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Social deprivation and adult tibial diaphyseal fractures
Injury, Int. J. Care Injured (2007) 38, 750—754
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Social deprivation and adult tibial diaphyseal fractures Charles M. Court-Brown *, Alistair Brydone Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SU, United Kingdom Accepted 5 December 2006
KEYWORDS Tibial fractures; Social deprivation; Intramedullary nailing; Carstairs index
Summary We present an analysis of the relationship between social deprivation and tibial diaphyseal fractures. We reviewed 1331 patients and have demonstrated a clear relationship between social deprivation and tibial fractures. Deprivation was also associated with male gender and with age, there being significantly less deprivation in older patients. The effect of deprivation on fracture outcome was assessed in 910 patients in whom the tibial fractures were treated by reamed intramedullary nailing. There was no association with non-union or infection, but there was a trend towards increased deprivation in patients who had an amputation which related to a trend for socially deprived patients to have more severe fractures. We believe that the main reason why the effects of deprivation decrease with age relates to the different modes of injury at different ages. # 2006 Elsevier Ltd. All rights reserved.
There is evidence that socio-economic deprivation correlates with a wide range of different diseases including congenital anomalies,23 myocardial ischaemia,1 colorectal cancer,11 diabetes,8 head trauma6 and rheumatoid disease.7 In orthopaedic surgery, social deprivation has been shown to correlate with musculoskeletal pain,21 childhood injuries,2,13,22,20 Perthes disease19 and high energy lower limb trauma.16 Bridgman and Wilson2 showed that the incidence of femoral fractures in children was higher in deprived areas but, to our knowledge, there has been no previous study of the relationship * Corresponding author. Tel.: +44 131 242 3516; fax: +44 131 660 4227. E-mail address: [email protected] (C.M. Court-Brown).
between socio-economic deprivation and an individual adult fracture. In the last 20 years, we have studied fractures of the adult tibial diaphysis in considerable detail and wished to test our hypothesis that there is a positive correlation between tibial fracture and socio-economic deprivation. We investigated this hypothesis by undertaking a retrospective study of tibial diaphyseal fractures over an 11-year period.
Materials and methods Since 1985, the demographic and clinical details of all patients who presented to the Unit with tibial diaphyseal fractures have been prospectively
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.12.008
Social deprivation and adult tibial diaphyseal fractures collected and stored on a database. The 1468 patients who presented with tibial diaphyseal fractures between 1 January 1990 and 31 December 2000 were analysed with respect to social deprivation. Eighty-seven were non-Scottish residents, 43 had an invalid postcode and 7 had a postcode sector that was too small to determine area deprivation. Thus, 1331 patients with tibial diaphyseal fractures were analysed for social deprivation, mode of injury and soft tissue injury using the Gustilo classification9,10 for the open fractures and the Tscherne18 classification for closed fractures. All classification was undertaken by the senior author to prevent inter-observer error. Analysis of the 1331 patients showed that the demography of the group was typical of tibial diaphyseal fractures with 69% of the group being male and the average age being 39.7 years. The fracture distribution curves of our population were typical of tibial diaphyseal fracture with a bimodal distribution affecting young males and older females.4 Further analysis of the age of the patients showed that 53.8% of the fractures occurred in patients less than 40 years of age with 13.8% of fractures occurring in patients of at least 70 years of age. In patients aged less than 40 years, only 10.1% of patients sustained a tibial diaphyseal fracture in a simple fall compared with 51.3% of the patients aged 70 years or over. Correlation between socio-economic deprivation and the outcome after fracture management was analysed in those fractures treated by reamed intramedullary nailing as different fracture treatment methods will affect outcome. There is good evidence that external fixation, plating and cast management are associated with different incidences of infection and non-union in particular.5 Thus, the 910 (68.4%) patients that were treated by reamed intramedullary nailing were analysed to investigate any correlation between deprivation and fracture nonunion, infection, compartment syndrome and the requirement for amputation. Deprivation was analysed using the Carstairs Index.3 This score has been extensively used for analysis of deprivation in many branches of medicine.1,6—8,11,23 In the Carstairs Index, deprivation categories range from 1 to 7 with category 1 representing the least deprived areas and 7 the most deprived. The Carstairs score is a Z-score created from each postcode sector by combining four variables from the 1991 census, these being overcrowding, male unemployment, low social class and car ownership. Positive numbers denote more deprived areas and negative numbers less deprived areas. The national mean Carstairs score is 0. As there is considerable variation in social deprivation throughout Scotland the tibial fracture population was
751
compared with the catchment population of Edinburgh, Midlothian and East Lothian, these being the geographical areas from which the tibial fractures patients came. The mean Carstairs Index for this part of Scotland is 1.0. The tibial fracture population was compared to the local population using x2- and t-tests. The incidences of open fractures, non-union, infection, compartment syndrome and amputation were related to the patients that did not present with these complications using two-sample t-tests. The Pearson correlation was used for union time. Univariate analysis and Pearson correlation were use to determine the significance of the open and closed fracture classifications and cause of injury. Multiple regression analysis was used to compare age groups, gender and the different years of injury.
Results A comparison of the prevalence of the overall population and the tibial fracture population in the seven different deprivation categories is shown in Fig. 1. It indicates that tibial fractures are more common in more deprived categories. The mean deprivation score for the tibial fracture population was 0.27 indicating that this group was significantly more deprived than the local population ( p < 0.001). Analysis of gender showed that social deprivation was independently associated with being male ( p < 0.05). The relationship between age and social deprivation in the tibial fracture population is shown in Fig. 2, which clearly demonstrates increasing affluence in older patients ( p < 0.01). The mean deprivation score in the 20—29 age group was 0.04 compared with 0.82 in the 70—79 years age group. Analysis of the four commonest modes of injury; falls, sports injuries, road traffic accidents and direct blows or assaults, is shown in Fig. 3. Sports injury patients were the most affluent group (mean deprivation score, 0.48) compared with falls ( 0.3) and road traffic accidents ( 0.08). However,
Figure 1 Distribution of tibial diaphyseal fractures by deprivation category.
752
Figure 2 The effect of age on socio-economic deprivation. There is increasing affluence with increasing age.
the most deprived were those with a fracture caused by a direct blow or assault (0.28). However, the differences were not statistically significant. There was no significant difference in the mean deprivation scores for patients with open or closed fractures. However, patients with a Tscherne C3 closed fracture, this representing the most severe soft tissue injury in a closed fracture, had a mean deprivation score of 0.25 compared with 0.28 for patients with C0 fractures. Despite this trend there were only 20 C3 fractures and the difference was not statistically significant. Open fractures also tended to be more severe in more socially deprived patients but again the difference was not significant. It was interesting to observe a significant change in deprivation throughout the 1990s (Fig. 4). Patients with tibial fractures were most affluent in 1990 and 1991 and since 1994 there has been increased variation around the national mean of 0. However, statistical analysis shows that deprivation increased during the 1990s ( p < 0.05). Fig. 5 shows the mean deprivation scores of the patients whose fractures were complicated by nonunion, infection, compartment syndrome and amputation compared with the scores of those patients who did not have these complications. The mean scores for patients with non-union and united fractures ( 0.41 and 0.31) showed no statistical difference. The same was true of infection ( 0.70
Figure 3 The relationship between mode of injury and social deprivation.
C.M. Court-Brown, A. Brydone
Figure 4 Social deprivation in patients who presented during the 1990s. There was increasing deprivation throughout the decade.
Figure 5 The relationship between fracture outcome and social deprivation. The black bars represent the patients who did not have the listed complications. The white bars represent the patients who did.
and 0.32), compartment syndrome (0.23 and 0.40) and amputation (0.30 and 0.37). However, Fig. 5 indicates that there could be a trend towards increasing deprivation in patients with compartment syndrome and amputation.
Discussion There has, to our knowledge, been no previous study of the effect of social deprivation on an adult fracture. We selected the tibia for two main reasons. Firstly, it has a bimodal distribution affecting mainly younger males and older females. There is evidence that deprivation does not appear to be a risk factor in fractures in the elderly12,24 and we wished to investigate a fracture that occurred relatively commonly in both young and old. Secondly, investigation of outcome requires consistency of treatment and as a majority of tibial fractures in our Unit are treated by reamed intramedullary nailing we had a large cohort of patients available for analysis. Previous studies of the association of social deprivation with orthopaedic trauma have mainly been undertaken in children and most authorities agree that children living in deprived areas have higher rates of fracture than children living in affluent
Social deprivation and adult tibial diaphyseal fractures areas.2,13,22,20 However, others have argued that the most important correlation in children is between deprivation and the incidence of fractures in road traffic accidents and that if this is ignored the effect of deprivation on childhood fractures is less clear cut.14 There have been very few studies of the effect of deprivation on fractures in adults although a recent study by Jones et al.12 showed that in a population of 60,106 patients who presented with a fracture in Wales there was evidence of social deprivation in older children and young adults, but not in younger children and the elderly. Our results show that tibial fractures are associated with social deprivation and confirm the association between age and deprivation in a tibial fracture population. Multiple regression analysis shows that age and male gender both correlate with social deprivation and the key question is why the effect of deprivation lessens with age? One might postulate that the cumulative effects of poor nutrition, smoking and co-existing medical conditions might increase the effect of deprivation in the elderly, presumably by increasing the incidence of falls and osteoporosis. However, there is little evidence that osteoporosis is linked to social deprivation.12 We think it likely that the decreasing influence of deprivation relates mainly to the mode of injury. Fig. 3 shows the mean deprivation scores for the four commonest modes of injury. It indicates that patients injured playing sport are apparently least deprived, but it must be remembered that sport covers many different activities. In fact, 81% of the sports related tibial fractures followed soccer injuries in patients in whom the mean deprivation score was 0.22. This compares with the 7.2% of patients who sustained a tibial fracture whilst horse riding or skiing. Their mean deprivation scores were 2.4 and 1.1, respectively! It would seem that tibial fractures in younger patients mainly occur in socially deprived young males, following soccer injuries, road traffic accidents and direct blows or assaults. There is also a trend for open fractures and more severe closed fractures to be associated with increased social deprivation and this presumably, at least in part, relates to social habits and activities that are different from those in more affluent communities. In older patients, there is a higher prevalence of simple falls and other low energy injuries which presumably occur in both deprived and affluent communities and it would seem therefore that aging is the great social leveller as far as tibial fractures, and probably other fractures, are concerned. This fits with the work of Jones et al.12 who examined musculoskeletal injury and with the study of Lyons et al.15 who examined hospital admission rates
753
following injury in children and the elderly. Both studies failed to demonstrate an association between deprivation and injury in the elderly population. West et al.24 examined the relationship between social deprivation and both falls and hip fractures. They showed correlation between deprivation and falls but not with hip fractures. They postulated that they may be an increased incidence of falls in deprived areas or that an individual from a deprived area who had a minor fall and who had medical co-morbidities and a poor social environment was more likely to be admitted to hospital. They believed that the lack of correlation between deprivation and hip fractures suggested that the incidence of falls severe enough to cause a hip fracture was independent of social grouping. We believe that this is true of tibial diaphyseal fractures. The other striking observation was that deprivation increased throughout the 1990s. We are not sure why this occurred and know of no major social changes in the local population to account for it. The increase in deprivation has occurred despite a relative decrease in the incidence of severe open tibial fractures and patients with multiple injuries presenting to the Unit over the decade. Fig. 5 shows the influence of social deprivation on outcome for union, infection, compartment syndrome and amputation. It shows no significant effect on union and infection but does suggest a trend towards increased deprivation in patients with compartment syndrome and who require an amputation. However, we doubt that there is an association with compartment syndrome as it is young males who present with this condition17 and the graph for compartment syndrome shown in Fig. 5 actually contrasts the deprivation of young males who present with tibial fractures with the comparative affluence of other members of the population who fracture their tibia. The trend to increased deprivation in patients who require amputation may be accurate as there is a corresponding trend in patients who have severe open fractures. However, only 14 amputations were performed and even if larger studies were undertaken it may be difficult to prove statistical significance given the relative infrequency of amputation for tibial diaphyseal fracture. We do not know if the association of social deprivation and tibial fractures applies to all fractures. Our results suggest that other fractures that occur mainly in young males, such as hand fractures, will be linked to social deprivation and that proximal humeral, distal radial and thoracolumbar fractures, which are commoner in the elderly, will not be. However, this remains to be proven. In a recent
754 study of the epidemiology of fractures in the year 2000,4 we drew attention to the fact that there are eight different fracture distribution curves depending on gender and age. Further studies are required to see if there is an association between different fracture distribution curves and social deprivation. We know of no association between social deprivation and the method of treatment of tibial diaphyseal fractures although we believe that reamed intramedullary nailing remains the optimal treatment method for patients of all ages.
Conflict of interest statement There are no conflicts of interest for either author.
C.M. Court-Brown, A. Brydone
10.
11.
12.
13.
14.
15.
16.
References 17. 1. Barakat K, Stevenson S, Wilkinson P, et al. Socioeconomic differentials in recurrent ischaemia and mortality after acute myocardial infarction. Heart 2000;85:390—4. 2. Bridgman S, Wilson R. Epidemiology of femoral fractures in children in the West Midlands region of England 1991—2001. J Bone Joint Surg Br 2004;86-B:1152—7. 3. Carstairs V, Morris R. Deprivation and Health in Scotland. Aberdeen: Aberdeen University Press; 1991. 4. Court-Brown CM, Koval KJ. The epidemiology of fractures. In: Bucholz RW, Heckman J, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 6th ed., Philadelphia: Lippincott Williams & Wilkins; 2006. p. 95—144. 5. Court-Brown CM. Fractures of the tibia and fibula. In: Bucholz RW, Heckman J, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 6th ed., Philadelphia: Lippincott Williams & Wilkins; 2006. p. 95—144. 6. Dunn L, Henry J, Beard D. Socal deprivation and adult head injury: a national study. J Neurol Neurosurg Psychiatry 2003;74:1060—4. 7. ERAS Study Group. Socioeconomic deprivation and rheumatoid disease: what lessons for the health service? Ann Rheum Dis 2000;59:794—9. 8. Evans JMM, Newton RW, Ruta DA, et al. Socio-economic status, obesity and prevalence of Type 1 and Type 2 diabetes mellitus. Diabet Med 2000;17:478—80. 9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1035 open fractures of long bones: retrospec-
18.
19.
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21.
22.
23.
24.
tive and prospective analysis. J Bone Joint Surg Am 1976;58A:453—8. Gustilo RB, Mendoza RM, Williams DM. Problems in the management of type III (severe) open fractures. A new classification of type III open fractures. J Trauma 1984;24: 742—6. Hole DJ, McArdle CS. Impact of socioeconomic deprivation on outcome after surgery for colorectal cancer. Br J Surg 2002;89:586—90. Jones S, Johansen A, Brennan J, et al. The effect of socioeconomic deprivation on fracture incidence in the United Kingdom. Osteoporos Int 2004;15:520—4. Laflamme L, Engstro ¨m K. Socioeconomic differences in Swedish children and adolescents in road traffic accidents: crosssectional study. BMJ 2002;324:396—7. Lyons RA, Delahunty AM, Heaven M, et al. Incidence of childhood fractures in affluent and deprived areas: population based study. BMJ 2000;320:149. Lyons RA, Jones SJ, Deacon T, Heaven M. Socioeconomic variation in injury in children and older people: a population based study. Inj Prev 2003;9:33—7. MacKenzie EJ, Bosse MJ, Kellam JF, et al. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma 2000;7:455—66. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br 2000;82B:932—3. Oestern H-J, Tscherne H. Pathophysiology and classification of soft tissue injuries associated with fractures. In: Tscherne H, Gotzen L, editors. Fractures with soft tissue injuries. Berlin: Springer-Verlag; 1984. p. 1—9. Pillai A, Atiya S, Costigan PS. The incidence of Perthes’ disease in Southwest Scotland. J Bone Joint Surg Br 2004;87-B:1531—5. Stark AD, Bennet GC, Stone DH, Chishti P. Association between childhood fractures and poverty: population based study. BMJ 2002;324:457. Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998;57:649—55. Urw Silversides JA, Gibson A, Glasgow JF, et al. Social deprivation and childhood injuries in North and West Belfast. Ulster Med J 2005;74:22—8. Vrijheid M, Dolk H, Stone D, et al. Socioeconomic inequalities in risk of congenital anomaly. Arch Dis Child 2000;82: 349—52. West J, Hippisley-Cox J, Coupland CA, et al. Do rates of hospital admission for falls and hip fracture in elderly people vary by socio-economic status. Public Health 2004;118:576— 81.
www.elsevier.com/locate/injury
Social deprivation and adult tibial diaphyseal fractures Charles M. Court-Brown *, Alistair Brydone Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SU, United Kingdom Accepted 5 December 2006
KEYWORDS Tibial fractures; Social deprivation; Intramedullary nailing; Carstairs index
Summary We present an analysis of the relationship between social deprivation and tibial diaphyseal fractures. We reviewed 1331 patients and have demonstrated a clear relationship between social deprivation and tibial fractures. Deprivation was also associated with male gender and with age, there being significantly less deprivation in older patients. The effect of deprivation on fracture outcome was assessed in 910 patients in whom the tibial fractures were treated by reamed intramedullary nailing. There was no association with non-union or infection, but there was a trend towards increased deprivation in patients who had an amputation which related to a trend for socially deprived patients to have more severe fractures. We believe that the main reason why the effects of deprivation decrease with age relates to the different modes of injury at different ages. # 2006 Elsevier Ltd. All rights reserved.
There is evidence that socio-economic deprivation correlates with a wide range of different diseases including congenital anomalies,23 myocardial ischaemia,1 colorectal cancer,11 diabetes,8 head trauma6 and rheumatoid disease.7 In orthopaedic surgery, social deprivation has been shown to correlate with musculoskeletal pain,21 childhood injuries,2,13,22,20 Perthes disease19 and high energy lower limb trauma.16 Bridgman and Wilson2 showed that the incidence of femoral fractures in children was higher in deprived areas but, to our knowledge, there has been no previous study of the relationship * Corresponding author. Tel.: +44 131 242 3516; fax: +44 131 660 4227. E-mail address: [email protected] (C.M. Court-Brown).
between socio-economic deprivation and an individual adult fracture. In the last 20 years, we have studied fractures of the adult tibial diaphysis in considerable detail and wished to test our hypothesis that there is a positive correlation between tibial fracture and socio-economic deprivation. We investigated this hypothesis by undertaking a retrospective study of tibial diaphyseal fractures over an 11-year period.
Materials and methods Since 1985, the demographic and clinical details of all patients who presented to the Unit with tibial diaphyseal fractures have been prospectively
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.12.008
Social deprivation and adult tibial diaphyseal fractures collected and stored on a database. The 1468 patients who presented with tibial diaphyseal fractures between 1 January 1990 and 31 December 2000 were analysed with respect to social deprivation. Eighty-seven were non-Scottish residents, 43 had an invalid postcode and 7 had a postcode sector that was too small to determine area deprivation. Thus, 1331 patients with tibial diaphyseal fractures were analysed for social deprivation, mode of injury and soft tissue injury using the Gustilo classification9,10 for the open fractures and the Tscherne18 classification for closed fractures. All classification was undertaken by the senior author to prevent inter-observer error. Analysis of the 1331 patients showed that the demography of the group was typical of tibial diaphyseal fractures with 69% of the group being male and the average age being 39.7 years. The fracture distribution curves of our population were typical of tibial diaphyseal fracture with a bimodal distribution affecting young males and older females.4 Further analysis of the age of the patients showed that 53.8% of the fractures occurred in patients less than 40 years of age with 13.8% of fractures occurring in patients of at least 70 years of age. In patients aged less than 40 years, only 10.1% of patients sustained a tibial diaphyseal fracture in a simple fall compared with 51.3% of the patients aged 70 years or over. Correlation between socio-economic deprivation and the outcome after fracture management was analysed in those fractures treated by reamed intramedullary nailing as different fracture treatment methods will affect outcome. There is good evidence that external fixation, plating and cast management are associated with different incidences of infection and non-union in particular.5 Thus, the 910 (68.4%) patients that were treated by reamed intramedullary nailing were analysed to investigate any correlation between deprivation and fracture nonunion, infection, compartment syndrome and the requirement for amputation. Deprivation was analysed using the Carstairs Index.3 This score has been extensively used for analysis of deprivation in many branches of medicine.1,6—8,11,23 In the Carstairs Index, deprivation categories range from 1 to 7 with category 1 representing the least deprived areas and 7 the most deprived. The Carstairs score is a Z-score created from each postcode sector by combining four variables from the 1991 census, these being overcrowding, male unemployment, low social class and car ownership. Positive numbers denote more deprived areas and negative numbers less deprived areas. The national mean Carstairs score is 0. As there is considerable variation in social deprivation throughout Scotland the tibial fracture population was
751
compared with the catchment population of Edinburgh, Midlothian and East Lothian, these being the geographical areas from which the tibial fractures patients came. The mean Carstairs Index for this part of Scotland is 1.0. The tibial fracture population was compared to the local population using x2- and t-tests. The incidences of open fractures, non-union, infection, compartment syndrome and amputation were related to the patients that did not present with these complications using two-sample t-tests. The Pearson correlation was used for union time. Univariate analysis and Pearson correlation were use to determine the significance of the open and closed fracture classifications and cause of injury. Multiple regression analysis was used to compare age groups, gender and the different years of injury.
Results A comparison of the prevalence of the overall population and the tibial fracture population in the seven different deprivation categories is shown in Fig. 1. It indicates that tibial fractures are more common in more deprived categories. The mean deprivation score for the tibial fracture population was 0.27 indicating that this group was significantly more deprived than the local population ( p < 0.001). Analysis of gender showed that social deprivation was independently associated with being male ( p < 0.05). The relationship between age and social deprivation in the tibial fracture population is shown in Fig. 2, which clearly demonstrates increasing affluence in older patients ( p < 0.01). The mean deprivation score in the 20—29 age group was 0.04 compared with 0.82 in the 70—79 years age group. Analysis of the four commonest modes of injury; falls, sports injuries, road traffic accidents and direct blows or assaults, is shown in Fig. 3. Sports injury patients were the most affluent group (mean deprivation score, 0.48) compared with falls ( 0.3) and road traffic accidents ( 0.08). However,
Figure 1 Distribution of tibial diaphyseal fractures by deprivation category.
752
Figure 2 The effect of age on socio-economic deprivation. There is increasing affluence with increasing age.
the most deprived were those with a fracture caused by a direct blow or assault (0.28). However, the differences were not statistically significant. There was no significant difference in the mean deprivation scores for patients with open or closed fractures. However, patients with a Tscherne C3 closed fracture, this representing the most severe soft tissue injury in a closed fracture, had a mean deprivation score of 0.25 compared with 0.28 for patients with C0 fractures. Despite this trend there were only 20 C3 fractures and the difference was not statistically significant. Open fractures also tended to be more severe in more socially deprived patients but again the difference was not significant. It was interesting to observe a significant change in deprivation throughout the 1990s (Fig. 4). Patients with tibial fractures were most affluent in 1990 and 1991 and since 1994 there has been increased variation around the national mean of 0. However, statistical analysis shows that deprivation increased during the 1990s ( p < 0.05). Fig. 5 shows the mean deprivation scores of the patients whose fractures were complicated by nonunion, infection, compartment syndrome and amputation compared with the scores of those patients who did not have these complications. The mean scores for patients with non-union and united fractures ( 0.41 and 0.31) showed no statistical difference. The same was true of infection ( 0.70
Figure 3 The relationship between mode of injury and social deprivation.
C.M. Court-Brown, A. Brydone
Figure 4 Social deprivation in patients who presented during the 1990s. There was increasing deprivation throughout the decade.
Figure 5 The relationship between fracture outcome and social deprivation. The black bars represent the patients who did not have the listed complications. The white bars represent the patients who did.
and 0.32), compartment syndrome (0.23 and 0.40) and amputation (0.30 and 0.37). However, Fig. 5 indicates that there could be a trend towards increasing deprivation in patients with compartment syndrome and amputation.
Discussion There has, to our knowledge, been no previous study of the effect of social deprivation on an adult fracture. We selected the tibia for two main reasons. Firstly, it has a bimodal distribution affecting mainly younger males and older females. There is evidence that deprivation does not appear to be a risk factor in fractures in the elderly12,24 and we wished to investigate a fracture that occurred relatively commonly in both young and old. Secondly, investigation of outcome requires consistency of treatment and as a majority of tibial fractures in our Unit are treated by reamed intramedullary nailing we had a large cohort of patients available for analysis. Previous studies of the association of social deprivation with orthopaedic trauma have mainly been undertaken in children and most authorities agree that children living in deprived areas have higher rates of fracture than children living in affluent
Social deprivation and adult tibial diaphyseal fractures areas.2,13,22,20 However, others have argued that the most important correlation in children is between deprivation and the incidence of fractures in road traffic accidents and that if this is ignored the effect of deprivation on childhood fractures is less clear cut.14 There have been very few studies of the effect of deprivation on fractures in adults although a recent study by Jones et al.12 showed that in a population of 60,106 patients who presented with a fracture in Wales there was evidence of social deprivation in older children and young adults, but not in younger children and the elderly. Our results show that tibial fractures are associated with social deprivation and confirm the association between age and deprivation in a tibial fracture population. Multiple regression analysis shows that age and male gender both correlate with social deprivation and the key question is why the effect of deprivation lessens with age? One might postulate that the cumulative effects of poor nutrition, smoking and co-existing medical conditions might increase the effect of deprivation in the elderly, presumably by increasing the incidence of falls and osteoporosis. However, there is little evidence that osteoporosis is linked to social deprivation.12 We think it likely that the decreasing influence of deprivation relates mainly to the mode of injury. Fig. 3 shows the mean deprivation scores for the four commonest modes of injury. It indicates that patients injured playing sport are apparently least deprived, but it must be remembered that sport covers many different activities. In fact, 81% of the sports related tibial fractures followed soccer injuries in patients in whom the mean deprivation score was 0.22. This compares with the 7.2% of patients who sustained a tibial fracture whilst horse riding or skiing. Their mean deprivation scores were 2.4 and 1.1, respectively! It would seem that tibial fractures in younger patients mainly occur in socially deprived young males, following soccer injuries, road traffic accidents and direct blows or assaults. There is also a trend for open fractures and more severe closed fractures to be associated with increased social deprivation and this presumably, at least in part, relates to social habits and activities that are different from those in more affluent communities. In older patients, there is a higher prevalence of simple falls and other low energy injuries which presumably occur in both deprived and affluent communities and it would seem therefore that aging is the great social leveller as far as tibial fractures, and probably other fractures, are concerned. This fits with the work of Jones et al.12 who examined musculoskeletal injury and with the study of Lyons et al.15 who examined hospital admission rates
753
following injury in children and the elderly. Both studies failed to demonstrate an association between deprivation and injury in the elderly population. West et al.24 examined the relationship between social deprivation and both falls and hip fractures. They showed correlation between deprivation and falls but not with hip fractures. They postulated that they may be an increased incidence of falls in deprived areas or that an individual from a deprived area who had a minor fall and who had medical co-morbidities and a poor social environment was more likely to be admitted to hospital. They believed that the lack of correlation between deprivation and hip fractures suggested that the incidence of falls severe enough to cause a hip fracture was independent of social grouping. We believe that this is true of tibial diaphyseal fractures. The other striking observation was that deprivation increased throughout the 1990s. We are not sure why this occurred and know of no major social changes in the local population to account for it. The increase in deprivation has occurred despite a relative decrease in the incidence of severe open tibial fractures and patients with multiple injuries presenting to the Unit over the decade. Fig. 5 shows the influence of social deprivation on outcome for union, infection, compartment syndrome and amputation. It shows no significant effect on union and infection but does suggest a trend towards increased deprivation in patients with compartment syndrome and who require an amputation. However, we doubt that there is an association with compartment syndrome as it is young males who present with this condition17 and the graph for compartment syndrome shown in Fig. 5 actually contrasts the deprivation of young males who present with tibial fractures with the comparative affluence of other members of the population who fracture their tibia. The trend to increased deprivation in patients who require amputation may be accurate as there is a corresponding trend in patients who have severe open fractures. However, only 14 amputations were performed and even if larger studies were undertaken it may be difficult to prove statistical significance given the relative infrequency of amputation for tibial diaphyseal fracture. We do not know if the association of social deprivation and tibial fractures applies to all fractures. Our results suggest that other fractures that occur mainly in young males, such as hand fractures, will be linked to social deprivation and that proximal humeral, distal radial and thoracolumbar fractures, which are commoner in the elderly, will not be. However, this remains to be proven. In a recent
754 study of the epidemiology of fractures in the year 2000,4 we drew attention to the fact that there are eight different fracture distribution curves depending on gender and age. Further studies are required to see if there is an association between different fracture distribution curves and social deprivation. We know of no association between social deprivation and the method of treatment of tibial diaphyseal fractures although we believe that reamed intramedullary nailing remains the optimal treatment method for patients of all ages.
Conflict of interest statement There are no conflicts of interest for either author.
C.M. Court-Brown, A. Brydone
10.
11.
12.
13.
14.
15.
16.
References 17. 1. Barakat K, Stevenson S, Wilkinson P, et al. Socioeconomic differentials in recurrent ischaemia and mortality after acute myocardial infarction. Heart 2000;85:390—4. 2. Bridgman S, Wilson R. Epidemiology of femoral fractures in children in the West Midlands region of England 1991—2001. J Bone Joint Surg Br 2004;86-B:1152—7. 3. Carstairs V, Morris R. Deprivation and Health in Scotland. Aberdeen: Aberdeen University Press; 1991. 4. Court-Brown CM, Koval KJ. The epidemiology of fractures. In: Bucholz RW, Heckman J, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 6th ed., Philadelphia: Lippincott Williams & Wilkins; 2006. p. 95—144. 5. Court-Brown CM. Fractures of the tibia and fibula. In: Bucholz RW, Heckman J, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 6th ed., Philadelphia: Lippincott Williams & Wilkins; 2006. p. 95—144. 6. Dunn L, Henry J, Beard D. Socal deprivation and adult head injury: a national study. J Neurol Neurosurg Psychiatry 2003;74:1060—4. 7. ERAS Study Group. Socioeconomic deprivation and rheumatoid disease: what lessons for the health service? Ann Rheum Dis 2000;59:794—9. 8. Evans JMM, Newton RW, Ruta DA, et al. Socio-economic status, obesity and prevalence of Type 1 and Type 2 diabetes mellitus. Diabet Med 2000;17:478—80. 9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1035 open fractures of long bones: retrospec-
18.
19.
20.
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