A Guide to Improving the Care of Patients With Fragility Fractures

Abstract

ForewordFragility fractures, low-energy injuries that occur from a fall from a standing or lower height, represent a serious public health problem. After age 50, the lifetime risk of having a fragility fracture is 33% for an American woman and 20% for a man. 1 In the United States, 2.1 million people will suffer a fragility fracture each year.1 The incidence of fragility fractures increases steeply after age 65.2 Osteoporosis is present in most patients with a fragility fracture.Hip fractures are the most serious in terms of cost and morbidity. The average cost of inpatient care for a hip fracture in 2005 was $33 962.3 The lifetime risk of having a hip fracture is 6% for men and 17.5% for women. Although the mortality risk after a hip fracture is much higher for a man, a woman's risk of dying from a hip fracture is high and exceeds the lifetime risk of death from breast cancer, uterine cancer, and ovarian cancer combined. For those who survive after a hip fracture, most do not regain their preinjury level of function, and 30% lose their independence. This loss of independence is greatly feared by patients and is very costly to patients and society.Although a hip fracture may have the most serious consequences, other bones, such as the wrist, shoulder, ankle, pelvis, and spine, frequently fracture in the osteoporotic patient. For example, the lifetime risk of a forearm or vertebral compression fracture is 16% and 15.6%, respectively, for a woman and 2.5% and 5%, respectively, for a man. 4 These statistics clearly show that fragility fractures are a major problem facing American society today, 5 and the care of such fractures presents an even greater challenge, in part because the quality of care delivered in the United States varies widely, even within one region. Many such fractures are treated in an outpatient setting, although some may be treated in the inpatient hospital setting. However, the quality of care for seniors with fragility fractures receives relatively little attention. In 2004, the United States Surgeon General issued a comprehensive report calling for health professionals to make significant improvements in our nation's bone health, and an improvement in the system and methods of care was suggested. 5There has been little written on the subject of improving the system of care delivery in the United States.The goals of this blue book are to review the methods used in inpatient and outpatient care, as well as rehabilitation of the patient with a fragility fracture. We discuss evidence-based best care models and, where evidence is lacking, present expert opinions in an effort to improve the standard and the quality of care for the patient with a fragility fracture. We hope that this monograph will provide guidance to physicians, nurses, rehabilitation therapists, other health care providers, and administrators.Stephen L. Kates, MD Editor-in-Chief Simon C. Mears, MD, PhD

End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity?

“…As such, the physicians treating the acute event of a hip fracture may not be the best ones to bring up the subject; however, they should not let the chance lapse either. A comment added to the discharge report proposed by Bukata et al [4], including notification of ''the type of procedure that was performed, care providers in the hospital and their contact information, complications encountered, weightbearing status, expected course, a description of any unresolved issue, and specific plans for followup treatment and visits,'' may be the best means to do so. This can dovetail nicely with the American Orthopaedic Association's ''Own the Bone'' campaign, especially its emphasis on ''customized letters to the primary-care physician'' [20].…”

Comanagement of Geriatric Patients With Hip Fractures

“…23 Models of interdisciplinary care of geriatric patients with hip fracture already exist in some locations. 24,25 In Australia, one group noted that interdisciplinary care of patients with hip fractures had reduced hospital lengths of stay without an increase in the complication rate. 11 In Great Britain, another group noted that a care pathway for elderly patients with femoral neck fracture resulted in improved clinical outcomes.…”

Is Supplementation of Vitamin D Beneficial for Fracture Healing? A Short Review of the Literature

“…22 In conclusion, a clear statement on the benefits of vitamin D for fracture healing awaits further trials, but all types of fractures in the elderly individuals indicate the need for secondary prevention and the implementation of appropriate guidelines concerning falls, vitamin D, and osteoporosis. 3,4,21,[23][24][25][26] A Swiss survey has shown that ''osteoporosis remains underdiagnosed and undertreated in patients aged 50 years and older presenting with a fragility fracture.'' 27 Meta-analyses indicate that vitamin D should always be given together with calcium, 25,28 and one study demonstrated that large boluses of vitamin D are counterproductive.…”