Painful Fractures Research Articles

Just the Facts: Fascia iliaca compartment block for hip fracture pain management

Just the Facts: Fascia iliaca compartment block for hip fracture pain management

Phase II Evaluation Of Stereotactic Ablative Radiotherapy (SABR) in 11C-Choline PET/CT (Cho-PET)-Identified Oligometastatic Castration-Resistant Prostate Cancer (CRPC)

Outcomes for metastatic castration-resistant prostate cancer (CRPC) remain poor. We prospectively sought to improve clinical outcomes in a subgroup of CRPC patients (pts) with oligometastases identified by 11C-Choline (Cho)-PET and treated with stereotactic ablative radiotherapy (SABR). This is a single arm, single institution Phase II study which enrolled 94 pts from Aug 2016-Dec 2019; 4 pts voluntarily withdrew and 1 pt had only 1 month follow up. Nine pts who received 8 Gy in 1 were also included in survival analysis. Eligibility included ECOG 0-2, pathologically proven prostate cancer, ≤ 3 metastases identified on Cho-PET, testosterone < 50 ng/dL on androgen deprivation therapy, and life expectancy > 6 months. Primary endpoints were 2-year overall survival (OS) and 1-year PSA-progression (Prostate Cancer Working Group criteria). Secondary endpoints included 1-year SABR-treated metastasis failure (MF) and 6-month rates of grade ≥ 3 adverse events (AEs) per CTCAE V4.0. Peripheral blood samples were collected for exploratory immunologic biomarker analyses. 89 pts are included in this analysis, and median age was 71 years. 58 pts had one lesion, 23 pts two lesions, and 8 pts three lesions. Prior to SABR (n = 80), 61%, 52%, and 20% had progressed on second-line chemotherapy, abiraterone, or enzalutamide, respectively; 38% progressed on both chemotherapy and next generation androgen axis inhibitors. Median PSA at SABR was 0.7 (IQR 0.25, 3.1), and 64% had PSA < 2 ng/mL. Mode dose and fractionation was 20 Gy and 1. At median follow-up of 23 months, median OS was 29 mos. 1- and 2-year OS was 96% (95% CI: 91-100) and 80% (70-92), respectively, for all and also for SABR pts. The cumulative incidence of PSA progression was 58% (48-71) and 76% (67-88), and MF was 12% (6-24) and 18% (11-32) at 1-and 2-years, respectively, for SABR pts. No grade ≥ 3 AEs were noted. Grade 2 AEs included fatigue (1%), fracture (3%), and flare-up pain (8%) in SABR pts. We observed an estimated 2-year OS of 80% in heavily-treated CRPC pts after metastasis-directed therapy to Cho-PET-defined oligometastatic sites with no grade ≥ 3 AEs. Approximately 20% of pts did not have a change or additional systemic therapy following SABR. These results are favorable compared to historical series and support the study of Cho-PET and SABR in CRPC pts in Phase III trials.

The efficacy of teriparatide on lumbar spine bone mineral density, vertebral fracture incidence and pain in post-menopausal osteoporotic patients: A systematic review and meta-analysis

ObjectiveTeriparatide has been increasingly utilized in the management of osteoporosis. The efficacy of low and high dose teriparatide on lumbar spine bone mineral density, vertebral fracture incidence and pain is unknown. We sought to determine the efficacy of teriparatide on these patient-important outcomes using a systematic review and meta-analysis. MethodsA systematic search of electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL) was performed to identify randomized controlled trials (RCTs) that evaluate teriparatide to any comparator for the treatment of osteoporosis in postmenopausal women. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria were used by two independent reviewers to assess the strength and quality of evidence. ResultsA total of 20 studies (n = 6024) were included in this review, with 2855 patients receiving teriparatide and 3169 patients receiving placebo or control treatment. A teriparatide dose of 20 μg/day increased lumbar spine bone mineral density (BMD) (standardized mean difference (SMD) 0.34 standard deviation (SD) units higher (95% CI 0.19–0.48 SDs higher) in comparison to placebo. Relative to anti-resorptive agents, 20 μg/day of teriparatide had a range from 0.14 SD units to 0.96 SD units higher (95% CI, 0.08 SDs lower to 0.36 SDs higher, CI, 0.33–1.59 SDs higher, respectively). 20 μg/day teriparatide had a significant effect on pain severity to placebo or control (SMD 0.80, 95% CI, 1.16–0.43 SDs lower) and also decreased the incidence of vertebral fractures compared to placebo (relative risk 0.31, 95% CI 0.21 to 0.46). Arthralgia and extremity pain incidence were also calculated; there were 15 and 8 fewer events per 1000 patients with the use of 20 μg/day of teriparatide compared to placebo or control, respectively. ConclusionHigh quality evidence supports the utilization of teriparatide 20 μg/day dose to significantly improve lumbar spine BMD and decrease incidence of vertebral fractures and pain severity relative to all comparators. 40 μg/day dose of teriparatide demonstrated significantly better results with prolonged treatment. This data is valuable for clinicians involved in the care of this growing demographic of patients. Further investigation on the safety and efficacy of teriparatide in higher doses for the long-term treatment of osteoporosis in postmenopausal women should be conducted through high-quality clinical trials.

Characteristics and outcomes of hip fractures in lower limb amputees.

Lower limb amputees, regardless of age are at an increased risk of developing fragility fractures of the neck of femur. The characteristics and outcomes of the fractures of the neck of femur in lower limb amputees have not been studied in detail. We undertook a retrospective review of a prospectively collected single centre and single surgeon database between March 1996 and January 2017, using a standard proforma to identify patients who required surgical intervention for fracture neck of femur and had sustained a previous lower limb amputation and compared them with a cohort of standard hip fracture patients. Twenty-seven patients, sustaining 28 fractures of the neck of femurs were identified of which 16 were females with mean age of 78 years (50-89). Nineteen fractures were sustained on the ipsilateral side of the amputation. Results showed that seventy percent of amputees returned to their previous level of mobility and prior residence. Mortality in this group is higher as compared to a standard hip fracture patient but pain and mobility were comparable in both groups. The incidence of both hip fractures and amputations in increasing worldwide but no study has compared outcomes of hip fractures in amputees and compared them to a standard hip fracture patient. Amputees exhibit reduced bone density both at the hip and stump end which increases risk for osteoporosis and fragility fractures in the hip. The management of our patients followed orthopaedic principles, well established surgical interventions and rehabilitation. This study reveals that hip fractures in amputees can have comparable results to a standard hip fracture cohort if preoperative optimisation, planning and postoperative rehabilitation is carried out.

Comparison of lag-screw versus miniplate for osteosynthesis of anterior mandibular fracture: A Randomized Control study

ABSTRACT Objective: The aim of this study was to evaluate the outcome of mandibular fractures fixation in order to compare lag screw technique with standard miniplates. Methods: This prospective randomized comparative study was conducted on 20 patients with mandibular anterior fractures treated with open reduction and internal fixation. The patients were then randomly allocated into two groups. Group 1: two lag screws were used for fracture osteosynthesis in 10 patients. Group 2: two miniplates were used for fracture osteosynthesis in 10 patients. The surgery was done by the same surgical team who did not involve within the research work. The time for hardware fixation was recorded intraoperatively. Patients were assessed clinically and radiographically for fracture stability, malocclusion, masticatory efficiency, mouth opening, paresthesia, pain, edema, infection, wound dehiscence, malunion/ununion and hardware loosening. A repeated measure ANOVA were used to evaluate the different between lag screw and miniplates. Results: Hardware fixation time showed a highly significant (p 0.05). regarding occlusion, fracture stability, mastication biting efficiency and postoperative complications a non-significant (p < 0.05) difference between both groups as revealed. Conclusions: According to the result of this prospective study it is concluded that, the internal fixation of anterior mandibular fractures with lag screws osteosynthesis is simple, successful, achieving rapid fixation with minimal complications.

Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up.

To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification. Retrospective. Main Trauma Center, University Hospital. One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records. Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification. Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up. The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessment, Quantification, and Management of Fracture Pain: from Animals to the Clinic.

Fractures are painful and disabling injuries that can occur due to trauma, especially when compounded with pathologic conditions, such as osteoporosis in older adults. It is well documented that acute pain management plays an integral role in the treatment of orthopedic patients. There is no current therapy available to completely control post-fracture pain that does not interfere with bone healing or have major adverse effects. In this review, we focus on recent advances in the understanding of pain behaviors post-fracture. We review animal models of bone fracture and the assays that have been developed to assess and quantify spontaneous and evoked pain behaviors, including the two most commonly used assays: dynamic weight bearing and von Frey testing to assess withdrawal from a cutaneous (hindpaw) stimulus. Additionally, we discuss the assessment and quantification of fracture pain in the clinical setting, including the use of numeric pain rating scales, satisfaction with pain relief, and other biopsychosocial factor measurements. We review how pain behaviors in animal models and clinical cases can change with the use of current pain management therapies. We conclude by discussing the use of pain behavioral analyses in assessing potential therapeutic treatment options for addressing acute and chronic fracture pain without compromising fracture healing. There currently is a lack of effective treatment options for fracture pain that reliably relieve pain without potentially interfering with bone healing. Continued development and verification of reliable measurements of fracture pain in both pre-clinical and clinical settings is an essential aspect of continued research into novel analgesic treatments for fracture pain.

Comparison of intravenous lidocaine versus epidural anesthesia for traumatic rib fracture pain: a retrospective cohort study

BackgroundEffective analgesia is essential in managing traumatic rib fractures. Intravenous lidocaine (IVL) is effective in treating perioperative pain, acute pain in the emergency department, cancer pain in hospice, and outpatient...

Erector Spine Block (ESB) for Pain Relief in a Patient With Multiple Ribs Fracture

Erector Spine Block is a simple and effective block in controlling chest wall and upper abdominal pain. It is also possible to increase painless period for a few days by placing a catheter. We used this block in a high-risk traumatic patient to reduce the pain of rib fractures.

Reducing the Use of Opioids for Pediatric Patients with Supracondylar Humerus Fractures

Supracondylar humerus (SCH) fractures, the most common elbow injuries in children, often require surgical reduction and percutaneous pinning. Postoperative pain medication management varies considerably, ranging from over-the-counter analgesics to multiday opioid prescriptions. In response to the Ohio opioid epidemic, this quality improvement project focused on limiting discharge opioid prescriptions to five or fewer doses. Orthopedic providers were surveyed on their opioid prescribing practices and given blinded peer-comparison feedback. All orthopedic prescribers were educated via e-mail or in person on the opioid dose guideline for this injury. Any outlying prescribers identified from monthly data queries were reeducated on the project's specific aim. Prescribing providers, patients, and their caregivers were instructed to schedule and alternate non-opioid analgesics postoperatively. When opioids were prescribed, education emphasized the use of this medication only for severely rated pain. Standardized discharge instructions for postoperative fracture care and pain management, as well as electronic medical record orders, were used to emphasize these pain management strategies. The percentage of opioid prescriptions of less than or equal to five doses for surgically managed SCH fracture patients was successfully increased by approximately 60 percentage points; 45.5% of surgical SCH fracture patients were discharged without an opioid prescription. Postdischarge requests for additional pain therapy remained stable. The implemented education changes for patients, families, and orthopedic providers at this facility have paved the way for a decline in opioid prescribing and use. Further reduction in opioid prescribing is anticipated, with the goal to translate these practices to other orthopedic diagnoses.

The evaluation of the treatment for old osteoporotic vertebral compression fracture pain by percutaneous vertebroplasty.

The aim of the present study was to evaluate the clinical effect of percutaneous vertebroplasty (PVP) in the treatment of old osteoporotic vertebral compression fracture (OVCF) pain.A retrospective study was conducted on the clinical and imaging data of 31 patients with old OVCF treated by PVP from June 2010 to September 2011. Clinical efficacy was evaluated by the visual analog scale (VAS) scores, the oswestry disability index (ODI), the Cobb angle, and vertebral kyphotic angle at pre-operation and post-operation 3 days, 3 months, and 12 months.The VAS scores and ODI scores of 3 day, 3 month, and 12 month after PVP were significantly improved compared with those before operation (P < .05), but the Cobb angle and vertebral kyphosis angle were not significantly improved compared with those before operation (P > .05).PVP can effectively relieve the pain caused by old OVCF, and the motor ability of the patients is improved obviously. However, the recovery of Cobb angle and vertebral kyphosis angle was not obvious.

Exercise Triage And Program Adaptations For Cancer Survivors With Multiple Myeloma: A Case Series.

Multiple myeloma (MM) is associated with fracture risk and deconditioning. Exercise training can attenuate functional declines, but the safety of exercise in this population remains unclear. PURPOSE: This case series explores the clinical history, considerations for triage, program adaptations, and functional changes in patients with MM taking part in the Alberta Cancer Exercise (ACE) study. METHODS: An exercise physiologist screened cases using a cancer-specific intake and the PAR-Q+. Due to MM diagnosis, physician approval was required for entry into the ACE study. ACE involved 60 mins of community or clinic-based exercise 2x/wk for 12 weeks. Pre/post measures included the 6-Minute Walk Test (6MWT), 30s sit-to-stand, sit and reach, and optional max bench press (1RM) and plank tests. RESULTS: CASE 1: 54-year old male on chemotherapy with a history of lytic lesions throughout the thoracic cage and pelvis, and radiation therapy (RT) to large lytic lesions in the pelvis and left clavicle. Goal: improve fitness for upcoming stem cell transplantation (SCT). Physician recommendation: controlled low loading due to fracture risk. Approved for community (1x/wk) and clinic-based (1x/wk) exercise. CASE 2: 37-year old female diagnosed with MM without bone involvement, receiving chemo and targeted therapy. She had undergone surgery and was recovering from a SCT. Goal: reduce fatigue and improve fitness. Approved for clinic-based exercise with transition to community after 12 wks. CASE 3: 54-year old female on maintenance chemo with multiple lytic lesions, history of cervicothoracic decompression, reduction and instrumentation C5-T3, and prior RT to spine and pelvis. Goal: improve fitness, strength and health. Approved for clinic-based exercise. Physician recommendation: low intensity exercise due to fracture risk and pain. No adverse events occurred and increases were seen across cases in 6MWT (8.2%, 5.6%, 9.5%), sit-to-stand (0%, 18.8%, 5.9%), sit and reach (18.6%, 56.7%, 42.2%), 1RM (4.1%, 21.4%, N/A), and plank (36.8%, 50%, N/A). CONCLUSIONS: The cases presented with unique complications and apprehension towards exercise. Presence and location of lytic lesions, fracture history and risk, surgical history, and treatment stage were key considerations for exercise triage and adaptations within the ACE program.

Effect of NSAID Use on Bone Healing in Pediatric Fractures: A Preliminary, Prospective, Randomized, Blinded Study.

This study aimed to investigate if nonsteroidal anti-inflammatory drugs (NSAIDs) used in the acute phase of bone healing in children with fractures result in delayed union or nonunion as compared with patients who do not take NSAIDs for pain control during this same time period. In this prospective, randomized, parallel, single-blinded study, skeletally immature patients with long bone fractures were randomized to 1 of 2 groups for their postfracture pain management. The NSAID group was prescribed weight-based ibuprofen, whereas the control group was not allowed any NSAID medication and instead prescribed weight-based acetaminophen. Both groups were allowed to use oxycodone for breakthrough pain. The primary outcome was fracture healing assessed at 2, 6, and 10 weeks. One-hundred-two patients were enrolled between February 6, 2014 and September 23, 2016. Ninety-five patients (with 97 fractures) completed a 6-month follow-up (46 patients with 47 fractures in the control group and 49 patients 50 fractures in the NSAID group). None achieved healing at 1 to 2 weeks. By 6 weeks, 37 of 45 patients (82%) of control group and 46 out of 50 patients (92%) of ibuprofen group had healed fractures (P=0.22). At 10 to 12 week follow-up, 46 (98%) of the control group fractures were healed and 50 (100%) of the ibuprofen group fractures were healed. All were healed by 6 months. Healing was documented at a mean of 40 days in the control group and 31 days in the ibuprofen group (P=0.76). The mean number of days breakthrough oxycodone was used was 2.4 days in the control group and 1.9 days in the NSAID group (P=0.48). Ibuprofen is an effective medication for fracture pain in children and its use does not impair clinical or radiographic long bone fracture healing in skeletally immature patients. Level I-therapeutic.

Relationship between the lateral acromion angle and postoperative persistent pain of distal clavicle fracture treated with clavicle hook plate

BackgroundThe clavicular hook plate is an accepted surgical procedure for distal clavicle fractures. The relationship of the characteristics of the hook plate, acromioclavicular joint and acromion morphology, and clinical outcome has remained poorly understood. We reviewed the clinical records of patients who had distal clavicle fractures with different lateral acromion angles treated using a clavicle hook plate and evaluated their clinical outcomes with respect to shoulder pain and acromial morphology.MethodsWe retrospectively reviewed 102 patients with distal clavicle fractures treated with hook plates at our institution from 2010 to 2017. They were divided into four groups according to lateral acromion angle on shoulder AP view X-rays. The angle was defined as the incline angle between the superior surface of distal clavicle and the inferior facet of acromion on coronal plane. We reviewed their clinical features, including Neer’s impingement sign, MRI findings, and outcomes using Japanese Orthopaedic Association Scores. The mean follow-up was 25.5 months (range, 24 to 28 months).ResultsAll patients in group D (large lateral acromion angle (α) > 40°, acromion coronal angle (β) < 60°) complained of postoperative symptoms. Compared to those with common lateral acromion angle, the incidence of postoperative impingement in group D was undoubtedly much higher (100%). Japanese Orthopaedic Association (JOA) scores in group D were worse at 3 months post-surgery, 3 months post plate removal, and at the last follow-up despite a slightly earlier removal in this group.ConclusionLateral acromion angle appears to be an important factor in the development of postoperative pain and worse outcomes (JOA scores) in patients treated with the hook plate. The incidence of subacromial impingement and rotator cuff lesion (RCL) increased with the α angle. Early limited mobility and removal of the implant may improve the prognosis and resolve the postoperative shoulder pain.Study designRetrospective review, level of evidence IV.

Effectiveness of Pulsed Electromagnetic Fields on Bone Healing: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The effect of pulsed electromagnetic field (PEMF) on bone healing is still uncertain and it has not been established as a standardized treatment. The aim of this systematic review and meta-analysis is to evaluate the effect of PEMF on bone healing in patients with fracture. We searched CNKI, Wan Fang, VIP, EMbase, PubMed, CENTRAL, Web of Science, Physiotherapy Evidence Database, and Open Grey websites for randomized controlled trials (published before July 2019 in English or Chinese) comparing any form of PEMF to sham. Reference lists were also searched. Related data were extracted by two investigators independently. The bias risk of the articles and the evidence strength of the outcomes were evaluated. Twenty-two studies were eligible and included in our analysis (n = 1,468 participants). The pooled results of 14 studies (n = 1,131 participants) demonstrated that healing rate in PEMF group was 79.7% (443/556), and that in the control group was 64.3% (370/575). PEMF increased healing rate (RR = 1.22; 95% confidence interval [CI] = 1.10-1.35; I2 = 48%) by the Mantel-Haenszel analysis, relieved pain (standardized mean difference (SMD) = -0.49; 95% CI = -0.88 to -0.10; I2 = 60%) by the inverse variance analysis, and accelerated healing time (SMD = -1.01; 95% CI = -2.01 to -0.00; I2 = 90%) by the inverse variance analysis. Moderate quality evidence suggested that PEMF increased healing rate and relieved pain of fracture, and very low-quality evidence showed that PEMF accelerated healing time. Larger and higher quality randomized controlled trials and pre-clinical studies of optimal frequency, amplitude, and duration parameters are needed. © 2020 Bioelectromagnetics Society.

Regional anesthesia in Canadian emergency departments: Emergency physician practices, perspectives, and barriers to use.

Regional anesthesia has many applications in the emergency department (ED). It has been shown to reduce general anesthetic dose, requirement for post-procedural opioids, and recovery time. We sought to characterize the use of regional anesthesia by Canadian emergency physicians, including practices, perspectives and barriers to use in the ED. A cross-sectional survey was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical response questions. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables. The survey was completed by 149/1144 staff emergency physicians, with a response rate of 13%. Respondents used regional anesthesia a median of 2 (IQR 0-4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of respondents, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). Respondents agreed that regional anesthesia is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had point of care ultrasound available, however less than half (49.0%) felt comfortable using it for RA. Respondents indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use of RA. Canadian emergency physicians use regional anesthesia infrequently but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake.

The use of bisphosphonates to meet orthopaedic challenges.

The anti-resorptive properties of bisphosphonates have been explored to manage several conditions that traditionally have required a surgical solution. In osteonecrosis, their use is predicated on the principle that bone collapse occurs during the revascularisation phase of the disease. If the associated resorptive activity were modulated, the resultant preserved joint architecture may improve clinical outcome and reduce the need for joint replacement. Pre-clinical and small-scale clinical studies have given non-conclusive support for this principle. Adequately powered clinical trials with relevant long-term endpoints are still required to firmly clarify the clinical efficacy of this treatment. Several clinical studies have shown that bisphosphonates can reduce periprosthetic bone loss and, in some situations, enhance implant fixation in the early period after joint replacement. This may be advantageous in settings where osseointegration is problematic. However, the ultimate goals of their use in joint replacement has been to reduce the incidence of late periprosthetic inflammatory osteolysis, the main cause of prosthesis failure. Population-based observational studies have associated bisphosphonate use with a lower incidence of revision surgery, supported by pre-clinical data. However, clinical trials have, to date, failed to demonstrate any efficacy for the human disease. The timing of bisphosphonate administration for secondary prevention after acute osteoporotic fracture has been subject to extensive investigation, with pre-clinical studies showing increased callus formation but decreased remodelling and no effect on the restoration of mechanical integrity of bone. Meta-analysis of clinical trial data indicates that early administration of bisphosphonate after acute fracture does not adversely affect fracture union, pain or functional outcomes. Finally, bisphosphonates have also been explored as a treatment for complex regional pain syndrome type-I. A recent meta-analysis has shown a beneficial effect on visual analogue scale pain scores, but an increase in mild adverse events.

Vertebral fracture: clinical presentation and severity are linked to fracture risk factors.

Data concerning the association between risk factors of vertebral fracture and its presentation are limited. In this study, several fracture risk factors were related to the clinical and radiological presentation of vertebral fractures. The findings suggest that these factors should be considered in patient assessments. The aims of this study were to describe the prevalence of fracture risk factors in patients with vertebral fractures (VF) and to analyze their association with VF clinical presentation and severity. The study design was observational and cross-sectional. Patients were recruited between 2015 and 2018. Fracture risk factors were recorded, including bone mineral density, fracture risk assessment (FRAX) score, pain characteristics, analgesia required, and radiological features such as number, location(s), and grade of VF, affected segment, kyphosis angle, and spine deformity index (SDI). A series of 422 patients was included (mean age, 75 ± 9 years; 74% women). Single VF was present in 59%, previous fragility fracture in 39%, and osteoporosis in 52%. L1 was the most affected location (28%); 38% had grade 2 VF, and 36% had grade 3. Acute onset back pain was present in 81%. Older age, history of previous fragility fracture, body mass index ≤ 20 kg/m2, low bone mineral density, smoking habit, and high FRAX score were significantly associated with the presence of multiple VF, greater kyphosis angle, and higher SDI. Gradual onset back pain was associated with higher SDI and irradiated pain with greater kyphosis angle. Previously unpublished associations were observed between clinical and radiological characteristics of fragility VF and several fracture risk factors. The results could lead to a better understanding of the complex relationships between these risk factors and clinical presentation, and should be considered when assessing patients with VF.

Management of Pediatric Fracture Pain Differs by Patient Race and Ethnicity

In a retrospective cohort study, researchers analyzed registry data for visits for long bone fractures at seven geographically diverse pediatric

Hip fracture pain management in a regional Australian emergency department: A retrospective descriptive study

BackgroundHip fractures are a common and painful emergency presentation amongst elderly patients and are associated with significant morbidity and mortality. This study observed the frequency of documentation of pain scores and use of nerve blocks in hip fracture patients in a regional Australian ED and describes current practice in relation to national guidelines. MethodsThis was a retrospective single-site observational study and included all patients with a recorded ED diagnosis of fracture neck of femur over the age of 18 presenting between 1 July 2017 and 31 December 2017 to a regional ED. Data collection included patient demographics, pain scores and analgesia administered. ResultsNinety-three patients were included in analysis. This population had a high proportion of patients who had a residential address remote to the base hospital. Thirty-eight patients (41%) had a documented pain score within 30min and the frequency of nerve blocks was 45%. ConclusionManagement of pain for patients with hip fracture in this regional ED varied from Australian guidelines and practice in other Australian EDs, demonstrating potential areas for further research and quality improvement in assessing and treating pain in older adults. Geographic remoteness may be an important factor.