Incidence of Lower-Extremity Fractures in US Nursing Homes

Atraumatic Fractures in Multi-Morbid Older Adults: A Series of Five Cases and Review of Literature

Atraumatic fractures (ATFs) are a fragility fracture subtype with occasional medicolegal issues. ATFs are defined as fractures because of a "low-energy mechanism that is usually considered incapable of producing a fracture." They are an underreported disorder, with epidemiological variations. ATF phenomena were previously reported not only in older adults, but also in children, young adults, older adults, and animals. This study is a short retrospective case series exploring atraumatic fractures in a tertiary care university hospital. Over a period of two years, a total of seven ATF cases were identified. However, only five fulfilled the inclusion criteria. Local causes of pathologic fractures (e.g., metastasis) and elder abuse or neglect were excluded. Comparison of the cases' clinical profile, fracture profile, and management was done. All five cases were frail females with significant osteotoxic burdens from medications and multi-morbidities. ATF presentations included typical (as pain) and atypical (as painless, loud crack, and sudden giveaway) symptomatology. One ATF had a coincident unexplained aseptic fever. Three cases had more than one fracture (fracture cascade), confirmed and followed up by x-rays. All the cases were managed conservatively except for one case that underwent hip hemiarthroplasty. Plans of care included managing the osteotoxic multi-morbidities burden, focusing on the whole body, not only on the fracture or bone. The study provided insights about challenges in presentations of ATF (as the bone fracture acute phase reaction: osteogenic aseptic fever). Risk factors are classically assumed to be osteoporosis, but it is usually systemic and multifactorial. A high risk of fracture warning sign could help decrease ATF occurrence or fracture cascades. Four ATF categories were detected to help healthcare systems identify high-risk patients and raise awareness among medical staff, families, and caregivers. Future studies of the at-risk groups are needed to understand ATF knowledge gaps, challenges, and the best treatments.

Development and validation of the fall-related injury risk in nursing homes (INJURE-NH) prediction tool

BACKGROUND

Existing models to predict fall-related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents.

METHODS

Retrospective cohort study of long-stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub-distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6-month and 2-year follow-up. Discrimination was evaluated via C-statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine-Gray model. Model performance was repeated in the validation sample.

RESULTS

Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow-up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2-year prediction model was good (C-index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6-month model were similar (C-index = 0.71). In the clinical tool to predict 2-year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14-2.41) and a history of non-hip fracture (HR 2.02; 95% CI 1.94-2.12). Performance results were similar in the validation sample.

CONCLUSIONS

We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies.

A Study on the Effect of Nursing Intervention Based on Health Behavior Change Integration Theory on Patients with Limb Fracture and Its Effect on Limb Function and Self-Efficacy

Objective

To assess the impact on nursing care based on the theory of health behavior change integration in patients with limb fracture and its effect on limb function and self-efficacy.

Methods

The starting and ending time of this study is from February 2021 to February 2022. In this study, 116 hospitalized patients with limb fracture were selected as the object of study. According to the method of random number table, the patients were divided into study group and control group. The patients of the study cohort were given nursing healthcare based on the theory of health behavior change integration, while those in the control cohort were given common nursing. The scores of self-rating anxiety scale (SAS), self-rating depression scale (SDS), Frankl compliance scale, self-efficacy scale (GSES), activity of daily living scale (ADL), and Fugl-Meyer limb motor function assessment (FMA) were studied before and 3 months after nursing.

Results

After 3 months of nursing, the SAS and SDS scores of the study group were lower than those of the control group, and the difference between groups was statistically significant (p < 0.05). After 3 months of nursing, the scores of Frankl scale, GSES, ADL scale, and FMA scale in the study group were higher than those in the control group, and the difference between groups was statistically significant (p < 0.05).

Conclusion

The value of nursing interventions based on the integration of health behavior change theory is even more significant in patients with limb fractures. It is more helpful in reducing patients' anxiety and depression, increasing compliance and improving limb function. Self-efficacy and daily living skills were also significantly improved.

[Mortality in patients with proximal femur fractures undergoing conservative and surgical treatment]

OBJECTIVE

To study the incidence of proximal femur fractures (PFF) in St. Petersburg and survival rate depending on treatment strategy.

MATERIAL AND METHODS

Considering the data of long-term monitoring of traumatology and orthopedic service in St. Petersburg, we assessed the incidence of PFF in adults and various treatment options. Moreover, we have studied all patients admitted to 2 large hospitals in St. Petersburg between December 2017 and December 2018 for at least 14 months. There were 914 requests for medical care for PFF from 903 patients.

RESULTS

Mean incidence of PFF in St. Petersburg is 0.88 per 1000. The discharged patients without surgical care make up 20%. About 37.5% and 42.4% of patients require hip arthroplasty or osteosynthesis, respectively. Postoperative mortality was 3.5%, in-hospital mortality after therapeutic management - 9.1% (p=0.016). Two-year mortality after osteosynthesis was 27.2%, after hip arthroplasty - 19.3%, after conservative treatment - 43.9% (p<0.001).

Effect of predictive trauma care on fracture healing and complications of traumatic fracture patients in emergency department

OBJECTIVE

To explore the advantages of predictive trauma care in fracture healing and prevention of complications in patients with traumatic fracture.

METHODS

Through prospective research methods, 80 patients with traumatic fractures were divided into a research group and a control group, each with 40 cases. The control group was given regular emergency care, while the research group was given predictive trauma care. The related clinical indicators, complications and scores on changes in joint range of motion (ROM), mental status and quality of life before and after intervention were compared between the two groups.

RESULTS

Compared with the control group, the time of pain relief, fracture recovery and hospital stay of the research group was significantly shortened (all P<0.01). The overall incidence of complications in the research group was lower than that in the control group (5.00% vs 20.00%, P<0.05). For patients with limb fractures, the ROM scores of the two groups after intervention were significantly higher than those before intervention, and the scores of the research group were higher than those of the control group (all P<0.05). Compared with the condition before intervention, the Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores of the two groups of patients were significantly reduced after intervention, and the scores of research group were lower than those of the control group (all P<0.05). Compared with the condition before intervention, the scores of physical function, social function, psychological function and daily life condition of the two groups of patients were significantly increased 3 months after discharge from hospital, and the scores of the research group were significantly higher than those of the control group (all P<0.05).

CONCLUSION

Predictive trauma care can effectively reduce the risk of postoperative complications in patients with traumatic fractures, promote the fracture healing, relieve the patients' anxiety and depression, and improve their quality of life.

Are Nursing Home Residents With Dementia Appropriately Treated for Fracture Prevention?

Clinicians struggle with whether to prescribe osteoporosis medications for fracture prevention for older nursing home (NH) residents with dementia, given the lack of evidence in this population. To better understand real-world clinical practice, we conducted a retrospective cohort study examining patterns of fracture prevention medication use for older NH residents with dementia and high fracture risk. Data sources included 2015-16 Medicare claims, Part D prescriptions, and Minimum Data Set (MDS) assessments. Among NH residents aged 65+ with dementia and prior fracture or high fracture risk based on the MDS FRAiL (Fracture Risk Assessment in Long-term care), we assessed medications for fracture prevention using prescription data from 1 year prior through 90 days after the first MDS assessment. Multivariable logistic regression was used to evaluate factors associated with receiving treatment. Most of the sample (n = 72,639) was >80 years (78%), female (82%), and white (88%); 63% had moderate/severe dementia and 60% had an osteoporosis diagnosis. Only 11.6% received fracture prevention medications. In adjusted analyses, treated residents were more likely to be female, Hispanic or other non-black minority, <90 years old, and newly admitted to the NH. Other associated factors included osteoporosis diagnosis, walker or wheelchair use, bone disorders (eg, Paget disease), >5 medications, steroid or proton pump inhibitor use, and regions outside of the Northeast. Resident characteristics suggestive of comorbidity burden and worsening dementia were associated with reduced likelihood of treatment. Low use of fracture prevention medications for NH residents with dementia may reflect an attempt by prescribers reconcile medication use with changing goals of care, or inappropriate underuse in patients who still have high fracture risk. Additional research is needed to help clinicians better evaluate when to use these medications in this heterogeneous and vulnerable population.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.