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PubMed2000

The effect of muscle flap transposition to the fracture site on TNFalpha levels during fracture healing.

The trauma and sepsis that follow open fractures and wounds may lead to the production of various cytokines. Understanding wound healing requires a direct knowledge of the specific cytokines and the respective wound fluid levels that are present at the wound site. An animal model was designed that mimics the open fracture and the clinical repair of the human, high-energy open fracture. Canine right tibiae were fractured with a penetrating, captive-bolt device, then repaired in a standard clinical fashion using an interlocking intramedullary nail. Before primary wound closure, microdialysis probes were placed at the fracture site and in a muscle located at a contralateral site. Canines received one of the following experimental protocols: (1) tibial fracture (n = 5); (2) tibial fracture plus Staphylococcus aureus inoculation at the fracture site (n = 5); and (3) tibial fracture, S. aureus inoculation, and a rotational gastrocnemius muscle flap (n = 5). Microdialysis fluid samples were collected intermittently for 7 days. Tumor necrosis factor alpha (TNFalpha) levels at the fracture site were significantly elevated 3 to 34-fold (p<0.02), as compared with respective serum levels at all time points for all treatment groups. Fracture site TNFalpha levels were elevated (p<0.02) in days 1 through 6, as compared with the baseline and contralateral in all treatment groups. At days 1 through 6, the TNFalpha levels of the muscle flap group fracture site were significantly decreased by approximately 50 percent (p<0.05), as compared with the fractures without muscle flaps and regardless of additional S. aureus inoculation. On day 7, fracture site TNFalpha levels in all animal groups were similar, yet remained well above those of baseline TNFalpha. These results demonstrate that S. aureus does not further elevate TNFalpha levels in the presence of an open fracture and that a muscle flap reduces pro-inflammatory TNFalpha levels during early wound healing. This experimental model allows for the characterization of specific biological signals and cellular pathways that are influenced by bacterial infection and surgical closure. These data provide a scientific framework on which to judge or validate therapeutic regimens for open-fracture wound healing.

Animals↗
PubMedDate not supplied

Radial and tibial fracture repair with external skeletal fixation. Effects of fracture type, reduction, and complications on healing.

Twenty-eight consecutive fractures of the canine radius and tibia were treated with external skeletal fixation as the primary method of stabilization. The time of fixation removal (T1) and the time to unsupported weight-bearing (T2) were correlated with: (1) bone involved; (2) communication of the fracture with the external environment; (3) severity of the fracture; (4) proximity of the fracture to the nutrient artery; (5) method of reduction; (6) diaphyseal displacement after reduction; and (7) gap between cortical fragments after reduction. The Kruskal-Wallis one-way analysis of variance was used to test the correlation with p less than .05 set as the criterion for significance. The median T1 was 10 weeks and the median T2 was 11 weeks. None of the variables correlated significantly with either of the healing times; however, there was a strong trend toward longer healing times associated with open fractures and shorter healing times associated with closed reduction. Periosteal and endosteal callus uniting the fragments were observed radiographically in comminuted fractures, with primary bone union observed in six fractures in which anatomic reduction was achieved. Complications observed in the treatment of these fractures included: bone lysis around pins (27 fractures), pin track drainage (27 fractures), pin track hemorrhage (1 fracture), periosteal reaction around pins (27 fractures), radiographic signs consistent with osteomyelitis (12 fractures), degenerative joint disease (2 dogs), and nonunion (1 fracture). Valgus or rotational malalignment resulted in 16 malunions of fractures. One external fixation device was replaced and four loose pins were removed before the fractures healed. One dog was treated with antibiotics during the postoperative period because clinical signs of osteomyelitis appeared.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of Variance↗
PubMed1983

Classification of femoral neck fractures in the elderly as pathologic fractures.

The following distinctions can be made between fractures of the femoral neck in elderly persons and similar fractures in younger patients: They are much more common in the elderly. They are more frequent in females than in males. There is a much higher incidence in the white than in the black population. Fractures of the opposite hip are more common in the elderly. Associated medical conditions in the elderly may make the patient more susceptible to falls and may increase the degree of osteopenia. There is a high rate of mortality in elderly patients within 1 year of the fracture. Minor trauma causes many of the fractures in elderly patients whereas severe trauma is usually the mechanism in younger ones. Osteopenia is more common in elderly women and places them at higher risk for fracture. Microfractures of the femoral head and neck may add to the high incidence of fracture in elderly persons. The anatomic configuration of the fracture is different in elderly patients, with impacted and displaced subcapital fractures more common. The incidence of union of the fracture is the same in older and younger patients, but in the older patient multiple pin fixation is necessary for impacted and nondisplaced fractures; also, in displaced fractures a device with side plate fixation is necessary to maximize fracture healing. The incidence of avascular necrosis is approximately the same in older and younger individuals, but revascularization of the avascular segment in older patients is a limited process. On the basis of these observations, fractures of the femoral neck in the elderly should be classified as pathologic fractures. There is a need for improved methods of reducing and treating nonunion and avascular necrosis, but also there is a need to obtain more data concerning factors related to the patient and to the quality of bone. Thus, it is hoped, some of these fractures can be prevented and better treatment can be provided.

Adolescent↗
PubMed1999

Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group.

BACKGROUND: Osteoporotic fractures, including clinically detected vertebral fractures, are associated with increased mortality. However, only one third of vertebral fractures are diagnosed. It is unknown whether vertebral fractures, whether clinically apparent or not, are associated with greater mortality. OBJECTIVES: To test the hypothesis that women with prevalent vertebral fractures have greater mortality than those without fractures and to describe causes of death associated with vertebral fractures. DESIGN: Prospective cohort study with mean follow-up of 8.3 years. SETTING: Four clinical centers in the United States. PARTICIPANTS: A total of 9575 women aged 65 years or older and enrolled in the Study of Osteoporotic Fractures. MEASUREMENTS: Vertebral fractures by radiographic morphometry; calcaneal bone mineral density; demographic, medical history, and lifestyle variables; blood pressure; and anthropometric measures. In a subset of 606 participants, thoracic curvature was measured during a second clinic visit. MAIN OUTCOME MEASURES: Hazard ratios for mortality and cause-specific mortality. RESULTS: At baseline, 1915 women (20.0%) were diagnosed as having vertebral fractures. Compared with women who did not have a vertebral fracture, women with 1 or more fractures had a 1.23-fold greater age-adjusted mortality rate (95% confidence interval, 1.10-1.37). Mortality rose with greater numbers of vertebral fractures, from 19 per 1000 woman-years in women with no fractures to 44 per 1000 woman-years in those with 5 or more fractures (P for trend, <.001). In particular, vertebral fractures were related to the risk of subsequent cancer (hazard ratio, 1.4;95% confidence interval, 1.1-1.7) and pulmonary death (hazard ratio, 2.1;95% confidence interval, 1.4-3.0). In the subset of women who underwent thoracic curvature measurements, severe kyphosis was also related to pulmonary deaths (hazard ratio, 2.6;95% confidence interval, 1.3-5.1). CONCLUSION: Women with radiographic evidence of vertebral fractures have an increased mortality rate, particularly from pulmonary disease and cancer.

Aged↗
PubMed2005

Fracture prediction by bone density measurements at sites other than the fracture site: the contribution of BMD correlation.

It is widely believed that the most reliable BMD measurement for predicting fracture risk at any given skeletal site is one made at the fracture site itself. This study examines the hypothesis that the ability of BMD measurements at other distant sites in the skeleton remote from the fracture site to predict fracture risk is due to their correlation with the BMD measurements at the fracture site. We refer to this assumption as the correlation hypothesis. We show that the correlation hypothesis predicts the relationship betadist = rbetafrac, where beta is the gradient of the exponential relationship between fracture risk and Z-score, betafrac is the beta-value for the fracture site, betadist the beta-value for the distant BMD site, and r is the correlation coefficient between the Z-scores at the two sites. In practice it is important to consider the effect of BMD measurement errors on the (r, beta) relationship. We show that the effect of errors at the distant site is to reduce betadist and r in a way that preserves their original relationship. When errors at the fracture site are taken into account the effect on the (r, beta) plot is for the point representing the fracture site to fall below the extrapolation of the straight-line relationship predicted for the points representing the distant BMD sites. We tested the correlation hypothesis by using data from the Study of Osteoporotic Fractures to examine the (r, beta) plots for hip, spine and forearm fractures. For the hip the data are consistent with a straight-line relationship and suggest that measurements made at other sites provide no additional information about fracture risk over and above that provided by hip BMD itself. For spine and forearm fractures the data show that distant sites do provide additional information about fracture risk in a way that is quantitatively consistent with the BMD measurement errors reported in cadaver studies. It is clear that random BMD errors at the fracture site cause loss of information about fracture risk and that some of this lost information is recoverable from measurements made at other sites in the skeleton. Overall, this study points to BMD correlation as an important factor in explaining the ability of measurements made at distant sites to predict fracture risk.

Absorptiometry, Photon↗
PubMed1998

Relationships between risk factors and fractures differ by type of fracture: a population-based study of 12,192 perimenopausal women.

Relationships between selected factors and fractures according to type of fracture were retrospectively examined in 12,192 women aged 47-56 years responding to the baseline postal enquiry of the Kuopio Osteoporosis Study, Finland, in 1989. A total of 1358 women reported fractures sustained during the previous 9.4 years, i.e. at ages 38-57 years. The incidence of fractures per 1000 person-years was 17.2 after menopause and 9.5 before (p < 0.0001). The adjusted fracture risk was elevated in smokers versus non-smokers (OR = 1.5; (95% CI = 1.3-1.9) and in those with chronic health disorders versus the healthy (OR = 1.3; 95% CI 1.1-1.5). Long-term work disability was associated with fractures independently of health disorders (OR = 1.3; 95% CI 1.1-1.6). Anthropometric measures were not associated with the overall fracture risk. Menopause was strongly and linearly related to wrist fracture but not to ankle fracture. A 1 SD increase in body mass index decreased the risk of wrist fracture by 21% (p = 0.0001) but increased that of ankle fracture by 24% (p = 0.002). Smoking was related to ankle fracture (OR = 2.2; 95% CI 1.6-3.2) but not to wrist fracture (OR = 0.9; 95% CI 0.6-1.4). Health disorders were more markedly associated with fractures other than those of the wrist or ankle. Relationships between several risk factors and pre- and perimenopausal fractures vary by type of fracture. This may affect, for example, the comparability of studies with varying fracture profiles.

Adult↗
PubMed2002

Classificational problems in ligamentary distraction type vertebral fractures: 30% of all B-type fractures are initially unrecognised.

The clinical records, operation records, X-rays and CT-scans of 160 operatively treated patients with A-type and B-type spinal fractures were evaluated in a retrospective study. The preoperative diagnosis was compared with the postoperative diagnosis. Analysis of characteristics of patients with A-type fractures (without the unrecognised B-type fractures), initially unrecognised B-type (uB) fractures, and B-type fractures (without the unrecognised B-type fractures) was performed. We analysed the age of the patients, the respective fracture levels, neurologic deficit, anterior wedge angles (AWA), anterior corporal height (ACH), posterior corporal height (PCH), and the percentage of frontal corporal collapse (FCC). The t-test was used for statistical analysis. The mean age of patients in each group did not show a significant difference. The group of unrecognised B-fractures had a more caudal fracture level than the recognised B-type fractures. The fracture levels of the A-group and the uB-group patients showed no difference using the t-test. The percentage of patients with spinal fractures with neurologic deficit is 16% in the A-type fracture group, 12% in the uB-fracture group and 50% in the B-type group. The preoperative classification of patients in the A-group and in the uB-group showed that patients in the uB-group have more than proportional relatively simple preoperative A-fractures. The AWA and ACH did not show significant differences between the groups. The mean PCH of the uB-group was higher than the PCH of the A-group. No differences were measured between the uB-group and the B-group. The mean percentages of frontal corporal collapse (FCC) did not show a significant difference. Thirty percent of B-type fractures are misdiagnosed when plain X-rays and CT scans with 2D reconstructions are used as the only preoperative diagnostic tools. A large PCH with a normal interspinous distance should raise the suspicion of a B-type lesion. A large AWA does not point to a ligamentary B-type fracture.

Adult↗
PubMed2006

Fractures and recurrent fractures in children; varying effects of environmental factors as well as bone size and mass.

BACKGROUND: Fractures are frequent in childhood and cause considerable morbidity. Previous reports have indicated a variety of potential contributors to fracture risk including low bone mineral content and density, milk avoidance, lack of exercise, asthma, obesity, and a high consumption of carbonated beverages. AIMS: We wished to test the hypothesis that children who sustain recurrent fractures have a lower bone mass and a higher prevalence of underlying risk factors for fracture than those who fracture once or not at all. METHODS: We studied 150 children aged 4-16 years: 50 who had suffered recurrent fractures, 50 who had fractured for the first time, and 50 fracture-free controls. Subjects underwent assessment of bone size and mass by total body (TB) and lumbar spine (L2-4) dual energy X-ray absorptiometry (DXA). Values were adjusted for body size, based on the control group measurements as unadjusted DXA values are substantially influenced by size in children. Anthropometry and grip dynamometry were carried out, and information about factors implicated in fracture aetiology such as milk intake, physical activity levels, asthma prevalence and carbonated beverage consumption were recorded using questionnaires. RESULTS: Children who had sustained one or more fractures had a significantly lower BMC and aBMD at all sites than controls after conversion to size adjusted z scores (L2-4 BMC P = 0.0002; L2-4 aBMD P < 0.0001; TB BMC P < 0.0001; TB aBMD P < 0.0001); estimates for TB excluded fracture sites. There was, however, no difference in adjusted bone mass between children with one and those with recurrent fractures. Children with recurrent fractures had a significantly lower milk intake, lower levels of physical activity, a higher BMI, and a higher consumption of carbonated beverages than controls. The prevalence of risk factors was not, however, significantly higher than controls in children with a single fracture. CONCLUSIONS: Children with fractures have a lower bone mass for body size than children without fractures. Modifiable risk factors such as diet and exercise increase the risk of recurrent fractures.

Adolescent↗
PubMed2006

Risk of thoracolumbar fractures doubled in victims of motor vehicle collisions with cervical spine fractures.

BACKGROUND: An association between cervical fractures and thoracolumbar fractures after blunt trauma has long been assumed, but not adequately demonstrated. We sought to determine the actual association between these injuries in a large nationwide data set. METHODS: The National Trauma Databank (NTDB) was queried for victims of blunt vehicular trauma with at least minimal injury. An odds ratio was calculated for the association between cervical spine fractures and thoracolumbar fractures. RESULTS: Overall 190,183 NTDB patient records met the criteria of a motor vehicle crash with more than minimal injury. Of these 7.51% (14,292) had cervical spine fractures, 4.73% (8,996) had thoracic spine fractures, 5.93% (11,280) had lumbar spine fractures, and 9.79% (18,623) had either thoracic or lumbar fractures. Of patients with a cervical spine fracture, 13.06% (2,433) also had a thoracic or lumbar fracture, whereas among patients without cervical spine fracture only 6.91% (11,859) had a thoracolumbar fracture. The odds ratio (OR) for a thoracolumbar fracture in the presence of a cervical spine fracture was 2.02 (p < 0.0001) (95% confidence interval 1.9318-2.1201). CONCLUSION: These data confirm a strong association between cervical spine fractures and thoracolumbar fractures after blunt vehicular trauma, and support the practice of imaging the complete spine when a cervical fracture is identified.

Accidents, Traffic↗
PubMed2004

beta-Blocker use, BMD, and fractures in the study of osteoporotic fractures.

UNLABELLED: A role for osteoblastic beta-adrenoreceptors in bone regulation is suggested by the finding that beta-blockers increase bone mass in mice. We studied the association of beta-blocker use with BMD and fractures in the Study of Osteoporotic Fractures. beta-blocker use and BMD are unrelated in this cohort, and associations with fracture risk are inconsistent. INTRODUCTION: The central nervous system has been shown to regulate bone mass in mice, possibly by way of the beta(2)-adrenoreceptors on osteoblasts. beta-blockers have been shown to increase bone mass in mice. Because these agents are widely used therapeutically, it is possible that they may influence fracture epidemiology in humans, and they are a potential therapy for osteoporosis. MATERIALS AND METHODS: We have studied the association of beta-blocker use with BMD and fracture rates in the Study of Osteoporotic Fractures. beta-blocker use was recorded at the fourth visit, in 8412 women, of whom 1099 were users, and these women were followed for 7 years. RESULTS: Users had significantly higher weight, more thiazide use, more estrogen use, less glucocorticoid use, more statin use, and more hypertension than nonusers, and they smoked less. Total hip BMD at the fourth visit was higher in the beta-blocker users (0.746 versus 0.735 g/cm(2), p = 0.02), but adjustment for weight alone, or together with these other variables, eliminated this difference (p = 0.62). There was no effect of beta-blocker use on loss of hip BMD over a mean follow-up of 4 years (p = 0.48). Os calcis BMD at visit 4 was also higher in those taking beta-blockers (0.385 versus 0.375 g/cm(2), p = 0.005), but weight adjustment eliminated this difference (p = 0.14). The frequencies of hip or any fracture (since age 50) were similar in users and nonusers (p = 0.80 and p = 0.51, respectively). Over a mean follow-up of 7 years, there were 2167 total fractures, including 431 at the wrist and 585 at the hip. Among beta-blocker users, hazards ratios were 0.92 (0.81, 1.05) for any fracture, 0.74 (0.54, 1.01) for wrist fracture, and 0.76 (0.58, 0.99) for hip fracture. Adjustment for weight and other factors previously shown to influence hip fracture incidence in this cohort made little difference to the outcome. When fracture data were analyzed for nonselective and beta(1)-selective agents separately, trends toward fewer fractures were confined to the users of selective beta(1)-blockers. CONCLUSIONS: beta-Blocker use and BMD are unrelated in this cohort, and associations with fracture risk are inconsistent. Therefore, a history of use of these drugs is not useful in assessing fracture risk, nor do they have a role in osteoporosis management at this time. The relationship between beta-blocker use and hip fracture deserves further study.

Adrenergic beta-Antagonists↗
PubMed1999

Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures.

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.

Facial Asymmetry↗
PubMed2003

The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture.

INTRODUCTION: Fracture care often represents the first opportunity for clinical management of osteoporosis; however, many patients do not receive any evaluation after a fracture. In Glasgow, Scotland, fewer than 10% of fracture patients underwent bone mineral density (BMD) testing. In an effort to better meet the needs of fracture patients by providing routine assessment and, where necessary, treatment for osteoporosis after their fracture, a novel service (The Fracture Liaison Service) was designed and implemented in two separate National Health Service trusts in Glasgow. METHODS: An agreed-upon standard of care for men and women 50+ years of age with fractures was established in collaboration with orthopedic surgeons and primary care physicians. The Fracture Liaison Service assumes responsibility for fracture case-finding and for assessing and performing diagnostic evaluations (including axial DXA), and making specific treatment recommendations for the secondary prevention of osteoporotic fractures. RESULTS: During the first 18 months of operation, more than 4,600 patients with fractures of the hip, wrist, humerus, ankle, foot, hand, and other sites were seen by the Fracture Liaison Service's osteoporosis specialist nurses. Nearly three quarters of these patients were considered for BMD testing; treatment was recommended for approximately 20% of the patients without need for BMD testing. Overall, 82.3% of patients who had BMD testing were found to be osteopenic or osteoporotic at the hip or spine. CONCLUSIONS: The Fracture Liaison Service has successfully identified and evaluated most patients with fractures. Only those patients who declined were not evaluated. The ultimate success of the program will be measured by the subsequent fracture experience of these patients, but clear improvements in diagnosing and treating low bone mineral density in patients with fracture have already been demonstrated.

Absorptiometry, Photon↗
PubMed1999

Forearm fractures as predictors of subsequent osteoporotic fractures.

To assess the ability of distal forearm fractures to predict future fractures, we conducted a population-based retrospective cohort study among the 1288 residents (243 men, 1045 women) of Rochester, Minnesota age 35 years or older who experienced their first distal forearm fracture in 1975-94. During 9664 person-years of follow-up, 548 patients experienced 1109 subsequent fractures, excluding 195 that occurred on the same day as the index forearm fracture. The cumulative incidence of any subsequent fracture was 55% by 10 years and 80% by 20 years following the initial distal forearm fracture. Compared to expected fracture rates in the community, the risk of a hip fracture following the index forearm fracture was increased 1.4-fold in women (95% CI, 1.1-1.8) and 2.7-fold in men (95% CI, 0.98-5.8). In women, the risk of hip fracture differed by age, as we had found in a previous study. Women over age 70 had a 1.6-fold increase (95% CI, 1.2-2.0) in subsequent hip fracture risk whereas women who sustained their first forearm fracture before age 70 years did not have significantly increase risk. By contrast, vertebral fractures were significantly increased at all ages, with a 5.2-fold increase (95% CI, 4.5-5.9) in risk among women and a 10.7-fold increase (95% CI, 6.7-16.3) among men following a first distal forearm fracture. The increased risk in men suggests that a sentinel forearm fracture should not be ignored. Among the women, we also found a missed opportunity for intervention as hormone replacement therapy was underutilized.

Adult↗
PubMed2007

Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol.

BACKGROUND: An ipsilateral fracture of the femoral neck is seen in association with 1% to 9% of femoral shaft fractures, and 20% to 50% of these injuries are missed initially. Recognition of an associated femoral neck fracture prior to stabilization of the femoral shaft fracture is imperative to avoid or minimize complications of displacement and osteonecrosis. METHODS: A protocol to look for a femoral neck fracture in all patients with a femoral shaft fracture was instituted at a single level-I trauma center. This protocol consisted of a dedicated anteroposterior internal rotation plain radiograph, a fine (2-mm) cut computed tomographic scan through the femoral neck, and an intraoperative fluoroscopic lateral radiograph prior to fixation as well as postoperative anteroposterior and lateral radiographs of the hip in the operating room prior to awakening the patient. A chi-square analysis comparing pre-protocol and post-protocol fracture prevalences was used to assess the relative risk of missing an associated femoral neck fracture. RESULTS: Two hundred and sixty-eight consecutive patients with a femoral shaft fracture formed the basis of the study group. Of 254 who were followed for at least two months, sixteen were identified as having an associated ipsilateral femoral neck fracture with use of the protocol. Thirteen associated femoral neck fractures were identified before the patient entered the operating room for definitive fixation, and twelve of them were identified with the fine-cut computed tomographic scan. One fracture was identified intraoperatively. There was one iatrogenic fracture and one delayed diagnosis of a femoral neck fracture. With this protocol, we reduced the delay in diagnosis by 91% as compared with our experience in the year prior to the initiation of the protocol. CONCLUSIONS: In the presence of a femoral shaft fracture, evaluation of the femoral neck with fine-cut computed tomography and dedicated internal rotation hip radiographs significantly improves the ability to diagnose an associated femoral neck fracture.

Adult↗
PubMed2005

Fragility fracture-related direct medical costs in the first year following a nonvertebral fracture in a managed care setting.

The objective of this study was to estimate the fracture-related direct medical costs during the first year following a fragility nonvertebral fracture in a managed care setting. This was a retrospective cohort study conducted among patients (aged 45+ years) with a primary diagnosis for a fragility nonvertebral fracture between July 1, 2000, and December 31, 2000, using MarketScan, an integrated administrative, medical, and pharmacy claims database. All patients had 6 months of observation prior to their fracture and 12 months following a nonvertebral fracture. Fracture-related direct medical costs were evaluated in the 12-month period following fracture diagnosis using 2003 Medicare fee schedule payments. The costs per fracture per year (PFPY) for specific nonvertebral fracture sites were determined, as well as costs by type of care (i.e., outpatient, inpatient, and other). A total of 4,477 women and men fulfilled the inclusion criteria. The sample was comprised of 73% women and the mean age was 70 years. The most prevalent nonvertebral fracture sites were wrist/forearm (37%), hip (25%), and humerus (15%). Mean total costs per patient per year were highest for fractures of the hip ($26,856), femur ($14,805), tibia ($10,224), and pelvis ($10,198). On average, 84% of the annual fracture-related costs were inpatient; 3% were outpatient, and 13% were long-term care and other costs. In a patient population aged 45+ years, the first month following a nonvertebral fracture has a major impact on medical care costs. The most costly nonvertebral fracture sites were hip, femur, and tibia fractures.

Age Distribution↗
PubMed2004

Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures.

OBJECTIVE: To summarize the complications and early clinical results of 123 distal femur fractures treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA). DESIGN: Retrospective analysis of prospectively enrolled patients. SETTING: Two academic level I trauma centers. SUBJECTS AND PARTICIPANTS: One hundred nineteen consecutive patients with 123 distal femur fractures (OTA type 33 and distal type 32 fractures) treated by 3 surgeons. One hundred three fractures (68 closed fractures and 35 open fractures) in 99 patients were followed up at least until union (mean follow-up = 14 months, range: 3-50 months). INTERVENTION: Surgical reduction and fixation of distal femur fractures. MAIN OUTCOME MEASUREMENTS: Perioperative complications, radiographic union, infection rate, loss of fixation, alignment, and range of motion. RESULTS: Ninety-six (93%) of 103 fractures healed without bone grafting. All fractures eventually healed with secondary procedures, including bone grafting (1 of 68 closed fractures and 6 of 35 open fractures). There were 5 losses of proximal fixation, 2 nonunions, and 3 acute infections. No cases of varus collapse or screw loosening in the distal femoral fragment were observed. Malreductions of the femoral fracture were seen in 6 fractures (6%). The mean range of knee motion was 1 degrees to 109 degrees . CONCLUSIONS: Treatment of distal femur fractures with the LISS is associated with high union rates without autogenous bone grafting (93%), a low incidence of infection (3%), and maintenance of distal femoral fixation (100%). No loss of fixation in the distal femoral condyles was observed despite the treatment of 30 patients older than 65 years. The LISS is an acceptable surgical option for treatment of distal femoral fractures.

Adult↗
PubMed1999

Incremental cost of medical care after hip fracture and first vertebral fracture: the Rotterdam study.

The aim of this study was to estimate the additional cost of medical care (the incremental cost) caused by incident hip and vertebral fractures, using a matched case cohort design within a longitudinal follow-up study. Incident hip fractures were recorded using the regular follow-up system of the Rotterdam Study. Incident vertebral fractures were recorded by morphometric comparison of spinal radiographs taken at intervals of 2.2 years on average. The matched control group was randomly selected from other participants of the Rotterdam Study in whom no fracture occurred during follow-up, but who were otherwise comparable at baseline. Cases were matched for age, gender, self-perceived health, ability to perform activities of daily life, living situation and general practitioner. Medical expenditure was assessed by retrieval of the general practice medical records and by recording all hospital and nursing home admissions, and all general practice and outpatient visits. Pharmaceutical consumption was recorded through the computerized records of the central pharmacy. Valid results were obtained for 44 pairs (91%) in the hip fracture and for 42 pairs (93%) in the vertebral fracture group. Cost of medical consumption in the year before the hip fracture was similar in patients and control subjects, but the incremental cost in the first year after the hip fracture was almost US$10 000. In the second year after hip fracture the incremental cost was still about $1000. Accounting for the excess mortality in hip fracture patients had little effect on cost in the first year, but cost in the second year was doubled to almost $2000. For vertebral fractures, we did not detect important acute care costs, but these fractures were associated with a yearly recurrent incremental cost of over $1000. However, almost half this difference was already present before the occurrence of the fracture, and was attributable to hospital admissions. The remainder of the incremental cost was mainly due to pharmaceutical consumption and to a lesser extent to admissions to orthopedic surgery wards. We conclude that hip fractures cause excess mortality and an important incremental cost especially during the first year, and that these could probably be avoided by prevention of hip fractures. For vertebral fractures we found no evidence of important acute care costs but we observed a yearly returning incremental cost. Part of this incremental cost, however, was pre-existing and might therefore by caused by co-morbidity.

Aged↗
PubMed2001

Acute and long-term increase in fracture risk after hospitalization for vertebral fracture.

The aims of this study were to determine the magnitude of the increase in risk of further fracture following hospitalization for vertebral fracture, and in particular to determine the time course of this risk. The records of the Swedish Patient Register were examined from 1987 to 1994 to identify all patients who were admitted to hospital for thoracic or lumbar vertebral fractures. Vertebral fractures were characterized as due to high- or low-energy trauma. Patients were followed for subsequent hospitalizations for hip fracture, and for all fractures combined. A Poisson model was used to determine the absolute risk of subsequent nonvertebral fracture and compared with that of the general population. We analyzed 13.4 million hospital admissions from which 28,869 individuals with vertebral fracture were identified, of which 60% were associated with low-energy trauma. There was a marked increase in subsequent incidence of hip and all fractures within the first year following hospitalization for vertebral fracture in both men and women. Thereafter, fracture incidence declined toward, but did not attain, baseline risk. Increased risks were particularly marked in the young. The increase in fracture risk was more marked following low-energy vertebral fracture than in the case of high-energy trauma. We conclude that the high incidence of new fractures within a year of hospitalization for vertebral fractures, irrespective of the degree of trauma involved, indicates that such patients should be preferentially targeted for treatment. It is speculated that short courses of treatment at the time of first vertebral fracture could provide important therapeutic dividends.

Acute Disease↗