Re: Comparison of outcomes between hip fracture patients with concurrent upper limb injuries and patients with an isolated hip fracture

I read with great interest the article by Ng et al. They found that 4.1% of patients with hip fractures had concurrent upper limb injuries who might require longer rehabilitation period. However, no significant differences were revealed regarding acute length of stay and mortality at discharge as well as at 30 days. I am delighted to see that the orthogeriatric service has been popularized in the Western Australia to facilitate multidisciplinary treatment of hip fractures. However, I think some critical issues have to be clarified in the article. First, geriatric hip fractures are mainly induced by a lowenergy mechanism, but these fractures in the young adults are predominantly caused by high energy with more concurrent injuries. This study enrolled patients over the age of 50 years, but not 65 and more, and used average age to reflect the distribution of the critical baseline data. I think a median age with quantile might be better for comparison, due to the wide range of age (50~102). Second, hip fracture is a fuzzy concept. Femoral neck fractures, intertrochanteric fractures and even rare subtrochanteric fractures are all considered as hip fractures. Furthermore, each type of fractures has detailed classification method, which represents the severity, indications for surgery and prognosis. Third, more common co-morbidities, except for dementia, should be taken into consideration in the elderly. Stroke, cardiovascular disease, chronic pulmonary disease and renal failure are all considerable to affect post-operative rehabilitation. Finally, the authors also did not tell us the treatment protocol in these patients. For femoral neck fractures, total hip arthroplasty or hemiarthroplasty is the treatment of choice. However, internal fixation with intramedullary nail and sliding hip screw is normally recommended for intertrochanteric fractures. Therefore, the rehabilitation strategies following different protocols varied, and may be individualized for patients with multiple injuries.