There is currently no information regarding long-term outcomes following total hip replacement (THR) for hip fracture in patients selected in accordance with national guidelines. We define the long-term outcomes and compare these to short-term outcomes in the same previously reported cohort.

We prospectively identified patients who underwent THR for a displaced hip fracture over a 3-year period from 2007–2010. These patients were followed up at 10 years using the Oxford hip score(OHS), the Short-form 12(SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously assessed at 2 years. We identified 128 patients. Mean follow up was 10.4 years. 60 patients(48%) died by the time of review and 5 patients(4%) developed dementia and were unable to respond. 3 patients were untraceable. This left a study group of 60 patients with a mean age of 81.2.

Patients reported excellent outcomes at 10 year follow up and, when compared with short-term outcomes, there was no statistically significant change in levels of satisfaction, OHS, or SF-12. The rates of dislocation(2%), deep infection(2%) and revision(3%) were comparable to those in the literature for elective THR. Mortality in the hip fracture group at 10 years is lower than that of elective registry data.

Long-term outcomes for THR after hip fracture in selected patients are excellent and the early proven benefits are sustained. Our data validates the selection process of national guidelines and confirms low complication rates. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

Epidemiological data about tibial plateau and associated intra-articular proximal tibial fractures provides clinicians with an understanding of the range, variety, and patterns of injury. There are relatively few studies examining this injury group as a whole. We prospectively recorded all tibial plateau and intra-articular proximal tibial fractures occurring in our regional population of 545,000 adults (aged 15 years or older) in 2007–2008. We then compared our results with previous research from our institution in 2000. There were 173 fractures around the knee, 65 of these involved the tibial plateau. Median age was 59 years (IQR, 36.5–77.5 yrs). Tibial plateau fractures were more common in women (58.5%vs 41.5%). The median age of men was 37 years (IQr, 29–52 yrs) compared to women, 73 years (IQR, 57–82 yrs). Tibial plateau fractures accounted for 0.9% overall and 2.5% of lower limb fractures. Incidence was 1.2/10,000/yr (95% CI, 0.9–1.5). We have prospectively identified and described the epidemiological characteristics of tibial plateau fractures in adults from our region. We have identified a change to the epidemiology of these fractures over a relatively short time frame as the patients at risk age.

The management of distal humeral fractures in low-demand patients with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for cases where achieving stable ORIF can be difficult. The ‘bag of bones’ technique, (early movement with fragments accepted in their displaced position), is now rarely considered as it is commonly believed to confer a poor functional result. The aim of this study was to present the short- and medium-term functional outcomes following the primary conservative treatment of distal humeral fractures in elderly and low-demand patients.

We carried out a retrospective case note and radiograph review of all patients (n=40) aged 50 years or more, with distal humeral fractures treated conservatively at our institution over a six-year period. Short-term function was assessed using the Broberg and Morrey (B&M) score. Medium term function was assessed by telephone interview (n=20) using the Oxford Elbow Score (OES), QuickDASH and a pain questionnaire.

The mean post-injury B&M score improved from 42 points at 6 weeks to 67 points by 3 months. By four years, surviving patients had a mean OES of 30 points, a mean QuickDASH of 38 points, and 95% reported a functional range of elbow flexion. Those with fracture non-union experienced greater pain on repetitive elbow activities, but no difference in rest pain, compared with patients whose fractures had united. The cumulative 1-year rate of fracture union was 53%, while the 5-year mortality approached 40%.

Conservative management of distal humeral fractures confers a reasonable functional result to the patient whilst avoiding the substantial surgical risks associated with primary ORIF or TEA.

We define the medium-term outcomes following total hip replacement (THR) for hip fracture. There is currently no information regarding longer term clinical and patient reported outcomes in this group of patients selected in accordance with national guidelines.

We prospectively identified patients who underwent THR for a displaced hip fracture over a three year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford hip score, Short-form 12(SF-12) questionnaire and satisfaction questionnaire.

We identified 128 patients. Mean follow up was at 5.4 years with a mean age of 76.5 years. 21 patients (16%) had died, 12 patients (9%) had developed dementia and 3 patients had no contact details, leaving a study group of 92 patients. 74 patients(80%) responded. Patients reported excellent functional outcomes and satisfaction at 5 years (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2 year follow up, there was no statistically significant change in outcome.

Medium-term outcomes for THR after hip fracture are excellent and the early proven benefits of this surgery are sustained. Mortality rates are equivalent to elective THR registry data and significantly lower than overall mortality rates following hip fracture. Our data validates the selection process detailed in national guidelines and confirms the low complication rate. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

Current Department of Health guidelines state that medical personnel should be ‘bare below the elbows’. Critics of this policy have raised concerns over the impact of these dress regulations on the portrayed image and professionalism of doctors. However, the importance of the doctor's appearance in relation to other professional attributes is largely unknown. The purpose of this study was to determine the opinion of patients and their relatives on the importance of appearance and the style of clothing worn by orthopaedic doctors. The secondary aim was to establish how patients would prefer orthopaedic doctors to be dressed.

The study consisted of the administration of a survey questionnaire to 427 subjects attending the orthopaedic outpatient clinics in four hospitals across Scotland. Subjects were asked about the importance or otherwise of various aspects of the doctors’ appearance and responded using a modified Likert 5-point scale. Subjects’ rank preferences for four different styles of doctors’ clothing were also determined. The study was appropriately powered to identify a 0.5 difference in mean rank values with 0.90 power at a = 0.05.

The majority of respondents felt doctors’ appearance was important but not as important as compassion, politeness and knowledge. Only 50% felt that the style of doctors clothing mattered; what proved more important was an impression of cleanliness and good personal hygiene. In terms of how patients would prefer doctors to dress in clinic, the most popular choice proved to be the smart casual style of dress, which conforms with the ‘bare below the elbows’ dress code policy. Indeed, the smart casual clothing style was the highest ranked choice irrespective of patient age, gender, regional or socioeconomic background.

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls.

Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively.

Cite this article: Bone Joint J 2014;96-B:366–72.

Rugby union is the second commonest cause of sporting fracture in the UK. Yet little is known about patient outcome following such fractures.

All rugby union fractures sustained during 2007–2008 in the Lothian were prospectively recorded. Patients were contacted by telephone in February 2012 to ascertain their progress in returning to rugby.

There were 145 fractures in 143 patients, including 122 upper limb and 25 lower limb fractures. 117 fractures (81%) were followed at mean 50 months (range 44–56 months). 87% returned to rugby post injury, with 85% returning to rugby at the same level or higher. 77% returned by three months and 91% by six months. In upper limb fractures 86% returned by six months and 94% by six months. In lower limb fractures 42% returned by three months and 79% by six months. 32% had ongoing fracture related problems. 9% had impaired rugby ability secondary to fractures.

Most patients sustaining a fracture playing rugby union will return to rugby at a similar level. While one third of them will have persisting symptoms post-injury, for the majority this will not impair their rugby ability.

Alcohol remains a significant cause of disease in the UK population. Yet the effect of alcohol on fractures remains conflicting. We present a prospective analysis of self-reported alcohol consumption and the epidemiology of fractures sustained.

1950 patients over 13 years of age were prospectively interviewed after sustaining a fracture with basic epidemiological data, fracture data and average alcohol consumption recorded.

1621 (83%) of interviewees provided information on alcohol consumption. 10% admitted to drinking in excess of Scottish Health guidelines. 18.1% of males drunk to excess, compared to 4.7% of females (p<0.001). The five most frequent fractures were distal radius (20%), metacarpals (12%), ankle fractures (12%), neck of femur (10%), phallanges (10%). 48% of fractures were falls from standing height. Excess drinkers were more likely to sustain an AO grade C fractures than safe drinkers (18.1% compared to 11.2%, p<0.05). Excess drinkers sustained more open fractures than safe drinkers (5% compared to 1%, p<0.001). Excess drinkers were on average 5.66 years younger than safe drinkers at the time of injury (44.57 years compared to 50.23 years, p<0.05).

People reporting alcohol excess who have sustained a fracture are more likely to be younger and suffer more severe fractures than those drinking within current guidelines. Opportune targetting of patients consuming excess alcohol should be targetted at problem drinkers sustaining a fracture.

Proximal femoral fractures remain the most common reason for admission to hospital following orthopaedic injury, with an annual cost of £1.7 billion to the National Health Service and social care services. Fragility fractures of the hip in the elderly are a substantial cause of mortality and morbidity. Revision surgery for any cause carries a higher morbidity, mortality, healthcare- and social economic burden. Which patients suffer failed surgery and the reasons for failure have not been established. The aim of this study was to determine which patients are at risk of failed proximal femoral fracture surgery, the mechanism and cause fo failed surgery and modifiable patient factors associated with failure of hip fracture surgery.

From prospectively collected data of 795 consecutive proximal femoral fractures admitted between July 2007 and July 2008, all peri-operative and post-operative complications were identified.

55 (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age (p=0.01), smoking (p=0.01) and cannulated screw fixation (p<0.01). Cannulated screw fixation was associated with a 30.9% complication rate. Mechanical cause was the most common reason for cannulated screw failure. Hip hemiarthroplasty most commonly failed by infective causes. Inter-trochanteric and subtrochanteric fracture fixation had very low failure rates. Surgical complication was not found to be associated with an increased mortality but a post-operative medical complication (21.8%) was associated with higher rate of mortality at 4-years (78.5%) and shorter time to mortality. (Median time 0.16 years (95% CI 0.00–0.33).

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports.

A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted. Demographic data were recorded prospectively for each patient with an acute clavicle fractures including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson system.

A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. More than half of simple fall fractures affected the lateral clavicle. The incidence of clavicle fractures has risen over a twenty year period, and a greater proportion of older adults are now affected. Overall, type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing.

We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region.

There are limited recent epidemiological data pertaining to the patterns of skeletal injury around the knee joint in adult patients. Data on fractures of the distal femur, proximal tibia and patella have been individually reported. We aimed to describe the collective epidemiological characteristics of all fractures around the knee.

We conducted a retrospective analysis of a prospectively collected fracture database from an institution serving 545,000 adults. The demographic and injury details for all patients suffering fractures of the distal femur, proximal tibia and patella were analysed. Fractures were classified according to the AO (distal femur, patella) and Schatzker (proximal tibia) systems.

A total of 173 fractures occurred in 170 patients (60% women), representing 6.7% of all lower limb fractures. There were 36 distal femoral fractures, 82 proximal tibial fractures (metaphyseal, plateau or bony avulsions) and 55 patella fractures.

Each fracture type displayed distinct epidemiological characteristics. Injuries of the distal femur occurred in older women. A proportion of tibial plateau fractures occurred in young men following high-energy trauma, but a greater number were encountered by older men and women following low-energy injury. The majority of fractures around the knee were caused by a simple fall from standing, followed by road traffic accidents, and falls from height.

When compared with historical data from our unit, the incidence of fractures around the knee has increased. The median age of affected patients has also risen, and this is particularly true for fractures of the distal femur and tibial plateau.

The epidemiological characteristics of fractures around the knee joint in our adult population are presented. Low-energy trauma in the elderly is likely to constitute an increasing proportion of knee injuries in the future, and this has implications for the provision of trauma services in our region.

The relationship between advancing patient age, decreasing bone mineral density and increasing distal radial fracture incidence is well established. Biomechanical and clinical work has shown that the radiographic severity of distal radial fractures is greater in patients with poor bone quality. Between 1991 and 2007, the number of elderly Scots (aged 75 years or more) increased by 18%, and population projections predict a further 82% increase by 2035. This study was conducted to investigate the effect of recent changes in the demographics of our population on the pattern and radiographic severity of distal radial fractures encountered at our institution.

The epidemiology of two distinct series of patients (1991–93; 2007–08) suffering distal radial fractures was compared. The patient and radiographic fracture characteristics known to be predictive of fracture instability and severity were compared using the MacKenney formulae, and a subgroup analysis of distal radial fragility fractures was performed.

The life expectancy of our catchment population has improved since 1991, and we have encountered a larger number of distal radial fractures occurring in older, more active and functionally independent patients. We identified an increase in the proportion of AO type B fractures, particularly in the oldest patient groups. The radiographic severity of distal radial fractures, especially low energy metaphyseal injuries, has increased.

If the current trend in population demographics continues, it seems likely that orthopaedic surgeons will encounter an increasing number of severe distal radial fractures deemed unsuitable for treatment by closed methods.

Background

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures.

To describe the treatment and morbidity of lower limb (LL) football fractures in regard to returning to football in a known UK population at all skill levels.

All football fractures during 2007–2008 sustained by the Lothian population were prospectively collected with the diagnosis being confirmed by the senior author when patients attended the only adult orthopaedic service in Lothian. Patients living outside the region were excluded from the study. Patients were contacted in August 2010 to ascertain their progress in return to football.

There were 424 fractures in 414 patients. 366 fractures (86%) in 357 patients (86%) were followed up with a mean interval of 30 months (range 24–36 months). Of these 32% were sustained in the LL. 88% of LL injuries returned to football compared to 85% of upper limb (UL) fractures (p=0.4). 60% of LL patients were treated as outpatients. 35% were operated on −26% had ORIF and 9% IM Nailing. The most common LL fractures were Ankle 38%, Tibial Diaphysis 14%, 5th Metatarsal 11%, Fibula 9% and Great Toe 7%. Only one of the fractures was an open injury - Gustillo Class 1 2nd Phallanx Foot. Three of the 12 patients who underwent IM nailing required fasciotomy. One patient in the operative cohort developed a significant infection. The mean time for return to football for conservative treatment was 17 weeks (range 3–104 weeks), and for operative treatment 41 weeks (range 10–104 weeks). 91% of patients treated conservatively returned to football, compared to 84% of the operative cohort (p=0.3). 43% of patients had ongoing symptoms from their injury. 9% of the operative cohort required removal of metal work or further operative intervention. 83% of patients returned to the same level of football or higher following injury. Patients under 30 were 1.4 times more likely to return to sport than those over 30 (p<0.05).

We have previously demonstrated that football is the most common cause of sporting fracture(1), yet little is known about patient outcome following fractures. LL fractures are less common than UL fractures, and there is no difference in the proportion of patients returning to football following LL fractures and UL fractures. Over half of LL fractures are treated as outpatients and the incidence of open fractures is very low. There is no significant difference between the operative and conservative groups in their return to football. In the over 30 age group, sustaining a fracture may act as a catalyst to quit football. This may explain the higher non-return rate compared to the under 30 age group. 43% of patients perceive that they have ongoing problems with their fracture over 24 months post-injury reflecting the considerable morbidity of football-related fractures.

Introduction

This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation.

We present the prevalence of multiple fractures in the elderly in a single catchment population of 780 000 treated over a 12-month period and describe the mechanisms of injury, common patterns of occurrence, management, and the associated mortality rate. A total of 2335 patients, aged ≥ 65 years of age, were prospectively assessed and of these 119 patients (5.1%) presented with multiple fractures. Distal radial (odds ratio (OR) 5.1, p <  0.0001), proximal humeral (OR 2.2, p < 0.0001) and pelvic (OR 4.9, p < 0.0001) fractures were associated with an increased risk of sustaining associated fractures. Only 4.5% of patients sustained multiple fractures after a simple fall, but due to the frequency of falls in the elderly this mechanism resulted in 80.7% of all multiple fractures. Most patients required admission (> 80%), of whom 42% did not need an operation but more than half needed an increased level of care before discharge (54%). The standardised mortality rate at one year was significantly greater after sustaining multiple fractures that included fractures of the pelvis, proximal humerus or proximal femur (p < 0.001). This mortality risk increased further if patients were < 80 years of age, indicating that the existence of multiple fractures after low-energy trauma is a marker of mortality.

Mountain biking is increasing in popularity worldwide. The injury patterns associated with elite level and competitive mountain biking are known. This study analysed the incidence, spectrum and risk factors for injuries sustained during recreational mountain biking.

The injury rate was 1.54 injuries per 1000 biker exposures. Males were more commonly injured than females, with those aged 30–39 years at highest risk. The commonest types of injury were wounding, skeletal fracture and musculoskeletal soft tissue injury. Joint dislocations occurred more commonly in older mountain bikers. The limbs were more commonly injured than the axial skeleton. The highest hospital admission rates were observed with head, neck and torso injuries. Protective body armour, clip-in pedals and the use of a full-suspension bicycle confer a significant protective effect.