Days Of Fracture Research Articles

An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture.

Patients with an osteoporotic fracture have at least a 2-fold risk for additional fracture and should benefit from targeted diagnostic and treatment procedures for osteoporosis. To address this issue, we set up an osteoporosis clinical pathway (OCP) for the medical management of patients with low-trauma fracture. Following acute management of the fracture by the orthopedic team, patients are enrolled in the pathway, which is based on an interaction between the OCP multidisciplinary team, orthopedic surgeons and/or primary care physicians. After collection of patient data, suggestions for additional diagnostic examinations with their interpretation, and treatment proposals are made. Patients and their families are also invited to attend a multidisciplinary interactive educational program on physical therapy, lifestyle habits and nutrition. During a 36-month period, 385 patients (311 women, 74 men; mean age +/- SD: 73.0 +/- 13.5 years; hip fracture 45%, ankle/tibia 24%, proximal humerus 8.6%, spine 5.5%, pelvis 3.9%, distal forearm 3.6%, other sites 17.4%) were enrolled in the OCP. An osteoporosis awareness questionnaire administered within 10 days of fracture showed that 73% of patients believed that their fracture was not related to the disease. Dual-energy X-ray absorptiometry, performed in 63% of patients, showed that 86% had low bone mass or osteoporosis. Specific antiosteoporotic therapy was proposed for 33% of patients in addition to calcium and vitamin D supplements, the latter suggested for 93%. A survey performed in 216 patients 6 months later, indicated that 63% of the suggested treatments had been prescribed and that 67% of this group were continuing treatment. Such a clinical pathway for the medical management of low-trauma fracture can help to identify patients with osteoporosis in a high-risk population, provide support to the orthopedic surgeon and/or the primary care physician for diagnostic and treatment procedures, and should significantly contribute to increase awareness of the disease in patients and their families.

Subspecialty Corner

A 9-year-old established patient presents as a walk-in to your clinic because of left wrist pain after a fall while riding a scooter. You perform an expanded problem-focused history and physical examination and take an x-ray that shows a non-displaced “buckle” fracture of the radius. You make a temporary fiberglass splint, and the patient is sent to a durable medical equipment (DME) supplier to be fitted for a removable Velcro splint.In your practice, which statement best characterizes the fracture care you currently provide?If you provide fracture care, which code(s) is the best to use to bill for the professional services for the example patient?The correct answers from a coding perspective are 2, 4, and 5.How do you currently bill for the nonprofessional services provided in the example?The best answers are 2 and 5.If you billed the global fracture code, all of the professional services for the next 90 days and initial splinting and supplies are included in this code. X-rays are always separately billable. Most offices are no longer reimbursed for DME (ie, the splint the child will wear). If you billed initially as an E/M service, itemized billing of all services and supplies is allowed (see Table 1).The patient returns for a follow-up visit in 10 days. On the initial visit, you billed the global fracture code. You perform a problem-focused visit followed by an x-ray that shows good alignment and healing. The patient is sent home with instructions about home care and an appointment is made for a return visit in 1 month.Which code(s) best represents the subsequent visit?The best answer is 4.Remember, all your professional services for all subsequent visits during the global period (90 days for fractures) are included in the initial fracture code. X-rays are also billable. Reapplication of casts is billable if done on subsequent visits.Whether you bill E/M codes or global codes might be influenced by Table 1.Other considerations in using the global code include the following:

Biomechanical experimental study on effective fraction of Radix Salviae miltiorrhizae in healing of fracture

To assess the effect of Danshen-9403 (DS-9403, an effective fraction of Radix Salviae Miltiorrhizae) on healing of bone fracture. Standardized radial fracture was performed in 120 Wistar rats. The model animals were randomized into four groups: group A was fed with DS-9403, group B injected with Staphylococcus Aureus, group C with normal saline, and group D with Salviae injection. The treatment began at the first day of fracture. The rats were sacrificed on the 25th, 39th and 50th day separately in batches and their intact radii were removed by dissection for detecting load and stress of three-point bending test with autograph universal material testing machine (Shimazu, Japan). The parameters of load in DS-9403 treated groups on the 39th day and that of stress at 25th, 39th and 50th day were (6.20 +/- 1.32) N, (5.71 +/- 3.58) N/mm2, (8.27 +/- 2.42) N/mm2 and (66.25 +/- 26.21) N/mm2 respectively, which were significantly higher than those in other groups, P < 0.05. DS-9403 has the action of increasing the strength of fracture healing site.

Healing of bones, cartilages, tendons, and ligaments: a new era

Descriptions of methods of accelerating healing and stimulating regeneration of bone, articular cartilage, tendon, and ligament mark the beginning of a new era in the practice of orthopaedics. Generat ions of orthopaedic surgeons have treated musculoskeletal injuries and diseases by preventing the progression of tissue damage and, when possible, creating conditions that allowed natural healing to proceed. They commonly accomplished these goals by immobilising injured or diseased limbs. Now, through controlled application of mechanical forces, electromagnetic fields, and ul t rasound they can promote healing; and experiments show that cytokines and cell transplants can stimulate tissue regeneration. Many orthopaedic surgeons assume that resting of musculoskeletal tissue allows healing to proceed at the maximum pace, and that loading or motion increase inflammation and disrupt repair tissue. Studies show that, while a brief period of rest may help avoid further tissue injury and allow tissue repair, the treatment of most musculoskeletal injuries should include early controlled loading and motion (Hand Clinics 1996; 12: 13). Excessive motion and loading can delay fracture healing, but micromotion or compression, promotes bony union (Injury 1995; 26: 117). Early controlled loading and motion of tendons and ligaments stimulates collagen synthesis, increases strength, and helps align the repair cells and collagen fibrils (Buckwalter). Orthopaedic surgeons can now use electromagnetic fields and low-density pulsed ultrasound to promote bone healing. Electromagnetic fields increase mesenchymal-cell proliferation and synthetic function. Clinical trials show that they stimulate healing of fractures including those that have failed to respond to other treatment (Scott). A prospective randomised double-blind study of ultrasound in tibial fractures showed healing of fractures treated with ultrasound at an average of 96 days after injury compared with 154 days for fractures treated by conventional methods (Heckman). Recent reports have described in-rive stimulation of healing in bone (Acta Ortho Scand 1994; 65: 37), articular cartilages (Hunziker), and ligaments (Clin Ortho 1994; 308: 207) with cytokines. Other reports describe formation of new articular surfaces after treatment of chondral and oestochondral defects with perichondrial grafts, artificial matrices, and chondrocyte transplants covered with periosteal grafts (N Engl J Med 1994; 331: 889 a n d J Bone Joint Surg 1994; 76A: 1405). Although these approaches have not been shown to stimulate formation of functional articular surfaces in osteoarthritic joints (J Bone Joint Surg 1996; 78A: 1), initial studies demonstrate their potential.

Early MR imaging of lower-extremity physeal fracture-separations: a preliminary report.

Magnetic resonance imaging (MRI) was used to evaluate physeal fracture-separations in children soon after at-risk lower-extremity fractures. MRI scans taken during the "acute" period (within 10 days of fracture) resulted in a change in three of four of the Salter-Harris classifications from the injury radiographs. Twelve children had MRI scans performed in the "early" period (3-17 weeks following fracture). Physeal narrowing or tethering and the absence of Harris arrest lines were found in those patients who subsequently required late surgical intervention. Acute MRI provides the most accurate evaluation of the physeal fracture anatomy. Early MRI can demonstrate transphyseal bridging or altered arrest lines in physeal fracture before they become manifest on radiographs.

Parathyroid Hormone, Calcitonin, and Vitamin D Metabolites during Normal Fracture Healing in Humans

The metabolism of calcium is regulated by hormones: parathyroid hormone, (PTH) calcitonin (CT), and vitamin D metabolites. To study the physiologic role of these hormones during the process of fracture healing in humans, the blood levels of PTH, CT, 25-(OH)-D3, 24,25-(OH)2-D3, and calcium were determined in 13 young patients with fractures of long bones. The parameters were measured first on admission and again after six to eight weeks. A group of healthy volunteers of similar age and sex served as control subjects. Plasma calcium level on the day of fracture was significantly reduced, 8.50 +/- 0.23 mg% (p less than 0.001). Serum CT level on the day of fracture was significantly increased, 0.18 +/- 0.02 ng/ml (p less than 0.05), and it continued to increase during the healing period, up to 0.23 +/- 0.02 ng/ml (p less than 0.001) after six to eight weeks. A significant rise was noted in plasma level of 24,25-(OH)2-D3, from 2.02 +/- 0.42 ng/ml on the day of fracture to 2.84 +/- 0.41 ng/ml six weeks later (p less than 0.05). No significant changes were found in serum PTH and plasma 25-(OH)-D3 levels on the day of fracture or during the healing process. The results suggest a possible physiologic active role for CT and 24,25-(OH)2-D3 in fracture healing in humans.

Cellular Response to Fracture Studied with Tritiated Thymidine

An autoradiographic study of femoral-fracture repair using tritiated thymidine was made on forty-two female mice, five weeks of age. Assessment of the periosteal labeling index was obtained from one hour to fourteen days after fracture. Results showed that the initial proliferative response is seen in the periosteum and adjacent soft tissues sixteen hours after fracture. No increase in proliferation was observed at eight hours. The reaction was not limited to the fracture site but extended along the entire femoral diaphysis. The maximum increase of the labeled periosteal population (25.4 per cent) was observed at thirty-two hours after fracture. After thirty-two hours, the size of the labeled population decreased with increasing time. The decrease was more apparent away from the fracture site, so that within five days of fracture the proliferative potential was similar to that of the non-fractured control femur. Fourteen days after fracture, the labeled population of periosteal cells at the fracture site was still above the value of the controls. The course of fracture repair was followed autoradiographically.