Low-energy Fall Research Articles

Fractures of humerus and their treatment modalities

Introduction: The majority of humerus fractures are low energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. Aim of the study: The aim of study is to understand current concepts with regards to treatment options for fractures of the humerus. Materials and Methods: This is a retrospective study involving 181 cases of fracture humerus which occurred due to fall or trauma. Results: In this study, 84 cases (46.40) were proximal humerus fractures, 58 cases (32.04) were shaft of the humerus fractures and 39 cases (21.56) were distal humerus fractures and which were treated conservatively, open reduction and internal fixation or other surgical methods. Conclusion: Patients presenting with fractures of the humerus were more commonly elderly women and occur due to low energy fall or minor trauma. Early restoration of function is the main aim of the treating orthopedician depending on the age and other comorbidities and surrounding structures involvement.

Incidence of Traumatic Spinal Fractures in the Netherlands: Analysis of a Nationwide Database.

Retrospective database study based on prospectively collected data. The aim of this study was to describe the current incidence and epidemiology of traumatic spinal fractures in the Netherlands SUMMARY OF BACKGROUND DATA.: Traumatic spinal fractures may lead to severe disability and have considerable consequences on healthcare capacity and costs. Several studies have reported a large and increasing share of fractures in elderly. Currently, a reliable, detailed, and up to date incidence of these injuries in the Netherlands is lacking. These numbers could aid in the composition of preventative measures. All patients from 2010 to 2017 that were admitted with a spinal fracture were included. Patients were selected based on Abbreviated Injury Scores (AIS) codes. Collected data consisted of patient- and injury characteristics, afflicted spine-region, associated injury, referral- and discharge location, and geographic region of admittance. Overall, 29,637 patients were included in this study. The incidence of spinal fractures increased from 2010 to 2017 (from 21.5 to 24.0 per 100,000 inhabitants). Most patients were injured by a (low-energy) fall from the same level followed by (high-energy) traffic accidents. Elderly patients (≥65 years of age) made up 42% of all patients. The proportion of elderly increased significantly faster over the years compared to younger patients. More than half of polytrauma (injury severity score ≥16) patients had fractures in multiple spine regions. 5,5% of all patients suffered spinal cord injury (SCI), most often associated with cervical fractures in polytrauma patients. Regional differences were found mainly in presentation through referral and low- and high-energy falls. The incidence of patients with spinal fractures increased and elderly made up a large part. Preventative measures could be regional dependent and should focus on low-energy falls, traffic accidents, and bicycle accidents in specific. In polytraumatized patients there should be special attention for any additional spine fractures and SCI. 3.

Comparison of outcomes in non-head injured trauma patients using pre-injury warfarin or direct oral anticoagulant therapy

BackgroundPatients on prehospital anticoagulation with warfarin or direct oral anticoagulants (DOACs) represent a vulnerable subset of the trauma population. While protocolized warfarin reversal is widely available and easily implemented, prehospital anticoagulation with DOAC is cost prohibitive with only a few reversal options. This study aims to compare hospital outcomes of non-head injured trauma patients taking pre-injury DOAC versus warfarin. MethodsA retrospective cohort study at a level 1 trauma center was performed. All adult trauma patients with pre-injury anticoagulation admitted between January 2015 and December 2018, were stratified into DOAC-using and warfarin-using groups. Patients were excluded if they had traumatic brain injury (TBI). Univariate and multivariable analyses were performed. Outcomes measures included in-hospital mortality, blood transfusion requirements, ICU length of stay (LOS), hospital LOS and discharge disposition. Results374 non-TBI trauma patients on anticoagulation were identified, of which 134 were on DOACs and 240 on warfarin. Patients on DOACs had a higher ISS (9 [IQR, 9–10] vs. 9 [IQR, 5–9]; p<0.001), and lower admission INR values (1.2 [IQR, 1.1–1.3] vs 2.4 [IQR, 1.8–2.7]; p<0.001) than warfarin users. Use of reversal agents was higher in warfarin users (p<0.001). Relative to warfarin, DOAC users did not differ significantly with respect to hospital mortality (OR 0.47, 95% CI [0.13–1.73]). Multivariable analysis (not possible for mortality) did not show significant difference for RBC transfusion requirements (OR 0.92 [0.51–1.67]), ICU LOS (OR 1.08 [0.53–2.19]), hospital LOS (OR 1.10 [0.70–1.74]) or discharge disposition (OR 0.56 [0.29–1.11]) between the groups. ConclusionDespite lower reversal rates and higher ISS, non-TBI trauma patients with pre-injury DOAC use had similar outcomes as patients on pre-injury warfarin. There may be equipoise to have larger, prospective studies evaluating the comparative safety of DOACs and warfarin in the population prone to low energy fall type injuries.

Does prehospital spinal immobilization influence in hospital decision to obtain imaging after trauma?

Importance: This study highlights the unnecessarily high suspicion for cervical spine injury among study providers and shows that cervical CT scans were more likely in patients who arrived to the emergency department wearing a cervical collar, even when clinically cleared for suspicion of cervical spine injury by the emergency department provider. Objective: To determine if patients with a cervical collar were more likely to undergo cervical spine imaging than those who arrived to the emergency department without a collar. Design: Adult trauma patients at a level 1 trauma center over 4 months (n = 1,438) were stratified by acuity (1,2, or 3), mechanism, and known injury cephalad to clavicles, defined as pain, wounds, or hematomas. Cervical spine imaging findings were recorded. Results: 975 patients (67.8%) had cervical CT scans. Twenty-six (1.81%) sustained a fracture or ligamentous injury, all with known injury cephalad to clavicles. 161 (11.2%) patients without injury cephalad to clavicles all had a negative cervical CT. Category 1 patients with gunshot wounds with injury cephalad to clavicles were more likely to have CT if they arrived with a collar versus without (66.7% vs 14.3%, p = 0.027). Category 2 and 3 patients with injury cephalad to clavicles after motor vehicle collision (MVC) (88.2% vs 69.6%, p = 0.011), low energy falls (88.3% vs 59.4%, p < 0.0001), and assault (86.0% vs 37.1%, p < 0.0001) underwent cervical CT more frequently if they arrived wearing a collar. Category 2 and 3 trauma patients without injury cephalad to clavicles were also more likely to undergo CT when wearing a collar after MVC (66.3% vs 21.4%, p = 0.001), low energy fall (81.8% vs 35.3%, p = 0.016), and pedestrian vs MVC (55.6% vs 12.5%, p = 0.04). Conclusion: Certain trauma patients were more likely to undergo cervical CT if they arrived wearing a cervical collar. No conscious patients without complaints proximal to the clavicles had cervical injury.

Prevalence of Fractures and Diagnostic Accuracy of Emergency X-ray in Older Adults Sustaining a Low-Energy Fall: A Retrospective Study.

Background: Plain radiography (XR) series are standard of care for detection of fall-related fractures in older patients with low-energy falls (LEF) in the emergency department (ED). We have investigated the prevalence of fractures and diagnostic accuracy of XR imaging in the ED. Methods: 2839 patients with LEF, who were presented to two urban level I trauma centers in 2016 and received XR and computed tomography (CT), were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of fractures of the vertebral column, rib cage, pelvic ring, and proximal long bones. Secondary endpoints were diagnostic accuracy of XR for fracture detection with CT as reference standard and cumulative radiation doses applied. Results: Median age was 82 years (range 65–105) with 64.1% female patients. Results revealed that 585/2839 (20.6%) patients sustained fractures and 452/2839 (15.9%) patients received subsequent XR and CT examinations of single body regions. Cross-tabulation analysis revealed sensitivity of XR of 49.7%, a positive likelihood ratio of 27.6, and negative likelihood ratio of 0.5. Conclusions: XR is of moderate diagnostic accuracy for ruling-out fractures of the spine, pelvic ring, and rib cage in older patients with LEF. Prospective validations are required to investigate the overall risk–benefit of direct CT imaging strategies, considering the trade-off between diagnostic safety, health care costs, and radiation exposure.

Fractures of the proximal humerus: overview and non-surgical management

Proximal humeral fractures account for 6% of all adult fractures, usually occurring in elderly patients following a low-energy fall. Fracture patterns occur because of the intricate bony anatomy of the proximal humerus and its rotator cuff attachments, which cause displacement of the tuberosities in a predictable nature. This can lead to long-term functional deficit, not only due to mechanical restrictions but also biological consequences such as impaired vascularity and avascular necrosis. The majority of fractures can be treated non-operatively to give satisfactory restoration of function for the vast majority of patients, with recent literature evidence supporting this method of management.

Outcome following proximal femoral nailing with helical head screw for intertrochanteric and subtrochanteric fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Intertrochanteric fractures are seen commonly in two patient groups, older osteopenic patients after a low-energy fall and younger patients involved in high-energy trauma. Early surgical intervention is advocated in the majority of these patients to reduce the complications associated with long-term immobilization.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this study proximal femoral nailing with helical head screw is used to achieve initial stability and early mobilization of the patients to avoid complications. In 60 patients undergoing proximal femoral nailing with helical head screw for intertrochanteric fractures the results of surgery were meticulously followed.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The patients were assed clinically and radiologically for time of union rate of infection stability and implant failure. All fracture in our study unites within 8 months following surgery.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Our study concludes that proximal femoral nailing with helical head screw is the best method of treatment for intertrochanteric fracture as it leads to lesser complications.&lt;/p&gt;

Tibial Plateau Fracture Following Low Energy Fall in the Rocky Mountains

Tibial plateau fractures are debilitating injuries. They can occurin younger individuals who sustain a high energy trauma or, withincreasing age, lesser degrees of trauma and underlying bone pathology such as osteoporosis, metabolic bone disease, and malignancy.1Outside these cases, tibial plateau fractures are relatively uncommon.However, these fractures can occur in healthy patients who have sustained direct trauma to the knee.Fractures of the tibial plateau often are classified according to theSchatzker or AO classification systems.2,3 These systems evaluate theinvolvement of both the medial and lateral plateaus, degree of comminution, extension into the joint, and displacement (both articularsurfaces and the relationship of the diaphysis to the metaphysis).Most tibial plateau fractures occur in the lateral aspect of the tibialplateau.1 The increased frequency of lateral fractures is due to themedial tibial plateau being able to resist higher weight-bearing loaddue to the presence of more cancellous bone. More importantly, thelateral plateau has more articular surface exposed during extensioncompared to the medial plateau, which increases likelihood of injury.4The standard of care for most displaced tibial plateau fracturesis surgical management with open reduction and internal fixation(ORIF).5 Conservative management, such as leg bracing, is an optionfor fractures that are nondisplaced or in patients too fragile for surgical intervention. In the senior population, a total knee arthroplasty(TKA) is a less common option. Tibial plateau fractures, particularlymedial tibial plateau fractures, caused by direct trauma in the elderly,non-osteoporotic population are uncommon.We present the case of an active male without overt risk for severefracture (10-year fracture risk of 10% via FRAX score) who wasworking to repair a trail in the Rocky Mountains. While other injurieswere more likely given the mechanism of injury and patient risk, thiscase highlighted the importance of considering tibial plateau fracture,even in atypical settings without significant risk. Improved awarenessof this mechanism of injury will lead to more accurate diagnosis andgreater post-injury management.

Surgical Repair of an Unstable Third Metatarsophalangeal Joint Dislocation via Direct Plantar Plate Repair: A Simple and Effective Technique

Traumatic dislocation of a lesser metatarsophalangeal (MTP) joint is a rare case for a foot and ankle surgeon to encounter. These dislocations can be difficult to reduce due to the surrounding connective tissues that may be interposed in the joint space. These include the plantar plate, deep transverse metatarsal ligament, flexor tendons, and lumbricals. When the clinician is unable to reduce the phalanx, surgery is required to prevent sequelae such as further swelling, ecchymosis, joint damage, and impingement of the neurovascular bundle. In this case report, we present the case of a 53-year-old female who suffered a traumatic dislocation after a low-energy trip and fall injury.

Lessons Learned from An Implant-Related Infection with Bacillus Spp of the Proximal Femur: A Rare and Insidious Complication After Internal Fixation of Closed Fractures

A 74 years old male, known for chronic alcohol abuse, suffered a trochanteric fracture of his left femur following a low energy fall.

Clinical Indications of Computed Tomography (CT) of the Head in Patients With Low-Energy Geriatric Hip Fractures: A Follow-Up Study at a Community Hospital.

Introduction:A seemingly large percentage of geriatric patients with isolated low-energy femur fractures undergo a head computed tomography (CT) scans during initial work up in the emergency department. This study aimed to evaluate the pertinent clinical variables that are associated with positive CT findings with the objective to decrease the number of unnecessary CT scans performed.Methods:A retrospective review performed at a level II trauma center including 713 patients over the age of 65 sustaining a femur fracture following a low-energy fall. The main outcome measure was pertinent clinical variables that are associated with CT scans that yielded positive findings.Results:A total of 713 patients over the age of 65 were included, with a low-energy fall, of which 76.2% (543/713) underwent a head CT scan as part of their evaluation. The most common presenting symptom reported was the patient hitting their head, 13% (93/713), and 1.8% (13/713) were unsure if they had hit their head. Of those evaluated with a head CT scan, only 3 (0.4%) had acute findings and none required acute neurosurgical intervention. All three patients with acute changes on the head CT scan had an Injury Severity Score (ISS) greater than 9, Glasgow Coma Scale (GCS) less than 15, and evidence of trauma above the clavicles.Discussion:None of the patients with a traumatic injury required a neurosurgical intervention after sustaining a low-energy fall (0/713).Conclusion:Head CT scans should have a limited role in the workup of this patient population and should be reserved for patients with a history and physical exam findings that support head trauma, an ISS > 9 and GCS < 15.

Odontoid fractures in combination with C1 fractures in the elderly treated by combined anterior odontoid and transarticular C1/2 screw fixation.

The purpose of this study was to evaluate risk factors of accompanied C1 fractures in elderly patients with type II odontoid fractures (OF) and to analyze the complication rate and the outcomes of patients after combined anterior odontoid and transarticular C1/2 screw fixation (AOTAF). The study represents a retrospective case series at a single level-1 trauma center. All elderly patients (≥ 70years) with acute combination injuries (CI) including type II OF with an accompanied C1 fracture, who were treated by an anterior approach, were included. All postoperative complications were analyzed based on the patient notes. Clinical and radiological controls were performed after 1 year. Main parameters of interest were 1-year mortality rate, pain level, and satisfaction rate after 1 year. A total of 23 patients were included. The average age was 84.6years (range 73-94years). All patients had atlanto-odontoid osteoarthritis (AOO) and all but two patients were injured by low-energy falls. Dysphagia was the most common postoperative complication (26.1%). Surgical revision was necessary in one of these patients due to hematoma. Dysphagia improved in all patients considerably. Loss of follow-up was 21.7%. The 1-year mortality was 21.7% (n = 5). The mean pain level and satisfaction rate was 2.5 (± 0.9) and 7.3 (± 0.7), respectively. After 1 year, no signs of non-union were visible. AOO was observed in all patients with CI. The main cause of trauma was a low-energy fall. The pain levels were low to moderate and satisfaction levelswere promising 1 year after surgery. Nonetheless, AOTAF is associated with a high rate of postoperative dysphagia, which resolves in the majority of patients due to conservative management.

Injury mechanisms, patterns and outcomes of older polytrauma patients-An analysis of the Dutch Trauma Registry.

BackgroundPolytrauma patients nowadays tend to be older due to the growth of the elderly population and its improved mobility. The aim of this study was to compare demographics, injury patterns, injury mechanisms and outcomes between younger and older polytrauma patients.MethodsData from polytrauma (ISS≥16) patients between 2009 and 2014 were extracted from the Dutch trauma registry (DTR). Younger (Group A: ages 18–59) and older (Group B: ages ≥60) polytrauma patients were compared. Differences in injury severity, trauma mechanism (only data for the year 2014), vital signs, injury patterns, ICU characteristics and hospital mortality were analyzed.ResultsData of 25,304 polytrauma patients were analyzed. The older patients represented 47.8% of the polytrauma population. Trauma mechanism in the older patients was more likely to be a bicycle accident (A: 17%; B: 21%) or a low-energy fall (A: 13%; B: 43%). Younger polytrauma patients were more likely to have the worst scores on the Glasgow coma scale (EMV = 3, A: 20%, B: 13%). However, serious head injuries were seen more often in the older patients (A: 53%; B: 69%). The hospital mortality was doubled for the older polytrauma patients (19.8% vs. 9.6%).ConclusionElderly are involved more often in polytrauma. Although injury severity did not differ between groups, the older polytrauma patients were at a higher risk of dying than their younger counterparts despite sustaining less high-energy accidents.

Case Series: Total Elbow Arthroplasty for Comminuted, Distal Humerus Fractures

Introduction: Total elbow arthroplasty (TEA) is an established treatment for late-stage arthritis of the elbow. In comminuted distal humerus fractures, there is a role in performing total elbow arthroplasty to aid in the restoration of function and range of motion. This is a case series describing TEA in 3 non-rheumatoid patients who sustained comminuted distal humerus fractures. Methods: Three elderly non-rheumatoid patients who sustained comminuted distal humerus fractures underwent total elbow arthroplasty using Zimmer® Coonrad/morrey prosthesis. Demographic data was retrospectively collected and outcomes were measured using the mayo elbow performance scores. Results: Post-operatively, the patients demonstrated improvement in mayo elbow performance scores and were able to return to functional activities in their daily lives. Conclusion: TEA is a viable option for non-rheumatoid elderly patients who sustain comminuted distal humerus fractures due to a low energy fall, with satisfactory outcome measures.

Hip Fracture in the Elderly Patients: A Sentinel Event.

Hip fracture in the elderly patients is associated with increased morbidity and mortality. There is great need for advance care planning should a patient fail to rehabilitate or experience an adverse event during or after recovery. This study was performed to evaluate for palliative care consultation and changes in code status and/or advance directives in elderly patients with hip fracture. We performed a retrospective review of 186 consecutive patients aged 65 years and older with a hip fracture due to a low-energy fall who underwent surgery at a large academic institution between August 1, 2013, and September 1, 2014. Risk factors assessed were patient demographics, home status, mobility, code status, comorbidities, medications, and hospitalizations prior to injury. Outcomes of interest included palliative care consultation, complications, mortality, and most recent code status, mobility, and home. About 186 patients with hip fractures were included. Three patients died, and 12 (6.5%) sustained major complications during admission. Nearly one-third (51 patients) died upon final follow-up approximately 1.5 years after surgery. Of the patients who died, palliative care consulted on 6 (11.8%) during initial admission. Eleven (21.6%) were full code at death. Three patients underwent cardiopulmonary resuscitation (CPR) and 1 underwent massive transfusion and extracorporeal membrane oxygenation prior to changing their code status to do not attempt resuscitation. Hip fracture in elderly patients is an important opportunity to reassess the patient's personal health-care priorities. Advance directives, goals of care, and code status documentation should be updated in all elderly patients with hip fracture, should the patient's health decompensate.

Morel-Lavallée lesion of the proximal tibia in an obese patient after low-energy trauma

Morel-Lavallée lesions (MLL) are usually localised in the hip or gluteal region, but have rarely been reported at the proximal tibia. We present a case of an overweight patient, aged...

Functional outcome of proximal humeral interlocking system plating for displaced proximal humeral fractures in adults

Objective: The objective of the study was to assess functional outcome of Proximal Humerus Inter Locking System (PHILOS) Plating in displaced proximal humeral fractures by Constant-Murley (Subjective and Objective) score. Material and methods: The PHILOS plate was used for internal fixation of displaced proximal humeral fractures in 25 patients 11 females, 14 males; mean age 60.64 years range(28-90yrs). Fractures were caused by low-energy trauma fall from standing height in 16 patients, and by an road traffic accident in 9 patients. Involvement was on the right in 15 cases and on the left in 10 cases. Bone graft was used in 2 cases to prevent varus malalignment. All patients received a similar physical therapy program following internal fixation with the PHILOS plate. The patients were assessed clinically and radiographically at regular intervals of 6 weeks, 12 weeks and 6 months. Functional outcome was assessed using the Constant- Murley score. Complications during the follow-up period were recorded. Results: 9 patients had Neer’s four part fracture, 12 patients had 3 part fracture and 4 patients had 2 part fracture. After 6 months of follow up mean Constant and Murley score of 63.76 was achieved. Outcomes were excellent, good, moderate and poor in 2(8%), 3(12%), 14(56%), 6(24%) respectively. The most frequent complication seen was shoulder stiffness in 6 patients, malreduction in 4 and impingement in 4 patients.Conclusion: Fixation of proximal humerus fractures with proximal humerus locking plates is associated with satisfactory functional outcomes in 2-part and 3-part and 4 part fracture. The incidence of complications is relatively high in 3 part and four part fractures. Advanced surgical skills and surgeon’s experience are considered to be more critical for successful operative treatment.

Results of Displaced Lisfranc Injuries with Open Reduction and Fixation with K-Wires

Background: The Lisfranc injury is an injury of the foot in which one or more metatarsal bones are displaced from the tarsal bones. Due to their low incidence and complexity, these injuries are often missed on initial evaluation. Prompt recognition and then anatomic reduction and stabilization gives best outcomes post treatment.Aim: The study aimed to compare short-term treatment results for tarso-metatarsal joint injuries with treatment outcomes and compare it with type of injury per classification.Methods: This was a prospective observational, analytical hospital based study. The subjects included in the study were classified according to radiological findings and treated with open reduction and K-wire fixation. Study subjects were immobilized for six weeks. Weight bearing was progressed slowly. Short term result was calculated by American orthopaedic foot and ankle society score (AOFAS) at six months. Results: Of the nine cases included in the study, low energy fall, five (55.55%) was commoner cause for injury followed by high energy road traffic accident (RTA) in four (44.44%) patients. Six fractures (66.67%) were of type A while, three (33.3%) were type B. Average day from injury to surgery was 3.11 (range 2-5). AOFAS Score calculated in six months average was 82.44(SD±12.79). In patients with type A injury mean AOFAS score was 89(SD±2.6), while in patients with type B injury had mean of 69.33(SD±15.82). The AOFAS score difference for the group A and B was statistically significant (P&lt;0.05). Conclusions: Lisfranc injuries are life changing injuries as scores of AOFAS get lower even after 6 months of injury. Patients with type B injuries have poorer outcome than type A injuries.JNGMC Vol. 13 No. 2 December 2015, Page: 35-37

Old post-traumatic malunited humeral head fracture with dislocated shoulder: Delayed effect of an underestimated fall

We present a case of a delayed effect of an old humeral head fracture with dislocated shoulder diagnosed an year after a low energy fall. After the injury, the patient experienced only mild pain and avoided radiological evaluation. The clinical and radiological evaluation showed a malunion of an underestimated displaced humeral head fracture with severe secondary arthritic changes.

A History of Falls Should Be Recorded in All Preoperative Patients

Simple low energy falls are a leading cause of morbidity and mortality among the elderly (65 years and older) population. The number of falls is increasing in the Western world due to the increasing elderly population, which has a significant burden upon healthcare services with falls costing in excess of $30 billion annually in the US when adjusting for inflation (Stevens et al., 2006). In addition the rate of fall induced mortality is also increasing, especially among elderly men (Kannus et al., 2005). Approximately one out of five falls result in a significant injury (Alexander et al., 1992), and falls are the predominant mechanism of elderly trauma admissions requiring operative intervention (Clement et al., 2012). Postoperative falls occur more often than falls in the general population (O'Loughlin et al., 1993). Hence, it would seem that elderly patients requiring surgery to address injuries from their simple low energy fall are more likely to fall again resulting in further morbidity and increased mortality. In the face of this growing problem there is limited literature identifying patients at risk of falls, where preventative measures could be targeted to prevent further falls and the associated consequences.