High-trauma Fracture Research Articles

Fracture risk following high-trauma versus low-trauma fracture: a registry-based cohort study.

Some have questioned the usefulness of distinguishing high-trauma fractures from low-trauma fractures. The aim of this study is to compare BMD measurements and risk of subsequent low-trauma fracture in patients with prior high- or low-trauma fractures. Using a clinical BMD registry for the province of Manitoba, Canada, we identified women and men age 40years or older with fracture records from linked population-based healthcare data. Age- and sex-adjusted BMD Z-scores and covariate-adjusted hazard ratios (HR) with 95% confidence intervals (CI) for incident fracture were studied in relation to prior fracture status, categorized as high-trauma if associated with external injury codes and low-trauma otherwise. The study population consisted of 64,428 women and men with no prior fracture (mean age 63.7years), 858 with prior high-trauma fractures (mean age 65.1years), and 14,758 with prior low-trauma fractures (mean age 67.2years). Mean Z-scores for those with any prior high-trauma fracture were significantly lower than in those without prior fracture (P < 0.001) and similar to those with prior low-trauma fracture. Median observation time for incident fractures was 8.8years (total 729,069 person-years). Any prior high-trauma fracture was significantly associated with increased risk for incident major osteoporotic fracture (MOF) (adjusted HR 1.31, 95% CI 1.08-1.59) as was prior low-trauma fracture (adjusted HR 1.55, 95% CI 1.47-1.63), and there was no significant difference between the two groups (prior trauma versus low-trauma fracture P = 0.093). A similar pattern was seen when incident MOF was studied in relation to prior hip fracture or prior MOF, or when the outcome was incident hip fracture or any incident fracture. High-trauma and low-trauma fractures showed similar relationships with low BMD and future fracture risk. This supports the inclusion of high-trauma fractures in clinical assessment for underlying osteoporosis and in the evaluation for intervention to reduce future fracture risk.

Preceding and subsequent high- and low-trauma fracture patterns-a 13-year epidemiological study in females and males in Austria.

Little is known about the impact of the skeletal fracture site in conjunction with the severity of a past fracture (high- or low-trauma preceding fracture) and its effect on future fracture risk. Patients with de novo high- and low-trauma fractures admitted to seven large trauma centers across Austria between 2000 and 2012 were stratified into sex and different age groups. Kaplan-Meier estimates, Cox proportional hazards regression models (HR), and likelihood calculations estimated effects of age, sex, and the anatomic region on the probability of a subsequent fracture in the same patient. Included in the study were 433,499 female and male patients at an age range of 0 to 100years with 575,772 de novo high- and low-trauma fractures. In the age range of 54-70years, subsequent fractures were observed in 16% of females and 12.1% of males. A preceding high-trauma fracture was associated with 12.9% of subsequent fractures, thereof 6.5% of high- and 6.4% of low-trauma in origin, usually at the hip, humerus, or pelvis. The highest effect sizes were observed for femur, humerus, and thorax fractures with hazard ratios (HR) of 1.26, 1.18, and 1.14. After splitting into high-trauma preceding and subsequent low-trauma fractures, the femoral neck (HR=1.59), the female sex (HR=2.02), and age (HR=1.03) were discriminators for increased future fracture risk. Preceding high-trauma fractures increase the risk of future low-trauma non-vertebral fractures including hip. For each patient with a fracture, regardless of the severity of the trauma, osteoporosis should be taken into clinical consideration.

Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture.

Wrist fracture is considered a typical initiating trauma for complex regional pain syndrome type I (CRPS I). However, few studies have comprehensively evaluated factors associated with the occurrence of CRPS I after the surgical treatment of a distal radius fracture (DRF). This study evaluates the factors influencing the occurrence of CRPS I after the surgical treatment of a DRF. A total of 477 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. Patients were followed for 6 months after surgery, and CRPS I was diagnosed using the Budapest diagnostic criteria for research. The factors assessed for the development of CPRS I were age, gender, the body mass index, the type of fracture, the energy of trauma, the number of trial reductions, the type of surgery, and the duration of immobilization. A multivariate logistic regression analysis was conducted to identify independent predictors of the occurrence of CRPS I. Among the 477 patients, 42 (8.8 %) satisfied the Budapest criteria for CRPS I within 6 months of surgery. Female patients developed CRPS I more frequently, and the patients who developed CRPS I were older and more likely to sustain a high energy injury or have a comminuted fracture. According to the multivariate analysis, female patients and those with a high energy trauma or severe fracture type were significantly more likely to develop CRPS I (p = 0.02, 0.01, and 0.01, respectively). High energy injuries, severe fractures, and the female gender contribute to the development of CRPS I after the surgical treatment of DRF. The results have important implications for physicians who wish to identify patients at high risk for CRPS I after operative fixation for DRF and instigate treatment accordingly.

Evaluation of association of fragility fracture and bone mineral density in Nepalese population

Background: Fragility fractures are one of the major health problems. Many factors are associated with it some of which are modifiable and some are not. If we know the value of T-score at which fragility fracture occurs and associated factors responsible for fragility fracture than we will be able to control this burden to the society. The objective of this study is to determine association between fragility fracture and bone mineral density (BMD) using bone densitometry and to know the value of T-score at which fragility fracture occurs. Methods: Patients presenting to B.P. Koirala Institute of Health Sciences with fragility fracture of distal end of radius, fracture around hip and vertebral fractures were included in the study to know the value of T-score at which fragility fracture occurs and their associated risk factor. Patients less than 50 years of age, high energy trauma fracture and pathological fractures were excluded from the study. Results: We found that being multipara, smoking, alcohol consumption, post-hysterectomized patients and steroid intake had significant association with fragility fracture. There was no association with religion, geographic location, associated medical illness, age, sex, associated injury and site of injury. Conclusion: The patients with risk factor for fragility fracture like smoking, alcohol consumption, multipara women, post-hysterectomized women and those who are on long term steroid therapy should undergo BMD test and the value at -3.254 are prone to fragility fracture and should be treated accordingly. Nepal Journal of Medical Sciences | Volume 02 | Number 02 | July-December 2013 | Page 130-134 DOI: http://dx.doi.org/10.3126/njms.v2i2.8956

Radiographically Occult and Subtle Fractures: A Pictorial Review

Radiographically occult and subtle fractures are a diagnostic challenge. They may be divided into (1) “high energy trauma fracture,” (2) “fatigue fracture” from cyclical and sustained mechanical stress, and (3) “insufficiency fracture” occurring in weakened bone (e.g., in osteoporosis and postradiotherapy). Independently of the cause, the initial radiographic examination can be negative either because the findings seem normal or are too subtle. Early detection of these fractures is crucial to explain the patient's symptoms and prevent further complications. Advanced imaging tools such as computed tomography, magnetic resonance imaging, and scintigraphy are highly valuable in this context. Our aim is to raise the awareness of radiologists and clinicians in these cases by presenting illustrative cases and a discussion of the relevant literature.

Acute compartment syndrome of the thigh following minor trauma in a patient on dual anti-platelet therapy

Acute compartment syndrome of the thigh is a rare surgical emergency. It is usually associated with high energy trauma and concomitant femoral fracture. We present the case of a 54 year old man who developed acute compartment syndrome of the thigh following a low energy traumatic hamstring tear. Background anti-platelet therapy and hospital prescribed anticoagulants were likely contributors to this pathology. We describe these factors and discuss the issues associated with assessment of minor trauma in the anti-coagulated patient.

Secular decreases in fracture rates 1986–2006 for Manitoba, Canada: a population-based analysis

We examined trends in fracture rates over 20 years in the Province of Manitoba, Canada. Hip fractures, major low-trauma fractures, and high-trauma fractures declined significantly from 1986 to 2006. Secular decreases in hip fracture rates have been reported in some countries. Whether this phenomenon applies to other fracture sites is not well described. We used 20 years of data from the Population Health Research Data Repository for the Province of Manitoba, Canada. Age-adjusted fracture rates were calculated for men and women age 50 years and older 1986-2006 according to fracture site and mechanism (presence/absence of external injury codes). Generalized linear models with generalized estimating equations were used to derive adjusted annual rates and test for linear change in men and women. Major low-trauma fractures (hip, forearm, spine, and humerus) showed a significant annual linear decline in women (-1.2% [95% CI, -0.7% to -1.8%]) and in men (-0.4% [95% CI, -0.7% to -0.2%]). Hip fracture showed a significant annual decline for both sexes, while forearm and humerus fractures showed a significant decline only in women. The only fracture category that did not show a significant annual decline in either sex was the spine. The observed annual reduction in high-trauma fractures was even larger and did not show a sex difference (-1.8% [95% CI, -2.8% to -0.7%]). We observed a decrease in both low-trauma and high-trauma fracture rates over the study period. This decline was apparent in years prior to widespread osteoporosis testing or availability of modern pharmacotherapy.

Does high-trauma fracture increase the risk of subsequent osteoporotic fracture?

Does high-trauma fracture increase the risk of subsequent osteoporotic fracture?

High-Trauma Fractures and Bone Mineral Density

OSTEOPOROTIC FRACTURES HAVE GENERALLY BEEN defined as fractures that occur following relatively low trauma, such as a fall from standing height or less. Implicit in this definition is the assumption that this type of skeletal trauma would not result in fracture of a normal bone, since the strength of the bone should be able to withstand such force. A surrogate marker for bone strength now used and considered the current gold standard for diagnosing osteoporosis prior to the occurrence of a fracture is calculation of areal bone mineral density (BMD) by dual-energy x-ray absorptiometry. This technique measures the amount of mineral in bone (in grams), typically at the lumbar spine, proximal femur, or distal forearm, and divides this amount by the projected area of the bone, providing a density expressed in grams per centimeter squared. Low BMD is a robust predictor of osteoporotic fracture risk; conversely, low-trauma fractures are related to BMD. In contrast to low-trauma fractures, the conventional view has been that high-trauma fractures, such as those related to a motor vehicle crash or fall from greater than standing height, should not be considered “osteoporotic” fractures, since even normal bones might be expected to fail under these greater loads. While plausible, this concept has not been rigorously tested. Moreover, the definition of hightrauma fractures has been fairly broad, ranging from severe forces that might cause any bone to fracture, to falls from a chair height that might not uniformly cause fracture. The specific definition of high-trauma fractures is of considerably more than academic interest, because current recommendations are to evaluate patients with lowtrauma fractures at any age for an underlying metabolic bone disease, particularly osteoporosis, but not to pursue this assessment for patients sustaining high-trauma fractures. In addition, this definition has far-reaching consequences for the design and analysis of clinical trials involving prevention or treatment of osteoporosis. High-trauma fractures are generally excluded as end points in trials, a factor that has implications for determining the effects of a particular intervention on fracture risk. In this context, the study by Mackey and colleagues in this issue of JAMA is of particular interest and has potential clinical importance. The authors used data from 2 large prospective cohort studies in the United States, the Study of Osteoporotic Fractures (SOF) in women and the Osteoporotic Fractures in Men Study (MrOS) in men to test whether there was an association between BMD and high-trauma fractures and whether high-trauma fractures increased risk of subsequent fracture in older women and men. The somewhat surprising, and perhaps counterintuitive, finding was that among women each 1-SD reduction in BMD was associated with virtually identical increases in risk of high-trauma fractures (multivariable relative hazard [RH], 1.45; 95% confidence interval [CI], 1.23-1.72) and low-trauma fractures (RH, 1.49; 95% CI, 1.42-1.57). Moreover, among women, the risk of subsequent fracture following a high-trauma fracture was the same as that following a low-trauma fracture (RH, 1.31; 95% CI, 1.20-1.43). Thus, highand low-trauma fractures (at least based on how these are currently defined) increased risk of subsequent fracture to exactly the same extent. Similar trends were observed among men, although power was limited due to fewer fractures in men. The study by Mackey et al has several strengths. It involved large numbers of patients (8022 women and 5995 men) who were followed up for fairly long periods (9.1 and 5.1 years, respectively). The determination of fractures appeared complete, including data from questionnaires, personal interviews, and clinical records coupled with radiological confirmation. However, there also were several limitations. Spine fractures were not evaluated, so the findings of the study might not be applicable to lowvs hightrauma spine fractures. In addition, all participants were 65 years or older, so the results may not apply to younger individuals. A previous retrospective case-control study of Australian women older than 50 years with high-trauma fractures also found that these women had lower BMD at the hip, spine, forearm, and total body sites as compared with control women.

High-Trauma Fractures and Low Bone Mineral Density in Older Women and Men

It is widely believed that fractures resulting from high trauma are not osteoporotic; however, this assumption has not been studied prospectively. To examine the association between bone mineral density (BMD) and high-trauma fracture and between high-trauma fracture and subsequent fracture in older women and men. Two prospective US cohort studies in community-dwelling adults 65 years or older from geographically diverse sites. The Study of Osteoporotic Fractures followed up 8022 women for 9.1 years (1988-2006). The Osteoporotic Fractures in Men Study followed up 5995 men for 5.1 years (2000-2007). Hip and spine BMD were assessed by dual-energy x-ray absorptiometry. Incident nonspine fractures were confirmed by radiographic report. Fractures were classified, without knowledge of BMD, as high trauma (due to motor vehicle crashes and falls from greater than standing height) or as low trauma (due to falls from standing height and less severe trauma). Overall, 264 women and 94 men sustained an initial high-trauma fracture and 3211 women and 346 men sustained an initial low-trauma fracture. For women, each 1-SD reduction in total hip BMD was similarly associated with an increased risk of high-trauma fracture (multivariate relative hazard [RH], 1.45; 95% confidence interval [CI], 1.23-1.72) and low-trauma fracture (RH, 1.49; 95% CI, 1.42-1.57). Results were consistent in men (high-trauma fracture RH, 1.54; 95% CI, 1.20-1.96; low-trauma fracture RH, 1.69; 95% CI, 1.49-1.91). Risk of subsequent fracture was 34% (95% CI, 7%-67%) greater among women with an initial high-trauma fracture and 31% (95% CI, 20%-43%) greater among women with an initial low-trauma fracture, compared with women having no high- or low-trauma fracture, respectively. Risk of subsequent fracture was not modeled for men. Similar to low-trauma nonspine fractures, high-trauma nonspine fractures are associated with low BMD and increased risk of subsequent fracture in older adults. High-trauma nonspine fractures should be included as outcomes in osteoporosis trials and observational studies.