Court-Brown CM, Clement N. Four score years and ten; an analysis of the epidemiology of fractures in the very elderly [Injury 2009;40(October (10)):1111–4

The article by authors CM Court-Brown and N Clement on the epidemiology of fractures in patients aged 90 or more years is impressive. This is the most extensive and detailed report on this theme executed to date, and conclusions the data present are very interesting. Of the 7907 fractures presented in 2000 at the Royal Infirmary of Edinburgh and the Royal Hospital for Sick Children, 208 patients (which had 236 fractures (3.02%)) were 90 years or older. Of the 208 injured patients 88.5% were female and 11.5% were male. With this advanced age it can be expected that there is a greater incidence of lower limb fractures, as shown by the authors, 65.3%, in comparison to younger patients; whilst upper limb fractures in the 90+ group in this research was 30.5%. Only 4.2% of fractures were associated with the axial skeleton (spinal and pelvis). A simple fall caused 86.14% of the fractures to the 90+ age group. The results of this epidemiologic study were expected in the area of commonest fractures: proximal femoral fractures 56.2%, distal radial fractures 13.6% and proximal humeral fractures 8.1%. I was surprised, however, that the only spinal fracture during the year was treated in a centenarian, because my experience with spinal fractures with patients older than 90 is different. Usually these fractures occur because of an osteoporosis change, and a precipitated fall often results in fracture to more than one vertebra. The authors were more than likely correct when they stated: “likely that there were many more spinal fractures that did not present to hospital.” Similarly the authors present the interesting result that they treated only three ankle fractures of 236 fractures during the year of patients 90 and older. That not one case of ankle fracture or humeral diaphysis treated was unusual because both of these types of fractures are seen in cases of falls (ankle fractures in 38.7% of cases, and humeral diaphysis in 53.3%) in younger adults. In looking at the results of CM Court-Brown and N Clement in this article I also noticed there were neither any fractures to the patella, scapula, midfoot, toe phalanges, carpus, talus, calcaneus, nor sesamoid bones. In my experience I have treated all these types of fractures in older people, though not inside of 1 year, nor in great numbers. However over the last year I have seen three patella fractures within the 90+ age group, of these two were treated conservatively with a cast, and a 96-year-old male was operated on for osteosynthesis of the patella. I have also treated several fractures of the calcaneus sustained from a fall in patients older than 90, all were treated conservatively. If the 90+ population continues in the UK to grow as the authors’ state, increasing from 0.65% in 2000 to the estimated 1.2% in 2025, then the part of society this population forms will continue to increase in importance and consequently more frequent fractures in this age group will be seen.