Tampe et al.

Scandinavian Journal of Trauma, Resuscitation and Emergency

Medicine (2018) 26:62
https://doi.org/10.1186/s13049-018-0531-0

ORIGINALRESEARCH

Mortality, risk factors and causes of

death in Swedish patients with open
tibial fractures - a nationwide study of
3, 777 patients
*
Ulrika Tampe , Lukas W. Widmer, Rüdiger J. Weiss and Karl-Åke Jansson

Abstract
Background: Open tibial fractures are serious, complicated injuries. Previous studies suggested an
increased risk of death, however, this has not been studied in large population-based settings. We aimed
to analyze mortality including causes of death in all patients with open tibial fractures in Sweden.
Moreover, we wanted to compare mortality rates with the Swedish population and determine whether
treatment-related or demographic variables were independently associated with death.
Method: We searched the Swedish National Hospital Discharge Register for all patients with open tibial
fracture between 1998 and 2010. We collected the following variables: age, gender, length of stay,
mechanism of injury and treatment rendered. We then cross-referenced the Swedish Cause of Death
Register to determine the cause of death, if applicable. We compared mortality in the study population
with population-based mortality data from Statistics Sweden and determined whether variables were
independently associated with death using regression analysis.
Results: Of the 3777 open tibial fractures, 425 (11.3%) patients died. The most common causes of death for
elderly patients were cardiovascular and respiratory disease. Patients aged 15–39 years succumbed to
external causes (accidents, suicides or poisoning). Increasing age (OR 25.7 (95% CI 11.8–64.8) p < 0.001),
length of hospital stay (HR 1.01, (95% CI 1.01–1.02,) p < 0.001), limb amputation (OR 4.8 (95% CI 1.86–11.1)
p < 0.001) and cause of the accident were independently associated with an increased mortality.
Conclusion: Patients with open tibial fractures have an increased risk of death compared with the
general population in all age- and gender-groups. External causes of death are over-represented and
indicate a subgroup with a risky behaviour among younger males. Elderly patients have an increased
risk of dying comparable to hip fracture patients. They are at risk for cardiovascular and respiratory
failure and should be treated with urgency, emphasizing the need for specialized geriatric trauma units.
Keywords: Causes of death, Epidemiology, Mortality, Open fracture, Tibial fracture

* Correspondence: [email protected]
Department of Molecular Medicine and Surgery, Section of Orthopaedics
and Sports Medicine, Karolinska Institutet at Karolinska University Hospital,
Stockholm, Sweden

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Tampe et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:62 Page 2 of 9

Background hospital admission in Sweden are available. Diagnoses are

Open tibial fractures are serious injuries, which endan-ger coded according to the International Classification of
both life and limb. The incidence in Northern Europe is Diseases (ICD). We extracted data from the Regis-ter on
between 2.3 and 3.4 per 100,000 person-years [1–3], and all hospital admissions and re-admissions of patients (≥15
consists of a unimodal age distribution for males, whereas years of age) with the following diagno-ses: open
women have a more even age distribu-tion. In fact, fractures of the proximal tibia (S82.11), tib-ial shaft
previous work identified the most common mechanisms (S82.21), and distal tibia (S82.31). No exclusions were
of injury as motor vehicle accidents (43%), most made.
commonly seen in males, age 15–50 years, and falls from Mechanism of injury was collected from ICD E-codes
a standing-height (21%), which are most com-monly seen and divided into categories: fall from standing height, fall
in females [2]. from height, car accidents, transport acci-dents with
Treatment of open tibial fractures is difficult and unprotected road users (bicycle accidents, motor bike
fraught with complications. Problems such as osteo- accidents, horse riders, and pedestrians hit by motor
myelitis, non-union, mal-union, compartment syn-drome vehicles), self-destructive injuries and miscellaneous.
and amputation contribute to an increase in healthcare Unprotected road users were gathered in one group as
costs (resource utilization) as well as a de-crease in there were very few individuals in the sub-groups.
patient quality of life [4–7]. In fact, the ampu-tation rate
is reported to be 3.6% in a study involving adult Swedish We cross-referenced data from the Swedish National
patients [2]. However, in trauma centres dealing with a Hospital Discharge Register to the Swedish Cause of
larger proportion of high-energy injuries, the amputation Death Register [17, 18]. Dates of death and causes of
rate is much higher, about 25% [8, 9]. death for patients from this cohort that died during the
In contrast to the well-studied mortality rate after hip study period were extracted. Causes of death were coded
fractures [10, 11] few studies report the risk of death after according to the International Classification of Diseases
open tibial fractures. It is possible that high compli-cation (ICD 10) and grouped according to the Euro-pean
rates translate to an increase in the risk of death. In fact, shortlist for causes of death [19]. According to this list,
previous studies involving small populations of elderly causes of death are grouped as diseases of the respiratory,
patients demonstrated relatively high mortality after open circulatory, digestive, nervous and muscu-loskeletal
tibial fractures [12, 13]. Other studies involv-ing larger system as well as malignant neoplasms, men-tal and
patient populations focus on closed as well as open behavioural disorders, endocrine and metabolic diseases,
fractures [14, 15]. However, neither provides a suit-able external, unknown and unspecified causes, and
population-based assessment of the risk of death miscellaneous. External causes were further divided into
following treatment for open tibial fracture. transport accidents, accidental falls, accidental poi-soning,
As such, there are no population-based reports docu- suicide and intentional self-harm, homicide and assault,
menting short- and long-term mortality rates in patients drowning accidents and events of undeter-mined intent.
with open tibial fractures. With this in mind, we aimed to
analyse mortality rates, causes of death and risk fac-tors Patients were grouped as young (15–39 years), middle-
for death in the Swedish population, with data from a aged (40–64 years) and old (≥65 years). Males aged 15–
nationwide inpatient register. In doing so, we describe the 60 years as a relatively large group was thor-oughly
mortality after open tibial fracture in the Swedish investigated. We hypothesized that they would be more
population, compare the mortality rates with those in the subjected to external causes and violent deaths, as shown
general Swedish population, and determine whether in previous studies [20, 21].
treatment-related or demographic variables were inde- The primary outcome variable was early mortality,
pendently associated with death. defined as death within 90 days after injury. Further-more,
secondary outcomes were late mortality, de-fined as death
Methods between 90 days and 2 years, total mortality during the
Source of data study period, length of stay (LOS), standard mortality
We obtained data from the Swedish National Hospital ratios (SMR) and variables associated with death.
Discharge Register (SNHDR), where 98% of all hos-pital
admissions in Sweden are covered [16]. The study period Statistics
was 1998–2010. All Swedish individuals can be identified Logistic regression analysis was used to assess factors
through a 10-digit national registra-tion number and associated with death within 90 days, as prevalence of
which allows epidemiological studies on a nationwide early death was not time-homogenous. Cox regression
basis. Data on diagnosis, surgical procedure codes, and analysis was used for the correlative analysis from
demographic data for each

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Tampe et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:62 Page 3 of 9

90 days and beyond. We hypothesized that by doing this, across age-groups, with the highest mortality being 11%
we would estimate the most critical external causes after 2 years in patients aged 65 years and older (Table 1).
directly associated with the earlier deaths. On the other
hand, we would also analyse other long term factors that
would influence the risk for a later death. Odds ratios Length of stay
(ORs), hazard ratios (HRs) and the associated 95% Mean LOS for primary admission ranged from 9 days
confidence intervals (CI) are pre-sented. The crude results (SD 15) in younger patients, to 10 days (SD 12) in
were adjusted for age, gen-der, mechanism of injury, middle-aged, and 14 days (SD 16) among the oldest.
occurrence of amputation, and length of stay.
Causes of death
The standardized mortality ratio (SMR) is a ratio Death was predominantly caused by cardiovascular dis-
between observed number of deaths in a study popu-lation orders (180 deaths, 42%), malignant neoplasms (79
and the number of expected deaths in the gen-eral deaths, 19%) and by external causes (83 deaths, 20%)
population, stratified by age and gender. SMR was (Fig. 1). A complete list of all causes of death is shown in
calculated comparing mortality in the study population the Appendix.
with data from Statistics Sweden [22]. The Mid-p exact Among younger patients with an age of 15–39 years,
test was used to calculate confidence in-tervals for SMR. the dominating cause of death was external (79%). In the
elderly (≥65) external causes accounted for only 12% of
The Kaplan-Meier survival function was plotted for the deaths. These proportions were similar in men and
different age and gender groups, compared to data from women. Death causes in different age groups are shown in
the general population, matched by age and gender (Sta- Fig. 1. A transport accident (35 cases out of all 425
tistics Sweden). The results were considered statistically deaths) was the most common external cause. Less
significant for p-values ≤0.05. The statistical software frequent were suicides (n = 12), poisoning (n = 10), falls
used was R. (n = 8), homicides (n = 3), drowning (n = 2) and miscel-
laneous (n = 13).
Characteristics of the study population We looked further at the subgroup of males aged 15– 60
There were 3777 patients (67% males) with open tibial years as males are specifically exposed to traumatic injuries
fractures admitted to Swedish hospitals during the study [1, 2] (Fig. 2). Twelve individuals died within 3 months after
period. Most fractures were located in the tibial shaft they sustained their open tibial fracture, all because of the
(60%), 14% were located in the proximal part and 26% in initial trauma or its complications. Six of them died on the
the distal part of tibia. The mean age of the patients at day of the accident. All individuals had sustained severe
admission was 47 (SD 20) years (males 42 [SD 20] and high-energy trauma like motor cycle acci-dents, pedestrians
females 55 [SD 22]). The mean follow-up time was 6 (SD hit by car, blast injury or a helicopter accident. Among those
3.8) years. Regarding surgical fixation methods, the most who died between 3 and 12 months (n = 10), 4 deaths were
usual method was intramedullary nailing (32%). caused by malignancies or co-morbidities and 6 deaths were
Subsequent methods were combinations of external fix- due to external causes.
ation and other (22%), plating (9%), external fixation only
(8%), closed reduction and cast (4%), whereas 26% were Standard mortality ratio (SMR)
fixated using miscellaneous methods. Causes of ac-cident Standard Mortality Ratio (SMR) and excess mortality in
were in descending order motor vehicle accident (MVA, the different age groups was estimated at 0–90 days and
43%), fall from standing height (21%), miscellan-eous 90 days–2 years (Tables 2, 3). There was an overall in-
(19%), fall from height (11%) and unspecified falls (6%). creased excess death rate, although in some groups there
were very few individuals. SMR was higher for early
mortality (Table 4).
Results
Mortality rate Table 1 Mean length of stay and mortality rates in different
Out of the population of 3777 patients, 425 individuals age groups
(212 males and 213 females) died during the study period. Age [years] 15–39 40–64 65–101
This resulted in a total mortality rate of 11% dur-ing the Number of patients [n] 1456 1564 744
study period of 13 years. We excluded 11 male patients Number of deaths [n] 28 111 286
from the analysis because of incomplete data. The 90-day mortality [n (%)] 6 (0.4) 11 (0.7) 49 (6.5)
primary outcome, mortality in the population after 90 90-day to 2-year mortality [n (%)] 8 (0.6) 24 (1.6) 77 (11.1)
days was 2% (66 patients). Mortality from 90 days to 2
Mortality during entire study period [%] 1.9 7.6 38.4
years was 3% (109 patients). These numbers varied
Tampe et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:62 Page 4 of 9

Fig. 1 Causes of death in different age groups

Logistic regression analysis revealed factors associated Younger males seem to be a subgroup of patients prone to
with death during the first 90 days. For early death, ad-justed violent death and self-destructive behaviour.
analysis showed that factors that elevated the risk for death
were age 65 and above and limb amputation (Table 4). Cox Mortality and SMR
regression analysis revealed risk factors for death from 90 Overall mortality after 90 days was 2%. This number is
days and beyond. For later death, the inde-pendent risk relatively low but pronouncedly higher than in the
factors were age 40 and above, limb amputa-tion, increasing population, showed by an increased SMR. In fact, SMR
length of stay and cause of accident. Fall from standing was increased in all age groups, men and women,
height was chosen as reference variable among causes of showing that the number of observed deaths exceeded the
accidents, regarded as a low energy acci-dent. Among later number of expected deaths in the population.
deaths, a fall from standing height was associated with a
higher mortality (Table 5). Connelly et al. conducted a study of 1474 patients with
tibial fractures, closed as well as open, with a long-time
Discussion follow-up of 12–22 years [15]. The mortal-ity rate in
In this nationwide study of all Swedish patients with open patients over the age of 75 years was 42%. In our study,
tibial fractures from 1998 to 2010 we found an in-crease total mortality during the study period of 13 years was
in mortality compared to the general population. 38% among patients 65–101 years. These results are
similar and also demographic data indicate a comparable
population. In a small pro-spective series of 54 elderly
patients (> 65 years) with tibial fractures the mortality
rate was 11% after 6-months follow-up [12]. No statistical
significant dif-ference was found between open and
closed fractures, in contrast to two other studies [13, 14].
Clement et al. stud-ied the outcome of 225 elderly
patients with tibia fractures during a 9 year period and
found a significantly higher mortality in patients with
open fractures compared with patients with closed
fractures (27% vs 17%, p < 0.001) [13]. They also found
an increased SMR.
Elderly patients are known to have an increased mor-
tality after injuries. This has been shown in hip fractures
[9, 23, 24], tibial fractures [12–14], open ankle fractures
[25] and polytraumatized elderly patients [26, 27]. Our
study supports this. Excess death rate was markedly
increased in the elderly. A great focus in Swedish
Fig. 2 Kaplan-Meier survival function with 95% confidence healthcare has been on hip fracture patients but in our
interval for males aged 15-60 years compared to the opinion there is a need to prioritize all elderly patients.
general population of Sweden
The impact of orthogeriatricians competency
Tampe et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:62 Page 5 of 9

Table 2 Standard Mortality Ratio (SMR) and excess death rate until 90 days after injury
Age Gender Person-years Deaths SMR (95%-CI) Expected deaths Excess deaths Excess death rate
15–39 males 286 5 28 (10–62) 0.178 4.822 1686
females 79 2 80 (13–264) 0.025 1.98 2532
40–64 males 270 8 6.8 (3.2–13) 1.17 6.83 2527
females 121 3 6.8 (1.7–19) 0.44 2.56 2119
65+ males 75 25 13 (9–19) 1.88 23.12 30,824
females 111 26 22.6 (15–74) 1.15 24.85 22,387
SMR and excess death rate in different age and gender groups until 90 days after injury. CI confidence interval

was studied in hip fracture patients [28]. In this study, individuals died relatively soon after their open frac-ture
they found that the number of orthogeriatri-cians hours and apparently the cause of death was linked to the injury
per patient had an effect to reduce mor-tality regardless of and its complications. Mortality rate con-tinued to be
time to surgery. increased even after the first months and we interpreted
Causes of death were extracted from registry data. The this as a subgroup of patients prone to dying of external
reliability of the underlying cause of death was 77% causes. Causes of death often in-dicated violent accidents
according to a study from 1995 [29]. Younger age, and self-destructive behav-iour among these patients. This
malignancies and acute diseases were associated with is consistent with work by Giannoudis et al., which
higher reliability. In our study, death was pre-dominantly demonstrated more problems with ongoing anxiety and
caused by cardiovascular and respiratory disorders (180 depression in pa-tient with Gustilo-type IIIB and IIIC
deaths, accounting for 42%), malignant neoplasms (79 fractures com-pared with the group of closed tibial
deaths, 19%) and by external causes (83 deaths, 20%). fractures [6]. This fact raises the need for interventional
External causes included accidents as well as self- measures such as psychosocial support after traumatic
destructive behaviour. As a comparison, in 2005 the injuries and sui-cide prevention. Causes of accident were
dominating causes of death in the Swed-ish population also analysed as independent risk factors for death. In our
were cardiovascular (42%) and malig-nant neoplasms study, other causes of accident than a fall on the same
(25%), whereas injuries and poisoning was the cause in plane were less associated with death. Our interpretation
only 5% of the cases [30]. In our study, external causes of this is that pa-tients with co-morbidities and frailty are
were overrepresented in all age groups and by far the prone to sustain these injuries by low-energy accidents.
most frequent cause among the youngest. This is in most Unprotected road-users as cyclists and motor bike drivers
cases explained by the acci-dent itself as leading to death. were shown to be at risk for fatal accidents in another
Among elderly patients still cardiovascular disease was study from France [31]. In our study the number of
the most common cause of death. This sub-group of individuals in those sub-groups was small, and a
elderly patients sus-tain preferably low energy accidents statistical asso-ciation may be difficult to show. Notably,
that mostly will not lead directly to death. However, they in Sweden there is a national goal of no deaths in traffic
are likely to have more co-morbidities that will be risk includ-ing work on separate roads for cyclists.
factors for cardiovascular causes of death.
Among the early deaths, a short LOS was associated
Kaplan-Meier survival curves for younger males with a higher risk of death. This illustrates the fact that
showed the increased mortality rate that was particularly many early deaths occur during the first few days after the
in-creased during the first 2 years after the injury. Most accident.

Table 3 Standard Mortality Ratio (SMR) and excess death rate from 90 days until 2 years
Age Gender Person years Deaths SMR (95%-CI) Expected deaths Excess deaths Excess death rate
15–39 males 2220 6 4.8 (2–10) 1.25 4.75 237
females 546 2 11.8 (2–39) 0.17 1.83 335
40–64 males 270 8 6.8 (3–13) 1.17 6.83 2527
females 845 5 1.6 (0.6–3.6) 3.09 1.91 227
65+ males 525 25 1.9 (1.3–2.8) 13.17 11.83 2252
females 777 55 6.8 (5–9) 8.05 46.95 6 04
SMR and excess death rate in different age and gender groups from 90 days until 2 years after injury. CI confidence interval
Tampe et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:62 Page 6 of 9

Table 4 Risk factors for death within 90 days of the injury

Crude Adjusted
OR 95%-CI p OR 95%-CI p
Gender
Males 1.0 ref 1.0 ref
Females 1.84 1.14–2.98 0.01 0.84 0.48–1.46 0.55
Age
15–39 1.0 ref 1.0 ref
40–64 1.54 0.61–4.20 0.37 1.56 0.61–4.31 0.36
65–101 23.3 11.2–56.6 < 0.005 25.7 11.8–64.8 < 0.001
Amputation
No 1.0 ref 1.0 ref
Yes 6.28 2.69–12.94 < 0.005 4.8 1.9–11.1 < 0.001
Length of stay
Unit per extra day 1.00 0.97–1.02 0.89 0.98 0.95–1.00 0.07
Mechanism of injury
Fall from standing height (n = 20) 1.0 ref 1.0 ref
Fall from height (n = 15) 0.03 0.019–0.045 0.76 1.05 0.51–2.13 0.90
Unprotected road-users (n = 14) 0.46 0.22–0.91 0.026 0.83 0.38–1.76 0.63
Car crash (n = 7) 0.77 0.30–1.76 0.56 1.65 0.61–4.06 0.29
Other vehicles/objects (n = 5) 0.42 0.14–1.05 0.087 0.74 0.23–2.01 0.58
Self-destructive injury (n = 2) 0.75 0.12–2.63 0.70 1.64 0.25–6.39 0.53
Else (n = 6) 0.69 0.25–1.64 0.43 0.68 0.23–1.71 0.44
OR odds ratio, CI confidence interval, ref reference value (adjusted for sex, age, amputation, length of stay (LOS) and mechanism of injury), p p-value, n number
of patients Logistic Regression Analysis and Cox Regression Analysis of Risk factors

Table 5 Risk factors for death from 90 days and beyond

Crude Adjusted
HR 95%-CI p HR 95%-CI p
Gender
Men 1.0 ref 1.0 ref
Women 2.39 1.95–2.94 0.005 0.94 0.75–1.17 0.58
Age
15–39 1.0 ref 1.0 ref
40–64 4.28 2.72–6.74 < 0.005 3.67 2.32–5.81 < 0.001
65–101 31.1 20.3–47.8 < 0.005 22.9 14.7–35.7 < 0.001
Amputation
No 1.0 ref 1.0 ref
Yes 2.6 1.60–4.23 < 0.005 1.79 1.08–2.95 0.02
Length of stay
Unit per extra day 1.011 1.009–1.014 < 0.005 1.01 1.009–1.017 < 0.001
Mechanism of injury
Fall from standing height (n = 66) 1.0 ref 1.0 ref
Fall from height (n = 19) 0.51 0.38–0.67 < 0.005 0.59 0.44–0.78 < 0.001
Unprotected road users (n = 8) 0.21 0.15–0.28 < 0.005 0.34 0.25–0.48 < 0.001
Car crash (n = 2) 0.21 0.13–0.36 < 0.005 0.36 0.21–0.62 < 0.001
Other vehicles/objects (n = 4) 0.17 0.10–0.29 < 0.005 0.30 0.18–0.51 < 0.001
Self-destructive injury (n = 3) 0.40 0.18–0.91 0.029 1.20 0.53–2.75 0.66
Else (n = 10) 0.43 0.29–0.63 < 0.005 0.48 0.32–0.72 < 0.001
HR hazard ratio, CI confidence interval, ref reference value (adjusted for sex, age, amputation, length of stay (LOS) and mechanism of injury), p p-value, n number of patients
Tampe et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:62 Page 7 of 9

On the other hand, among later deaths, a longer LOS analysis, are not available from the register. Further-more,
was associated with increased risk of death. A probable there is no registration of the severity of the injury such as
explanation could be that complications and co- Gustilo classification. More severe in-juries have higher
morbidities lead to longer time in hospital. We had no risk for complications, as infection and amputation, and
knowledge of co-morbidities in this set-up which is a this might influence the risk of death [33–35].
limitation of the study. In the Swedish pa-tient register,
primary diagnosis has a high validity but for co-
morbidities data are more unsecure [16]. Similar Conclusion
conclusions were drawn in another study from the Unites Absolute mortality after open tibial fracture is relatively
States [32]. Considering this, we chose not to perform low, 2% after 90 days and 3% after 2 years, although the
statistical analyses on co-morbidities. risk of death is increased for all age and gender groups
Even though this is a nationwide study of the entire compared with the Swedish general popu-lation. External
Swedish population of patients with open tibial fractures, causes of death are over-represented and indicates a
the number of deaths was low. There were subgroups with subgroup with a risky behaviour among younger males.
very few patients. Statistical associations may be difficult
to show. Patients aged 65 years and above have a pronouncedly
This is a registry study with its advantages and enhanced excess death rate after open tibial fracture and
disadvantages. Classifications like ASA (American should be treated with priority. Geriatric units and/or
Society of Anesthesiologists) class and ISS (Injury specialized geriatric care for elderly patients with trau-
Severity Score), that would have been of interest in matic injuries would be of value.

Appendix
Table 6 Death causes according to the European Shortlist in males and females in the different age groups
Death causes All Age
15–39 40–64 65+
Male Female Male Female Male Female Male Female
Respiratory 3 16 2 3 14
Circulatory
Ischemic heart disease 46 29 1 17 1 28 28
Cerebrovascular disease 9 25 3 2 6 23
Miscellaneous 18 34 1 7 2 10 32
Gastrointestinal 2 8 1 1 1 7
Mental disorders 9 13 1 1 2 7 11
Malignant neoplasms 46 33 2 20 10 24 23
Endocrine disorders 8 4 1 2 6 3
Musculoskeletal 1 1 1 1
Genitourinary 3 3
Diseases of the nervous system 8 2 6
Unknown 7 9 5 2 9
Miscellaneous 4 6 2 2 2 4
External causes
Transport accident 28 7 7 9 2 12 5
Fall 4 4 1 1 2 4
Poisoning 6 4 4 1 4 1
Suicide 8 4 6 1 1 2 1 1
Homicide 2 1 1 1 1
Drowning 2 1 1
Miscellaneous 9 4 6 2 5
Total 425 28 111 286
Tampe et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:62 Page 8 of 9

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national hospital discharge register Modig K. Declining incidence trends for hip fractures have not been
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