Death after proximal femoral fracture—an autopsy study

hyry

Vol.

26, No.

4. pp. 237-240,

1995

Copyright 0 1995 Eisevier Science Ltd Printed in Great Britain. All rights reserved 0020.1383195

$10.00

+ 0.00

0020-1383(95)0030-1

Death study

after proximal

J. V. Perez,

D. J. Warwick,

femoral

fracture

- an autopsy

C. P. Case and G. C. Bannister

Southmead Hospital, Bristol, UK

We reviewed 22 486 conseczffiveautopsy reporfs in f f single District General Hospital, from I#.? to 199.2. Five hundred and eighty-one patients with fractures of the proximal femur (hip fracture) were identified. Causes of death were correlated with timing of surgery and change of clinical practice. Tkromboembolic and kaemorrhagic potential were analysed. The principal causes of death after hip fracture were bronchopneumonia, cardiac failure, myocardial infarction and pulmonay embolism. Surgical intervention, within 24 h of injury significantly reduced death from bronckopneumonia and pulmonary embolism. Early mobilization reduced death from bronchopneumonia. Pulmonary embolism may be reduced by prophylactic anticoagulation, but I 7 per cent of patients are at risk of kaemorrhage, and mechanical methods seem safer in this population.

Injury, Vol. 26, No. 4, 237-240,

1995

injury, and ensuing surgical complications and the time of death after fracture were recorded. Patients were treated on emergency or trauma lists; anticoagulants were not used. Definitions The post-mortem reports identified the primary causeof death and other incidental pathology. For the purpose of this study, any death or morbidity from haemorrhage was defined as ‘haemorrhagic’ and from thrombosis or embolism as ‘thromboembolic’. Deaths and morbidity combined were designatedasan ‘episode’.Sepsiswas defined aslocal or generalized infection. Three pathologists performed the vast majority of autopsies. Statistical methods Data were analysed using the x2 test with Yates’ correction.

Introduction The outcome of proximal femoral fracture (hip fracture) continues to be a disappointing area in orthopaedic surgery with mortality of between 12 per cent’ and 41 per cent2 after 6 months with 42 per cent of survivors demonstrating impaired mobility I year after injury3. The vast majority of studies of this condition address problems of fixation. Some investigators have recorded cause of death following hip fracture but numbers have been small and data often based on clinical diagnosis4-7. The greater accuracy of necropsy diagnosis has been confirmed by several workers7-9. The necropsy studies published following hip fracture have addressedfixation devices’,“‘, survivorship curves” or pulmonary embolism ratesX2,13.The aims of this study were to investigate all post-mortem verified causesof death in a large population, to correlate this with clinical practice, to identify the potential for prevention and to explore the risks and benefits of thromboprophylaxis.

Patients

and methods

All post-mortem reports (22 486 records) over a 40-year period (1953-1992) in a single health district were reviewed. Five hundred and eighty-one patients who died following a hip fracture were identified. Age, sex, time of fracture, treatment modality and its delay from time of

Results Primary cause of death In this samplethe average age was 83 years and 74 per cent were female. Bronchopneumonia (46 per cent), cardiac failure and myocardial infarction (23 per cent), and pulmonary embolism(14 per cent) were the principal causesof death. All other causesof death were found in lessthan 5 per cent of cases (TableI). Death from cardiac failure occurred early after fracture peaking at 2 days whilst death from pulmonary embolismpeakedin the secondweek after injury and continued to be a significant causeof mortality with bronchopneumonia, accounting for the majority of late deaths. There were 14 (2.4 per cent) haemorrhagic deaths and 149 (26 per cent) thromboembolic deaths. Timing of surgery Mortality from bronchopneumonia and pulmonary embolism was significantly less when surgery was performed within 24 h of admission(PC 0.01). Mortality from cardiac failure and myocardial infarction remained unaffected (Figure I ).

Era of fracture In the last decade of the study (TableII) there was a significant reduction in death from bronchopneumonia (PC O.Ol), but not from pulmonary embolism. The rise in

Injury: International

238

death from cardiac failure over the study period was not statistically significant. Incidental Forty-one .

pathology patients (7 per cent) were

found

Journal of the Care of the Injured Vol.

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No.

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thromboembolic morbidity whilst 85 (15 per cent) patients had haemorrhagic morbidity (TubleIII). There was a total of 99 (I 7 per cent) bleeding episodes and a total of 190 (33 per cent) thromboembolic episodes (Table IV).

to have Pulmonary emboli Of the 111 pulmonary embolisms 80 (72 per cent) were fatal and 31 (28 per cent) were non-fatal. The overall sex incidence was 13 per cent (19/150) male and 21 (92/431) female (PC 0.05). Age did not affect the incidence. Sepsis was the commonest risk factor in 62 patients (56 per cent) followed by neoplasia in 12 patients (11 per cent); multiple recent surgical interventions had occurred in 9 patients (8 per cent) and concurrent fracture in 6 (5 per cent). Twenty-seven patients (24.3 per cent) with pulmonary emboli had a haemorrhagic episode of which three (11 per cent) were fatal. ._

TREATMENT

DELAY

IN DAYS

Figure 1. Treatment delay and cause of death. +, Myocardial infarction; I, cardiac failure; A, pulmonary embolism; x , bronchopneumonia.

Thromboembolic morbidity Pulmonary embolism Cerebrovascular accident Total

Table I. Primary cause of death % All deaths Bronchopneumonia Cardiac failure Myocardial infarct Pulmonary embolism Sepsis Cerebrovascular accident Acute/chronic renal failure Gastrointestinal bleed Other Total Haemorrhagic deaths Cerebrovascular accident Subdural haemorrhage Sofi tissue haemorrhage Ruptured thoracic aneurysm Ruptured renal artery aneurysm Gastrointestinal bleed Total Thromboembolic deaths Peripheral arterial thrombosis Coeliac artery thrombosis Mesenteric artery thrombosis Cerebrovascular accident Myocardial infarct Pulmonary embolism Total

Table III. Thromboembolicandhaemorrhagicmorbidity

N=581

46 14 9 14 4 3 1.5 1.5 7 100

266 81 55 80 24 16 9 9 41 581

2.4

1 1 1 1 1 9 14

Haemorrhagic morbidity Central Nervous System Cerebro Vascular Accident Subdural Haemorrhage Gastrointestinal Tract Oesophagitis Gastric Ulceration Duodenal Ulceration Jejunal Haemorrhage Diverticulitis Colitis Proctitis Miscellaneous Haemorrhagic renal tumour Total

26

N=581

5 2 7

31 IO 41

4 2 4 5 3

25 29 16 1 3 2 2 1 85

15

Table IV. Haemorrhagicandthromboembolicepisodes tiaemorrhage

1 1 1 11 55 80 149

%

Thromboembolism

%

N

%

N

Deaths Morbidity

2 15

14 85

26 7

149 41

Total

17

99

33

190

Table II. Change in mortality with decade Patients Year 1952-I 962 1963-l 972 1973-I 982 1983-I 992 Pre- 1983 Post-l 983

Cardiac failure

Bronchopneumonia

Pulmonary embolism

N=581

%

N=266

56

N=81

%

N=80

28 93 199 261 320 261

50 53 52 38 52 38

14 49 103 100 166 100

4 9 14 17 11 17

1 8 27 45 36 45

21 12 IO 17 12 17

6 11 20 43 37 43

Perez et al.: Death after proximal

femoral

239

fracture

Table V. Autopsy studiesof deathafter hip fracture

Year

Author

1971 1986 1990 1991 1993 1993

Beals” Holmberg et al.” Bannister et aL3 Bergqvist and FredinT2 Schroder and Andreasson13 Perez et al. (this paper)

Total

Autopsies W) 43 180 34 42 180 581 1060

Discussion In the United Kingdom, all patients dying as a result of violence must be referred to the coroner prior to issueof a death certificate. The Bristol coroners have routinely requested a post-mortem examination in patients sustaining hip fracture. The increasednumber of casesin the last decade of the study relates to the increase in the elderly population, the greater incidence of proximal femoral fracture and the expansion of trauma services at Southmead Hospital, where currently some 140 hip fractures are treated annually. The principle causesof death following hip fracture were bronchopneumonia, cardiac failure, myocardial infarction, and pulmonary embolism. These findings are consistent with those reported previously (Table V). Within the limitations of this study, we were unable to identify any variables that influenced death from cardiac failure or myocardial infarction. However, surgical intervention within 24 h of admission significantly reduced death from bronchopneumonia and pulmonary embolism. The significant decline in death from bronchopneumonia after 1983 may be related to the introduction of earlier postoperative mobilization and the routine useof prophylactic antibiotics at around the sametime. Pulmonary embolism caused fewer deaths than bronchopneumonia. Full anticoagulation with phenindione has been the only intervention to reduce mortality from this condition but haemorrhagic complications occurred in 20 per cent4. Similarly warfarin has been an effective antithrombotic agent but with haemorrhagic complications in 3 to 20 per cent of cases15-“. Lower rates of reduction in venous thrombosis have been reported with low dose and low molecular weight heparins but again with bleeding complications’8-z1. Dextran hasbeen reported aseffective with no haemorrhagic side effects22,23.The role of these agents remains unclear, with no single regimen having gained wide acceptance.Although thesemight prove to be effective, their routine use should be balanced against potential bleeding side effects. This study suggests that haemorrhagic episodesare common in hip fracture patients being found in I 7 per cent of autopsy examinations. BealslO found a 4 per cent incidence of fatal upper gastrointestinal haemorrhage,and emphasizedthe fact that most of these had been missed clinically and were only diagnosed at post-mortem. We found that female sex, sepsis,neoplasia, multiple operations and concurrent fracture were the most important associatedfactors for pulmonary embolism;identifying patients at greater risk from pulmonary embolism might possibly help selection of those most suitable for prophylaxis. As 24 per cent of pulmonary embolism patients had

Cardiac failure and myocardial infarct (W

Bronchopneumonia (W

Pulmonary embolism (W

41 12 41 31

12 25 2.5 48

46

23

7 14 16 7 15 14

38

24

14

concurrent haemorrhagic episodes,mechanicalmethods of prophylaxis seemmore appropriate and effective in sucha frail populationz4.

Acknowledgements D. J. W. would like to ac6owledge the Wishbone Trust, Laving Evans Fellowship and the South West Regional ResearchCommittee for their support of this work.

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bosis in patients with hip fracture. ] Trauma 1989; 29: 873. Jorgensen PS, Knudsen JB, Broeng L et al. The thromboprophylactic effect of a low molecular weight (Fragmin) in hip fracture surgery. C/in Orthop 1992; 278: 95. 22 Ahlberg A, Nylander G, Robertson B et al. Dextran in prophylaxis of thrombosis in fractures of the hip. Acfa Chir Stand (suppl) 1968; 387: 83. 23 Edwards DH, Steel WM and Bentley G. Prophylaxis with dextran 70 against thrombosis in patients with fractures of the upper end of the femur. Injury 1975; 6: 250. 24 Stranks GJ, MacKenzie NA, Grover ML et al. (1992) The A-V impulse system reduces deep vein thrombosis and swelling after hemiarthroplasty for hip fracture. ] Bone joint Surg [Br] 74B: 775. 21

Paper accepted

22 November

1994.

Requests for reprints should be addressed to: G. C. Bannister, Southmead Hospital, Westbury-on-Trym, Bristol BSlO 5NB, UK.