196
Injury, 6.196-201
A survey of fractures femur
of the proximal
J. A. R. Smith and J. McLauchlan Department
of Orthopaedic
Surgery, Aberdeen Royal Infirmary
Summary
A series of 1494 fractures of the proximal femur, admitted over a 68-month period to the North East Area Accident Unit, is presented. The mortality for the series was 18 per cent, with operative mortality varying according to the fracture site and the method of treatment, being 18.1 per cent for extracapsular fractures, 14 per cent for SmithPetersen nailing of intracapsular fractures, and 31 per cent for primary prosthetic replacement. In general terms, morbidity and mortality were proportional to age and to pre-existing general medical conditions. The results are presented in full, and are compared with other published series.
INTRODUCTION ACCORDING to Preston, Ambroise Pare, in the sixteenth century, was the first to describe fracture of the neck of the femur. Since that time, the proper treatment of this fracture has remained a bone of contention. The last survey of fractures of the neck of the femur in Great Britain was conducted in Dundee (Stewart, 1955) and since then, other statistical reviews have come from Scandinavia (Alffram, 1964) and North America (Naden and Denbesten, 1969). The present survey, in part prospective and in part retrospective, concerns all patients with fracture of the proximal femur admitted to the Aberdeen Accident Unit in the 68 months from the inception of the Unit on 1 May, 1967, to 31 December, 1972. The Unit serves a population of 475,495 of whom 59,540 are over sixty-five years of age. On the basis of the medical arrangements of the area, the figures presented represent virtually all such fractures occurring during the period of study in the North East area.
UNIT POLICY On admission, patients were assessed from the point of view of their specific injury, their general
health and their fitness for general anaesthesia. Those considered fit for anaesthesia were operated on, on the next available operating list, usually within twenty-four hours. Those considered unfit for anaesthetic received treatment for the particular condition contra-indicating surgery, and were re-assessed daily until considered fit for operation or allocated to the nonoperative group. Extracapsular fractures were treated by pinning and plating; intracapsular fractures usually by Smith-Petersen nailing or primary prosthetic replacement, except for a small number treated by a pin and short plate.
RESULTS A total of 1494 fractures of the proximal femur were admitted, of which 85 per cent were female and 15 per cent male-a sex ratio of five to one. Right and left sides were equally involved. Fifty-three per cent of fractures were intracapsular, it being decided to follow the findings of Klennerman and Marcuson (1970) that ‘ transcervical ’ is a radiological but not a clinical entity. Forty-five per cent of fractures were extracapsular (combined basal and trochanteric groups) and 2 per cent were in other sites (12 subtrochanteric, 5 greater trochanter fracture only, 2 lesser trochanter only, and 2 in unspecified sites). Considered in six-monthly periods (Fig. 1) there has been no increase in the numbers per six months over the period studied, nor any alteration in sex incidence. The ratio of intracapsular to extracapsular fractures (Fig. 2) has remained unchanged. The age distribution (Fig. 3) in this area has varied little over the 68 months studied, and the overall age distribution (Fig. 4) is similar to other published series. As one would expect, the incidence increases with increasing age (Fig. 4). The proportion of cases with significant preoperative disease fluctuated little over the study
Smith
and bvlcLauchlan
1967
Fig. 1.-Sex
: Fractures
of the PI,oximal
Illjlnj[l 1970
1969
1966
197
Femur
_
INTRACAPSULAA
-
EXTRACAPSULAR
L I
1
1967 Fig.
1972
1971
incidence and numbers of fractures in six-monthly periods.
I
1999
1
1969
2.-Distribution
1070
I
I
1971
1972
1
of fractures.
n , Males; 0, Females.
period (Fig. 5) and there was no evidence to support the clinical impression that the patients were progressively more frail over the years. (The asterisks denote periods for which records are incomplete.) There appears to be a significant relationship between the incidences of preoperative disease, of postoperative complications and mortality. This confirms that the overall morbidity and mortality depend on the general health at the time of injury. That incidence peaks occur at the times of coldest weather is confirmed in this series, as demonstrated by a record of operations performed in the three-year period 1970-72 (Fig. 6).
l*r
1959
1967
Fig. 3.-Age
1969
1972
1971
ism
distribution.
ii.,:dl,nnL 95
198
Injury: the British Journal of Accident Surgery Vol. ~/NO. 3 Tab/e /.-Ninety-two second Smith-Petersen nails
operations
following
Operation
No.
(Per cent)
Removal of SPN Secondary prosthesis 44 Austin Moore 5 Thompson Girdlestone arthroplasty lleofemoral thrombectomy
40 49
(43) (53)
2 1
(2)
lower than the 31 per cent mortality after primary prosthesis for intracapsular fractures (Pt0.02). There were 92 (23 per cent) second operations after Smith-Petersen nailing (Table I) of which 53 per cent were for insertion of secondary
significantly
rsal Fig.
5.-Preoperative disease (A), postoperative plications (B) and mortality (C).
Fig. 6.-Operations
com-
performed.
lntracapsular fractures An independently performed survey (J. McL.) of the intracapsular fractures alone was undertaken over the four-year period between May 1967 and 1971. The results are as follows: A total of 605 intracapsular fractures were admitted, with an overall mortality of 18 per cent, the same as in the series as a whole. Of these, 6 per cent were not accepted for operation. Sixtysix per cent were treated by a Smith-Petersen nail, 18 per cent by primary prosthesis, 4 per cent by multiple pins, 5 per cent by sliding nail and short plate and 5 per cent by Girdlestone arthroplasty. The mortality following Smith-Petersen nailing was 14 per cent, in which is included all deaths occurring during the period of in-patient treatment, in some cases over six months. This is lower than the 18.1 per cent mortality after nail plate fixation of extracapsular fractures, though not significantly so (P85 80-85 75-80 Cardiac causes Chest causes
30 26 22 56 70
(37.5
Table ///.-Operative
deaths
Indoors only Preoperative heart disease Preoperative chest disease Age : >a5 80-85 7 5-80 70-75 Operation time : t24 hr. ~48 hr. 2-7 days >7 days
Tab/e V.-Disposal Per cent 44 46 5 34 28 23 8 54 25 20 1
The sex ratio for intracapsular fractures is more clearly female biased than in the 5 : 1 of the series as a whole, being nearly 7 : 1 for Smith-Petersen nails and 11 : 1 for primary prosthesis. Extracapsular
There was no evidence that delay in time of operation from admission increased the mortality, probably because any delay was dictated by conditions that could be treated
fractures
The operative mortality after nail plate fixation of extracapsular fractures was 18.1 per cent, 5 of 109 deaths occurring after a second operation, a second operation mortality of 20 per cent, close to the 17 per cent following re-operation on nailed intracapsular fractures. Cardiac causes were implicated in 32 per cent and pulmonary in 59 per cent, with renal failure, pre-existing malignancy, cerebrovascular accident and atherosclerosis providing the other causes. Of those dying (Table ZZZ),44 per cent had been confined to home before injury, 46 per cent had significant cardiac disease and 5 per cent significant pulmonary disease, i.e. sufficiently severe to warrant treatment or to interfere with activities. Thirty-four per cent were over 85 years of age, 28 per cent between 80 and 8523 per cent between 75 and 80, and 80 per cent between 70 and 75 years, i.e. 93 per cent were over 70 years.
Home Other hospital Glenburn* Died
Per cent 55 24 3 18
Injury, 6.196-201
A survey of fractures femur
of the proximal
J. A. R. Smith and J. McLauchlan Department
of Orthopaedic
Surgery, Aberdeen Royal Infirmary
Summary
A series of 1494 fractures of the proximal femur, admitted over a 68-month period to the North East Area Accident Unit, is presented. The mortality for the series was 18 per cent, with operative mortality varying according to the fracture site and the method of treatment, being 18.1 per cent for extracapsular fractures, 14 per cent for SmithPetersen nailing of intracapsular fractures, and 31 per cent for primary prosthetic replacement. In general terms, morbidity and mortality were proportional to age and to pre-existing general medical conditions. The results are presented in full, and are compared with other published series.
INTRODUCTION ACCORDING to Preston, Ambroise Pare, in the sixteenth century, was the first to describe fracture of the neck of the femur. Since that time, the proper treatment of this fracture has remained a bone of contention. The last survey of fractures of the neck of the femur in Great Britain was conducted in Dundee (Stewart, 1955) and since then, other statistical reviews have come from Scandinavia (Alffram, 1964) and North America (Naden and Denbesten, 1969). The present survey, in part prospective and in part retrospective, concerns all patients with fracture of the proximal femur admitted to the Aberdeen Accident Unit in the 68 months from the inception of the Unit on 1 May, 1967, to 31 December, 1972. The Unit serves a population of 475,495 of whom 59,540 are over sixty-five years of age. On the basis of the medical arrangements of the area, the figures presented represent virtually all such fractures occurring during the period of study in the North East area.
UNIT POLICY On admission, patients were assessed from the point of view of their specific injury, their general
health and their fitness for general anaesthesia. Those considered fit for anaesthesia were operated on, on the next available operating list, usually within twenty-four hours. Those considered unfit for anaesthetic received treatment for the particular condition contra-indicating surgery, and were re-assessed daily until considered fit for operation or allocated to the nonoperative group. Extracapsular fractures were treated by pinning and plating; intracapsular fractures usually by Smith-Petersen nailing or primary prosthetic replacement, except for a small number treated by a pin and short plate.
RESULTS A total of 1494 fractures of the proximal femur were admitted, of which 85 per cent were female and 15 per cent male-a sex ratio of five to one. Right and left sides were equally involved. Fifty-three per cent of fractures were intracapsular, it being decided to follow the findings of Klennerman and Marcuson (1970) that ‘ transcervical ’ is a radiological but not a clinical entity. Forty-five per cent of fractures were extracapsular (combined basal and trochanteric groups) and 2 per cent were in other sites (12 subtrochanteric, 5 greater trochanter fracture only, 2 lesser trochanter only, and 2 in unspecified sites). Considered in six-monthly periods (Fig. 1) there has been no increase in the numbers per six months over the period studied, nor any alteration in sex incidence. The ratio of intracapsular to extracapsular fractures (Fig. 2) has remained unchanged. The age distribution (Fig. 3) in this area has varied little over the 68 months studied, and the overall age distribution (Fig. 4) is similar to other published series. As one would expect, the incidence increases with increasing age (Fig. 4). The proportion of cases with significant preoperative disease fluctuated little over the study
Smith
and bvlcLauchlan
1967
Fig. 1.-Sex
: Fractures
of the PI,oximal
Illjlnj[l 1970
1969
1966
197
Femur
_
INTRACAPSULAA
-
EXTRACAPSULAR
L I
1
1967 Fig.
1972
1971
incidence and numbers of fractures in six-monthly periods.
I
1999
1
1969
2.-Distribution
1070
I
I
1971
1972
1
of fractures.
n , Males; 0, Females.
period (Fig. 5) and there was no evidence to support the clinical impression that the patients were progressively more frail over the years. (The asterisks denote periods for which records are incomplete.) There appears to be a significant relationship between the incidences of preoperative disease, of postoperative complications and mortality. This confirms that the overall morbidity and mortality depend on the general health at the time of injury. That incidence peaks occur at the times of coldest weather is confirmed in this series, as demonstrated by a record of operations performed in the three-year period 1970-72 (Fig. 6).
l*r
1959
1967
Fig. 3.-Age
1969
1972
1971
ism
distribution.
ii.,:dl,nnL 95
198
Injury: the British Journal of Accident Surgery Vol. ~/NO. 3 Tab/e /.-Ninety-two second Smith-Petersen nails
operations
following
Operation
No.
(Per cent)
Removal of SPN Secondary prosthesis 44 Austin Moore 5 Thompson Girdlestone arthroplasty lleofemoral thrombectomy
40 49
(43) (53)
2 1
(2)
lower than the 31 per cent mortality after primary prosthesis for intracapsular fractures (Pt0.02). There were 92 (23 per cent) second operations after Smith-Petersen nailing (Table I) of which 53 per cent were for insertion of secondary
significantly
rsal Fig.
5.-Preoperative disease (A), postoperative plications (B) and mortality (C).
Fig. 6.-Operations
com-
performed.
lntracapsular fractures An independently performed survey (J. McL.) of the intracapsular fractures alone was undertaken over the four-year period between May 1967 and 1971. The results are as follows: A total of 605 intracapsular fractures were admitted, with an overall mortality of 18 per cent, the same as in the series as a whole. Of these, 6 per cent were not accepted for operation. Sixtysix per cent were treated by a Smith-Petersen nail, 18 per cent by primary prosthesis, 4 per cent by multiple pins, 5 per cent by sliding nail and short plate and 5 per cent by Girdlestone arthroplasty. The mortality following Smith-Petersen nailing was 14 per cent, in which is included all deaths occurring during the period of in-patient treatment, in some cases over six months. This is lower than the 18.1 per cent mortality after nail plate fixation of extracapsular fractures, though not significantly so (P85 80-85 75-80 Cardiac causes Chest causes
30 26 22 56 70
(37.5
Table ///.-Operative
deaths
Indoors only Preoperative heart disease Preoperative chest disease Age : >a5 80-85 7 5-80 70-75 Operation time : t24 hr. ~48 hr. 2-7 days >7 days
Tab/e V.-Disposal Per cent 44 46 5 34 28 23 8 54 25 20 1
The sex ratio for intracapsular fractures is more clearly female biased than in the 5 : 1 of the series as a whole, being nearly 7 : 1 for Smith-Petersen nails and 11 : 1 for primary prosthesis. Extracapsular
There was no evidence that delay in time of operation from admission increased the mortality, probably because any delay was dictated by conditions that could be treated
fractures
The operative mortality after nail plate fixation of extracapsular fractures was 18.1 per cent, 5 of 109 deaths occurring after a second operation, a second operation mortality of 20 per cent, close to the 17 per cent following re-operation on nailed intracapsular fractures. Cardiac causes were implicated in 32 per cent and pulmonary in 59 per cent, with renal failure, pre-existing malignancy, cerebrovascular accident and atherosclerosis providing the other causes. Of those dying (Table ZZZ),44 per cent had been confined to home before injury, 46 per cent had significant cardiac disease and 5 per cent significant pulmonary disease, i.e. sufficiently severe to warrant treatment or to interfere with activities. Thirty-four per cent were over 85 years of age, 28 per cent between 80 and 8523 per cent between 75 and 80, and 80 per cent between 70 and 75 years, i.e. 93 per cent were over 70 years.
Home Other hospital Glenburn* Died
Per cent 55 24 3 18
