The Effect of Fall Biomechanics on Risk for Hip Fracture in Older Adults: A Cohort Study of Video-Captured Falls in Long-Term Care

Yijian Yang, Vicki Komisar, Nataliya Shishov, Bryan Lo, Alexandra Mb Korall, Fabio Feldman, Stephen N Robinovitch, Yijian Yang, Vicki Komisar, Nataliya Shishov, Bryan Lo, Alexandra Mb Korall, Fabio Feldman, Stephen N Robinovitch

Abstract

Over 95% of hip fractures in older adults are caused by falls, yet only 1% to 2% of falls result in hip fracture. Our current understanding of the types of falls that lead to hip fracture is based on reports by the faller or witness. We analyzed videos of real-life falls in long-term care to provide objective evidence on the factors that separate falls that result in hip fracture from falls that do not. Between 2007 and 2018, we video-captured 2377 falls by 646 residents in two long-term care facilities. Hip fracture was documented in 30 falls. We analyzed each video with a structured questionnaire, and used generalized estimating equations (GEEs) to determine relative risk ratios (RRs) for hip fracture associated with various fall characteristics. All hip fractures involved falls from standing height, and pelvis impact with the ground. After excluding falls from lower than standing height, risk for hip fracture was higher for sideways landing configurations (RR = 5.50; 95% CI, 2.36-12.78) than forward or backward, and for falls causing hip impact (3.38; 95% CI, 1.49-7.67). However, hip fracture risk was just as high in falls initially directed sideways as forward (1.14; 95% CI, 0.49-2.67), due to the tendency for rotation during descent. Falling while using a mobility aid was associated with lower fracture risk (0.30; 95% CI, 0.09-1.00). Seventy percent of hip fractures involved impact to the posterolateral aspect of the pelvis. Hip protectors were worn in 73% of falls, and hip fracture risk was lower in falls where hip protectors were worn (0.45; 95% CI, 0.21-0.99). Age and sex were not associated with fracture risk. There was no evidence of spontaneous fractures. In this first study of video-captured falls causing hip fracture, we show that the biomechanics of falls involving hip fracture were different than nonfracture falls for fall height, fall direction, impact locations, and use of hip protectors. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Keywords: BIOMECHANICS; FALLS; HIP FRACTURE; HIP PROTECTORS; VIDEO CAPTURE.

© 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Figures

Fig 1
Fig 1
Snapshots from video footage of falls resulting in hip fracture. (A) This 94‐year‐old woman experienced a right‐side intertrochanteric hip fracture, from falling due a trip during walking. She fell forward but rotated during descent to impact the right side of her pelvis. (B) This 84‐year‐old woman experienced a left‐side femoral neck fracture after losing balance while standing and turning. She fell sideways and landed sideways, impacting the left side of her pelvis. Videos of falls (with and without hip fracture) are included in the Supplementary Material.
Fig 2
Fig 2
Flowchart of sample selection (participants and falls) in this study.
Fig 3
Fig 3
Distribution of pelvis orientation at impact with the ground for hip fracture cases (n = 30).

References

    1. Parkkari J, Kannus P, Palvanen M, et al. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int. 1999;65(3):183–7.
    1. Scott V, Wagar L, Elliott S. In Victoria Scott Consulting ed. , ed. Falls and related injuries among older Canadians: fall‐related hospitalizations & intervention initiatives. Prepared on behalf of the Public Health Agency of Canada. Victoria, BC, Canada: Division of Aging and Seniors; 2010.
    1. Public Health Agency of Canada . Seniors' falls in Canada: second report. Ottawa, ON, Canada: Public Health Agency of Canada; 2014.
    1. Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273–80.
    1. Papaioannou A, Santesso N, Morin SN, et al. Recommendations for preventing fracture in long‐term care. CMAJ. 2015;187(15):1135–44.
    1. Crilly RG, Tanner DA, Kloseck M, Chesworth BM. Hip fractures in long‐term care: is the excess explained by the age and gender distribution of the residents? J Aging Res. 2010;2010:291258.
    1. Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2018;9:CD005465.
    1. Santesso N, Carrasco‐Labra A, Brignardello‐Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2014;3:CD001255.
    1. Choi W, Hoffer J, Robinovitch S. Effect of hip protectors, falling angle and body mass index on pressure distribution over the hip during simulated falls. Clin Biomech. 2010;25(1):63–9.
    1. Compston JE, Flahive J, Hosmer DW, et al. Relationship of weight, height, and body mass index with fracture risk at different sites in postmenopausal women: the Global Longitudinal Study of Osteoporosis in Women (GLOW). J Bone Miner Res. 2014;29(2):487–93.
    1. Hayes WC, Myers ER, Morris JN, Gerhart TN, Yett HS, Lipsitz LA. Impact near the hip dominates fracture risk in elderly nursing home residents who fall. Calcif Tissue Int. 1993;52(3):192–8.
    1. Greenspan SL, Myers ER, Maitland LA, Resnick NM, Hayes WC. Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly. JAMA. 1994;271(2):128–33.
    1. Nevitt MC, Cummings SR. Type of fall and risk of hip and wrist fractures: The Study of Osteoporotic Fractures. J Am Geriatr Soc. 1993;41(11):1226–34. .
    1. Greenspan SL, Myers ER, Kiel DP, Parker RA, Hayes WC, Resnick NM. Fall direction, bone mineral density, and function: risk factors for hip fracture in frail nursing home elderly. Am J Med. 1998;104(6):539–45.
    1. Schwartz AV, Kelsey JL, Sidney S, Grisso JA. Characteristics of falls and risk of hip fracture in elderly men. Osteoporos Int. 1998;8(3):240–6.
    1. Cummings SR, Nevitt MC, Kidd S. Forgetting falls. The limited accuracy of recall of falls in the elderly. J Am Geriatr Soc. 1988;36(7):613–6.
    1. Yang Y, Feldman F, Leung PM, Scott V, Robinovitch SN. Agreement between video footage and fall incident reports on the circumstances of falls in long‐term care. J Am Med Dir Assoc. 2015;16(5):388–94.
    1. Yang Y, Mackey DC, Liu‐Ambrose T, Feldman F, Robinovitch SN. Risk factors for hip impact during real‐life falls captured on video in long‐term care. Osteoporos Int. 2016;27(2):537–47.
    1. Feldman F, Robinovitch SN. Reducing hip fracture risk during sideways falls: evidence in young adults of the protective effects of impact to the hands and stepping. J Biomech. 2007;40(12):2612–8.
    1. Cummings SR, Nevitt MC. A hypothesis: the causes of hip fractures. J Gerontol. 1989;44(5):M107–11.
    1. Lamb SE, Jorstad‐Stein EC, Hauer K, Becker C. Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe Consensus. J Am Geriatr Soc. 2005;53(9):1618–22.
    1. Yang Y, Schonnop R, Feldman F, Robinovitch SN. Development and validation of a questionnaire for analyzing real‐life falls in long‐term care captured on video. BMC Geriatr. 2013;13:40.
    1. Yang Y, Mackey DC, Liu‐Ambrose T, Leung PM, Feldman F, Robinovitch SN. Clinical risk factors for head impact during falls in older adults: a prospective cohort study in long‐term care. J Head Trauma Rehab. 2017;32(3):168–77.
    1. Berry SD, Zullo AR, Zhang T, Lee Y, McConeghy KW, Kiel DP. Validation of the FRAiL model to predict non‐vertebral and hip fractures in nursing home residents. Bone. 2019;128:115050.
    1. Cauley JA, Cawthon PM, Peters KE, et al. Risk factors for hip fracture in older men: the osteoporotic fractures in men study (MrOS). J Bone Miner Res. 2016;31(10):1810–9.
    1. Marks R. Hip fracture epidemiological trends, outcomes, and risk factors, 1970‐2009. Int J Gen Med. 2010;3:1–17.
    1. Norton R, Campbell AJ, Lee‐Joe T, Robinson E, Butler M. Circumstances of falls resulting in hip fractures among older people. J Am Geriatr Soc. 1997;45(9):1108–12.
    1. Grisso JA, Kelsey JL, Strom BL, et al. Risk factors for falls as a cause of hip fracture in women. The Northeast Hip Fracture Study Group. N Engl J Med. 1991;324(19):1326–31.
    1. Robinovitch SN, McMahon TA, Hayes WC. Force attenuation in trochanteric soft tissues during impact from a fall. J Orthop Res. 1995;13(6):956–62.
    1. Hwang HF, Lee HD, Huang HH, Chen CY, Lin MR. Fall mechanisms, bone strength, and hip fractures in elderly men and women in Taiwan. Osteoporos Int. 2011;22(8):2385–93.
    1. Sran MM, Stotz PJ, Normandin SC, Robinovitch SN. Age differences in energy absorption in the upper extremity during a descent movement: implications for arresting a fall. J Gerontol A Biol Sci Med Sci. 2010;65(3):312–7.
    1. Keyak JH. Improved prediction of proximal femoral fracture load using nonlinear finite element models. Med Eng Phys. 2001;23(3):165–73.
    1. Nankaku M, Kanzaki H, Tsuboyama T, Nakamura T. Evaluation of hip fracture risk in relation to fall direction. Osteoporos Int. 2005;16(11):1315–20.
    1. Schonnop R, Yang Y, Feldman F, Robinson E, Loughin M, Robinovitch SN. Prevalence of and factors associated with head impact during falls in older adults in long‐term care. CMAJ. 2013;185(17):E803–10.
    1. Korall AMB, Feldman F, Yang Y, et al. Effectiveness of hip protectors to reduce risk for hip fracture from falls in long‐term care. J Am Med Dir Assoc. 2019;20(11):1397–403.e1.
    1. Robinovitch SN, Evans SL, Minns J, et al. Hip protectors: recommendations for biomechanical testing—an international consensus statement (part I). Osteoporos Int. 2009;20(12):1977–88.
    1. Canadian Standards Association . CSA EXP08‐17 ‐ hip protectors. Annex A: method for measuring peak force at the proximal femur during a simulated fall on the hip. Toronto, Canada: CSA Group; 2017.
    1. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med. 1994;121(6):442–51.
    1. Mackey DC, Lachance CC, Wang PT, et al. The flooring for injury prevention (FLIP) study of compliant flooring for the prevention of fall‐related injuries in long‐term care: a randomized trial. PLoS Med. 2019;16(6):e1002843.
    1. van Schooten KS, Yang Y, Grajauskas L, Robinovitch SN. Similarity of repeated falls in older long‐term care residents: Do the circumstances of past falls predict those of future falls? J Am Med Dir Assoc. 2019;20(3):386–387.
    1. Thorpe LU, Whiting SJ, Li W, Dust W, Hadjistavropoulos T, Teare G. The incidence of hip fractures in long‐term care homes in Saskatchewan from 2008 to 2012: an analysis of provincial administrative databases. Can Geriatr J. 2017;20(3):97–104.
    1. Becker C, Cameron ID, Klenk J, et al. Reduction of femoral fractures in long‐term care facilities: the Bavarian Fracture Prevention Study. PLoS One. 2011;6(8):e24311.
    1. Berry SD, Lee Y, Zullo AR, Kiel DP, Dosa D, Mor V. Incidence of hip fracture in U.S. nursing homes. J Gerontol A Biol Sci Med Sci. 2016;71(9):1230–4.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться