Review of the Significance of Various Low Force Fractures in the Elderly

A case of fatal fulminant fat embolism syndrome following multiple fractures resulting from a fall

Fat embolism syndrome is a life-threatening condition in which fatty substances enter the circulation and cause respiratory distress and neurological symptoms. It can occur following trauma and severe fat embolism occurring soon after trauma is known as fulminant fat embolism syndrome. Although fat staining of the lungs is helpful for diagnosing fat embolism syndrome at autopsy, clinical and other information is needed to determine the relationship between cause of death and the syndrome. In this report, we describe the macroscopic, microscopic, and computed tomography (CT) findings specific for fat embolism that were observed in a patient with fulminant fat embolism syndrome who died soon after the injury. An 85-year-old woman fell from a bath stretcher during assisted bathing and died 3 h later. Autopsy revealed fractures of the left femoral neck and other bones, as well as large amounts of fat-like material in the right and left pulmonary arteries. Histological examination of the lung with Oil red O staining showed extensive fat vacuoles. Based on these findings and postmortem CT images of the fractures and fatty globules in the pulmonary arteries detected prior to death, the cause of death was determined to be blunt force trauma, with fat embolism syndrome playing a significant role. This case is an example of fulminant fat embolism, which can be fatal in a short period of time, and demonstrates that CT performed postmortem but before autopsy can be useful in detecting fat embolism syndrome due to trauma.

Classification of Injurious Fall Severity in Hospitalized Adults

BACKGROUND

Many hospital systems in the United States report injurious inpatient falls using the National Database of Nursing Quality Indicators categories: None, Minor, Moderate, Major, and Death. The Major category is imprecise, including injuries ranging from a wrist fracture to potentially fatal subdural hematoma. The purpose of this project was to refine the Major injury classification to derive a valid and reliable categorization of the types and severities of Major inpatient fall-related injuries.

METHODS

Based on published literature and ranking of injurious fall incident reports (n = 85) from a large Academic Medical Center, we divided the National Database of Nursing Quality Indicators Major category into three subcategories: Major A-injuries that caused temporary functional impairment (eg, wrist fracture), major facial injury without internal injury (eg, nasal bone fracture), or disruption of a surgical wound; Major B-injuries that caused long-term functional impairment or had the potential risk of increased mortality (eg, multiple rib fractures); and Major C-injuries that had a well-established risk of mortality (eg, hip fracture). Based on the literature and expert opinion, our research team reached consensus on an administration manual to promote accurate classification of Major injuries into one of the three subcategories.

RESULTS

The team tested and validated each of the categories which resulted in excellent interrater reliability (kappa = .96). Of the Major injuries, the distribution of Major A, B, and C was 40.3%, 16.1%, and 43.6%, respectively.

CONCLUSIONS

These subcategories enhance the National Database of Nursing Quality Indicators categorization. Using the administration manual, trained personnel can classify injurious fall severity with excellent reliability.

When falls become fatal-Clinical care sequence

OBJECTIVES

This study encompassed fall-related deaths, including those who died prior to medical care, that were admitted to multiple healthcare institutions, regardless of whether they died at home, in long-term care, or in hospice. The common element was that all deaths resulted directly or indirectly from injuries sustained during a fall, regardless of the temporal relationship. This comprehensive approach provides an unusual illustration of the clinical sequence of fall-related deaths. Understanding this pathway lays the groundwork for identification of gaps in healthcare needs.

DESIGN

This is a retrospective study of 2014 fall-related deaths recorded by one medical examiner's office (n = 511) within a larger dataset of all trauma related deaths (n = 1848). Decedent demographic characteristics and fall-related variables associated with the deaths were coded and described.

RESULTS

Of those falling, 483 (94.5%) were from heights less than 10 feet and 394 (77.1%) were aged 65+. The largest proportion of deaths (n = 267, 52.3%) occurred post-discharge from an acute care setting. Of those who had a documented prior fall, 216 (42.3%) had a history of one fall while 31 (6.1%) had ≥2 falls prior to their fatal incident. For the 267 post-acute care deaths, 440 healthcare admissions were involved in their care. Of 267 deaths occurring post-acute care, 129 (48.3%) were readmitted within 30 days. Preventability, defined as opportunities for improvement in care that may have influenced the outcome, was assessed. Of the 1848 trauma deaths, 511 (27.7%) were due to falls of which 361 (70.6%) were determined to be preventable or potentially preventable.

CONCLUSION

Our data show that readmissions and repeated falls are frequent events in the clinical sequence of fall fatalities. Efforts to prevent fall-related readmissions should be a top priority for improving fall outcomes and increasing the quality of life among those at risk of falling.

Elderly deaths in Ankara, Turkey

According to World Health Organization, the life expectancy at birth is increasing. An increase in life expectancy might result in increased morbidity and mortality in elderly. The increase in the elderly population also leads to an increase in medico-legal problems, as well. Autopsy is of high importance for determination of cause of death in clinical and forensic cases. The purpose of this study was to find out general characteristics elderly deaths by examining forensic autopsy records. Out of 7033 forensic autopsies performed between years of 2007 and 2011, 1324 were elderly deaths and were included in the scope of the study. The records of public prosecutor office, crime scene investigation and autopsy findings were examined. The majority of victims (70.6%) were male, while 29.4% were female, with a male to female ratio of 2.4/1. Victims' ages ranged between 65 and 96 years, and the mean age was 74.8 years. A great number of presented elderly deaths were due to unnatural causes, followed by natural deaths cases. Out of unnatural deaths, 63.2% were related to accidents, 23.7% were suicides, and remaining 13.1% were homicides. More than half (56.6%) of all suicidal deaths were due to hanging. Of natural deaths, the majority (82.7%) were due to cardiovascular system disease. In the presented series the cause of death was determined in 90.9% of all elderly deaths, which validates the need for a forensic autopsy. Data obtained through autopsy procedures is of high importance for death statistics.

Baseline and follow-up characteristics of participants and nonparticipants in a randomized clinical trial of multifactorial fall prevention in Denmark

OBJECTIVES

To address the external validity of a trial of multifactorial fall prevention through an analysis of differences between participants and nonparticipants regarding socioeconomic and morbidity variables.

DESIGN

Analysis of nonresponse in a randomized clinical trial.

SETTING

Geriatric outpatient department.

PARTICIPANTS

One thousand one hundred five community-dwelling adults aged 65 and older who had sustained at least one injurious fall.

MEASUREMENTS

Marital status, housing tenure, income, comorbidity, hospitalization, fractures, and drug use before invitation to participate in the trial. Fractures, hospitalization and death were measured for 6 months of follow-up.

RESULTS

Four hundred forty-seven responding nonparticipants and 266 nonresponding nonparticipants were compared with 392 participants in the trial. Lower income (odds ratio (OR)=2.38, 95% confidence interval (CI)=1.28-4.28) and more days of hospitalization during the previous 5 years (OR=1.96, 95% CI=1.15-3.33) predicted responding nonparticipation; independent predictors of being a nonresponding nonparticipant were unmarried status (OR=2.0, 95% CI=1.36-2.94), lower income (OR=4.74, 95% CI=2.30-9.78), more days of hospitalization (OR=3.49, 95% CI=1.99-6.11), and prior fractures (OR=1.56, 95% CI=1.02-2.38). Nonresponding nonparticipants were significantly more likely to die (OR=12.99, 95% CI=1.6-105.6) or be hospitalized (OR=2.66, 95% CI=1.7-4.1) than participants during 6 months of follow-up.

CONCLUSION

Nonresponding nonparticipants of a trial of multifactorial fall prevention differed significantly from participants in terms of socioeconomic and morbidity variables and were more likely to be hospitalized or die during 6 months of follow-up. Because of the differences between the two populations, it is questionable whether results from this randomized trial can be generalized to people potentially eligible for participation.

Mechanically-induced osteogenesis in the cortical bone of pre- to peripubertal stage and peri- to postpubertal stage mice

Background

Exercise during postnatal development plays a key role in determining adult bone mass and reducing the risk of fracture and osteoporosis later in life. However, the relationship between mechanically-induced osteogenesis and age is unclear. Elevated levels of estrogen during puberty may inhibit periosteal bone formation. Thus, magnitudes of mechanically-induced osteogenesis may be vary with pubertal state.

Methods

The present study uses a murine model to examine age-related changes in bone formation at the femoral midshaft with voluntary exercise. Pre- to peripubertal mice aged 3 weeks and peri- to postpubertal mice aged 7 weeks were randomly divided into sedentary and exercised groups and subjected to histomorphometric comparison after 4 weeks of treatment.

Results

Results of the experiment indicate that exercise significantly increased osteogenesis on the periosteal and endocortical surface of the mice in the older age group (P < 0.05). Exercise had no significant effect on bone formation of mice in the younger age group, although exercised mice exhibited more bone growth on average than controls. Endocortical apposition was the primary method of bone formation for all mice in the experiment; however exercised mice in the older age group were able to add more bone on the periosteal surface than age-matched controls and exercised mice in the younger age group (P < 0.05). Medullary area increased with age, but exercised mice in both age groups had smaller medullary cavities relative to overall bone area than controls.

Conclusion

These findings suggest that the amount and location of mechanically-induced osteogenesis differs by age during skeletal development. Late adolescence may be the optimal time to accrue bone mass and maximize bone strength.