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Fractured neck of femur in Leicestershire
PtehL It#h.. L+md. (1979) 93, 285-289
Fractured Neck of Femur in Leicestershire L. J. Donaldson M.Sc., F,FI.C.S.(Ed).
Lecturer T. F. Stoyle F.R,C.S+
Consultant Orthopaedic Surgeon and M. Clarke D.P,H.. M.F,C.M.
Senior Lecturer D~partments of Community Health and Orthopaedics, Leicester Royal Infirmary, P.O. Box 65, Leicester A retrospective analysis was made of the most recent 12 months data ava~Juble from Hospital Activity Analysis on fractured neck of femur cases in Leicester~(aire. The analysis o f "'new" cases showed that the greatest number of deaths and discharges occurred amongst females aged 75-84 years, whilst the highest rates (per 1000 population) were amongst females aged 85-94 years and over 95 years of age. After admission to the acute hospital, only 24% of females were able to return/tome directly. The mean stay was 30 days for males and 36 days for females and longest (52 days) for females awaiting transfer to a long-stay geriatric hospital. Of the types of hospital treating patients with fractured neck of femur the greatest load was taken by the acute orthopaedic service. The special needs of this group of patients are identified and consideration is given to the need to plan the most appropriate use of resources to meet this most pressing of Health Service problems.
Introduction Fracture o f the neck o f the femur is a c o m m o n condition amongst the elderly, a n d in particular amongst elderly w o m e n . ' Its incidence increases with advancing years, with rates for females rapidly overtaking those f o r males. ~ Moreover, it would seem likely that witll the shift towards an ageing population, it will become an increasingly i m p o r t a n t problem. Fractured neck o f femur, in addition to posing a bhallenging public health problem, confronts those responsible for the organization and planning o f t h e health a n d social services. This paper attempts to illustrate the magnitude o f the problem and t o point t o the need for special provision for this group o f patients. Method Using information from Hospital Activity Analysis (HAA), a retrospective analysis was made o f all cases, with the diagnosis fracture of the neck o f the femur admitted to hospitals 0038-3506/79/050285+05 $01.00[0
~ 1979 The Society of Community Medicine
2X6
L. ,I. l)onczhA+m, 7: "t': Storh' atul M. Clarke
~ilhin the Leicester Area Health Authority during the twelve m o n t h period ending 30 June 1977. Data were obtained on age. sex. length o f stay and outcome of admission for individual patients+ O f l h o s e patients treated at the acute hospital who were subsequently discharged to another N HS hospital, an analysis of the case notes gave the type of hospital concerned. A rate (per thousand population) for deaths and discharges was calculated by applying OPCS (Office o f Population Censu~s and Surveys) population estimate for inid-1976 in Leicestershire to the numbers of deaths and discharges from the acute orthopaedic hospital in each age group. O f special interest were the rates for people over 35 years, and since a more detailed breakdowa o f the population over 75 years is only available from the 1971 census, the proportions of differertt age groups over 75 from this source was applied to the mid-1976 estimate to obtain the denominator. Hospital Activity Analysis data only records deaths and discharges from hospital and thus it is wrong to equate rates obtained in this way with the true incidence of the condition. One major source of over-estimate of"new'" cases by using H A A data is that some patient s may be admitted and discharged (and therefore counted) more than once. e.g+ due to late complications o f operation. In this study we have attempted to minimize this effect by only collecting cases that were admitted as an emergency and also by excluding those admissions due to "'late effect". Even allowing for thfs adjustment, it should be noted that death~ti~harge rate cannot be said to be true incidence for the condition since som,z patients will be treated at home (although few would be expected because of the seriousness of the condition), some will be treated in private nursing homes, some will die withou~ diagnosis having been made and some Leicestershire residents will be treated outside the Leicester Area. This last category can be of particular imporlance where geographical, social or practitioner preferences can lead to large numbers o f patients being treated in hospitals outside the Health Area of their residence, in this study it was not practicable to trace Leicestershire residents with fractured neck o f femur t o all parts of the country. However, some idea of the magnitude of the effect was obtained from information kindly supplied by surrounding authorities, The numbers o f cases o f fractured neck of femur treated in these places during the study year were as follows: 13 males, 38 females (West Midlands Region); 3 males, I2 females (Oxford Region): 4 males, 15 females (Trent Region, Excluding Leicestershire Area). These cases were not included in the study, Patient movements of this type cannot be unique to Leicestershite and are thus of great importance not merely to ensure the precision of epidemiological measures but also to allow equitable allocation of resources between different Health Areas,
Results
Occurrence o f f tact,red neck of femur Reference to Table 1 shows that fracture o f the neck of the femur is largely a problem of elderly women with the greatest number o f deaths and discharges occurring in females aged 75-84 years. When expressed as a rate, per thousand population, the peak incidence is seen in females over 95 years with a high rate also being seen in females aged 85-94 years. Rates were also calculated for the years 1974, 1975 and 1976 and no increase was seen over those three years. The only comparable estimate of incidence o f fractured neck o f femur ~ is for the South+West Thames Region based on HAA returns for 1974, but makes no provision for patients being admitted and discharged more than once.
Fractured Neck o f Femur #t Leicestershire
287
TAm.r: i. Deaths and discharges (numbers and rates per thousand population) for acute cases o f fractured neck of femur for year ending 30 June 1977 m
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
< 45 Male Female Both sexes
26 (0.15) 9 (0.05) 35 (0.10)
. . . . . . . . . .
Age-Groups (Years) 45--64 65-74 75-84
85-94
95 +
A I1 ages
20 (0.21) 31 (0.33) 51 (0-27)
20 (11-2) 84 06.7) 104 (15.37
No cases ]3 (55-3) 13 (43-6)
117 (0-28) 352 (.0.83) 469 (0,56)
22 (0-7) 68 (1"77 90 (i.3)
29 (2-7) 147 (7.I) 176 (5.6)
Outcome of admission to acute hospital After admission to the acute hospital (Table 2), 2 0 ~ of males and 18 ~ o f females died. Forty-five per cent o f males and 24 ~ o f females were able to return home directly from the acute h0sDital. This difference between the sexes in terms o f their suitability for immediate h o m e discharge could b e explained by their different age structures. Amongst the female study population 69 )/~ o f patients were 75 years o r older whilst the corresponding figure for the males was only 42~o. T h e greatest numbers o f live patients ~-emaining in the a c u t e hospital b u t unable to be discharged home were females and they were transferred to other hospitals (preconvaIescent, short o r long-stay geriatric). TA~I.E 2. Outcome of admission to acute hospital with diagnosis'fractured neck of femur for year ending 30 June 1977 Outcome Oeath Home Preconvalescent bed Geriatric rehabilitation Geriatric tong-stay Unknown
Total
Number of patients Males 23 (20~) 53 (45 ~) 17 (14~) 19 (16~/o)
Females 62 (18~)
5 (5~/~}
88 (24 ~) 102 (29 ~,,) 46 (13,~) 41 (12 ~,~) I3 (4%)
] 17 (100K)
352 (100K)
Mean length of stay (days} prior to outcome Males 32 29 27 29 --
Females 26 33 28 30 52 --
30
36
Length of stay in acute hospital T a b l e 2 also depicts the mean length o f stay in the acute hospital prior to each o f Ihe possible o u t c o m e s of the admission. It c a n be seen that the mean length o f stay for all outcomes was 30 days for males and 36 days for females. T h e shortest mean stay was 26 days, amongst females who died and the longest mean stay (52 days) was amongst females awaiting transfer to geriatric long-stay hospitals.
Bed usage b),.fractured neck offemur To give a measure of t h e load imposed by patients with fractured neck o f femur in each p a r t of the hospital service, the n u m b e r of" bed-days occupied b y these cases has been expressed as a percentage o f the number ,of bed-days occupied by all cases in which the discharge specialty was either orthopaedics or geriatrics, whichever was appropriate to the type o f hospital concerned.
L. J. Douald.votx, 1". F. Stovh" altd hi. (Tt~rkc
It can bc seen (Table 3) Ihat a considerable part o f the work o f the acute orthopaedic service is taken up with these patients. In the acute orthopaedic hospital, fractured neck o f femur accounts for 44°~ o f the work-load amongst females and lg"~ amongst males. A simi~r picture is .~en in the preconvalescent hosr~itai (also under the auspices of the acute orthopac&c serx zcc) ~herc the figures are 34 ~, for males and 4 6 'o for females. TAttLE 3. Bed u~ge by -fractured neck of femur in different types of hospilal for one year iveriod
ending 30 June t977
Type of hospital Acute orthopaedic Prcconvalescenl Geriatric rehabilitalion Geriatric long-stay
Bed-days occupied by fractured neck of femur Male 2894 571 48 300
Female ]0,208 2426 1810 3750
Total bed-days Tolal bed-day.~ occupied in occupied in orthopaedic specialty' geriatric specialty Male 16.218 1702 ---
Female 23.244 5320 -~
Male --11,708 67,270
Female --47,080 183,694
Percentage of fi~ctured neck of femur Male 18 34 1 0.4
Female 44 46 5 2
Discussion Femoral neck fracture occurs at a time o f life when, because o f increasing frailty and the emergence o f the c o m m o n pathologies o f old age, independence within the c o m m u n i t y is tenuously maintained. M a n y pa.tients are unable to regain their pre-fracture level o f social independence and this effect is most m a r k e d when there was already some degree o f dependency a. The resulting acute hospitai stay has been shown from this study to be between four and five weeks whatever the oulcome, extending beyond the confines of what would normally be expected for an acute illness. Moreover, amongst the numerically important group, elderly women, only a quarter were able to return home directly without additional re. habilitation, and some required long-term institutional care. It is almost the rule, amongst these elderly patients, to find that there are other illnesses, in addition to the fracture ~, whose assessment and treatment will inevitably prolong the stay in hospital. When consideration is given to the load imposed by these cases on the hospital service it is apparent that the main burden is being borne by the acute service (Table 3). Yet treatment o f the fracture by prolonged immobilization on traction (the assassin of fhe elderly) has long since been superseded by a more active policyofimmediateinternal fixation or prosthetic replacement o f the femoral head which allows mobilization within a few days of" operation, Whilst ~t is true that Leicestershire is an under-resourced area, other pubished work suggests that the problem exists elsewhere ~ and anecdotal evidence suggests that it is very widespread indeed. Therefore, those concerned with the planning o f health and social services should decide whether it is appropriate that the acute orthopaedic service should be utilized in this way. One solution to the problem is proposed by Strange, ~ who employs a policy o f pinning femora] r,eck fractures under local anaesthetic and discharging s o m e patients within 24 hours, thereby keeping bed occupancy low. He reasons that the ease with which elderly patients become hospitalized and ~zhe high morbidity attendant u p o n general anaesthesia accounts for why patients are so slow to recover from this fracture. Whilst this solution prevents blocked beds on the orthopaedic wards, it is not suitable for all grades o f fracture and fails to take account o f concurrent medical problems or the fact that patients m a y be
Fractured 3leek of Fetm,fr hi Leicestershire
289
ill-equipped to manage at h o m e following their discharge. Castleden r, advocates lhat orthopaedic surgeons should become more skilled in the assessment of medical and social problems of the elderly, thereby providing more efficient treatment and rehabilitation. A more widely held view ~ sees the need f o r a rnultidisciplinary approach to the problem and is recognized by the recent setting up o f special geriatric-orthopaedic units 5. 8 through which patients enter, within a few days of" operation, the day-to-day charge of geriatric physician, nursing staff, physiotherapist, occupational therapist and social worker, the last named providing a valuable interface veith the community social services. This last solution would seem the most logical since, in keeping with m a n y other diseases of the elderly, the special needs o f the patient with fractured neck o f femur seem to cry oul for a team approach and for the integration o f hospital and community services. References 1. Zisserman, L, (1973). Fractures in the aged, with special reference to the femur. Joun~al qflhe American Geriatrics Society 21, 193-9. 2. Knowleden, J., Buhr, A. J. & Dunbar, O. (1964). Incidence o f fractures in persons over 35 years of age. A report to the M.R.C. Working Party on fractures in the elderly. British ,rournal of Preventive and Social Medicine 18~ 1304 1. 3. Gallannaugh, S. C., Martin, A. & Millard, ]P. H. (1976). Regional Survey of femoral neck fractures. British Medical Journal it, 1496--7. 4. Thomas, T. G. & Stevens, R. S. (1974). Social Effects o f Fractures of the neck of the femur. British Medical Journal iii, 456-8. 5. Campbell, A. J. (1976). Femoral neck fractures in elderly women: a prospective study. Age and Ageing 5, 102-9. 6. Strange, F. G. (1969). Pinning under 10eal anaesthesia for treatment of subcapital fractures of the femoral neck. lt•ury 1, I00-6. 7. Castleden, C. M. (1977). Who is responsible for elderly patients on orthopaedic wards ?Geriatrics 32, 65-8. 8. Devas, M. B. (1974). Geriatric orthopaedics. British Medical Journal i, 190-2.
Fractured Neck of Femur in Leicestershire L. J. Donaldson M.Sc., F,FI.C.S.(Ed).
Lecturer T. F. Stoyle F.R,C.S+
Consultant Orthopaedic Surgeon and M. Clarke D.P,H.. M.F,C.M.
Senior Lecturer D~partments of Community Health and Orthopaedics, Leicester Royal Infirmary, P.O. Box 65, Leicester A retrospective analysis was made of the most recent 12 months data ava~Juble from Hospital Activity Analysis on fractured neck of femur cases in Leicester~(aire. The analysis o f "'new" cases showed that the greatest number of deaths and discharges occurred amongst females aged 75-84 years, whilst the highest rates (per 1000 population) were amongst females aged 85-94 years and over 95 years of age. After admission to the acute hospital, only 24% of females were able to return/tome directly. The mean stay was 30 days for males and 36 days for females and longest (52 days) for females awaiting transfer to a long-stay geriatric hospital. Of the types of hospital treating patients with fractured neck of femur the greatest load was taken by the acute orthopaedic service. The special needs of this group of patients are identified and consideration is given to the need to plan the most appropriate use of resources to meet this most pressing of Health Service problems.
Introduction Fracture o f the neck o f the femur is a c o m m o n condition amongst the elderly, a n d in particular amongst elderly w o m e n . ' Its incidence increases with advancing years, with rates for females rapidly overtaking those f o r males. ~ Moreover, it would seem likely that witll the shift towards an ageing population, it will become an increasingly i m p o r t a n t problem. Fractured neck o f femur, in addition to posing a bhallenging public health problem, confronts those responsible for the organization and planning o f t h e health a n d social services. This paper attempts to illustrate the magnitude o f the problem and t o point t o the need for special provision for this group o f patients. Method Using information from Hospital Activity Analysis (HAA), a retrospective analysis was made o f all cases, with the diagnosis fracture of the neck o f the femur admitted to hospitals 0038-3506/79/050285+05 $01.00[0
~ 1979 The Society of Community Medicine
2X6
L. ,I. l)onczhA+m, 7: "t': Storh' atul M. Clarke
~ilhin the Leicester Area Health Authority during the twelve m o n t h period ending 30 June 1977. Data were obtained on age. sex. length o f stay and outcome of admission for individual patients+ O f l h o s e patients treated at the acute hospital who were subsequently discharged to another N HS hospital, an analysis of the case notes gave the type of hospital concerned. A rate (per thousand population) for deaths and discharges was calculated by applying OPCS (Office o f Population Censu~s and Surveys) population estimate for inid-1976 in Leicestershire to the numbers of deaths and discharges from the acute orthopaedic hospital in each age group. O f special interest were the rates for people over 35 years, and since a more detailed breakdowa o f the population over 75 years is only available from the 1971 census, the proportions of differertt age groups over 75 from this source was applied to the mid-1976 estimate to obtain the denominator. Hospital Activity Analysis data only records deaths and discharges from hospital and thus it is wrong to equate rates obtained in this way with the true incidence of the condition. One major source of over-estimate of"new'" cases by using H A A data is that some patient s may be admitted and discharged (and therefore counted) more than once. e.g+ due to late complications o f operation. In this study we have attempted to minimize this effect by only collecting cases that were admitted as an emergency and also by excluding those admissions due to "'late effect". Even allowing for thfs adjustment, it should be noted that death~ti~harge rate cannot be said to be true incidence for the condition since som,z patients will be treated at home (although few would be expected because of the seriousness of the condition), some will be treated in private nursing homes, some will die withou~ diagnosis having been made and some Leicestershire residents will be treated outside the Leicester Area. This last category can be of particular imporlance where geographical, social or practitioner preferences can lead to large numbers o f patients being treated in hospitals outside the Health Area of their residence, in this study it was not practicable to trace Leicestershire residents with fractured neck o f femur t o all parts of the country. However, some idea of the magnitude of the effect was obtained from information kindly supplied by surrounding authorities, The numbers o f cases o f fractured neck of femur treated in these places during the study year were as follows: 13 males, 38 females (West Midlands Region); 3 males, I2 females (Oxford Region): 4 males, 15 females (Trent Region, Excluding Leicestershire Area). These cases were not included in the study, Patient movements of this type cannot be unique to Leicestershite and are thus of great importance not merely to ensure the precision of epidemiological measures but also to allow equitable allocation of resources between different Health Areas,
Results
Occurrence o f f tact,red neck of femur Reference to Table 1 shows that fracture o f the neck of the femur is largely a problem of elderly women with the greatest number o f deaths and discharges occurring in females aged 75-84 years. When expressed as a rate, per thousand population, the peak incidence is seen in females over 95 years with a high rate also being seen in females aged 85-94 years. Rates were also calculated for the years 1974, 1975 and 1976 and no increase was seen over those three years. The only comparable estimate of incidence o f fractured neck o f femur ~ is for the South+West Thames Region based on HAA returns for 1974, but makes no provision for patients being admitted and discharged more than once.
Fractured Neck o f Femur #t Leicestershire
287
TAm.r: i. Deaths and discharges (numbers and rates per thousand population) for acute cases o f fractured neck of femur for year ending 30 June 1977 m
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
< 45 Male Female Both sexes
26 (0.15) 9 (0.05) 35 (0.10)
. . . . . . . . . .
Age-Groups (Years) 45--64 65-74 75-84
85-94
95 +
A I1 ages
20 (0.21) 31 (0.33) 51 (0-27)
20 (11-2) 84 06.7) 104 (15.37
No cases ]3 (55-3) 13 (43-6)
117 (0-28) 352 (.0.83) 469 (0,56)
22 (0-7) 68 (1"77 90 (i.3)
29 (2-7) 147 (7.I) 176 (5.6)
Outcome of admission to acute hospital After admission to the acute hospital (Table 2), 2 0 ~ of males and 18 ~ o f females died. Forty-five per cent o f males and 24 ~ o f females were able to return home directly from the acute h0sDital. This difference between the sexes in terms o f their suitability for immediate h o m e discharge could b e explained by their different age structures. Amongst the female study population 69 )/~ o f patients were 75 years o r older whilst the corresponding figure for the males was only 42~o. T h e greatest numbers o f live patients ~-emaining in the a c u t e hospital b u t unable to be discharged home were females and they were transferred to other hospitals (preconvaIescent, short o r long-stay geriatric). TA~I.E 2. Outcome of admission to acute hospital with diagnosis'fractured neck of femur for year ending 30 June 1977 Outcome Oeath Home Preconvalescent bed Geriatric rehabilitation Geriatric tong-stay Unknown
Total
Number of patients Males 23 (20~) 53 (45 ~) 17 (14~) 19 (16~/o)
Females 62 (18~)
5 (5~/~}
88 (24 ~) 102 (29 ~,,) 46 (13,~) 41 (12 ~,~) I3 (4%)
] 17 (100K)
352 (100K)
Mean length of stay (days} prior to outcome Males 32 29 27 29 --
Females 26 33 28 30 52 --
30
36
Length of stay in acute hospital T a b l e 2 also depicts the mean length o f stay in the acute hospital prior to each o f Ihe possible o u t c o m e s of the admission. It c a n be seen that the mean length o f stay for all outcomes was 30 days for males and 36 days for females. T h e shortest mean stay was 26 days, amongst females who died and the longest mean stay (52 days) was amongst females awaiting transfer to geriatric long-stay hospitals.
Bed usage b),.fractured neck offemur To give a measure of t h e load imposed by patients with fractured neck o f femur in each p a r t of the hospital service, the n u m b e r of" bed-days occupied b y these cases has been expressed as a percentage o f the number ,of bed-days occupied by all cases in which the discharge specialty was either orthopaedics or geriatrics, whichever was appropriate to the type o f hospital concerned.
L. J. Douald.votx, 1". F. Stovh" altd hi. (Tt~rkc
It can bc seen (Table 3) Ihat a considerable part o f the work o f the acute orthopaedic service is taken up with these patients. In the acute orthopaedic hospital, fractured neck o f femur accounts for 44°~ o f the work-load amongst females and lg"~ amongst males. A simi~r picture is .~en in the preconvalescent hosr~itai (also under the auspices of the acute orthopac&c serx zcc) ~herc the figures are 34 ~, for males and 4 6 'o for females. TAttLE 3. Bed u~ge by -fractured neck of femur in different types of hospilal for one year iveriod
ending 30 June t977
Type of hospital Acute orthopaedic Prcconvalescenl Geriatric rehabilitalion Geriatric long-stay
Bed-days occupied by fractured neck of femur Male 2894 571 48 300
Female ]0,208 2426 1810 3750
Total bed-days Tolal bed-day.~ occupied in occupied in orthopaedic specialty' geriatric specialty Male 16.218 1702 ---
Female 23.244 5320 -~
Male --11,708 67,270
Female --47,080 183,694
Percentage of fi~ctured neck of femur Male 18 34 1 0.4
Female 44 46 5 2
Discussion Femoral neck fracture occurs at a time o f life when, because o f increasing frailty and the emergence o f the c o m m o n pathologies o f old age, independence within the c o m m u n i t y is tenuously maintained. M a n y pa.tients are unable to regain their pre-fracture level o f social independence and this effect is most m a r k e d when there was already some degree o f dependency a. The resulting acute hospitai stay has been shown from this study to be between four and five weeks whatever the oulcome, extending beyond the confines of what would normally be expected for an acute illness. Moreover, amongst the numerically important group, elderly women, only a quarter were able to return home directly without additional re. habilitation, and some required long-term institutional care. It is almost the rule, amongst these elderly patients, to find that there are other illnesses, in addition to the fracture ~, whose assessment and treatment will inevitably prolong the stay in hospital. When consideration is given to the load imposed by these cases on the hospital service it is apparent that the main burden is being borne by the acute service (Table 3). Yet treatment o f the fracture by prolonged immobilization on traction (the assassin of fhe elderly) has long since been superseded by a more active policyofimmediateinternal fixation or prosthetic replacement o f the femoral head which allows mobilization within a few days of" operation, Whilst ~t is true that Leicestershire is an under-resourced area, other pubished work suggests that the problem exists elsewhere ~ and anecdotal evidence suggests that it is very widespread indeed. Therefore, those concerned with the planning o f health and social services should decide whether it is appropriate that the acute orthopaedic service should be utilized in this way. One solution to the problem is proposed by Strange, ~ who employs a policy o f pinning femora] r,eck fractures under local anaesthetic and discharging s o m e patients within 24 hours, thereby keeping bed occupancy low. He reasons that the ease with which elderly patients become hospitalized and ~zhe high morbidity attendant u p o n general anaesthesia accounts for why patients are so slow to recover from this fracture. Whilst this solution prevents blocked beds on the orthopaedic wards, it is not suitable for all grades o f fracture and fails to take account o f concurrent medical problems or the fact that patients m a y be
Fractured 3leek of Fetm,fr hi Leicestershire
289
ill-equipped to manage at h o m e following their discharge. Castleden r, advocates lhat orthopaedic surgeons should become more skilled in the assessment of medical and social problems of the elderly, thereby providing more efficient treatment and rehabilitation. A more widely held view ~ sees the need f o r a rnultidisciplinary approach to the problem and is recognized by the recent setting up o f special geriatric-orthopaedic units 5. 8 through which patients enter, within a few days of" operation, the day-to-day charge of geriatric physician, nursing staff, physiotherapist, occupational therapist and social worker, the last named providing a valuable interface veith the community social services. This last solution would seem the most logical since, in keeping with m a n y other diseases of the elderly, the special needs o f the patient with fractured neck o f femur seem to cry oul for a team approach and for the integration o f hospital and community services. References 1. Zisserman, L, (1973). Fractures in the aged, with special reference to the femur. Joun~al qflhe American Geriatrics Society 21, 193-9. 2. Knowleden, J., Buhr, A. J. & Dunbar, O. (1964). Incidence o f fractures in persons over 35 years of age. A report to the M.R.C. Working Party on fractures in the elderly. British ,rournal of Preventive and Social Medicine 18~ 1304 1. 3. Gallannaugh, S. C., Martin, A. & Millard, ]P. H. (1976). Regional Survey of femoral neck fractures. British Medical Journal it, 1496--7. 4. Thomas, T. G. & Stevens, R. S. (1974). Social Effects o f Fractures of the neck of the femur. British Medical Journal iii, 456-8. 5. Campbell, A. J. (1976). Femoral neck fractures in elderly women: a prospective study. Age and Ageing 5, 102-9. 6. Strange, F. G. (1969). Pinning under 10eal anaesthesia for treatment of subcapital fractures of the femoral neck. lt•ury 1, I00-6. 7. Castleden, C. M. (1977). Who is responsible for elderly patients on orthopaedic wards ?Geriatrics 32, 65-8. 8. Devas, M. B. (1974). Geriatric orthopaedics. British Medical Journal i, 190-2.