American Academy of Orthopaedic Surgeons Annual Meeting

American Academy of Orthopaedic Surgeons Annual Meeting

Issue: June 2011
June 01, 2011
3 min read
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Traumatic clavicle fractures linked with doubled mortality rate for elderly patients

Issue: June 2011
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The results of a recently presented study highlight clavicle fractures as indicators of increased mortality in patients older than 65 years who sustain traumatic injuries.

“Clavicle fractures are a marker for severe injury in trauma patients, and the combination of advanced age, a high energy mechanism and a clavicle fracture appear to produce a strikingly elevated death rate,” Julie M. Keller, MD, said during a presentation at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons.

The 23% mortality rate that Keller and colleagues identified in patients aged 65 years and older with clavicle fractures was almost double the 12% overall mortality rate of injured elderly patients without these fractures, according to the findings.

“It was also significantly higher than the mortality in the patients under 65, both with and without clavicle fractures,” Keller said. “This two-fold increase was much more than we would have ever anticipated.”

Trauma center database

Keller and colleagues used a database of prospectively collected information from a level 1 trauma center to study elderly patients with multiple injuries of a traumatic nature that were sustained between January 2004 and July 2009. The investigators compared 611 patients aged 65 years or older who had at least one orthopedic injury with the control group of 6,564 patients with an orthopedic injury who were younger than 65 years.

After identifying patients with clavicle fractures, the investigators compared the two groups’ in-patient mortality rates. They found the elevated mortality rates observed in the elderly patients were higher than those in both groups of younger patients, where the mortality rates were 6.9% for those with clavicle fractures and 4.6% for those without clavicle fractures.

“All of the 23 patients [in the study group] who died had associated thoracic trauma, and thirteen of these had associated brain injuries,” Keller said.

Markers of note

Contributing causes of death in the elderly group with clavicle fractures included brain injury, respiratory failure, hemorrhagic shock and cardiac failure, Keller said.

The average admission Injury Severity Score, the Glasgow Coma Scales and the Brain, Thorax, and Lower Extremity Abbreviated Scores were worse in the geriatric patients with clavicle fractures compared with patients of any age without clavicle fractures. However, using these same measures, the study group’s trauma scores were similar to those of younger patients with clavicle fractures. – by Susan M. Rapp

Reference:
  • Keller JM, Sciadini MF, O’Toole RV. High energy trauma and clavicle fractures: A marker for death in the elderly? Paper #723. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeon. Feb. 15-19. San Diego.

  • Julie M. Keller, MD, can be reached at Elite Orthopedics & Sports Medicine PA, 342 Hamburg Turnpike, Suite 209, Wayne, NJ 07470; 973-956-8100; email: juliemkelle@hotmail.com.
  • Disclosure: Keller has no relevant financial disclosures.

Perspective

Clavicle fractures are very rare in patients over 65 years. Most upper extremity fractures in older patients occur as a result of low energy falls. Fractures of the wrist, elbow and proximal humerus are quite common. Fortunately, the mortality associated with these common fractures is quite low and associated injuries are rare.

The key findings of this study include the high injury severity scores in these patients and the recognition of the clavicle fracture as a marker for the amount of energy absorbed by the patient at the time of injury. Polytraumatized elderly patients with clavicle fractures had worse injury severity scores and Glasgow Coma Scale scores than those without clavicle fractures (P <0.05), so it is no surprise they had a higher mortality rate. All patients that died had significant thoracic and/or brain injuries. I suspect a similar finding would be noted for polytraumatized elderly patients with multiple rib fractures.

It is important to note, however, that nearly 80% of polytraumatized elderly patients with clavicle fracture did not die from their injuries, therefore, the relatively dramatic title of the presentation “a marker of death in the elderly” should probably be softened a bit. In my opinion, a better distillation of the abstract would read, “Surgeons should be aware that polytraumatized elderly patients with clavicle fractures have worse injury severity scores and higher mortality rates compared to those without clavicle fractures.”

— George J. Haidukewych, MD
Academic Chairman and Chief of Orthopedic Trauma
Orlando Regional Medical Center, Orlando, Fla.
Professor of Orthopedic Surgery
University of Central Florida
Disclosure: He receives royalties from DePuy, a Johnson & Johnson Company, for trauma products.