Session II - Tibia

The Early Mortality Rate of Tibial Fractures in the Elderly

Nigel Beauchamp, MD; Charles M. Court-Brown, MD; Margaret M. McQueen, MD; Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Purpose: We defined the mortality rate of patients 65 years of age or over who sustained tibial diaphyseal fractures and identified high risk factors for mortality in this group.

Methods: Between January 1990 and December 1999, 230 patients ages 65 years of age or over with 238 tibial diaphyseal fractures were treated in our unit. Five patients were excluded because their place of domicile was out of the country and mortality data could not be obtained, leaving 225 patients with 233 fractures available for study. Demographic and descriptive data about the fracture were obtained from prospectively recorded databases held in the unit. The severity of the soft tissue injury was classified by the Tscherne classification for closed fractures and the Gustilo classification for open fractures. Fractures were also classified by using the OTA classification. Patient information was matched with the databases of the national General Register Office, thus retrieving mortality data and dates of death. Hip fracture mortality data were obtained from the national hip fracture audit database for 2018 patients during the period 1993 to 1997. Mortality rates were recorded up to 120 days after fracture because it was thought that this time period best reflected deaths related to the fracture itself rather than to other intervening events. Statistical analysis was performed by using the Kaplan-Meier survival analysis with a log rank test.

Results: Of the 225 patients studied, 165 (73%) were women and 60 (27%) were men; the average age was 77.9 years (range, 65 to 99). The majority of patients sustained their fracture in a fall from standing height (38.6%), a motor vehicle accident as a pedestrian (29.2%), or by falling down a slope (19.3%). The majority of the 164 (70.4%) closed fractures were Tscherne 0 or 1, and Gustilo type III fractures predominated among the 69 (29.6%) open fractures. The overall mortality rate at 120 days after injury for patients aged 65 or over was 17.2%. The mortality rate increased with increasing age, with a peak of 36% in the age group from 85 to 89 years. There were no differences by sex in 120-day mortality rates (men 13%, women 19%, P = 0.28). There was a significantly higher death rate among patients with open fractures compared with those with closed fractures (open, 33%, closed 10%; P = 0.000). Gustilo grade III fractures had a higher mortality rate than did other open fractures, and mortality rates rose with increasing Gustilo grade from 27% in grade 1 fractures to 50% in grade IIIC injuries. In comparison with hip fractures, there was a similar mortality rate at 30 days after injury (tibia 11%, hip 13%, P = NS), but at 120 days hip fracture mortality is greater (tibia 17%, hip 25%: P = 0.02). However open tibial fractures have a higher mortality rate at 120 days than do hip fractures (open tibia, 33%; hip, 25%).

Conclusions: There is a significant mortality rate for elderly patients who sustain a tibial fracture. Open tibial fractures in particular have a significant risk of death with one in three patients dying by 120 days after fracture. Half of all patients with Gustilo IIIC fractures died in this time period. This is a higher death rate than that for hip fractures, which are acknowledged as being a high-risk injury for the elderly patient.

Significance: These data illustrate that injury carries a significant risk for the elderly patient. Orthopaedic trauma surgeons should be aware of the inherent risks of tibial fracture for the elderly so that they may advise their patients and their relatives accordingly.