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What can we learn from Sweden?

Proximal femoral fractures occur more often with advancing age and especially in very old people. The projected population figures for the rest of this century indicate that the incidence of these injuries will continue to increase for the next three decades because of the increasing numbers of people over 75 years. Not surprisingly, therefore, geriatricians and orthopaedic surgeons take a common interest in this group of fractures which so often presents combined medical and social problems. Ideally a combined clinical approach is needed when the patient is admitted so that his or her medical state can be completely diagnosed before operation. In this paper we emphasize the importance of pre-existing medical abnormalities. The team should continue to devise the rehabilitation programme to suit and improve the mechanical and medical potential of each individual. By such means some patients may be medically more fit on discharge than before the accident. In this respect we are tempted to go further than Beals's8 goal of returning the patient to his prefracture state, though our ideal was not applicable to this series. Several factors affect the quality of life attainable one year after the injury, some of which can be influenced by treatment or other means and some of which are unalterable. For example, the chances of social deterioration seem to be doubled if the patient is over 75 years. We have shown that the surgical result influences the social outcome, and we hope that improved techniques, particularly directed at displaced subcapital and very unstable trochanteric fractures, will eventually achieve better results. Perhaps general acceptance of the idea of the orthopaedic-geriatric team would improve recovery rates. Nevertheless, and despite any marginal improvements that may be obtained by these means, the real need is for adequate resources in hospital and community to deal with the social consequences, especially because pre-existing social handicaps lead to further social breakdown when complicated by femoral fractures. To claim the need for resources is to state the obvious, but a larger prospective study is now being planned to measure these needs and to identify more precisely the possible ways to meet them.