A Year of Fractures: a snapshot analysis of the logistics, problems and outcomes of a hospital-based fracture liaison service

Summary

Our fracture liaison service identifies patients with low trauma fractures, determines the need for osteoporosis therapy and instigates therapy if necessary. We describe the tracking and outcome of 768 patients attending our emergency department over 1 year and discuss the problems we encountered and potential solutions.

Introduction

Osteoporotic fractures result in substantial morbidity, mortality and economic cost, and patients sustaining a first fracture are known to be at higher risk of sustaining future fracture. Treatment of at-risk patients has been shown to assist in prevention of future fracture including hip fracture. We established a “First Fracture Project” to identify and treat these patients in 2003.

Methods

We assessed “A Year of Fractures”: the logistics, outcome and problems in tracking patients presenting to our emergency department with a low trauma fracture by our fracture liaison service, over 1 year from July 2008 to June 2009. Patients were tracked by our osteoporosis nurse and offered assessment, and treatment where necessary.

Results

In 1 year, 768 patients aged 50 or over were identified from emergency department records as attending with a low trauma fracture. About 84 % of patients eventually received assessment. Of the162 patients progressing through the entire process, 74 % had osteoporosis treatment planned and/or commenced.

Conclusions

Our fracture liaison service was effective at identifying most low trauma fracture patients at risk of further fracture and providing access to osteoporosis assessment. There were many difficulties: we outline logistic and practical issues in delivering our service and suggest potential improvements.     

A sample of Canadian orthopedic surgeons expressed willingness to participate in osteoporosis management for fragility fracture patients

Objective

The orthopedic community is in a unique position to initiate and provide osteoporosis care in fragility fracture patients to prevent future hip fractures in a high-risk population. The attitudes and intentions of Canadian orthopedic surgeons in the domain of osteoporosis care are unknown. Our objective was to identify current attitudes and osteoporosis management practices and to determine their overall willingness to participate in osteoporosis care for fragility fracture patients.

Methods

A real-time interactive polling session was conducted at the 58th Annual Meeting of the Canadian Orthopaedic Association.

Results

Of the orthopedic surgeons who responded, 90.4% agreed that the current emphasis on osteoporosis in orthopedic practice is appropriate; 85.2% of surgeons indicated that they currently refer or personally investigate for osteoporosis, or both, in fragility fracture patients.

Conclusion

Most of the Canadian orthopedic surgeons sampled consider themselves to be currently engaged or ready to engage in osteoporosis care for fragility fracture patients. Focus should now shift from education and persuasion to program support through provision of resources and system modification that will enable Canadian orthopedic surgeons to effectively manage osteoporosis in their fracture patients.     

Retrograde Intramedullary Nailing for Distal Femur Fracture with Osteoporosis

Background

The incidence of distal femur fracture in the elderly has been increasing recently, and commonly occurs with osteoporosis. Retrograde intramedullary nailing has been considered a good surgical option for distal femur fracture. The purpose of the present study was to present our surgical results with retrograde intramedullary nailing for distal femur fractures with osteoporosis.

Methods

Thirteen patients diagnosed with extra-articular distal femur fracture and osteoporosis and managed with retrograde intramedullary nailing were retrospectively reviewed. Cement augmentation was used in four patients, shape memory alloy was used in eight patients and both were used in one patient. All patients were followed up for more than 2 years. Radiologic alignments were scored and Tegner and the Lysholm activity score was used for a functional assessment.

Results

The average time to clinical union was 13 weeks (range, 10 to 15 weeks). In 12 of our cases, the total alignment scores were excellent. At the last follow-up, the mean range of motion was 116° (range, 110° to 125°). The average functional score at postoperative 1 year was 2.6 (range, 1 to 5).

Conclusions

Retrograde intramedullary nailing is a good surgical option for distal femur fracture with osteoporosis. Cement augmentation and shape memory alloy can also be used for added mechanical stability. This surgical technique is very useful for distal femur fracture with osteoporosis as it promotes fracture healing and early rehabilitation.     

Managing Osteoporosis in Patients with Fragility Fractures: Did the British Orthopaedic Association Guidelines Have Any Impact?

INTRODUCTION

The incidence of fragility fractures could double in the next 50 years. Effective treatments for osteoporosis exist and the British Orthopaedic Association (BOA) has guidelines governing how to manage underlying osteoporosis in patients with fragility fractures. This study assessed how well two trauma units treat underlying osteoporosis and whether the BOA guidelines made any impact.

PATIENTS AND METHODS

Case notes of patients with a fracture of their proximal femur admitted during January and February in 2003, 2004 and 2005 were reviewed. The results were analysed for differences between site and year.

RESULTS

A total of 602 case notes were reviewed. There was a significant difference in the number of patients discharged on osteoporosis medication between the two sites (27% at LRI, 8% at KGH; P < 0.001), but not between 2003 and 2005 (22% and 16%; P = 0.16). Of the patients started on treatment, 83% were started on calcium and/or vitamin D₃ supplements.

CONCLUSIONS

The number of patients who had their underlying osteoporosis addressed was low and the type of treatment sub-optimal. This suggests the BOA guidelines have not made an impact and further work is required to improve the management of these patients.     

Knowledge of orthopaedic surgeons in managing patients with fragility fracture

Purpose

Fragility fractures represent a major health problem, as they cause deformity, disability and increased mortality rates. Orthopaedic surgeons should identify patients with fragility fractures and manage their osteoporosis in order to reduce the risk of future fracture; therefore, orthopaedic surgeons’ knowledge about managing fragile fracture should be evaluated.

Methods

A questionnaire was administered to 2,910 orthopaedic surgeons to address the respondents’ knowledge. The questions covered the topics of diagnosis, treatment and approach to a patient with a fragility fracture. The data-collection period for this survey spanned one year.

Results

There were 2,021 orthopaedic surgeons who participated in this study. Less than 10% of the respondents included bone mass densitometry (BMD) when evaluating patients with fragile fractures 32% prescribed proper dosage of calcium and vitamin D; approximately 30% would refer if falling from a height was suspected.

Conclusions

The majority of orthopaedic surgeons questioned lacked knowledge of fragility fracture management. This is reflected by limited knowledge of osteoporosis assessment and treatment in most areas. An appropriate method should be created to manage patients with fragility fractures to guarantee the patient the best possible care.     

An audit of orthopaedic referrals via Multi-Professional Triage Teams

INTRODUCTION

Multi-Professional Triage Teams (MPTTs) were created to reduce the caseload of hospital orthopaedic clinics and this prospective study evaluated referrals made to a district general hospital orthopaedic department from a lower limb MPTT clinic.

PATIENTS AND METHODS

Over 9 months, 277 referrals to a lower limb hospital orthopaedic clinic were assessed. The temporal delay to hospital clinic review between patients seen at the MPTT clinic and those referred directly by their general practitioner (GP) was analysed using an ANOVA test. A qualitative assessment of diagnoses given to patients reviewed at the MPTT clinic was performed.

RESULTS

The 132 patients initially reviewed at the MPTT clinic and subsequently referred to a hospital consultant waited significantly longer (140 days compared to 62 days by direct GP referral; P < 0.05) to see an orthopaedic consultant. Over three-quarters of this patient cohort incorrectly identified the healthcare professional conducting their consultation at the MPTT clinic. One-third of cases (31%) had no diagnosis made and 22% were assessed as having an incorrect diagnosis.

CONCLUSIONS

Time delays, patient confusion regarding professional roles and diagnostic indecision are significant problems for patients referred to hospital orthopaedic clinics from MPTT clinics. This risks sub-optimal patient care and may lead to future medicolegal implications.     

The importance of patient compliance in nonunion of forearm fracture

INTRODUCTION

Studies on radius ulna shaft fractures are very important. Surgical treatment is generally administered due to the unstability caused by the dynamic effect of forearm muscles. Surgical technique, implant, osteoporosis, patient compliance can affect the surgical treatment and healing.

PRESENTATION OF CASE

An 86-year-old female patient was admitted to emergency service with the complaint of protrusion of forearm implant from the skin. Physical examination revealed that 80° nonunion developed on the radial side. Therefore, protruded and exposed internal fixation materials were excised under axillary block. We used zoledronic acid as a treatment of osteoporosis with the value of −3.2 Dexa score.

DISCUSSION

Complication rate is reported to be 25% in patients treated with plate fixation. Patient compliance is very crucial in forearm fractures as in all surgical procedures. Presence of comorbidities and socioeconomical status of the patient are important factors in fracture healing.

CONCLUSION

This case emphasizes the importance of compliance of the patient to the follow-up after surgical treatment of forearm fracture.     

Impact of infection by verotoxigenic Escherichia coli O157:H7 on the use of surgical services in a children’s hospital

Objectives

To determine the impact of Escherichia coli O157:H7 infection in children on the need for surgical assessment in a pediatric surgical practice and whether clinical and bacteriologic variables might contribute to that need.

Design

Examination of a case series.

Setting

A tertiary-care pediatric hospital.

Patients

Between 1990 and 1994, E. coli O157:H7 gastrointestinal infections were documented among 85 children, 29 of whom suffered from hemolytic-uremic syndrome.

Intervention

Surgical consultation for presumed or proven complications of the infection.

Main Outcome Measures

The frequency of and reasons for surgical consultation, clinical and bacteriologic variables between patients who did or did not require surgical assessment.

Results

Of the 85 children, 17 (20%) were assessed by the surgical service. The majority of these children were inpatients. Two required abdominal surgery. Female gender, older age and progression to hemolytic-uremic syndrome were factors associated in univariate analyses with a likelihood of need for surgical assessment; variation in bacterial genotype was not.

Conclusion

There is the potential for verotoxigenic E. coli O157:H7 infection to have a considerable impact on the utilization of pediatric surgical services.     

Prospective evaluation of a novel one-stop testicular clinic

INTRODUCTION

In 2003, the waiting time for routine scrotal assessment approached 6 months in our hospital. The patients'' diagnostic pathway was not uniform and involved several delays between general practitioner, radiologist and urologist. If malignancy was suspected, patients were seen and assessed within 2 weeks. However, it was possible for patients with unsuspected malignancy to have their diagnosis delayed.

PATIENTS AND METHODS

Funding was provided by the NHS Modernisation Agency''s Action On Urology project. Men who were referred by their general practitioner (GP) with a testicular or scrotal condition would be reviewed in a one-stop joint sonographer and urology nurse specialist clinic provided entirely within the urology department with rapid open access. Data were prospectively collected for 2 years. Source of referral, suspected diagnosis, findings and outcome were recorded.

RESULTS

A total of 1017 patients attended the clinic over this period; of these, 203 (4%) were referred under the ‘2-week wait’ criteria. Of patients attending the clinic, 79% were discharged to GP care, 8% were added to the waiting list for a surgical procedure and 20% were referred with ‘testicular lump’. Eleven patients were suspected to have testicular tumour on ultrasound and proceeded to orchidectomy in this period. One patient (0.1%) was found to have an unsuspected seminoma. The waiting time for all scrotal ultrasound examinations has fallen from 22 to 2 weeks. The waiting times for intravenous urography and general ultrasound were also significantly reduced following the introduction of this service (P = 0.005).

CONCLUSIONS

The majority of patients passing through this clinic are the ‘worried-well’ with benign scrotal pathology. They can now be seen within 2 weeks regardless of whether their GP suspects testicular tumour. This reduces anxiety in this large group of patients freeing capacity elsewhere in the diagnostic imaging department.     

Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity

Objective

To develop an improved method for measuring the deformity caused by fracture of the proximal end of the proximal phalanx of the little finger in children.

Design

A prospective case study.

Setting

Regional hospitals with an orthopedic service.

Patients

Forty-two children with a proximal phalangeal fracture of the little finger and 42 children without a phalangeal fracture, who acted as a control. The type of deformity resulting from the fracture was noted, and the angle of deformity was measured. Rotational deformities were measured clinically in all patients and angulation deformities were measured from radiographs. The deformities were graded and classified.

Main outcome measures

Measurements of the fracture deformity before and after manipulation.

Results

There were 38 ulnar angulation deformities, 26 dorsal angulation deformities, 10 ulnar rotation deformities, 3 palmar angulation deformities, 2 radial angulation deformities and 1 radial rotation deformity. The deformities could be graded into 6 different types.

Conclusion

The measurements of deformity made it possible to describe and classify isolated deformities and combinations of various deformities.     

Clinical Analysis of Femur Shaft Insufficiency Fractures

Background

To characterize the recently issued femur shaft insufficiency fracture in terms of a patient''s own epidemiological status.

Methods

Fourteen patients were treated for insufficiency fracture from July 2002 to June 2008, excluding cases including the risk factors of insufficiency fracture. All patients were female, and their mean age was 75.6 years (range, 65 to 89 years). The mean follow-up period was 50.6 months (range, 14 to 86 months).

Results

The mean body weight of the Koreans in the same age group was 58.1 ± 9.7 kg, and the mean height was 155.5 ± 8.8 cm. The mean body weight of our insufficiency fracture patients was 45.7 kg and it was statistically significantly lower than that of the Koreans in the same age group (p < 0.001). The mean height was 147.3 cm and it was significantly shorter than the mean height of the Koreans in the same age group (p = 0.002). In regard to menopausal time, the mean menopausal time of the Koreans was 48.0 ± 4.2 years, it was 44 years in our study, as menopause occurred statistically significantly earlier (p = 0.017). The patients with insufficiency fracture showed statistically lower weight, shorter stature and an earlier menopausal period than that of the general population.

Conclusions

In early menopausal, underweight, and short patients prescribed osteoporosis medication for an extended period of time, if predromal symptom is present, it is necessary to suspect insufficiency fracture of the femur.     

Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial

Summary

Osteoporosis management post fragility fracture has traditionally been deficient with up to 60–90 % of patients remaining untreated for osteoporosis in some studies. Efforts have been made to address this deficiency with some successes reported.

Introduction

The aim of this study was to assess the efficacy of two different models of screening for osteoporosis in a community fracture clinic setting.

Methods

A prospective randomised clinical trial was conducted to assess the DXA scan and treatment rates in patients with fragility fractures when assessment for osteoporosis had been initiated in the fracture clinic compared with the “usual care” of assessment initiation by the participant’s general practitioner.

Results

Sixty-six patients were enrolled in the study. Thirty-three patients each were in the control and intervention groups. The assessment rate (DXA scan rate) was significantly better in the intervention group where participants were referred for assessment from fracture clinic compared to the control group where participants were referred for assessment by their general practitioner (68 vs 36 %, respectively; p?<?0.05). For patients who were assessed for osteoporosis, treatment rates were similar in both the control and intervention groups (100 vs 88 %, p?>?0.05).

Conclusion

This study demonstrates that screening for osteoporosis initiated in fracture clinic results in improved osteoporosis management compared to screening initiated in primary care. Orthopaedic surgeons and other specialists need to be more active in managing osteoporosis in patients who present with fragility fractures and should at the very least initiate assessment in the fracture clinic setting.     

The impact and consequences of hip fracture in Ontario

Objectives

To assess the magnitude and the burden of hip fracture on the health care system, including time trends in hip fracture rates, in-hospital death rates, length of hospital stay (LHS) and discharge destination.

Design

A retrospective study of discharge abstracts.

Setting

The Province of Ontario.

Patients

All patients (n = 93 660) over the age of 50 years and with a diagnosis of hip fracture discharged from hospital between 1981 and 1992 (excluding transfers).

Main Outcome Measures

Age-sex standardized hip fracture rates per 1000 population, in-hospital death rates and age-adjusted mean LHS.

Results

The overall hip fracture rate was 3.3 per 1000 persons (1.7 per 1000 men and 4.6 per 1000 women). There was no change in rates between 1981 and 1992 (p = 0.089), but there have been increases in the numbers of hip fractures. There was no change in the in-hospital death rate over time (p = 0.78). The age-adjusted mean LHS in 1981 was 28.6 days compared with 22.2 days in 1992. The numbers of hip fractures will increase from 8490 in 1990 to 16 963 in 2010.

Conclusions

Despite stable age-adjusted rates of hip fractures, the doubling of the number of hip fractures by the year 2010 due to an aging population will become an increasing burden on the health care system.     

An electronic clinic for arthroplasty follow-up: a pilot study

Background

Most outpatient orthopedic follow-up visits for patients who had total joint arthroplasty are routine among those with well-functioning implants. The technology and resources now exist to enable patient assessment without requiring attendance in hospital. We tested an electronic clinic for routine follow-up in a small cohort of arthroplasty patients.

Methods

We randomly assigned primary arthroplasty patients scheduled for routine annual outpatient review into 2 groups: group A completed a Web-based assessment 4 weeks after the clinical assessment, whereas group B completed the Web-based assessment first. Standard clinical questionnaires were included. We also collected radiographic data and information on assessment duration and cost.

Results

Forty patients participated in the study. The average age of participants was 58 years. There were 12 men and 8 women in each of the 2 groups. The average total time spent by patients on an outpatient visit was 115 minutes, compared with 52 minutes for the electronic assessment. Participants reported the electronic assessment to be more convenient and less costly.

Conclusion

This pilot study supports the practical use of an electronic clinic for the follow-up of arthroplasty patients. Further studies examining the complex interaction of factors involved in patient clinics are needed.     

Indomethacin and ketorolac given preoperatively are equally effective in reducing early postoperative pain after laparoscopic cholecystectomy

Objective

To evaluate the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) on pain after laparoscopic cholecystectomy.

Design

A prospective, randomized, placebo-controlled, double-blind study.

Setting

A university hospital.

Patients

Fifty-two patients with cholelithiasis but without known allergy to one of the study drugs, history of bleeding, peptic ulcer disease, known cardiac, lung or renal disease, abnormal liver function or use of opiates or NSAIDs within 2 weeks before operation. Patients were assigned to one of three groups, and treatment was randomized by placing the drugs in sealed, numbered envelopes.

Intervention

Administration of the NSAIDs ketorolac, intramuscularly, or indomethacin, rectally, before laparoscopic cholecystectomy.

Main Outcome Measures

Postoperative pain scored on a visual analogue scale and by nurse assessment, total dose of fentanyl citrate given, and nausea or emesis.

Results

Patients in the placebo group reported significantly more pain than either NSAID group (p < 0.05) and were reported as having significantly more pain by the nurses (p < 0.05). These patients were subsequently treated with a higher mean postoperative dose of fentanyl citrate than either NSAID group (p < 0.05). Furthermore, the placebo group reported more nausea and emesis (p < 0.05). There was no significant difference in any of the parameters measured between the ketorolac or indomethacin group.

Conclusions

The data demonstrate that the NSAIDs ketolorac and indomethacin, administered preoperatively, decrease early postoperative pain and nausea after laparoscopic cholecystectomy and are equally efficacious in producing these results.     

Carpometacarpal Joint Fracture Dislocation of Second to Fifth Finger

Background

Carpometacarpal joint fracture dislocation of the second to fifth finger is a rare hand injury associated with high energy trauma. Due to severe swelling and overlapping of bones on the radiograph of wrist-hand, dislocations are missed. We reported a series of six patients with rare carpometacarpal joint fracture dislocation treated with open reduction.

Methods

We retrospectively studied six cases of carpometacarpal joint fracture dislocation. All patients were treated with open reduction and internal fixation with Kirschner wire. Functional assessment was done with Quick Disabilities of the Arm, Shoulder and Hand score (Quick DASH score) at regular intervals.

Results

Average Quick DASH score was improved from 75.76 to 1.9 from 6 weeks to 18 months of duration. Of the six patients, three patients had a Quick DASH score of 0 at the end of 18 months.

Conclusions

Careful hand examination and radiographic assessment is necessary to avoid missed diagnosis of carpometacarpal joint fracture dislocation. Early open reduction and internal fixation lead to excellent recovery of hand function.     

Patient compliance with a group model of care: the hernia clinic

Background

In February 2006, a hernia clinic was established at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. It was based on a group model of care and was established to increase effective use of resources to reduce waiting times. We conducted a survey of patients referred to the hernia clinic to determine compliance.

Methods

We developed and mailed a questionnaire to all patients who had surgery after assessment at the hernia clinic. Data were analyzed for the entire study group and for 2 subgroups: patients in group I had the same surgeon for assessment and surgery, whereas patients in group II had a different surgeon for assessment and surgery. Differences between subgroups were assessed using the 2-tailed Fisher exact test. Waiting times were recorded.

Results

In all, 94 patients responded to the survey. Of these, 67% had the same surgeon for assessment and surgery, and 31% had a different surgeon; 2% were not sure. Two-thirds were comfortable having their surgery performed by a surgeon whom they met the day of surgery. Most patients had confidence in the competence of any surgeon and considered service to be better and faster in a specialized centre. Most felt that a group of surgeons providing hernia care uses resources more effectively. The waiting times from referral to initial consult decreased from 208 (standard deviation [SD] 139) days in 2007 to 59 (SD 70) days in 2009.

Conclusion

Patient compliance with a group model of care for hernia surgery is high.