Pressure ulcer risk in hip fracture patients

Hip fracture patients have a high risk of pressure ulcers (PU). We followed 121 hip fracture patients for the development of pressure ulcers and evaluated a risk assessment tool for sensitivity and specificity. More than half of the patients presented with PU, mostly stage I. Risk factors for PU were high age and the length of time on the operating table. The risk assessment tool had a low predictive value, however. It is thus hard to predict which patients will develop PU and which will not. Accordingly, we propose maximum preventive measures against PU for all patients presenting with hip fractures.     

Risk factors for pressure ulcers among elderly hip fracture patients

The purpose of this study was to estimate the incidence of hospital-acquired pressure ulcers among elderly patients hospitalized for hip fracture surgery and to identify extrinsic factors that are associated with increased risk. We conducted a secondary analysis of data abstracted from medical records at 20 hospitals in Pennsylvania, Texas, New Jersey, and Virginia. Participants were patients aged 60 years and older admitted with hip fracture to the study hospitals between 1983 and 1993. The incidence of hospital-acquired pressure ulcers was 8.8% (95% confidence interval 8.2%-9.4%). After adjusting for confounding variables, longer wait before surgery, intensive care unit stay, longer surgical procedure, and general anesthesia were significantly associated with higher pressure ulcer risk. Extrinsic factors may be important markers for high pressure ulcer risk in hospitalized hip fracture patients. Although it is not possible to eliminate factors such as requiring an intensive care unit stay or having a long surgical procedure, it may be possible to develop interventions that minimize pressure ulcer risk in patients who experience these factors.     

Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.     

Association Between Low Admission Norton Scale Scores and Postoperative Complications After Elective THA in Elderly Patients

The Norton scoring system is used by nurses to evaluate pressure ulcer risk. The authors have previously shown that low admission Norton scale scores (ANSS) are associated with postoperative complications other than pressure ulcers following hip fracture and spine fracture surgery in elderly patients. The purpose of this retrospective, cross-sectional study study was to determine whether low ANSS are associated with postoperative complications other than pressure ulcers following elective total hip arthroplasty (THA) in elderly patients. The medical charts of consecutive elderly (older than 65 years) patients admitted between February 2008 and November 2010 were studied for acute renal failure, cardiovascular events, confusion, pneumonia, pressure ulcers, urinary infection, urinary retention, venous thromboembolism, wound infection, and other complications. The final cohort included 166 patients (108 [65.1%] women; aged 75.2±6.4 years). Overall, 24 (14.5%) patients had low (16 or less) ANSS. Patients with low ANSS had significantly more postoperative complications other than pressure ulcers compared with patients with high ANSS (0.5±0.7 vs 0.2±0.4, respectively; P=.018). Binary regression analysis showed that low ANSS were independently associated with all postoperative complications other than pressure ulcers (P=.039).In addition to predicting pressure ulcer risk, the Norton scoring system may be used for predicting other postoperative complications in elderly patients following elective THA.     

应用FRAX工具评估类风湿关节炎患者骨质疏松性骨折风险

目的应用骨折风险评估工具(FRAX)评估类风湿关节炎(RA)患者10年内主要骨折及髋部骨折的发生率及相关危险因素。方法回顾性分析2013年至2019年于北京市石景山医院风湿免疫科就诊且资料完整的RA患者206例,应用FRAX工具评估患者10年内主要骨折及髋部骨折发生风险。结果 (1)病程长、绝经时间长、病情活动度高及曾应用激素的RA患者10年内主要骨折及髋部骨折风险更高;(2)糖皮质激素日剂量及使用时间与RA患者10年内主要骨折及髋部骨折风险无明显相关性;(3)RF及抗CCP阳性与阴性患者间10年骨折发生风险无明显差异。结论绝经时间长、病程长、病情活动度高的RA患者骨质疏松性骨折发生风险更高,而FRAX模型中并未考虑到这些因素,因此,可能低估了这部分患者的骨折风险,临床工作中对这部分患者更应该防治骨质疏松及骨质疏松性骨折。     

Effectiveness of using a new polyurethane foam multi‐layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial

Hip fractures in the elderly are a serious problem for the health service due to the high rate of complications. One of these complications is pressure ulcers that, according to the literature, occur in 8.8% to 55% of patients and mainly arise in the sacral area. The present randomised controlled trial tests whether applying a new innovative multi‐layer polyurethane foam dressing (ALLEVYN LIFE™), reduces the onset of pressure ulcers in the sacral area. From March to December 2016, 359 fragility hip fracture patients were randomly divided into 2 groups: 182 in the control group and 177 in the experimental group. Pressure ulcers occurred overall in 36 patients (10%): 8 patients (4.5%) in the experimental group compared to 28 (15.4%) in the control group: P = 0.001, relative risk 0.29 (95% CI 0.14‐0.61) with NNT of 9 (95% CI 6‐21). In the experimental group the onset of pressure ulcers occurred on average on the 6th day compared to the 4th day in the control group (HR 4.4). Using polyurethane foam is effective at reducing the rate of pressure ulcers in the sacrum in elderly patients with hip fracture. The adhesiveness of this device also enables costs to be kept down.     

Risk factors associated with pressure ulcers in the pediatric intensive care unit.

OBJECTIVE: To identify risk factors that are associated with the development of pressure ulcers in children admitted to the pediatric intensive care unit (PICU). DESIGN: Case control study with no interventions held in a 30-bed PICU of Texas Children's Hospital, Houston. SETTING AND SUBJECTS: The study included 59 patients who developed pressure ulcers in the PICU and 59 patients who were critically ill who did not develop pressure ulcers during the same time period. INSTRUMENTS: Risk assessment data collection tool and Braden scale. METHODS: A comparison was done to identify risk factors between 2 groups of pediatric patients with and without pressure ulcers. A 45-indicator assessment tool was used. Physical assessment including staging of pressure ulcers was performed. RESULTS: Risk factors associated with pressure ulcers include edema (P = .0016), length of stay > 96 hours (P = .001), increasing positive end expiratory pressure (P = .002), not turning the patient or use of a specialty bed in the turning mode (P = .0001), and weight loss (P < .0001). CONCLUSIONS: The presence of edema, increasing length of stay, patients on increasing positive-end expiratory pressure, not turning the patient, use of a specialty bed in the turning mode, and weight loss are associated with the increased risk of development of pressure ulcers in patients in the PICU.     

Risk of hip fracture following a wrist fracture—A meta-analysis

AimsThis purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture.MethodStudies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included.Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool.A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies.Results12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93–4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used.ConclusionRisk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43).Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture.This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.     

High fracture probability with FRAX® usually indicates densitometric osteoporosis: implications for clinical practice

Summary

Most patients designated as high risk of fracture using fracture risk assessment tool (FRAX^®) with femoral neck bone mineral density (BMD) (i.e., 10-year major osteoporotic fracture probability exceeding 20% or hip fracture exceeding 3%) have one or more T-scores in the osteoporotic range; conversely, almost no high risk patients have normal T-scores at all bone mineral density measurement sites.

Introduction

We determined the agreement between a FRAX^® designation of high risk of fracture [defined as 10-year major osteoporotic fracture probability (≥20%) or hip fracture probability (≥3%)] and the WHO categorizations of bone mineral density according to T-score.

Methods

Ten-year FRAX^® probabilities calculated with femoral neck BMD were derived using both Canadian and US white tools for a large clinical cohort of 36,730 women and 2,873 men age 50 years and older from Manitoba, Canada. Individuals were classified according to FRAX fracture probability and BMD T-scores alone.

Results

Most individuals designated by FRAX as high risk of major osteoporotic fracture had a T-score in the osteoporotic range at one or more BMD measurement sites (85% with Canadian tool and 83% with US white tool). The majority of individuals deemed at high risk of hip fracture had one or more T-scores in the osteoporotic range (66% with Canadian tool and 64% with US white tool). Conversely, there were extremely few individuals (<1%) who were at high risk of major osteoporotic or hip fracture with normal T-scores at all BMD measurement sites.

Conclusions

A FRAX designation of high risk of fracture is usually associated with a densitometric diagnosis of osteoporosis.     

Clinical features and management of pressure ulcers for the general surgeon

Although widely considered to be preventable, pressure ulcers (PU) are common and cause a significant burden to the individual, their carers and healthcare services. International collaborative panels publish consensus documents and guidelines aiming to standardize PU classification, assessment and management. There is a huge emphasis on prevention, which requires awareness and education for clinicians, patients and carers. Surgeons may be referred patients with PU for advice on surgical options or management of infected wounds. Surgical patients may develop PU after prolonged surgical procedures, during periods of critical illness or in association with their surgical condition. Additionally, as some PU become chronic and non-healing, individuals with PU may be referred for assessment of other medical issues. An awareness and understanding of PU aetiology, management strategies and complications are therefore important for the surgical trainee.     

Pressure Ulcers and Prolonged Hospital Stay in Hip Fracture Patients Affected by Time-to-Surgery

Abstract Background: Hip fractures are associated with high morbidity. Pressure ulcer formation after hip surgery is often related to delayed patient mobilization. The objectives of this study were to determine whether time-to-surgery affects development of pressure ulcers postoperatively and, thus, length of hospital stay. Patients and Methods: We performed a retrospective analysis of consecutive hip fracture patients, aged 60 years and above, who underwent surgery between 1995 and 2001. The primary outcome was in-hospital development of pressure ulcers. The secondary outcome measure was the overall length of hospital stay. Analyses were adjusted for relevant confounders. Results: Of the 722 patients enrolled, 488 patients (68%) received surgery at 12 h after admission. Approximately 30% (n = 214) developed pressure ulcers during admission, whilst 19% of patients operated within 12 h of admission developed pressure ulcers. Time-to-surgery was an independent predictor of both development of pressure ulcers (OR = 1.7, 95% confidence interval [CI] = 1.2–2.6; p = 0.008) and length of hospital stay (11.3 vs 13.3 days in the early and the late surgery group, respectively, p = 0.050). Furthermore, development of pressure ulcers was associated with prolonged postoperative hospital stay (19.5 vs 11.1 days for patients with and without pressure ulcers, respectively, p = 0.001) Interpretation: In hip fracture patients, time-to-surgery was an independent predictor of both postoperative pressure ulcer development and prolonged hospital stay. These data suggest that the implementation of an early surgery protocol following admission for hip fractures may reduce both the postoperative complications and overall hospital stay. Investigation performed at the Department of Traumatology, Maastricht University Hospital, Maastricht, The Netherlands.     

FRAX评估南京地区中老年人群骨折风险的临床研究

目的评价WHO发布的骨折风险评估工具FRAX对南京地区中老年人群的适用性,预测本地区不同性别组中老年人群的骨折风险,讨论联合股骨颈BMD及既往骨折病史对于FRAX的影响。材料和方法对1383例南京地区中老年人群进行分组性研究。输入相关资料及FRAX工具中所包含的危险因素,计算10年内髋部骨折及全身骨质疏松性骨折风险概率,比较骨折既往病史人群及髋部BMD对FRAX预测结果影响。结果南京地区女性中老年人群未来10年内骨折风险远高于同年龄组男性;伴随年龄增大,髋部及全身骨折风险概率均同步增高;有既往骨折史的老年人群10年内再发骨折风险远高于无骨折史人群。除外既往骨折史,联合或不联合BMD后预测髋部及全身骨折结果无显著性差异。结论 FRAX工具可以对南京中老年人群骨折风险做出有效评估,联合髋部BMD值后获取的FRAX预测在既往骨折或未骨折患者中均具有临床应用价值。     

Point prevalence of pressure ulcers in three second‐level hospitals in Mexico

Pressure ulcers (PU) are the source of multiple complications and even death. To our knowledge, there is no available data about PU prevalence in Mexico. The objective of this study was to determine the point prevalence of PU in three second‐level hospitals in Mexico. Every adult hospitalised patient was included in each hospital. Age, gender, hospitalisation ward, Braden score, and the number, location and stage of the ulcers encountered were recorded, as well as any pressure relief measures. In total, 294 patients were examined (127 were male); of these, 63 were considered to be at risk. The average age was 48·6 years. The overall prevalence of the PU was 17%. The service with the highest prevalence was the ICU. The most frequent stage was II (32%) and they were most commonly found in the sacrum (74%). The average Braden score of the patients with ulcers was 10, and 21·4% of the patients obtained moderate‐ to high‐risk Braden scores. Of them, 60·3% had ulcers and only 46% had any preventive measures. The prevalence of PU in three hospitals in Mexico is 17%. The most common stage is II and the most commonly affected site is the sacrum. Only 46% of patients with PU had at least one pressure release measure.     

Development of a risk assessment tool for intraoperative pressure ulcers.

This article discusses the current literature related to intraoperative and preoperative risk factors for pressure ulcer development. Although surgical patients have a high risk of pressure ulcer development, the intraoperative period of patient care has often been missed as a time of increased risk. Pressure ulcers, which may originate in the operating room, may be incorrectly blamed on postoperative areas of care resulting from delay of pressure ulcer demarcation. In the literature review, current risk assessment tools do not adequately address intraoperative risk factors. A risk assessment tool that incorporates the specific variables relevant to the preoperative and intraoperative environment is proposed based on existing literature. A pilot study of the tool was done testing for intrarater reliability.     

Bone density, geometry, and fracture in elderly men

Bone geometry is a major determinant of the mechanical resistance of bone. Mechanical strength of the vertebrae depends on the cross-sectional area of the vertebral body and on the size of the posterior arch. Smaller bone width is associated with higher risk of stress fracture. A longer femoral neck axis and a more open neck-shaft angle are associated with higher risk of cervical hip fracture. No consistent association between the femoral neck width and the cervical fracture risk was found. Areal bone mineral density (aBMD) is not a good tool for the identification of elderly men with high fracture risk. Fracture risk increases with decreasing aBMD, but only a minority of men who will sustain an osteoporotic fracture are identified by a given threshold of baseline aBMD. Bone width seems to be an independent predictor of the fracture risk in elderly men, and its assessment can improve the prediction of fractures in this population.     

A systematic review of movement monitoring devices to aid the prediction of pressure ulcers in at-risk adults

The present study sought to explore the impact of movement monitoring devices on risk prediction and prevention of pressure ulcers (PU) among adults. Using systematic review methodology, we included original research studies using a prospective design, written in English, assessing adult patients' movement in bed, using a movement monitoring device. The search was conducted in March 2021, using PubMed, CINAHL, Scopus, Cochrane, and EMBASE databases, and returned 1537 records, of which 25 met the inclusion criteria. Data were extracted using a pre-designed extraction tool and quality appraisal was undertaken using the evidence-based librarianship (EBL). In total, 19 different movement monitoring devices were used in the studies, using a range of physical sensing principles. The studies focused on quantifying the number and types of movements. In four studies the authors compared the monitoring system with PU risk assessment tools, with a variety of high and low correlations observed. Four studies compared the relationship between movement magnitude and frequency and the development of PUs, with variability in results also identified. Two of these studies showed, as expected, that those who made less movements developed more PU; however, the two studies also unexpectedly found that PUs occurred in both low movers and high movers. In the final two studies, the authors focused on the concordance with recommended repositioning based on the results of the monitoring device. Overall, concordance with repositioning increased with the use of a monitoring device. The synthesis of the literature surrounding bed monitoring technologies for PU risk prediction showed that a range of physical sensors can be used to detect the frequency of movement. Clinical studies showed some correlation between parameters of movement and PU risk/incidence, although the heterogeneity of approaches limits generalisable recommendations.     

Frequent manual repositioning and incidence of pressure ulcers among bed‐bound elderly hip fracture patients

Frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between repositioning and pressure ulcer incidence among bed‐bound elderly hip fracture patients, using data from a 2004–2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n=269) were age ≥65 years, underwent hip fracture surgery, and were bed‐bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index visits was collected from patient charts; study nurses assessed presence of stage 2+ pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person‐day did not differ between the two groups (incidence rate ratio 1.1, 95% confidence interval 0.5–2.4). No association was found between frequent repositioning of bed‐bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.     

Population-based Canadian hip fracture rates with international comparisons

Summary

We identified hospitalizations throughout Canada during 2000–2005 in which the most responsible diagnosis was a proximal femoral fracture. Use of the US fracture risk assessment tool (FRAX) would be inappropriate for Canada as it would overestimate fracture risk in Canadian women and older men.

Introduction

It is recommended that the WHO fracture risk assessment tool should be calibrated to the target population.

Methods

We identified hospitalizations for women and men throughout Canada during the study period 2000–2005 in which the most responsible diagnosis was a proximal femoral fracture (147,982 hip fractures). Age-standardized hip fracture rates were compared between Canadian provinces, and national rates were compared with those reported for the USA and Germany.

Results

There were relatively small differences in hip fracture rates between provinces, and most did not differ appreciably from the Canadian average. Hip fracture rates for women in Canada in 2001 were substantially lower than in the USA (population-weighted rate ratio 0.70) and were also lower than in Germany for 2004 (population-weighted rate ratio 0.74).

Conclusions

Overall hip fracture rates for Canadian women were found to be substantially lower than those for the USA and Germany. This study underscores the importance of assessing country-specific fracture patterns prior to adopting an existing FRAX tool.     

艾灸联合紫草油预防压疮效果观察

目的探讨预防高危压疮的护理方法。方法将108例住院高危压疮患者随机分为观察组和对照组各54例,两组均予常规治疗与护理,对照组在骶尾部、髋部、臀部皮肤受压部位贴敷康惠尔泡沫敷料,观察组采用艾灸疗法及紫草油涂搽。比较两组14d内压疮发生情况及压疮分期、压疮发生部位、观察观察组局部皮肤烫伤情况。结果两组无一例发生可疑深层组织损伤期、Ⅲ、Ⅳ期及不可分期压疮;两组I、Ⅱ期压疮发生率比较,差异有统计学意义（P〈0．01）;观察组无烫伤发生。结论艾灸联合紫草油可有效预防高危压疮患者发生压疮,减轻患者痛苦。