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The Effect of Fall Biomechanics on Risk for Hip Fracture in Older Adults: A Cohort Study of Video-Captured Falls in Long-Term Care
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.
Introduction
Falls cause 95% of hip fractures in older adults.1, 2 Nearly 25% of hip fracture patients will die within 1 year of the fracture, and 50% will have major declines in independence.3, 4 The rates of falls and hip fractures are especially high among older adults in long-term care (LTC). Only 6% of older adults in Canada live in LTC, but this population experiences 30% of hip fractures.5, 6 Strategies that are effective in preventing falls in community-dwelling seniors (eg, exercise) have been unsuccessful in LTC, due to the high prevalence of physical and cognitive impairment in residents.7 This highlights the importance of complementary strategies in LTC for preventing hip fracture in the event of a fall, through approaches such as vitamin D and calcium supplementation, pharmacologic therapy, and the use of wearable hip protectors,5, 8 which may be especially beneficial for individuals with low body mass index (BMI) who have higher risk for fracture.9-11 Improved understanding of the factors that separate injurious and noninjurious falls may lead to refinements to existing strategies, and new approaches to prevention.
Previous case-control studies in older adults have found that risk for hip fracture in a fall depends at least as much on the biomechanics of the fall, as it does on bone density.12, 39 In particular, although a one standard deviation (1SD) decline in bone density increased fracture risk twofold to threefold,12 falling sideways increased fracture risk sixfold,13 and landing on the hip increased fracture risk 30-fold.14 Furthermore, hip fractures were less common when the person landed on their hand, or grabbed or hit an object to break the fall.39 However, a major limitation of these studies is their reliance on interviews or questionnaires completed by the faller and witnesses (if any) to determine a narrow range of fall characteristics (fall direction, fall height, and contact sites). Recalling the circumstances of falls is challenging, especially for older adults with cognitive impairment.15, 16 Also, fallers who sustained a fracture may bias their response based on the notion that they must have landed on the hip for fracture to occur.11 To date, objective evidence on the circumstances of falls causing hip fracture has not been available to overcome these limitations.
In this study, we address this knowledge gap by analyzing videos of real-life falls experienced by older adults living in LTC, and comparing the characteristics of falls that did result in hip fracture versus those that did not result in hip fracture. We hypothesized that fracture risk would associate with fall characteristics that have previously been shown to be important, as reviewed above (fall height, fall direction, contact sites, use of hip protectors, and BMI). We considered initial fall direction and landing configuration separately, based on our previous observation that falls in LTC often involve rotation during descent.17 In addition to hip and hand impact, we examined knee impact (which may decrease impact severity to the hip), use of mobility aids, and attempts to recover balance by stepping, which we previously found to decrease hip impact velocity.18 We also tested whether fracture risk, as hypothesized by Cummings and Nevitt,19 associated with activity at the time of the fall (eg, walking versus standing), and with cause of imbalance.
