Eur J Trauma Emerg Surg DOI 10.1007/s00068-013-0358-3
ORIGINAL ARTICLE
Lower extremity fractures in falls P. Hadjizacharia • B. Joseph • H. Aziz • V. Pandit L. S. Chan • D. Demetriades • P. Rhee
•
Received: 13 September 2013 / Accepted: 14 November 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Lower extremity fractures are very common in victims of falls. These fractures are usually associated with other bodily injuries and can lead to permanent disability if appropriate management is not provided. The aim of this study was to evaluate the incidence and outcomes of associated injuries in victims of falls with lower extremity fractures. Methods This is a retrospective review (1995–2006) of all fall-related trauma patients evaluated at our Level I trauma center. Injuries were categorized as: isolated femur fractures (FF), isolated tibia fractures (TF), and both femur and tibia fractures (FTF). Data were analyzed for differences in patterns of injury, associated fractures and injuries, and mortality and morbidity according to age groups within patients with minor body injuries expressed by Abbreviated Injury Score (AIS) \ 3. Results Three hundred and thirty-two patients (64.8 %) had FF, 164 patients (32 %) had TF, and 16 patients (3.2 %) presented with FTF. The incidence of severe trauma was 9.4 % (Injury Severity Score, ISS [ 25). A higher incidence of ISS [ 25 was observed in patients with
P. Hadjizacharia B. Joseph (&) H. Aziz V. Pandit P. Rhee Division of Trauma, Critical Care, Emergency Surgery, and Burn, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ 85727, USA e-mail: [email protected] L. S. Chan D. Demetriades Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County/University of Southern California Medical Center, Los Angeles, CA, USA
FF. Increased mortality was observed in the elderly group, especially in patients with an isolated femur fracture. Conclusion Patients with a combination of femur and tibia fractures have a significantly higher risk of associated injuries compared to patients with either a femur or a tibia fracture. Elderly patients (C65 years of age) have higher morbidity and mortality compared to younger patients after falls. Clinicians evaluating these patients should be aware of these injury patterns. Further studies assessing the impact of age and pattern of injury in patients following falls are warranted. Keywords severity
Extremity fractures Falls Injury
Introduction Falls are characterized by a myriad of injuries, with the musculoskeletal system being the most commonly injured anatomical region [1]. Of note, falls are the second leading cause of both spinal and brain injury in the United States [2]. Long bone lower extremity fractures are very common in victims of falls. These fractures are usually associated with other bodily injuries and can lead to permanent disability if appropriate management is not provided [3, 4]. Disability resulting from lower extremity injuries poses a tremendous burden to individuals and society. As the US population ages, both the number of falls and the costs to treat fall injuries are likely to increase. In 2005, falls among older adults cost the US health care system over $23.6 billion. Having information on the economic burden of older adult falls can help make the case to fund prevention programs and reduce overall health care costs [3].
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Several studies have shown that the anatomic patterns and severity of injury differ according to the height of the fall and the age of the patient [2–5]. However, few studies have addressed the outcomes of victims of falls after acute orthopedic trauma [6]. The aim of this study was to investigate victims of falls with femur and/or tibia fractures and evaluate the effect of age on the incidence and severity of specific associated injuries and outcomes with these fractures.
Methods This is a retrospective review of all victims of falls admitted to the Los Angeles County and University of Southern California General Hospital, a Level I trauma center, between January 1995 and June 2006. Patients were identified through a prospectively maintained trauma registry. Our inclusion criteria for this study were based on the presence of a significant lower extremity fracture, namely, femur and/or tibia fracture after a fall from height. Patients with ground-level falls and with isolated fibula and/or ankle fractures (coded as medial and/or lateral malleolus) were excluded from the study. Table 1 shows the International Classification of Diseases (ICD)-9 codes used for the description of a femur and tibia fracture. Patient variables were collected using Microsoft Excel 2003 (Microsoft Corporation, Redmond, WA), which included age, gender, admission vitals [heart rate, systolic blood pressure, Glasgow Coma Scale (GCS) score], associated injuries sustained identified by the ICD-9 code, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), hospital and intensive care unit (ICU) length of stay, and mortality. Injuries were categorized as: isolated femur fractures (FF), isolated tibia fractures (TF), and both femur and tibia fractures (FTF). For the purpose of data analysis, we grouped the patients on the basis of age in years as follows: B14, 15–55, 56–65, and C65. Data were analyzed for differences in patterns of injury as represented by injury severity scale scores (ISS), associated fractures and injuries; spine fractures, severity of head (h-AIS), chest (c-AIS), and abdomen AIS (a-AIS) according to age group and associated lower limb fractures; Table 1 List of International Classification of Diseases (ICD)-9 codes used for femur and tibia fractures Variables
ICD-9 codes
Femur
820.00, 820.01-3&9, 820.10, 820.11-3&9, 820.20, 820.21-2, 820.30, 820.31-2, 820.8-9, 821.00, 821.01, 821.10-1, 821.20-3&9, 821.30-3&9 823.00, 823.10, 823.20, 823.30, 823.40, 823.80, 823.90
Tibia
123
and mortality and morbidity according to age groups within patients with minor body injuries expressed by AIS \3. We performed all statistical analyses using the SAS System, version 8.2 (SAS Institute Inc., Cary, NC). Univariate analysis was performed to compare femur, tibia, and a combination of femur and tibia fractures with respect to baseline demographics and outcome. Categorical variables were compared using Pearson’s v2 test, and for ordinal variables, we computed the trend with the Mantel–Haenszel v2 test. For variables in which one or more cells had expected counts \5, we used Fisher’s exact test. Differences were considered statistically significant at P \ 0.05. The Institutional Review Board at our institute approved the study.
Results During the 11.5-year study period, there were 5,364 fall trauma patients, of which 512 (9.5 %) met our inclusion criteria. Three hundred and thirty-two patients (64.8 %) had femur fractures (FF) and 164 patients (32 %) had tibia fractures (TF), while 16 patients (3.2 %) presented with fractures of both the femur and the tibia (FTF). Of the patients with both femur and tibia fracture (n = 16), 18.75 % (n = 3) had ipsilateral femur and tibial fractures, while the remainder (n = 13) had tibial and femoral fractures on opposite limbs. No patient had bilateral femur fracture. The mean age of the study population was 40.3 ± 21.4 years, 69.5 % were male, and the mean ISS was 20.4 ± 9.3. The majority of the patients (66.6 %) belonged in the 15–55 years age group followed by the C65 (18.6 %) years age group. Moreover, patients were categorized into four age groups, namely: 32 (6.3 %) in the B14 years age group, 341 (66.6 %) in the 15–55 years age group, 44 (8.6 %) in the 56–65 years age group, and 95 (18.6 %) in the C65 years age group. The incidence of severe trauma was 9.4 % (ISS [25). A higher incidence of ISS [25 was observed in patients with FF. There was no severe trauma in B14 years age group. Table 2 shows the incidence of mild/moderate and severe injuries according to the age group and type of lower extremity fracture. Patients with FTF had a statistically significant increase in skull fractures (5.1 vs. 3.1 vs. 18.8 %, P = 0.02), spinal column fractures (6.6 vs. 14 vs. 25 %; P = 0.003), pelvic fractures (14.8 vs. 6.7 vs. 25 %; P = 0.01), spinal cord injuries (6.6 vs. 14 vs. 25 %; P = 0.02), hemopneumothorax (5.4 vs. 3.7 vs. 31.3 %; P \ 0.0001), and iliac vessel injuries (1.2 vs. 0 vs. 6.3 %; P = 0.04) in comparison to patients with either a femur or a tibia fracture. In addition, patients with both a femur and a tibia fracture
Lower extremity fractures in falls Table 2 Age and Injury Severity Score (ISS) stratification Injury severity
Age groups (years)
ISS B15
B14
ISS 16–25
Femur
Femur and tibia
23/32 (71.9 %)
1/32 (3.1 %)
15–55
135/341 (39.6 %)
24/341 (7.0 %)
56–65
27/44 (61.4 %)
3/44 (6.8 %)
C65
81/95 (85.3 %)
4/95 (4.2 %)
B14
8/32 (25 %)
0/32
0/32 28/341 (8.2 %) 0/44 6/95 (6.3 %) 0/32
15–55
119/341 (34.9 %)
56–65
13/44 (29.5 %)
0/44
4/95 (4.2 %)
0/95
0/95
0/32
0/32
C65 ISS [25
Tibia
B14
11/341 (3.2 %)
0/32
15–55
8/341 (2.3 %)
56–65 C65
1/44 (2.3 %)
3/341 (0.9 %)
0/44 0/95
8/341 (2.3 %)
0/44 0/95
5/341 (1.5 %) 0/44 0/95
Table 3 Associated fractures and injuries Variables
Total N = 512
Femur fractures N = 332
Tibia fractures N = 164
Both fractures N = 16
P-value*
Skull
25
17 (5.1 %)
5 (3.1 %)
3 (18.8 %)
0.0197
Facial
31
22 (6.6 %)
5 (3.1 %)
4 (25 %)
0.0016
Upper extremity
76
57 (17.2 %)
16 (9.8 %)
3 (18.8 %)
0.0833
Spinal column
49
22 (6.6 %)
23 (14.0 %)
4 (25.0 %)
0.0032
Pelvic
64
49 (14.8 %)
11 (6.7 %)
4 (25 %)
0.0119
Fractures
Injuries Cardiac
4
3 (0.9 %)
1 (0.6 %)
0
0.8815
Aorta
6
4 (1.2 %)
2 (1.2 %)
0
0.9066
Intracranial
19
18 (5.42 %)
1 (0.6 %)
0
0.0208
Spinal cord
15
6 (1.8 %)
7 (4.3 %)
2 (12.5 %)
0.0217
Hemopneumothorax
29
18 (5.4 %)
6 (3.7 %)
5 (31.3 %)
\0.0001
Abdominal hollow viscus
6
4 (1.2 %)
2 (1.2 %)
0
0.9066
Abdominal solid organ
12
9 (2.7 %)
3 (1.8 %)
0
0.6807
Lower extremity nerve
0
0
0
0
NA
Lower extremity vascular
5
3 (0.9 %)
2 (1.2 %)
0
0.8710
Iliac vessels
5
4 (1.2 %)
0
1 (6.3 %)
0.0408
* Chi-square test
were statistically significantly more likely to have a laparotomy (P \ 0.0001) and a thoracotomy (P = 0.0016) as compared to patients with either a femur or a tibia fracture. Associated injuries are shown in Table 3 according to the three categories of lower extremity fractures. Overall, 19 patients (3.7 %) were found to have an intracranial hemorrhage. The most common intracranial hemorrhage was subarachnoid (78.9 %), followed by subdural (1.0 %) and epidural (0.2 %). Only patients with either a femur or a tibia fracture presented with an intracranial hemorrhage, with proportions of 5.42 and 0.6 %, respectively (P = 0.0208).
Spinal injuries were found in 49 patients (9.5 %). Overall, there were more lumbar spine fractures (n = 31), followed by thoracic spine fractures (n = 16) and cervical spine fractures (n = 10). A total of 15 patients (2.9 %) were diagnosed with a spinal cord injury. Again, the most commonly injured anatomic site was the lumbar spinal cord (n = 13; 2.5 %), followed by the cervical spinal cord (n = 1; 0.2 %), and one patient had injury to all three anatomical areas of his spinal cord. Table 4 shows the incidence of spinal column fractures according to the age group and type of lower extremity fracture pattern.
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Overall, 16 patients (3.1 %) had associated abdominal injuries occurring in patients with either a femur or a tibia fracture; of note, patients with both a femur and tibia fracture did not present with an intra-abdominal injury. There were 12 patients (2.3 %) with abdominal solid organ injuries and six patients (1.2 %) with hollow viscus gastrointestinal injuries. The most commonly injured solid organ was the liver (1.6 %), followed by the kidney (1.2 %) and spleen (0.4 %); for the hollow viscus injuries, the small and large intestine had a similar injury rate of 0.6 % each, and there was no stomach injury. Aortic injuries were diagnosed in six patients (1.2 %). The incidence of 1.2 % was the same in patients with either a femur or a tibia fracture. No aortic injury was found in patients with a combination of a femur and tibia fracture. In addition, the pediatric age group had no aortic injury, and patients in the adult and elderly age groups suffered this type of injury.
Table 4 Spine fractures Fracture type
Age group (years)
Femur
B14
0/32
15–55
16/341 (4.7 %)
56–65 C65
4/44 (9.1 %) 2/95 (2.1 %)
Tibia
Femur and tibia
Spine fracture
B14
0/32
15–55
20/341 (5.9 %)
56–65
2/44 (4.5 %)
C65
1/95 (1.1 %)
B14
0/32
15–55
4/341 (1.2 %)
56–65
0/44
C65
0/95
When we looked at a subset of the total population, patients with at least one anatomic region with moderate to severe injury (AIS C3), we had a total of 229 patients (44.7 %). The most common body region with moderate to severe trauma for victims of falls with the presence of a lower extremity fracture was the head (46 patients; 9.0 %), followed by the abdomen (46 patients; 8.6 %) and chest (43 patients; 8.4 %). Table 5 shows the incidence of moderate to severe trauma to the anatomic regions according to the age group and type of lower extremity fracture. After exclusion of the 133 patients (26.0 %) with a head or chest or abdomen AIS C3 from the total population (n = 513), we were left with a total of 379 patients (74.0 %) with exclusive extremity fractures/injuries. According to the age groups, adult and elderly patients were significantly more likely to have longer ICU and hospital stay, more complications, and a higher mortality, as shown in Table 6. Overall, there were 40 deaths (7.8 %). According to the fracture pattern, there were 31 deaths (6.1 %) with a femur fracture, six deaths (1.2 %) with a tibia fracture, and three deaths (0.6 %) with a combination a femur and tibia fracture. The mortality for the age groups showed no deaths in the pediatric group and an increased mortality in the elderly group, especially in patients with an isolated femur fracture (Table 7).
Discussion The literature on the incidence of acute orthopedic trauma is scarce concerning falls [4, 6]. Importantly, the most commonly injured anatomical region is the musculoskeletal system [1, 2]. Many patients have evidence of a lower extremity fracture upon admission to the emergency
Table 5 Severe injuries (head, chest, and abdomen Abbreviated Injury Score, AIS C 3) according to fracture pattern and age group Injury severity
Age group (years)
Head AIS [3
Chest AIS [3
Abdomen AIS [3
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Femur
Tibia
Femur and tibia
B14
1/32 (3.1 %)
0/32
0/32
15–55
28/341 (8.2 %)
26/341 (7.6 %)
23/341 (6.7 %)
56–65
1/44 (2.3 %)
0/44
1/44 (2.3 %)
C65
7/95 (7.4 %)
2/95 (2.1 %)
3/95 (3.2 %)
B14
0/32
0/32
0/32
15–55
6/341 (1.8 %)
9/341 (2.6 %)
12/341 (3.5 %)
56–65
1/44 (2.3 %)
1/44 (2.3 %)
1/44 (2.3 %)
[65
0/95
0/95
0/95
B14
0/32
0/32
0/32
15–55
2/341 (0.6 %)
5/341 (1.5 %)
6/341 (1.8 %)
56–65 C65
0/44 0/95
0/44 0/95
0/44 0/95
Lower extremity fractures in falls Table 6 Morbidity and mortality (excluding all patients with head, chest, and abdomen AIS C3) Age (years) B14
Total number 31
ICU stay
Hospital stay
Complications
Pneumonia
Deaths 0
0±0
5.5 ± 5.7
0
0
15–55
260
0.6 ± 2.5
11.4 ± 15.1
2 (0.8 %)
0
1 (0.4 %)
56–65
40
0.9 ± 2.8
13.5 ± 12.3
0
0
1 (2.5 %)
C65
86
P-value
1.3 ± 5.1
14.3 ± 8.3
8 (9.3 %)
3 (3.5 %)
9 (10.5 %)
0.0176
\0.0001
\0.0001
0.0088
\0.0001
Table 7 Mortality based on the type of fracture and age group Fracture type
Age group (years)
Femur
B14
0/32
15–55
18/341 (5.3 %)
56–65 C65
1/44 (2.3 %) 12/95 (12.6 %)
Tibia
Both femur and tibia
Mortality
B14
0/32
15–55
6/341 (1.8 %)
56–65
0/44
C65
0/95
B14
0/32
15–55
3/341 (0.9 %)
56–65
0/44
C65
0/95
department. Our intentions were to gain knowledge of falls patients with a significant lower extremity fracture, which may assist with the initial assessment of these patients and prioritize the management to specific problems. The present study identified many important differences between the different patterns of lower extremity fractures and differences between the various age groups. Victims of falls had a significantly higher incidence of femur fractures (64.8 %). The incidence of severe trauma (ISS [25) was not evident in any of the pediatric patients, and was generally found in the adult and elderly groups. Also, the most commonly associated moderate to severe injury (AIS C3) in falls with a lower extremity fracture was a concomitant head injury. Overall, in patients with a combination of femur and tibia fractures, there was an increase in fractures of the skull, spinal column, and pelvis, and an increase in injuries of the spinal cord, hemopneumothorax, and iliac vessels as compared to patients with either a femur or a tibia fracture, which was found to be statistically significant. In addition, patients with both a femur and tibia fracture had a statistically higher incidence of laparotomies and thoracotomies as compared to patients with either a femur or a tibia fracture. The most common fracture found in this group of patients was an upper extremity fracture (humerus and/or
radius/ulna), found in 76 patients (14.8 %). One can postulate that the patients in our study landed on their legs and/ or feet because we only included patients with a lower extremity fracture. In other words, the difference in body position on impact is an important factor in determining the nature of a patient’s injuries. From our group of patients, lower and upper extremity fractures, it appears that, through natural instinct, many patients try to protect themselves by using their extremities as a defensive mechanism. The overall incidence of intra-abdominal injuries was 3.1 %, which is less than that of other previously reported studies of 4.0–4.6 % [2, 4, 5]. As suggested earlier, patients used their extremities as a defensive mechanism and suffered less intra-abdominal injuries in the presence of a femur and/or a tibia fracture. We found a much lower incidence of spinal injuries (9.5 %) as compared to other studies reporting a 20–24 % incidence [2, 4, 5]. In particular, we found no spinal injuries in the pediatric age group. Other studies have also reported a lower incidence of spinal injuries among children after high-level falls [4, 7]. Velmahos et al. showed that more than two-thirds of their patients with a spinal injury had injuries to their T-12 to L-5 spine, and a spinal cord injury incidence of 2.7 % [2]. Similarly, in this study, we found that 63.3 % of spinal fractures were confined to the lumbar spine and 2.9 % of patients had injury to their spinal cord. Head injuries have been reported to range from 14.4 % to as high as 46 % of fall trauma patients [2, 5]; in our study, we found 75 patients (14.6 %), of which 46 (61.3 %) patients had a head AIS C 3. There was a higher incidence of skull fractures in patients with both a femur and tibia fracture; however, they were not diagnosed with an intracranial hemorrhage. In contrast, patients with either a femur or a tibia fracture had a lower incidence of skull fractures; however, they were found to have a statistically significantly higher incidence of intracranial injuries in comparison to patients with both femur and tibia fractures. In a previous study, Demetriades and colleagues showed that falls from a height [15 feet had a 12.9 % incidence of pelvic fractures [8]. Similarly, in this study, there is a 12.5 % incidence of pelvic fractures, which was
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predominantly found in patients with a combination of a femur and tibia fracture as compared to patients with either a femur or a tibia fracture [9]. Studies have shown a low incidence of aortic injury in victims of falls [4]. In our study, we show a 1.2 % incidence of aortic injury in falls patients with a lower extremity fracture. Interestingly, we found that 66.7 % of patients with aortic injury had an associated pelvic fracture. The study by Demetriades et al. [8] showed a seven times higher incidence of aortic injury in the presence of a pelvic fracture as compared to patients without a pelvic fracture. The findings of this study must be interpreted within the context of its limitations. First, this study is of a retrospective observational design. Second, this study is from a single center; therefore, the findings of this study may not be reproducible at other institutions and, so, cannot be generalized to a larger population. As this study comes from a Level I trauma center, patients with a higher injury severity were probably more likely to be hospitalized at our center compared to a Level II trauma center. As a result of this, the association between long bone fractures and other associated injuries may be overestimated. Third, we did not record the details regarding the mechanism of injury, including the height of the fall.
Conclusion This study shows that lower extremity fracture pattern and age determine the severity and distribution of injuries in victims of falls. Patients with a combination of femur and tibia fractures have a significantly higher risk of associated injuries compared to patients with either a femur or a tibia fracture. Elderly patients (C65 years old) have higher
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morbidity and mortality compared to younger patients after falls. Clinicians evaluating these patients should be aware of these injury patterns. Further studies assessing the impact of age and pattern of injury in patients with falls are warranted. Conflict of interest There are no identifiable conflicts of interest to report. The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript.
References 1. Mosenthal AC, Livingston DH, Elcavage J, et al. Falls: epidemiology and strategies for prevention. J Trauma. 1995;38:753–6. 2. Velmahos GC, Demetriades D, Theodorou D, et al. Patterns of injury in victims of urban free-falls. World J Surg. 1997;21: 816–21. 3. Centers for Disease Control and Prevention (CDC). Cost of fall injuries in older persons in the United States, 2005. 2011. http:// www.cdc.gov/homeandrecreationalsafety/Falls/data/cost-estimates. html. Accessed 21 Aug 2012. 4. Demetriades D, Murray J, Brown C, et al. High-level falls: type and severity of injuries and survival outcome according to age. J Trauma. 2005;58:342–5. 5. Helling TS, Watkins M, Evans LL, et al. Low falls: an underappreciated mechanism of injury. J Trauma. 1999;46:453–6. 6. Gomberg BFC, Gruen GS, Smith WR, et al. Outcomes in acute orthopaedic trauma: a review of 130,506 patients by age. Injury. 1999;30:431–7. 7. Murray JA, Chen D, Velmahos GC, et al. Pediatric falls: is height a predictor of injury and outcome? Am Surg. 2000;66:863–5. 8. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002;195:1–10. 9. Demetriades D, Karaiskakis M, Velmahos GC, et al. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J Trauma. 2003;54:1146–51.
ORIGINAL ARTICLE
Lower extremity fractures in falls P. Hadjizacharia • B. Joseph • H. Aziz • V. Pandit L. S. Chan • D. Demetriades • P. Rhee
•
Received: 13 September 2013 / Accepted: 14 November 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Lower extremity fractures are very common in victims of falls. These fractures are usually associated with other bodily injuries and can lead to permanent disability if appropriate management is not provided. The aim of this study was to evaluate the incidence and outcomes of associated injuries in victims of falls with lower extremity fractures. Methods This is a retrospective review (1995–2006) of all fall-related trauma patients evaluated at our Level I trauma center. Injuries were categorized as: isolated femur fractures (FF), isolated tibia fractures (TF), and both femur and tibia fractures (FTF). Data were analyzed for differences in patterns of injury, associated fractures and injuries, and mortality and morbidity according to age groups within patients with minor body injuries expressed by Abbreviated Injury Score (AIS) \ 3. Results Three hundred and thirty-two patients (64.8 %) had FF, 164 patients (32 %) had TF, and 16 patients (3.2 %) presented with FTF. The incidence of severe trauma was 9.4 % (Injury Severity Score, ISS [ 25). A higher incidence of ISS [ 25 was observed in patients with
P. Hadjizacharia B. Joseph (&) H. Aziz V. Pandit P. Rhee Division of Trauma, Critical Care, Emergency Surgery, and Burn, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ 85727, USA e-mail: [email protected] L. S. Chan D. Demetriades Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County/University of Southern California Medical Center, Los Angeles, CA, USA
FF. Increased mortality was observed in the elderly group, especially in patients with an isolated femur fracture. Conclusion Patients with a combination of femur and tibia fractures have a significantly higher risk of associated injuries compared to patients with either a femur or a tibia fracture. Elderly patients (C65 years of age) have higher morbidity and mortality compared to younger patients after falls. Clinicians evaluating these patients should be aware of these injury patterns. Further studies assessing the impact of age and pattern of injury in patients following falls are warranted. Keywords severity
Extremity fractures Falls Injury
Introduction Falls are characterized by a myriad of injuries, with the musculoskeletal system being the most commonly injured anatomical region [1]. Of note, falls are the second leading cause of both spinal and brain injury in the United States [2]. Long bone lower extremity fractures are very common in victims of falls. These fractures are usually associated with other bodily injuries and can lead to permanent disability if appropriate management is not provided [3, 4]. Disability resulting from lower extremity injuries poses a tremendous burden to individuals and society. As the US population ages, both the number of falls and the costs to treat fall injuries are likely to increase. In 2005, falls among older adults cost the US health care system over $23.6 billion. Having information on the economic burden of older adult falls can help make the case to fund prevention programs and reduce overall health care costs [3].
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P. Hadjizacharia et al.
Several studies have shown that the anatomic patterns and severity of injury differ according to the height of the fall and the age of the patient [2–5]. However, few studies have addressed the outcomes of victims of falls after acute orthopedic trauma [6]. The aim of this study was to investigate victims of falls with femur and/or tibia fractures and evaluate the effect of age on the incidence and severity of specific associated injuries and outcomes with these fractures.
Methods This is a retrospective review of all victims of falls admitted to the Los Angeles County and University of Southern California General Hospital, a Level I trauma center, between January 1995 and June 2006. Patients were identified through a prospectively maintained trauma registry. Our inclusion criteria for this study were based on the presence of a significant lower extremity fracture, namely, femur and/or tibia fracture after a fall from height. Patients with ground-level falls and with isolated fibula and/or ankle fractures (coded as medial and/or lateral malleolus) were excluded from the study. Table 1 shows the International Classification of Diseases (ICD)-9 codes used for the description of a femur and tibia fracture. Patient variables were collected using Microsoft Excel 2003 (Microsoft Corporation, Redmond, WA), which included age, gender, admission vitals [heart rate, systolic blood pressure, Glasgow Coma Scale (GCS) score], associated injuries sustained identified by the ICD-9 code, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), hospital and intensive care unit (ICU) length of stay, and mortality. Injuries were categorized as: isolated femur fractures (FF), isolated tibia fractures (TF), and both femur and tibia fractures (FTF). For the purpose of data analysis, we grouped the patients on the basis of age in years as follows: B14, 15–55, 56–65, and C65. Data were analyzed for differences in patterns of injury as represented by injury severity scale scores (ISS), associated fractures and injuries; spine fractures, severity of head (h-AIS), chest (c-AIS), and abdomen AIS (a-AIS) according to age group and associated lower limb fractures; Table 1 List of International Classification of Diseases (ICD)-9 codes used for femur and tibia fractures Variables
ICD-9 codes
Femur
820.00, 820.01-3&9, 820.10, 820.11-3&9, 820.20, 820.21-2, 820.30, 820.31-2, 820.8-9, 821.00, 821.01, 821.10-1, 821.20-3&9, 821.30-3&9 823.00, 823.10, 823.20, 823.30, 823.40, 823.80, 823.90
Tibia
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and mortality and morbidity according to age groups within patients with minor body injuries expressed by AIS \3. We performed all statistical analyses using the SAS System, version 8.2 (SAS Institute Inc., Cary, NC). Univariate analysis was performed to compare femur, tibia, and a combination of femur and tibia fractures with respect to baseline demographics and outcome. Categorical variables were compared using Pearson’s v2 test, and for ordinal variables, we computed the trend with the Mantel–Haenszel v2 test. For variables in which one or more cells had expected counts \5, we used Fisher’s exact test. Differences were considered statistically significant at P \ 0.05. The Institutional Review Board at our institute approved the study.
Results During the 11.5-year study period, there were 5,364 fall trauma patients, of which 512 (9.5 %) met our inclusion criteria. Three hundred and thirty-two patients (64.8 %) had femur fractures (FF) and 164 patients (32 %) had tibia fractures (TF), while 16 patients (3.2 %) presented with fractures of both the femur and the tibia (FTF). Of the patients with both femur and tibia fracture (n = 16), 18.75 % (n = 3) had ipsilateral femur and tibial fractures, while the remainder (n = 13) had tibial and femoral fractures on opposite limbs. No patient had bilateral femur fracture. The mean age of the study population was 40.3 ± 21.4 years, 69.5 % were male, and the mean ISS was 20.4 ± 9.3. The majority of the patients (66.6 %) belonged in the 15–55 years age group followed by the C65 (18.6 %) years age group. Moreover, patients were categorized into four age groups, namely: 32 (6.3 %) in the B14 years age group, 341 (66.6 %) in the 15–55 years age group, 44 (8.6 %) in the 56–65 years age group, and 95 (18.6 %) in the C65 years age group. The incidence of severe trauma was 9.4 % (ISS [25). A higher incidence of ISS [25 was observed in patients with FF. There was no severe trauma in B14 years age group. Table 2 shows the incidence of mild/moderate and severe injuries according to the age group and type of lower extremity fracture. Patients with FTF had a statistically significant increase in skull fractures (5.1 vs. 3.1 vs. 18.8 %, P = 0.02), spinal column fractures (6.6 vs. 14 vs. 25 %; P = 0.003), pelvic fractures (14.8 vs. 6.7 vs. 25 %; P = 0.01), spinal cord injuries (6.6 vs. 14 vs. 25 %; P = 0.02), hemopneumothorax (5.4 vs. 3.7 vs. 31.3 %; P \ 0.0001), and iliac vessel injuries (1.2 vs. 0 vs. 6.3 %; P = 0.04) in comparison to patients with either a femur or a tibia fracture. In addition, patients with both a femur and a tibia fracture
Lower extremity fractures in falls Table 2 Age and Injury Severity Score (ISS) stratification Injury severity
Age groups (years)
ISS B15
B14
ISS 16–25
Femur
Femur and tibia
23/32 (71.9 %)
1/32 (3.1 %)
15–55
135/341 (39.6 %)
24/341 (7.0 %)
56–65
27/44 (61.4 %)
3/44 (6.8 %)
C65
81/95 (85.3 %)
4/95 (4.2 %)
B14
8/32 (25 %)
0/32
0/32 28/341 (8.2 %) 0/44 6/95 (6.3 %) 0/32
15–55
119/341 (34.9 %)
56–65
13/44 (29.5 %)
0/44
4/95 (4.2 %)
0/95
0/95
0/32
0/32
C65 ISS [25
Tibia
B14
11/341 (3.2 %)
0/32
15–55
8/341 (2.3 %)
56–65 C65
1/44 (2.3 %)
3/341 (0.9 %)
0/44 0/95
8/341 (2.3 %)
0/44 0/95
5/341 (1.5 %) 0/44 0/95
Table 3 Associated fractures and injuries Variables
Total N = 512
Femur fractures N = 332
Tibia fractures N = 164
Both fractures N = 16
P-value*
Skull
25
17 (5.1 %)
5 (3.1 %)
3 (18.8 %)
0.0197
Facial
31
22 (6.6 %)
5 (3.1 %)
4 (25 %)
0.0016
Upper extremity
76
57 (17.2 %)
16 (9.8 %)
3 (18.8 %)
0.0833
Spinal column
49
22 (6.6 %)
23 (14.0 %)
4 (25.0 %)
0.0032
Pelvic
64
49 (14.8 %)
11 (6.7 %)
4 (25 %)
0.0119
Fractures
Injuries Cardiac
4
3 (0.9 %)
1 (0.6 %)
0
0.8815
Aorta
6
4 (1.2 %)
2 (1.2 %)
0
0.9066
Intracranial
19
18 (5.42 %)
1 (0.6 %)
0
0.0208
Spinal cord
15
6 (1.8 %)
7 (4.3 %)
2 (12.5 %)
0.0217
Hemopneumothorax
29
18 (5.4 %)
6 (3.7 %)
5 (31.3 %)
\0.0001
Abdominal hollow viscus
6
4 (1.2 %)
2 (1.2 %)
0
0.9066
Abdominal solid organ
12
9 (2.7 %)
3 (1.8 %)
0
0.6807
Lower extremity nerve
0
0
0
0
NA
Lower extremity vascular
5
3 (0.9 %)
2 (1.2 %)
0
0.8710
Iliac vessels
5
4 (1.2 %)
0
1 (6.3 %)
0.0408
* Chi-square test
were statistically significantly more likely to have a laparotomy (P \ 0.0001) and a thoracotomy (P = 0.0016) as compared to patients with either a femur or a tibia fracture. Associated injuries are shown in Table 3 according to the three categories of lower extremity fractures. Overall, 19 patients (3.7 %) were found to have an intracranial hemorrhage. The most common intracranial hemorrhage was subarachnoid (78.9 %), followed by subdural (1.0 %) and epidural (0.2 %). Only patients with either a femur or a tibia fracture presented with an intracranial hemorrhage, with proportions of 5.42 and 0.6 %, respectively (P = 0.0208).
Spinal injuries were found in 49 patients (9.5 %). Overall, there were more lumbar spine fractures (n = 31), followed by thoracic spine fractures (n = 16) and cervical spine fractures (n = 10). A total of 15 patients (2.9 %) were diagnosed with a spinal cord injury. Again, the most commonly injured anatomic site was the lumbar spinal cord (n = 13; 2.5 %), followed by the cervical spinal cord (n = 1; 0.2 %), and one patient had injury to all three anatomical areas of his spinal cord. Table 4 shows the incidence of spinal column fractures according to the age group and type of lower extremity fracture pattern.
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Overall, 16 patients (3.1 %) had associated abdominal injuries occurring in patients with either a femur or a tibia fracture; of note, patients with both a femur and tibia fracture did not present with an intra-abdominal injury. There were 12 patients (2.3 %) with abdominal solid organ injuries and six patients (1.2 %) with hollow viscus gastrointestinal injuries. The most commonly injured solid organ was the liver (1.6 %), followed by the kidney (1.2 %) and spleen (0.4 %); for the hollow viscus injuries, the small and large intestine had a similar injury rate of 0.6 % each, and there was no stomach injury. Aortic injuries were diagnosed in six patients (1.2 %). The incidence of 1.2 % was the same in patients with either a femur or a tibia fracture. No aortic injury was found in patients with a combination of a femur and tibia fracture. In addition, the pediatric age group had no aortic injury, and patients in the adult and elderly age groups suffered this type of injury.
Table 4 Spine fractures Fracture type
Age group (years)
Femur
B14
0/32
15–55
16/341 (4.7 %)
56–65 C65
4/44 (9.1 %) 2/95 (2.1 %)
Tibia
Femur and tibia
Spine fracture
B14
0/32
15–55
20/341 (5.9 %)
56–65
2/44 (4.5 %)
C65
1/95 (1.1 %)
B14
0/32
15–55
4/341 (1.2 %)
56–65
0/44
C65
0/95
When we looked at a subset of the total population, patients with at least one anatomic region with moderate to severe injury (AIS C3), we had a total of 229 patients (44.7 %). The most common body region with moderate to severe trauma for victims of falls with the presence of a lower extremity fracture was the head (46 patients; 9.0 %), followed by the abdomen (46 patients; 8.6 %) and chest (43 patients; 8.4 %). Table 5 shows the incidence of moderate to severe trauma to the anatomic regions according to the age group and type of lower extremity fracture. After exclusion of the 133 patients (26.0 %) with a head or chest or abdomen AIS C3 from the total population (n = 513), we were left with a total of 379 patients (74.0 %) with exclusive extremity fractures/injuries. According to the age groups, adult and elderly patients were significantly more likely to have longer ICU and hospital stay, more complications, and a higher mortality, as shown in Table 6. Overall, there were 40 deaths (7.8 %). According to the fracture pattern, there were 31 deaths (6.1 %) with a femur fracture, six deaths (1.2 %) with a tibia fracture, and three deaths (0.6 %) with a combination a femur and tibia fracture. The mortality for the age groups showed no deaths in the pediatric group and an increased mortality in the elderly group, especially in patients with an isolated femur fracture (Table 7).
Discussion The literature on the incidence of acute orthopedic trauma is scarce concerning falls [4, 6]. Importantly, the most commonly injured anatomical region is the musculoskeletal system [1, 2]. Many patients have evidence of a lower extremity fracture upon admission to the emergency
Table 5 Severe injuries (head, chest, and abdomen Abbreviated Injury Score, AIS C 3) according to fracture pattern and age group Injury severity
Age group (years)
Head AIS [3
Chest AIS [3
Abdomen AIS [3
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Femur
Tibia
Femur and tibia
B14
1/32 (3.1 %)
0/32
0/32
15–55
28/341 (8.2 %)
26/341 (7.6 %)
23/341 (6.7 %)
56–65
1/44 (2.3 %)
0/44
1/44 (2.3 %)
C65
7/95 (7.4 %)
2/95 (2.1 %)
3/95 (3.2 %)
B14
0/32
0/32
0/32
15–55
6/341 (1.8 %)
9/341 (2.6 %)
12/341 (3.5 %)
56–65
1/44 (2.3 %)
1/44 (2.3 %)
1/44 (2.3 %)
[65
0/95
0/95
0/95
B14
0/32
0/32
0/32
15–55
2/341 (0.6 %)
5/341 (1.5 %)
6/341 (1.8 %)
56–65 C65
0/44 0/95
0/44 0/95
0/44 0/95
Lower extremity fractures in falls Table 6 Morbidity and mortality (excluding all patients with head, chest, and abdomen AIS C3) Age (years) B14
Total number 31
ICU stay
Hospital stay
Complications
Pneumonia
Deaths 0
0±0
5.5 ± 5.7
0
0
15–55
260
0.6 ± 2.5
11.4 ± 15.1
2 (0.8 %)
0
1 (0.4 %)
56–65
40
0.9 ± 2.8
13.5 ± 12.3
0
0
1 (2.5 %)
C65
86
P-value
1.3 ± 5.1
14.3 ± 8.3
8 (9.3 %)
3 (3.5 %)
9 (10.5 %)
0.0176
\0.0001
\0.0001
0.0088
\0.0001
Table 7 Mortality based on the type of fracture and age group Fracture type
Age group (years)
Femur
B14
0/32
15–55
18/341 (5.3 %)
56–65 C65
1/44 (2.3 %) 12/95 (12.6 %)
Tibia
Both femur and tibia
Mortality
B14
0/32
15–55
6/341 (1.8 %)
56–65
0/44
C65
0/95
B14
0/32
15–55
3/341 (0.9 %)
56–65
0/44
C65
0/95
department. Our intentions were to gain knowledge of falls patients with a significant lower extremity fracture, which may assist with the initial assessment of these patients and prioritize the management to specific problems. The present study identified many important differences between the different patterns of lower extremity fractures and differences between the various age groups. Victims of falls had a significantly higher incidence of femur fractures (64.8 %). The incidence of severe trauma (ISS [25) was not evident in any of the pediatric patients, and was generally found in the adult and elderly groups. Also, the most commonly associated moderate to severe injury (AIS C3) in falls with a lower extremity fracture was a concomitant head injury. Overall, in patients with a combination of femur and tibia fractures, there was an increase in fractures of the skull, spinal column, and pelvis, and an increase in injuries of the spinal cord, hemopneumothorax, and iliac vessels as compared to patients with either a femur or a tibia fracture, which was found to be statistically significant. In addition, patients with both a femur and tibia fracture had a statistically higher incidence of laparotomies and thoracotomies as compared to patients with either a femur or a tibia fracture. The most common fracture found in this group of patients was an upper extremity fracture (humerus and/or
radius/ulna), found in 76 patients (14.8 %). One can postulate that the patients in our study landed on their legs and/ or feet because we only included patients with a lower extremity fracture. In other words, the difference in body position on impact is an important factor in determining the nature of a patient’s injuries. From our group of patients, lower and upper extremity fractures, it appears that, through natural instinct, many patients try to protect themselves by using their extremities as a defensive mechanism. The overall incidence of intra-abdominal injuries was 3.1 %, which is less than that of other previously reported studies of 4.0–4.6 % [2, 4, 5]. As suggested earlier, patients used their extremities as a defensive mechanism and suffered less intra-abdominal injuries in the presence of a femur and/or a tibia fracture. We found a much lower incidence of spinal injuries (9.5 %) as compared to other studies reporting a 20–24 % incidence [2, 4, 5]. In particular, we found no spinal injuries in the pediatric age group. Other studies have also reported a lower incidence of spinal injuries among children after high-level falls [4, 7]. Velmahos et al. showed that more than two-thirds of their patients with a spinal injury had injuries to their T-12 to L-5 spine, and a spinal cord injury incidence of 2.7 % [2]. Similarly, in this study, we found that 63.3 % of spinal fractures were confined to the lumbar spine and 2.9 % of patients had injury to their spinal cord. Head injuries have been reported to range from 14.4 % to as high as 46 % of fall trauma patients [2, 5]; in our study, we found 75 patients (14.6 %), of which 46 (61.3 %) patients had a head AIS C 3. There was a higher incidence of skull fractures in patients with both a femur and tibia fracture; however, they were not diagnosed with an intracranial hemorrhage. In contrast, patients with either a femur or a tibia fracture had a lower incidence of skull fractures; however, they were found to have a statistically significantly higher incidence of intracranial injuries in comparison to patients with both femur and tibia fractures. In a previous study, Demetriades and colleagues showed that falls from a height [15 feet had a 12.9 % incidence of pelvic fractures [8]. Similarly, in this study, there is a 12.5 % incidence of pelvic fractures, which was
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predominantly found in patients with a combination of a femur and tibia fracture as compared to patients with either a femur or a tibia fracture [9]. Studies have shown a low incidence of aortic injury in victims of falls [4]. In our study, we show a 1.2 % incidence of aortic injury in falls patients with a lower extremity fracture. Interestingly, we found that 66.7 % of patients with aortic injury had an associated pelvic fracture. The study by Demetriades et al. [8] showed a seven times higher incidence of aortic injury in the presence of a pelvic fracture as compared to patients without a pelvic fracture. The findings of this study must be interpreted within the context of its limitations. First, this study is of a retrospective observational design. Second, this study is from a single center; therefore, the findings of this study may not be reproducible at other institutions and, so, cannot be generalized to a larger population. As this study comes from a Level I trauma center, patients with a higher injury severity were probably more likely to be hospitalized at our center compared to a Level II trauma center. As a result of this, the association between long bone fractures and other associated injuries may be overestimated. Third, we did not record the details regarding the mechanism of injury, including the height of the fall.
Conclusion This study shows that lower extremity fracture pattern and age determine the severity and distribution of injuries in victims of falls. Patients with a combination of femur and tibia fractures have a significantly higher risk of associated injuries compared to patients with either a femur or a tibia fracture. Elderly patients (C65 years old) have higher
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morbidity and mortality compared to younger patients after falls. Clinicians evaluating these patients should be aware of these injury patterns. Further studies assessing the impact of age and pattern of injury in patients with falls are warranted. Conflict of interest There are no identifiable conflicts of interest to report. The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript.
References 1. Mosenthal AC, Livingston DH, Elcavage J, et al. Falls: epidemiology and strategies for prevention. J Trauma. 1995;38:753–6. 2. Velmahos GC, Demetriades D, Theodorou D, et al. Patterns of injury in victims of urban free-falls. World J Surg. 1997;21: 816–21. 3. Centers for Disease Control and Prevention (CDC). Cost of fall injuries in older persons in the United States, 2005. 2011. http:// www.cdc.gov/homeandrecreationalsafety/Falls/data/cost-estimates. html. Accessed 21 Aug 2012. 4. Demetriades D, Murray J, Brown C, et al. High-level falls: type and severity of injuries and survival outcome according to age. J Trauma. 2005;58:342–5. 5. Helling TS, Watkins M, Evans LL, et al. Low falls: an underappreciated mechanism of injury. J Trauma. 1999;46:453–6. 6. Gomberg BFC, Gruen GS, Smith WR, et al. Outcomes in acute orthopaedic trauma: a review of 130,506 patients by age. Injury. 1999;30:431–7. 7. Murray JA, Chen D, Velmahos GC, et al. Pediatric falls: is height a predictor of injury and outcome? Am Surg. 2000;66:863–5. 8. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002;195:1–10. 9. Demetriades D, Karaiskakis M, Velmahos GC, et al. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J Trauma. 2003;54:1146–51.
