Clin Proc 2001 Mar;76(3):295-8
Medical care of elderly patients with hip fractures.
Huddleston JM, Whitford KJ
Division of Area General Internal Medicine, Mayo Clinic, Rochester, Minn
55905, USA. email@example.com
Medical morbidity associated with hip fractures in the elderly population
is considerable. The all-cause mortality rate is 24% at 12 months. The
functional limitations of survivors can be pronounced. As the American
population ages, hip fractures will substantially affect the utilization
of hospital resources. Several issues, including preoperative clearance
and related surgical timing, deep venous thrombosis prophylaxis, delirium,
nutrition, and urinary tract management, are important in the care of
these patients. A close partnership between orthopedic surgeons and
clinicians provides the best strategy of care for the subset of patients
with multisystemic complications.
J Rheumatol 2000 Sep;27(9):2227-31
Mortality and morbidity after hip fracture: can evidence based clinical
pathways make a difference?
March LM, Cameron ID, Cumming RG, Chamberlain AC, Schwarz JM, Brnabic AJ,
O'Meara P, Taylor TF, Riley S, Sambrook PN
University of Sydney Professorial Department of Rheumatology, Royal North
Shore Hospital, St. Leonards, NSW, Australia. firstname.lastname@example.org
OBJECTIVE: To evaluate whether evidence based clinical pathways for acute
management of hip fracture have an effect on patient care, short term
mortality, or residential status. METHODS: Observational cohort study
comparing management, as determined by medical record review, and outcomes,
as determined by telephone followup 4 months post-fracture, before (n =
455) and after (n = 481) clinical pathway implementation within pathway
hospitals as well as between patients admitted to hospitals with (n = 2)
and without (n = 4) pathways. RESULTS: Mean age was 82 years, 80% were
women and 30% were admitted from nursing homes. Significant improvement in
best practice as recommended by evidence based clinical guidelines was
evident in pathway hospitals for most components of care. However,
compliance was variable and nonpathway hospitals performed better for some
(use of spinal anesthesia, avoidance of urinary catheters). After
adjusting for potential confounders, no difference was found in 4 month
mortality between the pathway (17.6%) and non-pathway (16.8%) patients (OR
0.8, 95% CI 0.5-1.5). There was a nonsignificant reduction in median acute
care hospital length of stay of 1 day (p = 0.200) for non-nursing home
patients and a significant reduction of 1 day (p = 0.038) for nursing home
patients in the pathway hospitals. There was a nonsignificant decrease in
admission rates for new patients to nursing homes in pathway hospitals
(18.5%) compared to non-pathway hospitals (24.3%) (OR 0.5, 95% CI
0.3-1.1). CONCLUSION: Clinical pathways were associated with increased use
of evidence based best practice, some reduction in acute hospital length
of stay, but no significant effect on 4 month mortality or residential
status. Their development and maintenance were resource intensive and
further work on the implementation of evidence based guidelines is needed
to determine whether they can influence patient outcomes.
J Rheumatol 2000 Sep;27(9):2071-3
Integrated care pathways in hip fracture management: demonstrated benefits
Syed KA, Bogoch ER
Clin Orthop 2000 Aug;(377):15-23
Diagnosis and imaging studies of traumatic hip dislocations in the adult.
Brooks RA, Ribbans WJ
Department of Orthopaedics, Northampton General Hospital, UK.
Traumatic dislocation of the hip represents a major injury that is
associated with significant morbidity. In particular, the risk of
osteonecrosis of the femoral head is greatly affected by the time it takes
to reduce the hip. Therefore, thorough understanding of the clinical and
radiologic features is essential if this injury is to be recognized and
treated promptly. Most patients present in severe distress after a high-energy
injury such as a motor vehicle accident. Associated injuries, particularly
of the knee, are common and the leg usually is held in a specific posture
characteristic of the direction of dislocation. Plain anteroposterior
radiographs of the pelvis will clearly show the dislocation in most
patients but lateral views or a computed tomography scan may be required
to confirm the diagnosis and to show the direction if the signs are subtle.
Associated acetabular wall fractures and femoral head fractures also may
be identified by computed tomography scans. After reduction, plain
radiographs alone are not adequate to assess reduction; computed
tomography is more sensitive in detecting osteochondral fragments and may
reliably detect residual subluxation of 2 mm in any part of the joint.
Magnetic resonance imaging is useful in detecting changes of osteonecrosis
but rarely is indicated in the early treatment of this condition.
Med Clin (Barc) 2000;114 Suppl 2:79-84
[Effect of alendronate on bone mineral density and incidence of fractures
in postmenopausal women with osteoporosis. A meta-analysis of published
[Article in Spanish]
Arboleya LR, Morales A, Fiter J
Unidad de Reumatologia, Hospital de Cabuenes, Gijon.
BACKGROUND: To perform a systematic review, completed with a meta-analysis,
of the published evidences about the effect of oral alendronate on bone
mineral density and the incidence of fractures in postmenopausal women
with low bone mass. METHODS: We search for all alendronate clinical trials
in postmenopausal women with low bone mass which were randomized, double
blind, placebo controlled, with a duration of one year or more and with
bone mineral density measurement and/or fractures as outcomes. We used the
weighted average of individual study results as an estimation of the
global effect. RESULTS: Seven studies meet all the inclusion criteria.
Relative Risks (RR) with 95% Confidence Intervals (CI 95%) for the
combined effect under fixed effects model were: RR 0.54 (CI 95%: 0.45 to
0.66) for vertebral fractures, RR 0.81 (CI 95%: 0.72 to 0.92) for non
vertebral fractures and RR 0.64 (CI 95%: 0.40 to 1.01) for hip fractures.
CONCLUSIONS: Our results demonstrate that alendronate reduces the risk of
vertebral, non vertebral and hip fractures in postmenopausal women with
low bone mass. This meta-analysis allows the classification of alendronate
anti-fracture evidences in the highest level.
Geriatrics 2000 Apr;55(4):50-2, 55-6 [Texto
completo en formato PDF]
Hip fracture. Surgical decisions that affect medical management.
Mount Sinai School of Medicine, New York, NY, USA.
Primary care physicians can provide optimal care for their older patients
with hip fracture when they are familiar with the repair techniques used
by the orthopedic surgeon. For medically stable patients, surgical repair
is now recommended 24 to 72 hours after the fracture. The type of surgery
depends on the type of fracture and the degree of the patient's
prefracture mobility; options range from simple percutaneous pinning to
total hip replacement. Surgery is not advisable for bed-ridden or moribund
patients, nor for those with very osteoporotic bones and extensively
comminuted fractures. Complications of a hip fracture and its surgical
repair that require medical management include anemia, phlebitis,
pulmonary embolism, decubitus ulcer, fluid or electrolyte imbalance, and
Emerg Med Clin North Am 2000 Feb;18(1):29-66, v
Emergency department evaluation and treatment of hip and thigh injuries.
Rudman N, McIlmail D
Department of Emergency Medicine, Cape Cod Hospital, Hyannis,
This article reviews the clinical and diagnostic evaluation of patients
with injuries to the hip and thigh. The history and physical examination,
appropriate imaging strategies, complications and associated injuries,
analgesia, treatment, and appropriate patient disposition are emphasized.
Hosp Pract (Off Ed) 1998 Sep 15;33(9):131-2, 135-6
Evaluation and treatment of hip pain.
Ann Intern Med 1998 Jun 15;128(12 Pt 1):1010-20 [Texto
The medical consultant's role in caring for patients with hip fracture.
Morrison RS, Chassin MR, Siu AL
Mount Sinai School of Medicine, New York, New York 10029, USA. email@example.com
BACKGROUND: Hip fractures are an important cause of death and functional
dependence in the United States. PURPOSE: To review the evidence for
clinical decisions that medical consultants make for patients with hip
fracture and to develop recommendations for care. DATA SOURCES: Published
reports of clinical studies were found by searching MEDLINE and selected
bibliographies. STUDY SELECTION: Studies were included if data were
presented on clinical interventions to improve care of conditions
typically encountered by medical consultants in the care of patients with
hip fracture. Such conditions include timing of surgery, infection
prophylaxis, thromboembolic prophylaxis, postoperative nutritional
management, urinary tract management, prevention and management of
delirium, application and timing of rehabilitation services, and
prevention of subsequent falls. Meta-analyses; randomized, controlled
trials; or other controlled studies were included if possible. If no such
trials were identified, the best evidence from studies with other designs
was included. DATA EXTRACTION: Interventions were selected on the basis of
their efficacy or potential efficacy in improving functional outcome.
Trials with positive and negative results were compared for differences in
intervention and strength of study methods. DATA SYNTHESIS: Strong
evidence supports medical recommendations for decisions about timing and
duration of prophylactic antibiotics, selection of thromboembolic
prophylaxis, urinary tract and nutritional management, and rehabilitative
services. Many case series support early surgical repair, although
patients who would benefit from delay and further medical work-up have not
been well identified. Evidence for decisions about assessment of
subsequent risk for fall and risk for and management of delirium is based
largely on data from patients without hip fracture but is probably
applicable. Future research should target optimal duration of
thromboembolic prophylaxis, cost-effectiveness of low-molecular-weight
heparin compared with that of other thromboembolic prophylactic regimens,
management of delirium, rehabilitative services, and efficacy of
assessment of risk for later falls. CONCLUSIONS: The data suggest that
evidence-based medical care can improve hip fracture outcomes. The medical
consultant has a key role in providing this care and managing the
preoperative conditions and postoperative complications that may affect
optimal functional recovery.
Am Fam Physician 1998 Mar 15;57(6):1314-22 [Texto
Pitfalls in the radiologic evaluation of extremity trauma: Part II. The
Shearman CM, el-Khoury GY
University of Iowa College of Medicine, Iowa City, USA.
Fractures of the lower extremity are common reasons for visits to family
physicians. Some lower extremity fractures are especially likely to be
missed. Examples of lesions that commonly go unrecognized include sacral
insufficiency or fatigue fracture, fracture of the femoral neck (especially
if the fracture is nondisplaced and/or impacted), tibial plateau fracture,
Segond fracture (vertical fracture of the lateral tibia), patellar
fracture, calcaneal fracture of the foot, Lisfranc fracture/dislocation of
the tarsometatarsal apparatus, and Jones fracture of the fifth metatarsal.
Lower extremity fracture in children may suggest the possibility of child
abuse, especially in the case of multiple or bilateral fractures.
Postgrad Med 1998 Jan;103(1):157-8, 163-4, 167-70
Hip fracture in the elderly. An interdisciplinary team approach to
Ethans KD, MacKnight C
Division of Physical Medicine and Rehabilitation, Dalhousie University
Faculty of Medicine, Halifax, Nova Scotia, Canada. firstname.lastname@example.org
The rising incidence of hip fractures in the elderly is a disturbing trend
with serious health and socioeconomic consequences, including morbidity,
loss of function, long-term institutionalization, and mortality. When
preventive measures fail, the interdisciplinary healthcare team works
together to provide operative treatment, reduce the risk of postoperative
complications, and guide the patient through the recovery process. A team
approach that ensures appropriate treatment, careful discharge planning,
and coordinated rehabilitation can reduce the impact of the injury, speed
recovery, and restore patient independence.
Am J Med 1997 Aug 18;103(2A):65S-71S; discussion 71S-73S
Prevention of hip fractures: risk factor modification.
Department of Medicine, Indiana University School of Medicine,
Factors that influence the risk of hip fracture have been identified, many
of which can be eliminated or modified. Even those risk factors that
cannot be modified are important for identifying at-risk patients, who may
benefit most from therapies that after other risk factors. Bone mineral
density (BMD) is the major measurable determinant of the risk of fragility
fractures. However, recent prospective studies have identified factors
that influence the risk of having a hip fracture independently of the risk
associated with low BMD. Skeletal factors other than BMD that may increase
the risk of hip fracture in women include hip geometry and height (tallness).
Other factors, some of which are potentially modifiable, operate through
effects on the risk of trauma, including decreased visual acuity,
neuromuscular impairment, cognitive impairment, residence in a nursing
home, poor general physical health, and use of medications that diminish
alertness. Fall mechanics also play an important role in the etiology of
hip fractures. Falls to the side, particularly those with impact on the
hip or side of the leg, more often result in hip fractures than do other
falls. Protection of the hip with external padding offers great promise in
the prevention of hip fracture in patients with very low bone mass or with
conditions that make falls almost inevitable. Increases in hip fracture
rates in developing countries suggest a possible relationship with
declining physical activity (particularly load-bearing activity). Although
the role of exercise in the prevention of osteoporosis and hip fracture
has not yet been proven, there is evidence of independent protective
effects of both past physical activity and moderate levels of recent
physical activity on the risk of hip fracture. Low body weight secondary
to poor appetite or poor health (as opposed to intentional weight loss)
has been associated with increased hip fracture risk, and nutritional
deficiencies may also play a role in hip fracture pathogenesis. These are
potentially modifiable. Future studies should be aimed at confirming the
hip fracture risk factors identified, ascertaining their independence from
other factors, assessing their prevalence, and determining the outcomes
and costs involved in interventions to modify them.
N Engl J Med 1996 Jun 6;334(23):1519-25
Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York,
NY 10003, USA.