The Management of the Multiply Injured Elderly Patient

Injury severity score <25

GCS <9

Systolic blood pressure <90 mmHg

Pulse >90/min

Increased transfusion requirement

Increased volume replacement

Associated injuries (AIS >3)

Head

Chest

Abdomen

Spine

Comorbidities

Haematological disease

Diabetes

Cardiovascular disease

Renal disease

Hepatic disease

Neurological disease

Respiratory disease

Data from Giannoudis et al [21], Tornetta et al [24] and McGwin et al [41]

15.2.9 Outcome

15.2.9.1 Polytrauma

There is very little information about outcome, other than mortality, in the elderly admitted with severe injury. There is some evidence that older patients have fewer long-term psychological problems than younger patients [43] but these results came from patients who were not polytraumatised patients but were patients admitted with severe fractures. Studies on the outcome of elderly polytrauma survivors are required.

Mortality following polytrauma clearly varies with the degree of injury and in the large multi-centre studies where a wide spectrum of injury has been included the mortality is less than in studies that concentrate on polytrauma victims. There is also considerable variation between mortality in different countries. In countries such as the United States and Germany where there are formal trauma systems, the results are better than in the United Kingdom where such a system has only recently been instituted. The literature suggests that the average mortality for elderly polytraumatised patients in countries with a formal trauma system is 15–25 % [24–26] but of course it depends on the age of the patients and the severity of injury. Kuhne et al. [26] analysed mortality in 5375 patients in Germany who had an ISS ≥16 and were aged between 15 and 95 years. The overall mortality was 23 % but it was 8.1 % if the ISS was 16–24, 27.2 % if the ISS was 25–50 and 66.1 % if the ISS was 51–75. Their results are shown in Fig. 15.1. They stated that mortality rose from 56 years onwards. These overall mortality figures are not dissimilar from those reported from other trauma centres but higher figures have been reported. Aldrian et al. [44] reported a mortality of 53.3 % in the elderly with 31.1 % dying within 24 h. Their average ISS was 32.1.

Fig. 15.1

Mortality following multiple injury for different ages and different severity of injury. Note the increase in mortality in the 6th decade (Data taken, with permission, from Kuhne et al [26])

The statement by Kuhne et al. [26] that mortality in polytraumatised patients rose after the age of 56 once again highlights the polarisation of much of the literature dealing with severely injured patients. Their assessment of a group of polytraumatised patients admitted to trauma centres in Germany should be compared with the study of Caterino et al. [45] in the United States. They examined the Ohio State Registry which records a wider range of admissions from both trauma and non-trauma centres. They found that 70 years was the equivalent age at which mortality increased. They recommended that 70 years should be taken as the cut-off age for considering a patient to be elderly in trauma studies but it is vital that the type of injury be accurately recorded given the differences between these two papers.

In the United Kingdom, which lacked a formal trauma system until recently, Giannoudis et al. [21] reported 42 % mortality in elderly polytraumatised patients. As with other studies the mortality was age dependent and it reached almost 50 % in patients aged over 75 years. In their earlier study DeMaria et al. [3] had reported 80 % mortality in patients with an ISS ≥25 who were at least 80 years of age. More recently it has been shown that elderly patients with an ISS >30 require less ICU facilities than younger patients because of their higher mortality [46]. It is also interesting to note that in the United States mortality following injury in the very elderly (>80 years) is less in trauma centres than in acute care hospitals [47]. Mortality obviously increases with age and degree of injury but it is also influenced significantly by the type of hospital and the trauma system within the country.

15.2.9.2 Falls

The mortality from falls has increased in the last few decades. As with the incidence of fall-induced injury Kannus and his co-workers have used the Finnish Cause-of-Death register to assess the incidence of fall-induced mortality between 1971 and 2002 [48]. They pointed out that in 2002 falls were responsible for 285 % more deaths than motor vehicle accidents and that there had been an overall 136 % increase in fall-induced deaths in the study period. The relevant figures for males and females were 201 % and 97 % respectively. They also showed that while the incidence of fall-induced deaths had been relatively steady in females between 1975 and 2002 it had continued to increase in females. They theorised that there would be a 108 % increase in mortality by 2030.

15.2.9.3 Types of Injury

In the elderly there are two main types of serious injury that frequently occur with both low-energy and high-energy injuries and may be associated with significant mortality. These are head injuries and fractures. Obviously injuries may occur in other body systems but they are usually caused by high-energy trauma and their characterisation and management is discussed elsewhere in the book.

Head Injury

In a recent study of head injury in the elderly Mitra et al. [49] analysed 96 patients and showed that 31.2 % of head injuries followed a low fall, 30.2 % occurred because the patient was struck by a motor vehicle and 17.7 % were caused by a high fall. All patients presented with an initial GCS <8 which had not been caused by sedation or paralysis. They reported that 62.2 % of patients aged 65–74 years died compared with 68.2 % aged 75–84 years and 100 % of patients aged at least 85 years. Increasing age and brainstem injury were identified as predictors of mortality. Frankel et al. [50] analysed the outcome of traumatic brain injury in the elderly and showed that elderly patients were significantly less likely to be discharged home. However they felt that the results of treatment were encouraging and they stated that older patients exhibited the potential to achieve functional goals.

Multiple Fractures

Multiple fractures in the elderly may occur as a result of high-energy or low-energy injuries. The assumption is often made that they are mainly caused by motor vehicle accidents or falls from a height but this is simply not the case. In a review of 6872 inpatient and outpatient fractures in the Royal Infirmary of Edinburgh in 2007/8 [51] there were 2293 patients aged at least 65 years of age. Of these 117 (5.1 %) presented with multiple fractures. One hundred and ten (94.0 %) had two fractures, 6 (5.1 %) had three fractures and one (0.9 %) 75 year old pedestrian presented with four fractures after a motor vehicle accident. Table 15.2 shows the causes of multiple fractures in the elderly population. It can be seen that the highest prevalence is indeed related to motor vehicle accidents with 36.4 % of patients presenting with multiple fractures. Predictably the next most common cause of multiple fractures in the elderly was falls from a height followed by falls down stairs. However although the prevalence of multiple fractures following simple falls was only 4.4 %, the frequency of fall-related fractures in the elderly population means that 92 patients presented with multiple fractures following a fall during the year, this constituting 78.6 % of all the multiple fractures. Table 15.2 shows that the average of the multiple fracture group was 71.3 years and about 80 % were female.

Table 15.2

The epidemiology of multiple fractures in patients aged at least 65 years of age presenting to the Royal Infirmary of Edinburgh in a 1-year period in 2007/2008

	Patients (n)	Multiple fractures	%	Average age (year)	Gender ratio
Simple fall	2111	96	4.5	79.0	16/84
Fall from height	11	3	27.3	72.0	67/33
Fall down stairs	80	10	12.5	77.0	30/70
Motor vehicle accident	22	8	36.4	80.2	75/25
Direct blow/assault	45	2	4.4	77.5	0/100
Sport	17	0	–	–	–
Spontaneous	24	0	–	–	–
Others	25	0	–	–	–
	2335	119	5.1	78.7	22/78

A review of the 32 fractures that resulted from motor vehicle accidents shows that they occurred in 22 patients with 7 patients presenting with two fractures and one patient with four fractures. The average age was 80.2 years and 75 % of the patients were male. Five (22.7 %) of the 22 patients were bicyclists all of whom presented with a single fracture. A further 4 (18.2 %) were vehicle occupants and one vehicle passenger presented with two fractures. The remaining 13 (59.1 %) elderly patients were pedestrians struck by a vehicle of which 7 (53.8 %) presented with multiple fractures. The average age of this group was 78.9 years and 14 (63.6 %) of the fractures were in the lower limb or pelvis and 8 (36.4 %) were in the upper limb. Three (13.6 %) of the fractures were open.

Table 15.2 shows that the prevalence of multiple fractures following a fall from a height approaches that of motor vehicle accidents but all the fractures were closed suggesting that either falls from a height in the elderly are not as severe as in younger patients or possibly that many falls are fatal. Table 15.2 also shows that falls down stairs are associated with a high prevalence of multiple fractures. The results indicate that the highest frequency of multiple fractures in the 65+ year group follows motor vehicle accidents where the elderly patient is a pedestrian struck by a vehicle.

Table 15.3 shows the fractures associated with all index fractures in a consecutive group of patients aged ≥65 years treated in the Royal Infirmary of Edinburgh in a 1-year period in 2010/2011. All modes of injury are included. Overall 8.5 % of fractures were associated with other fractures during the study year but 12 fracture types were associated with at least 10 % other fractures. Obviously the location of some of the associated fractures depended on the circumstances of the injury but generally speaking the associated fractures are often near the location of the index fracture. The greatest number of multiple fractures in the elderly that will present to orthopaedic surgeons will follow a simple fall and these will be examined in more detail.

Table 15.3

The prevalence of multiple fractures in patients aged ≥65 years

Fractures	No	Multiple fractures		Other fractures (%)
		No	%
Scapula	12	2	16.7	Clavicle 66.6 %, proximal humerus 33.3 %
Clavicle	54	4	7.4	Scapula 50 %, proximal humerus 25 %
Proximal humerus	267	27	10.1	Proximal femur 59.3 %, distal radius 14.8 %
Humeral diaphysis	30	1	3.3	Distal radius 100 %
Distal humerus	27	5	18.5	Metacarpal 40 %, proximal radius 40 %
Proximal radius/ulna	2	0	0
Proximal radius	31	5	16.1	Distal humerus 40 %, pelvis 20 %
Proximal ulna	32	6	18.7	Proximal femur 33.3 %, distal radius 33.3 %
Radial/ulna diaphyses	2	0	0
Radial diaphysis	7	0	0
Ulnar diaphysis	6	1	16.7	Proximal tibia 100 %
Distal radius/ulna	510	42	8.2	Proximal femur 31.0 %, bilateral 26.2 %
Carpus	15	1	6.7	Metatarsal 100 %
Metacarpus	64	14	21.9	Metacarpal 71.4 %, distal radius 28.6 %
Finger phalanges	90	13	14.4	Phalanx 53.8 %, pelvis 15.4 %
Pelvis	89	8	9.0	Phalanx 25 %, metacarpal 25 %
Proximal femur	683	38	5.6	Distal radius 44.7 %, proximal humerus 39.5 %
Femoral diaphysis	55	2	3.6	Ankle 50 %, proximal humerus 50 %
Distal femur	19	2	10.5	Ankle 50 %, proximal humerus 50 %
Patella	27	0	0
Proximal tibia	18	5	27.8	Metacarpal 40 %, pelvis 20 %
Tibia/fibular diaphyses	12	1	8.3	Clavicle 8.3 %
Distal tibia	8	0	0
Ankle	170	9	5.3	Metatarsal 33.3 %, calcaneus 11.1 %
Talus	0	0	0
Calcaneus	6	2	33.3	Metatarsal 50 %, ankle 50 %
Midfoot	2	0	0
Metatarsus	79	13	12.7	Metatarsal 61.5 %, ankle 23.1 %
Toes	4	0	0
Total	2355	201	8.5

The fractures represent all inpatient and outpatient fractures treated in the Royal Infirmary of Edinburgh in a 1-year period in 2010/2011. The two commonest other fractures associated with each index fracture are shown

Fall-Related Multiple Fractures

A review of all patients aged at least 16 years presenting to the Orthopaedic Trauma Unit of the Edinburgh Royal Infirmary in a 1-year period during 2007/2008 shows that 3843 fractures were caused by simple falls, this being 55.9 % of all the fractures. Analysis of the patients of at least 65 years of age shows that 2213 fractures were caused by simple falls. These fractures occurred in 2111 patients with 2015 patients presenting with a single fracture, 90 presenting with two fractures and six patients presenting with three fractures. Table 15.2 shows that the average age of patients presenting with multiple fractures after a fall was 79 years. The average age of males was 76.6 years with 79.5 years being recorded for females. This compares with 79.2 years and 80.0 years for males and females who presented with single fractures. The gender ration for single fractures was 20/80 indicating that multiple fractures are more common in elderly females but the average ages of males and females are not dissimilar.

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