Ankle fractures in the elderly: What you get depends on where you live and who you see

Department of Orthopaedics, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
Journal of Orthopaedic Trauma (Impact Factor: 1.8). 11/2005; 19(9):635-9.
Source: PubMed


This study was performed to determine 1) the rate of ankle fractures in the elderly in the United States stratified by hospital referral region, and 2) whether the percentage of ankle fractures treated surgically is affected by factors, such as fracture location, hospital referral region, concentration of orthopaedists, presence of a teaching hospital in that region, patient age, race, gender, or the number and type of specific medical comorbidities.
A 20% sample of Medicare Part B claims from the years 1998 to 2000 was analyzed.
The CPT codes for operative and nonoperative treatment of isolated medial malleolar, isolated lateral malleolar, bimalleolar, and trimalleolar fractures were identified. These codes were used to determine the overall rate of ankle fractures and individual fracture types.
: The rate of ankle fractures was evaluated by hospital referral region, patient age (groups of 5 years, aged 65 years or older), gender, and race. The percentage of surgical treatment was determined for each fracture type as the number of surgically treated fractures over the total number of ankle fractures within each subtype and analyzed by fracture type, hospital referral region, and concentration of orthopaedists in that region, presence of a teaching hospital within the hospital service area, patient age, gender, race, and number and type of specific medical comorbidities. Regression was performed by using the above variables.
We identified 33,704 ankle fractures: 7.6% were isolated medial malleolar, 50.8% were isolated lateral malleolar, 27.4% were bimalleolar, and 14.2% were trimalleolar fractures. The overall United States average was 4.2 ankle fractures per 1000 Medicare enrollees. The rate of ankle fractures varied by a factor of 8, from 1 per 1000 Medicare enrollees in San Francisco, CA, to 8.3 in Hickory, NC. The rate of ankle fractures was highest in white women at 5.8 and lowest in nonwhite men at 1.5 per 1000 Medicare enrollees. The overall rate of ankle fractures that underwent surgical stabilization was 33%, ranging from 14% in Binghampton, NY, to 72% in Napa, CA. The rate of surgical intervention was 22% for isolated medial malleolar fractures, 11% for isolated lateral malleolar fractures, 58% for bimalleolar fractures, and 74% for trimalleolar fractures. In regression analysis, the factors associated with nonoperative care after ankle fracture were: older age, female gender, increasing number of comorbidities as measured by the Charlson index, presence of diabetes or peripheral vascular disease, and living in a hospital service area that had a designated teaching hospital. Beneficiaries living in areas in which a hospital was a member of the Council of Teaching Hospitals were less likely to receive surgical treatment of their ankle fracture. Increasingly older age was strongly associated with decreased likelihood of having surgical intervention, with each 5 year age grouping progressively less likely to have surgical treatment. The concentration of orthopaedists in the region was not associated with the likelihood of having surgical treatment.
The term ankle fracture involves a wide spectrum of injuries. We found a large variation through the United States in both the rate of ankle fractures and the percentage of those that undergo surgical intervention.

12 Reads
  • Source
    • "The incidence of ankle fracture is likely to increase over the next 20 years [69] [70] [71] [72]. Although osteoporosis is not a risk factor for ankle fractures, it is a risk factor for the failure of surgical fixation in ankle fracture healing [69] [70] [71] [72]. Previously, the trend was to treat all osteoporotic ankle fractures non-surgically due to the high compli cation rate [70] [73] [74]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Orthopaedic trauma is an increasingly common problem in geriatric patients. As demands of daily life and recreational activities are increasing in these patients, surgeons need to be able to manage geriatric fractures to achieve good functional results. Reduced bone quality in the elderly presents a considerable challenge and may preclude the use of established surgical stabilisation techniques that are performed in younger trauma patients. Furthermore, pre-existing medical conditions and considerable comorbidities in the elderly could complicate standard surgical procedures that younger patients would be offered. In this respect, application of external fixators represents a validated, minimally-invasive treatment opportunity. This review article summarises the use of external fixation in geriatric trauma patients for wrist fractures, proximal femoral fractures, pelvic fractures, and ankle fractures. Modern modifications, like pin coating with hydroxyapatite, and aspects of pin care will be discussed.
    Injury 09/2015; 46:S7-S12. DOI:10.1016/S0020-1383(15)30004-8 · 2.14 Impact Factor
  • Source
    • "Operative treatment of AF in the elderly may pose a challenge. There is controversy in the management of AF in the elderly.60 "
    [Show abstract] [Hide abstract]
    ABSTRACT: Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.
    Indian Journal of Orthopaedics 09/2014; 48(5):445-52. DOI:10.4103/0019-5413.139829 · 0.64 Impact Factor
  • Source
    • "The Danis-Weber classification system not only indicates the injuries relative to the distal tibiofibular syndesmosis, but also aids surgeons in selecting the location of the fibular incision (7,17). For type A and B fractures, the steel plate is placed on the lateral side of the fibula using a lateral incision and the distal end is usually fixed with one or two unicortical cancellous bone screws. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Several operative approaches are available at present for the exposure and fixation of distal fibular fractures combined with posterior malleolus fractures. The present study was designed to study the anatomical characteristics of the distal fibula and to thereby evaluate the advantages and limitations of various operative approaches, as well as their indications for specific conditions. Ten leg specimens from below the knee joint were dissected using posterior, lateral and posterolateral approaches to the fibula. The adjacent vulnerable structures, including nerves, blood vessels, tendons and ligaments, were carefully examined and their distances from the posterior malleolus were recorded. The distance was 7.2±4.1 mm between the sural nerve and the posterior section of the fibula, 79.2±23.5 mm between the lateral malleolus tip and the point where the shape changes in the lower fibula and 66.4±17.4 mm between the lateral malleolus and the jointed tendon of the peroneal and flexor hallux longus muscles. The widest anteroposterior diameter of the distal fibula was 27.3±3.5 mm. Various approaches have certain advantages and limitations when these anatomical factors are taken into account. The choice should be based on the height of the fibular fracture line, the type of posterior malleolus fracture, the effect of the fracture on the stability of the ankle joint and the materials used for internal fixation.
    Experimental and therapeutic medicine 03/2013; 5(3):757-760. DOI:10.3892/etm.2012.872 · 1.27 Impact Factor
Show more