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Proximal femoral fractures in psychiatric patients
Injury, 11, 19-22
Printed in Great Britain
19
Proximal femoral fractures in psychiatric patients A. D Craxford and J. Stevens Department of Orthopaedics, Royal Victoria Infirmary, Newcastle upon Tyne Summary During an 8-year period, 122 inpatients of a psychiatric hospital sustained fractures of the proximal part of the femur. They were treated by operative as well as by conservative methods and their subsequent mobility, morbidity and mortality have been reviewed. The results suggest that these patients are best managed within their familiar environment, that femoral head replacement arthroplasty is appropriate for high fractures and that the prevention of bedsores in conservatively treated patients is of great importance.
Traction was shown to be a satisfactory treatment for trochanteric fractures in nonpsychiatric patients by Murray and Frew (1949) and for impacted intracapsular fractures by Crawford (1965). Very little information exists about the results of this method of treatment in psychogeriatric patients. This report reviews the results achieved by treating psychogeriatric patients with proximal femoral fractures within the familiar surroundings of their psychiatric hospital for as much of the treatment period as possible.
INTRODUCTION
FRACTURES of the proximal part of the femur in the elderly constitute an expanding sociomedical problem which awaits an acceptable solution. When the patients concerned also suffer from mental illness, the difficulties in management are increased and the prospect of a satisfactory outcome is smaller. Engh et al. (1968) showed that the extent of violence required to produce a proximal femoral fracture in patients in long term institutional care was often minimal. There is also evidence to suggest that prolonged intake of psychotropic or anticonvulsant drugs may predispose to fracture, perhaps because these drugs can cause osteoporosis and osteomalacia (Dent et al., 1970; Medlinsky, 1974; Muckle, 1976). Most reported series have dealt only with operative treatment of these fractures in psychogeriatric patients. Among these, Meyn et al. (1977) reported encouraging results, although Niemann and Mankin (1968) recorded a high early mortality and poor final mobility and Sherk et al. 0974) reported a high infection rate as well.
PATIENTS AND METHODS
Between 1969 and 1976, 122 of the 12958 patients admitted to a 1016-bed psychiatric hospital sustained proximal femoral fractures. The age and sex of these patients and the type of fractures involved are listed in Table L the distribution being similar to that encountered in non-psychiatric patients. The terms 'high' and 'low' correspond to 'intracapsular' and 'extracapsular' fractures respectively. The patients were followed continuously from the time of injury until death or until December 1977. At the time of injury, appropriate radiography and routine investigations were conducted by the resident psychiatric staff, who also performed any necessary resuscitation and applied 81b of skin traction to the injured limb. Treatment of the mental disorders (see Table II) was continued. A visiting member of the duty fracture team decided upon each patient's fitness for operation. Fit patients were then transferred to the fracture unit of another hospital as soon as possible, but often after several days' delay, and operation was then performed within 48 h.
2O
Injury:.the British Journal of Accident SurgeryVol. 1 1/No. 1
Table/. Distribution of fractures according to age and sex
Table I/. Psychiatric diagnosis of patients
Age (yr)
High fracture M F
Lowfracture M F
Total
41-60 61-70 71-60 81-90 91-100+
0 0 5 1 0
0 4 14 11 1
3 0 5 5 0
3 4 23 42 1
6 8 47 59 2
Total
6
30
13
73
122
Table ///. operation
Interval
between
fracture
Psychiatric diagnosis
and
Senile dementia Schizophrenia Paranoid psychosis Manic depression Mental subnormality Organic confusional state Post-encephalitic syndrome Tabes dorsalis
94 15 5 4 1 1 1 1
77 12 4 3
Table IV. Treatment methods Fractures
Delay (days)
No. of patients
Deaths (within 3 months)
%
High
1-2 3-7 8-14 15+
11 20 27 17
3 8 9 5
27"3 40"0 30"0 29"4
Total
Table III indicates the interval between fracture and operation and illustrates that delay had no statistically significant effect on mortality. Those patients treated by operation were returned to the psychiatric hospital within 48 h, whilst those considered to be unfit for operation remained in the psychiatric hospital and were treated in traction for between 10 and 12 weeks. Femoral head replacement arthroplasty was the commonest technique employed amongst the operations for high fractures whilst low fractures were immobilized with McLaughlin nail plates. The number of patients treated by the different methods is given in Table IV. Daily attention from physiotherapists assisted in the mobilization in bed and the return to weight bearing of both groups of patients. There was no restriction of activity in operatively treated patients from the time that they returned to the psychiatric hospital or in patients treated in traction immediately after this was discontinued.
No. of patients %
Low
Total
Treatment Primary prosthesis Sliding nail plate Smith-Petersen pin Conservative
No. 25 1 1 9 36
McLaughlin pin and plate 44 Sliding nail plate 4 Conservative 38 86
hospital stay before fracture and delay between fracture and operation. Mortality
The overall survival times are presented in Table V. Thirty-five patients (29 per cent) died within six weeks of fracture and a further 40 (32 per cent) succumbed before the end of a year. All patients treated in traction for high fractures and 71 per cent of those treated in the same way for low fractures died within the first year. However, these patients had been deemed unsafe for operation at initial assessment. Half of all the patients treated by operation died within a year. The certified causes ofdeath in the 75 patients who succumbed within the first year after fracture or operation are given in Table VI.
RESULTS
Morbidity
Some of the factors examined were found not to affect the outcome significantly. These were age, sex, side of injury, psychiatric diagnosis, presence or absence of incontinence, duration of
The complications of treatment considered to be important were venous thromboembolism, wound infection and pressure sores. Anticoagulants were not given routinely for prophy-
Cra~ord and Stevens: Femoral Fractures
21
Table V. Survival times
Death occurred
High fracture Opera- Conservative tive
Total
Within 6 wk 6 wk-1 yr 1-3 yr Over 3 yr Still alive
5 8 4 0 10
6 3 0 0 0
9 17 6 6 10
15 12 2 4 5
35 40 12 10 25
Total
27
9
48
38
122
Table VI. Cause of death (first year)
Cause of death Bronchopneumonia Myocardial infarct Septicaemia Pulmonary embolism Cerebrovascular accident Renal failure uraemia Left ventricular failure Others Total
Low fracture Opera- Conservative tive
Table VII. Survival and incidence of pressure sores
Operarive
Conservative
22 5 5 4
21 3 2 2
43 8 7 6
1 2 2 2
2 1 0 1
3 3 2 3
43(56%)
32(44%)
Total
75
laxis and although patients were examined daily for clinical evidence of leg vein thrombosis, no special diagnostic aids were used. Four patients who developed thrombosis were treated with anticoagulants and none died from pulmonary embolism. None of the 75 patients treated by operation were given prophylactic antibiotics and 8 (11 per cent) had serious wound infections, 5 with Staphylococcus aureus and 3 with coliform organisms. Important pressure sores were regarded as involving full thickness skin loss, calling for intensive treatment and causing delay in rehabilitation. Two patients died within three days of fracture and a quarter of the remainder developed sores over the sacrum or on the heels. These patients were arbitrarily divided into two groups, 59 (group 1) who survived the fracture and associated primary treatment (twelve weeks in traction or operation and two weeks thereafter) and 63 (group 2) who did not. Table VII gives the incidence of pressure sores in those two groups. Of the 47 patients treated in traction, 8 (17 per cent) developed sores and 5 ofthese died; of the 50 treated with a nail plate, 18 (36 per cent) developed sores and 16 of them died; of the
Treatment
Group I Group 2 (survived) (died) Without With Without With sores sores sores sores
Conservative (47) 15 Internal fixation (50) 26 Prosthesis (25) 12
3 2 1
24 6 8
5 16 4
Total
6
38
25
53
25 treated by femoral head replacement, 5 (20 per cent) developed sores and 4 of them died. The femoral head prosthesis dislocated in 4 patients, 2 of whom subsequently died, the other 2 being rendered bedridden as a result. Mobility
Table VIII lists the ability of the patients to walk before the fracture occurred. No less than 84 per cent were able to do so independently. Ninety-five patients survived long enough for walking to have been possible and their mobility at death or final review is given in Table IX. Independent walking was impossible for 18 per cent and a further 40 per cent were bedridden. Among patients with low fractures, there was no difference in final mobility between those treated by internal fixation and those treated by traction. The apparently better outcome in patients with high fractures treated by operation is not statistically significant. DISCUSSION
This study confirms the magnitude of the problem of proximal femoral fracture in psychiatric patients already reported (Niemann and Mankin, 1968). In this population group, the prevalence of fracture was 100 per 100000 compared with 57 per 100000 of a normal
22
Injury: the BritishJournal of Accident Surgery Vol. 11/No. 1
Tab/e VIII, Patient mobility before fracture
Tab/e/X. Final patient mobility (95 patients)
Mobility
No.
% MobtTity
Normal Sticks or frame Mobile only with help Bedridden Total
80 23 13 6
66 18 11 5
122
1O0
population over the age of 20 years (Colbert et al., 1976). The mortality rates o f 29 per cent at six weeks and 60 per cent at one year after fracture are about twice those encountered in nonpsychiatric patients treated in the same hospital group (Stevens, 1978). By far the commonest psychiatric diagnosis was senile dementia and it seems likely that this diminished the cooperation o f the patient through inability to understand the aims of treatment, intolerance of discomfort and decrease in the effort required it, physical rehabilitation. These factors are especially important in the management o f patients treated by operation and may be responsible for the greater incidence of pressure sores in this group. On the other hand, patients treated in traction may, by virtue of being unfit for operation and confined to bed, receive more attentive nursing care. The policy has been followed of keeping these patients in the familiar surroundings of the psychiatric hospital for as much of the treatment period as possible. Whether this is beneficial cannot be assessed without comparison with a group of patients managed differently, but the advantages to the local fracture service are clear. Compared with non-psychiatric patients in the same hospital group, wound infection was no commoner in this series, but the 16 per cent incidence of dislocation of a femoral head prosthesis was very much greater (Stevens, 1978). The degree of patient mobility before fracture was not significantly different, but the final mobility was worse to a highly significant degree than with non-psychiatric patients (Stevens, 1978). Thus, 74 per cent of patients were capable o f independent walking before fracture, whilst 58 per cent were either bedridden or mobile only with personal assistance after treatment.
Conserva- Nail tive plate Prosthesis Total
Unchanged Slight reduction Severe reduction Bedridden
2 7 4 11
8 10 8 18
7 6 5 9
17 23 17 38
Total
24
44
27
95
It is concluded that among psychiatric patients the treatment of choice for high proximal femoral fractures is primary prosthetic replacement with rapid mobilization, whilst low fractures are best treated in traction. Acknowledgements
We would like to record our thanks to the staffof the St Nicholas and Newcastle General Hospitals.
REFERENCES
Colbert D. S., O'Muircheartaigh I., Chater E. H. et al. ( 1976) A study of fracture of the neck of the femur in the West oflreland 1968-1973. lr. Med. J. 1, I. Crawford H. B. (1965) Experience with the nonoperative treatment of impacted fractures of the neck of the femur. J. Bone Joint Surg. 47A, 830. Dent C. E., Richens A. and Rowe D. J. F. (1970) Osteomalacia with long-term anticonvulsant therapy in epilepsy. Br. Med. J. 4, 69. Engh G., Bollet A. J., Hardin G. et al. (1968) Incidence of hip fractures in mental institutions. J. Bone Joint Surg. 50A, 557. Medlinsky L. (1974) Rickets associated with anticonvulsant medication. Pediatrics 53, 91. Meyn M. A., Hopson C. and Jayasankar S. (1977) Fractures of the hip in the institutionalized psychotic patient: a mortality and morbidity survey of 106 cases. Clin. Orthop. 122, 128. Muckle D. S. (1976) latrogenic factors in femoral neck fractures. Injury g, 98. Murray R. C. and Frew J. F. M. (1949) Trochanteric fractures of the femur. J. Bone Joint Surg. 31B, 204. Niemann K. M. W. and Mankin H. J. (1968) Fractures about the hip in the institutionalised patient population. J. Bone Joint Surg. 50A, 1327. Sherk H. H., Crouse F. R. and Probst C. (1974) The treatment of hip fractures in institutionalised patients: a comparison of operative and nonoperative methods. Orthop. Clin. North Am. 5, 543. Stevens J. (I 978) Unpublished data.
Requests for reprints should be addressed to: Mr A. D. Craxford, Department of Orthopaedics, Royal Victoria Infirmary,
Newcastleupon Tyne, NEI 4LP.
Printed in Great Britain
19
Proximal femoral fractures in psychiatric patients A. D Craxford and J. Stevens Department of Orthopaedics, Royal Victoria Infirmary, Newcastle upon Tyne Summary During an 8-year period, 122 inpatients of a psychiatric hospital sustained fractures of the proximal part of the femur. They were treated by operative as well as by conservative methods and their subsequent mobility, morbidity and mortality have been reviewed. The results suggest that these patients are best managed within their familiar environment, that femoral head replacement arthroplasty is appropriate for high fractures and that the prevention of bedsores in conservatively treated patients is of great importance.
Traction was shown to be a satisfactory treatment for trochanteric fractures in nonpsychiatric patients by Murray and Frew (1949) and for impacted intracapsular fractures by Crawford (1965). Very little information exists about the results of this method of treatment in psychogeriatric patients. This report reviews the results achieved by treating psychogeriatric patients with proximal femoral fractures within the familiar surroundings of their psychiatric hospital for as much of the treatment period as possible.
INTRODUCTION
FRACTURES of the proximal part of the femur in the elderly constitute an expanding sociomedical problem which awaits an acceptable solution. When the patients concerned also suffer from mental illness, the difficulties in management are increased and the prospect of a satisfactory outcome is smaller. Engh et al. (1968) showed that the extent of violence required to produce a proximal femoral fracture in patients in long term institutional care was often minimal. There is also evidence to suggest that prolonged intake of psychotropic or anticonvulsant drugs may predispose to fracture, perhaps because these drugs can cause osteoporosis and osteomalacia (Dent et al., 1970; Medlinsky, 1974; Muckle, 1976). Most reported series have dealt only with operative treatment of these fractures in psychogeriatric patients. Among these, Meyn et al. (1977) reported encouraging results, although Niemann and Mankin (1968) recorded a high early mortality and poor final mobility and Sherk et al. 0974) reported a high infection rate as well.
PATIENTS AND METHODS
Between 1969 and 1976, 122 of the 12958 patients admitted to a 1016-bed psychiatric hospital sustained proximal femoral fractures. The age and sex of these patients and the type of fractures involved are listed in Table L the distribution being similar to that encountered in non-psychiatric patients. The terms 'high' and 'low' correspond to 'intracapsular' and 'extracapsular' fractures respectively. The patients were followed continuously from the time of injury until death or until December 1977. At the time of injury, appropriate radiography and routine investigations were conducted by the resident psychiatric staff, who also performed any necessary resuscitation and applied 81b of skin traction to the injured limb. Treatment of the mental disorders (see Table II) was continued. A visiting member of the duty fracture team decided upon each patient's fitness for operation. Fit patients were then transferred to the fracture unit of another hospital as soon as possible, but often after several days' delay, and operation was then performed within 48 h.
2O
Injury:.the British Journal of Accident SurgeryVol. 1 1/No. 1
Table/. Distribution of fractures according to age and sex
Table I/. Psychiatric diagnosis of patients
Age (yr)
High fracture M F
Lowfracture M F
Total
41-60 61-70 71-60 81-90 91-100+
0 0 5 1 0
0 4 14 11 1
3 0 5 5 0
3 4 23 42 1
6 8 47 59 2
Total
6
30
13
73
122
Table ///. operation
Interval
between
fracture
Psychiatric diagnosis
and
Senile dementia Schizophrenia Paranoid psychosis Manic depression Mental subnormality Organic confusional state Post-encephalitic syndrome Tabes dorsalis
94 15 5 4 1 1 1 1
77 12 4 3
Table IV. Treatment methods Fractures
Delay (days)
No. of patients
Deaths (within 3 months)
%
High
1-2 3-7 8-14 15+
11 20 27 17
3 8 9 5
27"3 40"0 30"0 29"4
Total
Table III indicates the interval between fracture and operation and illustrates that delay had no statistically significant effect on mortality. Those patients treated by operation were returned to the psychiatric hospital within 48 h, whilst those considered to be unfit for operation remained in the psychiatric hospital and were treated in traction for between 10 and 12 weeks. Femoral head replacement arthroplasty was the commonest technique employed amongst the operations for high fractures whilst low fractures were immobilized with McLaughlin nail plates. The number of patients treated by the different methods is given in Table IV. Daily attention from physiotherapists assisted in the mobilization in bed and the return to weight bearing of both groups of patients. There was no restriction of activity in operatively treated patients from the time that they returned to the psychiatric hospital or in patients treated in traction immediately after this was discontinued.
No. of patients %
Low
Total
Treatment Primary prosthesis Sliding nail plate Smith-Petersen pin Conservative
No. 25 1 1 9 36
McLaughlin pin and plate 44 Sliding nail plate 4 Conservative 38 86
hospital stay before fracture and delay between fracture and operation. Mortality
The overall survival times are presented in Table V. Thirty-five patients (29 per cent) died within six weeks of fracture and a further 40 (32 per cent) succumbed before the end of a year. All patients treated in traction for high fractures and 71 per cent of those treated in the same way for low fractures died within the first year. However, these patients had been deemed unsafe for operation at initial assessment. Half of all the patients treated by operation died within a year. The certified causes ofdeath in the 75 patients who succumbed within the first year after fracture or operation are given in Table VI.
RESULTS
Morbidity
Some of the factors examined were found not to affect the outcome significantly. These were age, sex, side of injury, psychiatric diagnosis, presence or absence of incontinence, duration of
The complications of treatment considered to be important were venous thromboembolism, wound infection and pressure sores. Anticoagulants were not given routinely for prophy-
Cra~ord and Stevens: Femoral Fractures
21
Table V. Survival times
Death occurred
High fracture Opera- Conservative tive
Total
Within 6 wk 6 wk-1 yr 1-3 yr Over 3 yr Still alive
5 8 4 0 10
6 3 0 0 0
9 17 6 6 10
15 12 2 4 5
35 40 12 10 25
Total
27
9
48
38
122
Table VI. Cause of death (first year)
Cause of death Bronchopneumonia Myocardial infarct Septicaemia Pulmonary embolism Cerebrovascular accident Renal failure uraemia Left ventricular failure Others Total
Low fracture Opera- Conservative tive
Table VII. Survival and incidence of pressure sores
Operarive
Conservative
22 5 5 4
21 3 2 2
43 8 7 6
1 2 2 2
2 1 0 1
3 3 2 3
43(56%)
32(44%)
Total
75
laxis and although patients were examined daily for clinical evidence of leg vein thrombosis, no special diagnostic aids were used. Four patients who developed thrombosis were treated with anticoagulants and none died from pulmonary embolism. None of the 75 patients treated by operation were given prophylactic antibiotics and 8 (11 per cent) had serious wound infections, 5 with Staphylococcus aureus and 3 with coliform organisms. Important pressure sores were regarded as involving full thickness skin loss, calling for intensive treatment and causing delay in rehabilitation. Two patients died within three days of fracture and a quarter of the remainder developed sores over the sacrum or on the heels. These patients were arbitrarily divided into two groups, 59 (group 1) who survived the fracture and associated primary treatment (twelve weeks in traction or operation and two weeks thereafter) and 63 (group 2) who did not. Table VII gives the incidence of pressure sores in those two groups. Of the 47 patients treated in traction, 8 (17 per cent) developed sores and 5 ofthese died; of the 50 treated with a nail plate, 18 (36 per cent) developed sores and 16 of them died; of the
Treatment
Group I Group 2 (survived) (died) Without With Without With sores sores sores sores
Conservative (47) 15 Internal fixation (50) 26 Prosthesis (25) 12
3 2 1
24 6 8
5 16 4
Total
6
38
25
53
25 treated by femoral head replacement, 5 (20 per cent) developed sores and 4 of them died. The femoral head prosthesis dislocated in 4 patients, 2 of whom subsequently died, the other 2 being rendered bedridden as a result. Mobility
Table VIII lists the ability of the patients to walk before the fracture occurred. No less than 84 per cent were able to do so independently. Ninety-five patients survived long enough for walking to have been possible and their mobility at death or final review is given in Table IX. Independent walking was impossible for 18 per cent and a further 40 per cent were bedridden. Among patients with low fractures, there was no difference in final mobility between those treated by internal fixation and those treated by traction. The apparently better outcome in patients with high fractures treated by operation is not statistically significant. DISCUSSION
This study confirms the magnitude of the problem of proximal femoral fracture in psychiatric patients already reported (Niemann and Mankin, 1968). In this population group, the prevalence of fracture was 100 per 100000 compared with 57 per 100000 of a normal
22
Injury: the BritishJournal of Accident Surgery Vol. 11/No. 1
Tab/e VIII, Patient mobility before fracture
Tab/e/X. Final patient mobility (95 patients)
Mobility
No.
% MobtTity
Normal Sticks or frame Mobile only with help Bedridden Total
80 23 13 6
66 18 11 5
122
1O0
population over the age of 20 years (Colbert et al., 1976). The mortality rates o f 29 per cent at six weeks and 60 per cent at one year after fracture are about twice those encountered in nonpsychiatric patients treated in the same hospital group (Stevens, 1978). By far the commonest psychiatric diagnosis was senile dementia and it seems likely that this diminished the cooperation o f the patient through inability to understand the aims of treatment, intolerance of discomfort and decrease in the effort required it, physical rehabilitation. These factors are especially important in the management o f patients treated by operation and may be responsible for the greater incidence of pressure sores in this group. On the other hand, patients treated in traction may, by virtue of being unfit for operation and confined to bed, receive more attentive nursing care. The policy has been followed of keeping these patients in the familiar surroundings of the psychiatric hospital for as much of the treatment period as possible. Whether this is beneficial cannot be assessed without comparison with a group of patients managed differently, but the advantages to the local fracture service are clear. Compared with non-psychiatric patients in the same hospital group, wound infection was no commoner in this series, but the 16 per cent incidence of dislocation of a femoral head prosthesis was very much greater (Stevens, 1978). The degree of patient mobility before fracture was not significantly different, but the final mobility was worse to a highly significant degree than with non-psychiatric patients (Stevens, 1978). Thus, 74 per cent of patients were capable o f independent walking before fracture, whilst 58 per cent were either bedridden or mobile only with personal assistance after treatment.
Conserva- Nail tive plate Prosthesis Total
Unchanged Slight reduction Severe reduction Bedridden
2 7 4 11
8 10 8 18
7 6 5 9
17 23 17 38
Total
24
44
27
95
It is concluded that among psychiatric patients the treatment of choice for high proximal femoral fractures is primary prosthetic replacement with rapid mobilization, whilst low fractures are best treated in traction. Acknowledgements
We would like to record our thanks to the staffof the St Nicholas and Newcastle General Hospitals.
REFERENCES
Colbert D. S., O'Muircheartaigh I., Chater E. H. et al. ( 1976) A study of fracture of the neck of the femur in the West oflreland 1968-1973. lr. Med. J. 1, I. Crawford H. B. (1965) Experience with the nonoperative treatment of impacted fractures of the neck of the femur. J. Bone Joint Surg. 47A, 830. Dent C. E., Richens A. and Rowe D. J. F. (1970) Osteomalacia with long-term anticonvulsant therapy in epilepsy. Br. Med. J. 4, 69. Engh G., Bollet A. J., Hardin G. et al. (1968) Incidence of hip fractures in mental institutions. J. Bone Joint Surg. 50A, 557. Medlinsky L. (1974) Rickets associated with anticonvulsant medication. Pediatrics 53, 91. Meyn M. A., Hopson C. and Jayasankar S. (1977) Fractures of the hip in the institutionalized psychotic patient: a mortality and morbidity survey of 106 cases. Clin. Orthop. 122, 128. Muckle D. S. (1976) latrogenic factors in femoral neck fractures. Injury g, 98. Murray R. C. and Frew J. F. M. (1949) Trochanteric fractures of the femur. J. Bone Joint Surg. 31B, 204. Niemann K. M. W. and Mankin H. J. (1968) Fractures about the hip in the institutionalised patient population. J. Bone Joint Surg. 50A, 1327. Sherk H. H., Crouse F. R. and Probst C. (1974) The treatment of hip fractures in institutionalised patients: a comparison of operative and nonoperative methods. Orthop. Clin. North Am. 5, 543. Stevens J. (I 978) Unpublished data.
Requests for reprints should be addressed to: Mr A. D. Craxford, Department of Orthopaedics, Royal Victoria Infirmary,
Newcastleupon Tyne, NEI 4LP.