifications and guidelines for its use. J Shoulder Elbow Surg. 2008;17:355–361.

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Furthermore, it is interesting to note the outcome of these studies according to the Constant score. The Constant score has been demonstrated to diminish with age in a normal population.43 The variation in the reported Constant score after PHILOS plating varies from 58 to 95 (Table 20-21). In part this may reflect the differing mean age between study cohorts. However, even if these scores are adjusted for age, the variation in score ranges from 24 points less than predicted to 21 points greater than predicted (Fig. 20-10). This variation may also be because of the inclusion criteria of the studies, which may reflect that only higher functioning patients were offered surgery. However, it is hard to believe that most patients will regain their prior functional status or even improve relative to their predicted score. 
Figure 20-10
 
Difference in the reported Constant score relative to the age-matched score for the 29 identified studies reporting the outcome of the PHILOS plate for proximal humeral fractures (Table 20-21).
Difference in the reported Constant score relative to the age-matched score for the 29 identified studies reporting the outcome of the PHILOS plate for proximal humeral fractures (Table 20-21).
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Figure 20-10
Difference in the reported Constant score relative to the age-matched score for the 29 identified studies reporting the outcome of the PHILOS plate for proximal humeral fractures (Table 20-21).
Difference in the reported Constant score relative to the age-matched score for the 29 identified studies reporting the outcome of the PHILOS plate for proximal humeral fractures (Table 20-21).
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The only randomized controlled trial comparing the outcome of the PHILOS plate (n = 30) with conservative management (n = 29) for proximal humeral fractures in elderly patients concluded in favor of the PHILOS plate.142 However, there was no statistical difference in any of the outcome measures assessed, and the three-point difference they found in the Constant score at 2 years (61 vs. 58) is not clinically significant.43 The authors also demonstrated a re-operation rate of 17% for those plated. The cost and complication risk of operative intervention with a PHILOS plate would seem, with current evidence, to be of no significant benefit to the elderly patients for whom this plate was designed. 
In contrast to the fixation versus conservative management randomized control trial described above, the same study group performed another randomized controlled trial comparing nonoperative with hemiarthroplasty for four-part proximal humeral fractures in the elderly (>57 years with a mean of 77 years). They demonstrated a significant functional improvement according to the EQ-5D questionnaire in the operative group but no difference in the DASH score, Constant score, pain, or range of movement. Whether these results translates to the super-elderly remains unknown, but future studies should acknowledge this age group and analyze whether there is a diminishing improvement offered by operative intervention for proximal humeral fractures in these low-demand patients. 

Pelvic Fractures

Although the predominant fracture of the super-elderly involves the proximal femur, 73% of all pelvic fractures occur in this age group.48 Currently pelvic fractures are three times less common than proximal femoral fractures.128 However, a recent epidemiologic study from Europe demonstrated a three-fold increase of pelvic fractures in the elderly from 1970 to 1997.96 The predominant pelvic fracture in the elderly is that of the pubic rami,46 which is associated with considerable morbidity and mortality.23,77,113,132,173 The changing epidemiology of the elderly may have major repercussions on the trauma workload in the future, placing a major burden on medical resources both acutely and for the ongoing care of these frail patients after discharge.92,113,132,154 The majority of what modest literature exists, regarding pelvic injuries in the elderly, focuses on pubic rami fractures.23,77,113,114,173 
The average length of stay on an acute trauma ward for an elderly hip fracture patient is 23 days,119 which is the same as elderly patients sustaining pelvic fractures other than those of the pubic rami. The length of stay of patients with pubic rami fractures ranges from 9 to 14 days, although the studies reporting these figures included all ages in their analysis.77,113 Super-elderly patients have a significantly longer length of hospital stay relative to their elderly counterparts and the same can be assumed for pubic rami fractures.36 Furthermore, a recent study demonstrated that the average length of stay was 45 days for elderly patients sustaining either combined pubic rami fractures or a sacral fracture,7 which is a considerably longer length of stay than observed for isolated pubic rami fractures. 
Koval et al.113 demonstrated that three or more comorbidities increased the length of stay, and Hill et al.77 found younger age to be a predictor of discharge to the patient’s original domicile. In addition, the place of residence, level of mobility, and socioeconomic status are also isolated independent predictors of length of stay and discharge destination for patients sustaining a pubic rami fracture. These predictors could be used to identify patients who may have a longer-than-average stay or need an increased care package on discharge. 
The 1-year mortality rate of super-elderly patients sustaining a pubic rami fracture is 22%,36 which is greater than previous studies have observed.77,113 This is clearly due to the exclusion of patients younger than 80 years of age, who have an improved 1-year survival. However, despite the absolute mortality rate being higher in the super-elderly, the standardized mortality ratio (SMR) at 1 year is actually lowest in the super-elderly group.35 These frail patients may benefit from input from a geriatrician and multidisciplinary therapy team to medically optimize their comorbidities and rehabilitation as has been demonstrated for hip fractures.120 Alternatively, in frail patients, a palliative care approach may be preferred to facilitate end-of-life management.133 Although the standard treatment of pubic rami fractures is nonoperative, Krappinger et al.114 and Beall et al.15 suggested that “ramoplasty,” percutaneous injection of polymethyl methacrylate into acute pubic rami fractures, may relieve pain and facilitate early mobilization, but this is not widespread practice nor is there any level 1 evidence to support this management intervention. 

Tibia

Not all fractures show the same trend as fractures of the proximal femur, proximal humerus, and distal radius with an increasing prevalence in older males and females. A good example of this is the tibial diaphyseal fracture. The epidemiology of tibial fractures has changed significantly during the last 20 years mainly because of improved road safety.46 The overall incidence of tibial diaphyseal fractures is declining, nearly halving in number from 27/105/year in 199050 to 13/105/year in 2010/11 (Table 20-2). The gender distribution is predominately male (Table 20-2) but the literature suggests that there was a change in the distribution in the latter half of the last century with an increased incidence of female patients, including elderly patients.16,62 The mean age of the patients, particularly females, increased during this period and Table 3-14 shows that in 1991, in Edinburgh, the average age of males and females who presented with tibial fractures was 33 years and 61 years, respectively. The mechanism of injury has also changed. In 1990 most tibial diaphyseal fractures occurred after a motor vehicle accident (37.5%) or a sports injury (30.9%),50 whereas in 2008 two-thirds occurred after a low-energy fall from standing height.46 
Table 3-14 shows that since 1991 there has been further changes in the epidemiology of tibial fractures. The average age of males has risen from 33 to 41 years whereas the average age of females has fallen from 61 to 44 years. However, in both males and females, the prevalence of tibial fractures caused by standing falls has risen from 16% to 37% in males and from 53% to 65% in females. The number of tibial diaphyseal fractures caused by road traffic accidents has fallen considerably and many fewer elderly female pedestrians are now being hit by automobiles. As tibial diaphyseal fractures are not osteoporotic fractures (Table 20-3) this means that although the relative number of fractures caused by standing falls will rise, the average age will fall. A review of the data from 2010/11 (Table 20-2) shows that 8.7% of open tibial diaphyseal fractures occurred in the elderly and there were no open fractures in the super-elderly population. The gender distribution of open fractures in the elderly population was 83/17. 
There is a wealth of literature regarding the management and outcome of tibial diaphyseal fractures in young patients.58,161 However, there is a very limited literature regarding the outcome in elderly patients after tibial diaphyseal fractures, with only a small cohorts reported.51,156 The demographics and outcome of these fractures is different in the elderly patients relative to their younger counterparts and therefore a different management approach may be required. 
Age has been shown to correlate with injury severity, as elderly patients are more likely to suffer an open fracture after a relatively minor injury.50 In the 2010/11 study (Table 20-2) 50% of the tibial fractures in the elderly group were open compared with 17.4% of fractures in patients aged less than 65 years. These open fractures are more likely to occur as a result of minor injury, with falls being responsible for 66% of all elderly tibial fractures and 66% of open fractures. In the elderly population, whose bone and soft tissues are becoming increasingly fragile,44 an increased injury severity for less severe modes of injury might be expected. 
The 10% nonunion rate of elderly tibial fractures is greater than that expected relative to the general population.143 Chatziyiannakis et al.31 theorized that increased soft tissue injury and fracture comminution, combined with soft tissue stripping during surgery, may increase the rate of nonunion. There is another factor in open fractures which significantly increases the risk of nonunion in the elderly. Fracture fixation with an intramedullary nail significantly reduces the nonunion rate after adjusting for other confounding variables. Hence, the increased rate of nonunion in our elderly cohort may be explained by the greater rate of open fractures and increased rate of fixation by methods other than an intramedullary nail. There are, however, other factors which may contribute to this increased nonunion rate which are more prevalent within the elderly population. Examples are medications such as statins, nonsteroidal anti-inflammatory drugs and steroids, and diseases such as hypothyroidism, diabetes, and vascular insufficiency, which have all been associated with nonunion.65 
Cox et al.51 published the only other study to examine both closed and open elderly tibial diaphyseal fractures and compare the mortality of these injuries. They found no difference between the 6-month mortality rates. A lower mortality rate, compared to our elderly patients,160 was demonstrated, with an 8% and 11% mortality rate at 6 months for closed and open fractures, respectively. Although our mortality rate at 6 months for closed fractures of 13% is similar to their 8%, the mortality associated with an open fracture in our group was significantly different with a 33% mortality rate at 6 months. The reason for this difference may reflect a type II statistical error because of their small number of patients (n = 54), which Cox et al. acknowledge in their discussion. In addition, their study centre is a tertiary referral unit for trauma, and did not exclude patients’ resident out with their own catch area. This may have skewed the results, with the most unwell or frail patients not being referred, and hence the improved survivorship of their open elderly fractures. 
The unadjusted mortality rate is 17% at 120 days and 27% at 1 year for elderly tibial fractures, with age and whether the fracture was open or closed predicting mortality. These unadjusted rates are similar to the 18%82 120 day and 29%179 1-year mortality rates observed after a fractured neck of femur. The unadjusted rate peaks at 33% for elderly patients with open tibial diaphyseal fractures at 120 days post injury. Clement et al.36 demonstrated that unadjusted mortality rates of lower limb fractures in the elderly are similar to that of a fractured hip. They also suggested that if targets are set for operating on hip fractures within 48 hours of admission, which is associated with a decreased number of post-operative complications and shorter hospital stays,32 then it would seem appropriate to apply this principle to all lower limb fractures requiring surgery in the elderly. For tibial diaphyseal fractures in the elderly, with a mortality rate similar to that of a hip fracture, outcome may also improve by adopting the fast-track care that now benefits hip fracture patients.118 
The SMR we observed for elderly patients with tibial fractures is greater than that observed after an isolated hip fracture. The SMR for a hip fracture in the elderly is 3.4,35 whereas the SMR we observed for elderly tibial diaphyseal fractures was 4.2, which increased to 8.1 in elderly females. This excess adjusted mortality associated with elderly tibial fractures confirms that they should receive the same priority as those patients with a hip fracture in an effort to improve their morbidity and mortality.157 

Olecranon

Undisplaced fractures of the olecranon are routinely managed nonoperatively137,155 with tension band wiring and plate fixation being frequently employed for displaced fractures.9,13,29,85,102,158,177 However, there is conflicting literature regarding the outcome and complications of operative fixation in elderly patients due to poor fixation in osteoporotic bone and wound breakdown.76,79,108,123 Fracture excision with advancement of the triceps has been suggested as an alternative option for osteoporotic patients,64,87 although some authors have also demonstrated triceps weakness with this technique.40,57 There is a paucity of data on the outcome following nonoperative management for displaced fractures of the olecranon, particularly in elderly patients with multiple comorbidities, low functional demand, and poor bone quality. 
There is an increasing incidence of olecranon fractures in the elderly,59 and it is now acknowledged that further work is needed to determine whether the surgical treatment for displaced olecranon fractures in these patients provides any significant long-term benefit over nonoperative management.60 There are two small case series reporting favorable short-term results following the nonoperative management of displaced olecranon fractures in both young and elderly patients.146,174 
The use of operative fixation for a displaced olecranon fracture in elderly patients can be associated with an increased anesthetic risk, poor fixation in osteoporotic bone, problems with wound breakdown, and an inferior outcome.76,79,108,123 However, it is necessary for nonoperative treatment to adequately manage pain, allow early movement, provide active extension power at the elbow, and meet the long-term demands of the patient.40,57,174 Parker et al.146 documented the short-term outcome of 23 patients with a mean age of 48 years (range, 13 to 91) who were managed conservatively using early active motion within the first 2 weeks following injury for a displaced fracture of the olecranon. In their study they included young patients, comminuted fractures, concomitant fractures to the ipsilateral elbow, and also open fractures. At a mean follow-up of 2 years the outcome was reported as good or fair in 21 (91%) patients, with comparable findings in patients over the age of 50 years. Only three patients noted a loss of power at the elbow and radiologic union was achieved in 30% of patients, with fibrous union achieved in the rest. The other series in the literature reports the short-term outcome of 12 elderly low-demand patients, who presented with a displaced fracture of the olecranon, with a mean age of 82 years managed in a 90-degree above elbow cast for a mean of 4 weeks.149 They reported patient satisfaction was excellent in 11 (92%) cases at a mean of 15 months after injury. In their series, eight (67%) patients were pain-free and nine patients had radiologic evidence of a pseudoarthrosis. 
The current evidence would suggest that nonoperative management of displaced olecranon fractures in low-demand patients with multiple comorbidities results in a satisfactory outcome in the majority of patients. However, further work is required to directly compare operative and nonoperative management in this low-demand patient group. 

Multiple Fractures in the Elderly

The majority of the literature concerning fractures in the elderly has focused on isolated fractures, particularly those of the proximal femur, proximal humerus, and distal radius. However elderly patients frequently present with more than one fracture.48 The epidemiology of multiple fractures in the elderly was studied by Clement et al.35 This study showed that the majority of multiple fractures in the elderly occur after low-energy trauma in females. Distal radius, proximal humerus, and pelvic fractures are associated with an increased risk of sustaining multiple fractures (Table 20-22). The commonest combination of multiple fractures is that of combined fractures involving the upper and lower limbs (Table 20-23). Most elderly patients sustaining multiple fractures required hospital admission, despite the fact that 42% did not require surgical treatment. However, 54% needed an increased level of social care at discharge (Table 20-24). There is a significantly increased SMR associated with multiple fractures that include a proximal humerus, pelvic, or proximal femur fracture (Table 20-25). However, this increased mortality risk diminished with increasing age, with very elderly patients actually having a lower risk. Combined fractures of the proximal humerus and femur are associated with the highest mortality risk at 1 year. 
Table 20-22
The Demographic Characteristics of Elderly Patients Who Present with Single or Multiple Fractures from All Modes of Injury. The Prevalence and Risk of Sustaining One of the Most Common Six Fractures are Shown
Single Fractures Multiple Fractures Odds Ratio p Value
Patients (%) 2,216 (94.9) 119 (5.1)
Average Age (yrs)
 All 78.9 78.7 0.78a
 Male 77.7 76.5 0.61a
 Female 79.2 79.4 0.54a
Male/Female (%) 23/77 22/78 1 0.9b
Fracture Prevalence (%)
 Proximal femur 30.6 32.8 1.1 0.34b
 Distal radius 21.1 37 2.2 <0.0001b
 Proximal humerus 9.9 35.3 5.1 <0.0001b
 Ankle 6.7 9.2 1.4 0.19b
 Finger phalanx 3.8 7.6 2.1 0.05b
 Pelvis 3.1 12.6 4.9 <0.0001b
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Table 20-23
A Comparison of the Demographic Characteristics of Double Fractures in Elderly Patients Caused by a Fall with those Caused by Other Modes of Injury
Falls Other Modes of Injury Odds Ratio p Value
Number of patients 90 19
Fractures 180 38
Average age (yrs) 79.1 77.9 0.4a
Male/female (%) 16/84 42/58 3.8 0.03b
Fracture combinations
 Upper limb fractures (%) 32.2 47.4 1.8 0.29b
 Lower limb fractures (%) 12.2 31.6 3.4 0.04b
 Combined fractures (%) 55.5 21 4.6 0.007b
Fracture types
 Proximal femur (%) 21.7 5.3 5 0.01b
 Distal radius (%) 21.1 18.4 1 0.59b
 Proximal humerus (%) 18.8 10.5 2 0.16b
 Pelvis (%)  8.9 10.5 1.2 0.47b
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Table 20-24
Rate of Admission, Operative Intervention, Fixation of Both Fractures, Length of Stay, and Rate of Discharge to Original Domicile for those Patients Admitted to Hospital, for Each Double Fracture Group
Outcome Upper Limb Lower Limb Combined p Value
Admission (%) 24/29 (82.8) 11/11 (100) 46/50 (92) 0.14a
Operative intervention (%) 7/29 (24.1) 5/11 (45.5) 40/50 (80) <0.001a
Both fractures fixed (%) 2/29 (6.9) 1/11 (9.1) 6/50 (12) 0.75a
Length of stay (days) 8.3 32.8 29.3 0.002b
Return to original place of domicile (%) 21/24 (87.5) 2/11 (18.2) 21/46 (45.6) <0.001a
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Table 20-25
The 1-Year Standardized Mortality Ratios and p Values for Single and Multiple Fractures of the Ankle, Distal Radius, Pubic Rami, Proximal Femur, and Proximal Humerus According to Age Group
Fractures Single Fracture (95% CI) p Valuea Multiple Fractures (95% CI)
All Ages p Valuea 65–79 yrs p Valuea ≥80 yrs p Valuea
Ankle 1.85 (1.03–3.10) 0.02 1.95 (0.34–6.61) 0.32 2.66 (0.33–6.61) 0.31 No deaths
Distal radius 0.75 (0.50–1.08) 0.13 1.43 (0.64–4.82) 0.15 2.18 (0.33–6.61) 0.31 1.07 (0.16–3.30) 1
Pelvis 2.28 (1.35–3.63) <0.001 10.50 (2.43–13.05) <0.001 11.64 (5.38–19.22) 0.03 3.45 (1.27–9.65) 0.003
Proximal femur 3.41 (2.99–3.87) <0.001 4.66 (2.66–7.64) <0.001 8.39 (1.83–11.08) <0.001 3.53 (1.46–5.51) <0.001
Proximal humerus 2.06 (1.47–2.80) <0.001 4.95 (2.66–7.64) <0.001 6.64 (1.83–11.08) <0.001 4.34 (2.19–8.25) <0.001
X
Surgeons may assume multiple fractures are the result of high-energy injuries and this is frequently the case in younger patients. High-energy modes of injury were associated with the highest incidence of multiple fractures in the elderly. However, these modes of injury are uncommon in the elderly and the majority of multiple fractures actually occur after low-energy trauma (88.1%).35 
There is no significant difference in the average age or gender ratios in elderly patients who present with single or multiple fractures (Table 20-22). Patients who have multiple fractures are more likely to present with a distal radius, proximal humerus, or pelvic fracture. There is, however, no consistency in the distribution of fractures in the patients who presented with three or four fractures, or for fractures that had been sustained by high-energy modes of injury in the elderly.35 This is probably because of the relative infrequency of these fractures. However, double fracture combinations that occur as a result of a fall demonstrate definite fracture patterns. 
In the study 86.7% of the fractures in fall-related double fracture combinations were in the proximal femur, proximal humerus, and distal radius. Patients who presented with upper limb fracture combinations were significantly younger than those in the other groups, with the majority of patients sustaining a distal radial fracture. However, the highest frequency of double fractures following a fall was observed in patients with combined upper and lower limb fractures. The combination of a proximal femur fracture with either a proximal humerus or distal radius fracture accounted for 31% of all fall-related double fracture combinations with a mean age of 82.2 years. 
There is a considerable difference between the double fractures caused by low-energy and high-energy modes of injury. Despite a similar mean age, high-energy trauma is significantly more common in males, with a higher prevalence of combined upper limb fractures, and less likelihood of proximal femoral fractures. This suggests that the patients who sustain double fractures, especially those of the lower limb, following a low-energy injury may be frailer than those who present with high-energy related double fractures, regardless of the fact that the mean ages are similar. 
The frailty of patients who present with double fractures is confirmed by the associated increased standardized mortality rate at 1 year. This is supported by subgroup analysis. Elderly patients, relative to super-elderly patients, were demonstrated to have an increased mortality risk, which may reflect the frailty of this younger-elderly age group after sustaining low-energy multiple fractures. The mortality risk is significantly increased for multiple fractures that included pelvic or proximal humeral fractures in all elderly patients, or proximal femoral fractures in those aged 65 to 79 years old, relative to fractures sustained in isolation. Patients sustaining these multiple fracture combinations should be identified, and both the medical and surgical management should be prioritized in an effort to improve their outcome. 
1-year mortality approached 50% for the most common double fracture combination of a proximal femoral and proximal humeral fracture. However, in contrast, the combination of a proximal femoral fracture and a distal radial fracture is associated with a decreased mortality of 18%. Allum et al.6 studied age-dependent balance correction and arm movements for falls in different age groups, and showed that compensatory movements to facilitate protection from falls were less effective with increasing age. Frailer patients were more likely to incur proximal limb girdle fractures because of diminished protective reflexes and hence sustain proximal humeral and femoral fractures.6,153 Patients who retain their protective reflexes are more likely to sustain a distal radial fracture, which may reflect a superior physiologic status. This may account for the observed improved survival rate of proximal femoral fractures associated with distal radial fracture. 
There is evidence that there is an increased incidence of fractures in socially deprived patients after falls47 and one might therefore hypothesize that there is an association between multiple fractures and deprivation. In Scotland, the population can be divided into quintiles based on social deprivation with quintile 1 being the most affluent and quintile 5 the least affluent. Figure 20-11 illustrates the incidence of multiple fractures in the five social quintiles. It shows a significant increase in the incidence of multiple fractures in the most deprived social quintile (odds ratio 2.5, 95% confidence interval (CI) 1.8 to 3.9, p = 0.001). However, a similar pattern is observed for single fractures and there is no significant difference in the relationship between single and multiple fractures and social deprivation.135 
Figure 20-11
A histogram showing the relationship between social deprivation and the incidence of fractures.
Rockwood-ch020-image011.png
View Original | Slide (.ppt)
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End-of-Life Care

Multiple studies have demonstrated that one in five people sustaining a hip fracture will die within 4 months of injury.82 This figure increases with increasing age, with a one in three mortality rate for super-elderly patients at 4 months.36 This is not unique to hip fractures. The same mortality rate has been demonstrated for pelvic fracture and other lower limb fractures in super-elderly patients.36 This unadjusted mortality rate is greater than for some malignant diseases.94 A palliative care approach is therefore appropriate for patients with advanced nonmalignant as well as malignant diseases.135 Thus a fragility fracture in a frail super-elderly person may reasonably trigger a palliative care approach: Anticipating and planning for physical, social, psychological and spiritual needs, and end-of-life care.133 
1-year mortality following hip fracture (26% to 37%) is greater than the equivalent mortality of many solid tumors.94 The mortality is even higher in specific groups, such as those graded preoperatively as ASA III or ASA IV, with 38% of patients dying within 4 months of surgery.82 However, predicting those individuals who will die is very difficult. Many such patients have multiple comorbidities, including dementia, and the fracture may precipitate a rapid physical and social decline. Even in patients who may have only days or weeks to live, surgery may be indicated to achieve pain control and avoid prolonged immobility and opiate therapy with its associated side effects. Death in the year after their fracture may be because of acute cardiovascular, respiratory, or neurologic events, but a typical pattern of decline in the final months or years has not been described. Even trivial physical events in the frail older person can cause major decompensation.136 A hip fracture is a major physical insult which can foreshorten the frailty trajectory where gradual physical or cognitive deterioration may last for many years.134 
The question “Would I be surprised if this patient were to die in the next year?” is being increasingly used to identify nonmalignant patients for a palliative care approach.135 Orthopedic surgeons, orthogeriatric clinicians, and family physicians considering individual hip fracture patients might not be surprised in many cases. Relatives frequently underestimate the 1-year mortality associated with a hip fracture. In patients with a real risk of dying, even when the prognosis is uncertain, it is appropriate to make a care plan, together with the patient and relatives where appropriate, just in case this does happen. It is then possible to anticipate problems and possibly prevent unnecessary interventions and admissions. For the majority of such patients, postoperative care planning includes nutritional, cognitive, social, physiotherapy, and occupational therapy assessments.122 In some trauma units a geriatrician is responsible for ensuring appropriate medical treatments are undertaken and is often involved in discussions with the patient and family over a poor prognosis. Comprehensive geriatric intervention may reduce short- and long-term mortality, but overall mortality remains high.176 A recent controlled trial of advance care planning in geriatric inpatients was shown to improve end-of-life care and family anxiety.54 
Active supportive care following their fracture is useful to help patients live and die well. It is currently good practice for a hip fracture in a frail, older person to trigger an orthogeriatric review to prevent and treat medical complications.3 Some authors have suggested that for such patients, the orthopedic surgeons, orthogeriatricians, patient, and family should be involved in discussions about anticipatory care to optimize the quality of life, and in due course, death.133 These care plans could then be reviewed and taken forward by family physicians, nurses, and social carers in the community. A fracture, especially those of the lower limb and pelvis, in the frail super-elderly patient may act as a stimulus to consider holistic planning and care typical of a palliative care approach. Specialist palliative care in people with lung cancer has been shown to be associated with improved quality of life and even longevity.170 It may also be beneficial if clinicians adopt a palliative care approach in selected super-elderly patients with fractures. 

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