- Email: [email protected]
High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture
G Model JINJ 7031 No. of Pages 7
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture$ Bong-Gun Leea , Yoon-Kyoung Sungb , Dam Kimb , Yun Young Choic, Hunchul Kima , Yeesuk Kima,* a b c
Department of Orthopedic Surgery, College of Medicine, Hanyang University, South Korea Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, South Korea Department of Nuclear Medicine, Hanyang University Medical Center, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 March 2016 Received in revised form 17 September 2016 Accepted 28 December 2016
Purpose: The purpose was to evaluate the prevalence and location of simultaneous fracture using bone scans in patients with hip fracture and to determine the risk factors associated with simultaneous fracture. Patients and methods: One hundred eighty two patients with hip fracture were reviewed for this study. Clinical parameters and bone mineral density (BMD) of the lumbar vertebra and femoral neck were investigated. To identify acute simultaneous fracture, a bone scan was performed at 15.4 4.1 days after hip fracture. The prevalence and location of simultaneous fracture were evaluated, and multivariate logistic regression analysis was performed to determine the risk factors. Results: Simultaneous fracture was observed in 102 of 182 patients, a prevalence of 56.0%. Rib fracture was the most common type of simultaneous fracture followed by rib with vertebral fracture. The BMD of the lumbar vertebra was significantly lower in patients with simultaneous fracture (p = 0.044) and was identified as an independent risk factor (odds ratio: OR 0.05, 95% confidence interval: CI 0.01–0.57). Conclusions: The prevalence of simultaneous fracture was relatively high among patients with hip fracture, and BMD was significantly lower in patients with simultaneous fracture than in patients without it. Surgeons should be aware of the possibility of simultaneous fracture in patients with hip fracture. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Simultaneous fracture Rib Vertebra Hip Bone scan
1 Introduction Osteoporosis is a condition of low bone mass and microarchitecture disruption that results in fractures caused by minimal trauma [1]. The most clinically important fragility fractures are those of the vertebra and hip because they have both high incidence rates and devastating consequences, including early mortality and permanent activity limitations [2]. The vast majority of fragility fractures involving the hip result from a fall from standing height or less [3]. Several studies have shown that a history of vertebral fracture increases the risk of subsequent hip fracture [4,5]. The presence of one fragility fracture is a major risk factor for future fractures because osteoporosis is a systemic
$ This work should be attribute to Department of Orthopedic Surgery, College of Medicine, Hanyang University. * Corresponding author at: Department of Orthopedic Surgery, College of Medicine, Hanyang University, 222 Wangsimni-ro,Seongdong-gu, Seoul, 133-791, South Korea. E-mail address: [email protected] (Y. Kim).
condition of the skeleton, and osteoporosis-related fracture is a hallmark of the disease [6,7]. Hip fracture is known as a high-mortality fracture, and the mortality rate within one year of hip fracture has been reported to range from 10.1% to 31% [8–11]. Several investigators have reported that subsequent fragility fractures are associated with increased mortality risk and poor functional outcome [12–14]. However, vertebral fracture is underdiagnosed, and patients with hip fracture often have vertebral fracture without knowing it [15]. Accurate diagnosis of a fracture is not always possible due to neurological diseases, such as dementia, and the severe pain of the hip fracture, which can lead to delayed diagnosis of the overlooked fracture. This can delay proper treatment and negate the possibility of early rehabilitation due to the long hospital stay. In severe cases, systemic complications, such as sepsis due to pneumonia and sores, can occur and lead to death [16,17]. The purpose of this study was to evaluate the prevalence and location of simultaneous fracture using bone scan in patients with hip fracture and to determine the risk factors associated with simultaneous fracture.
http://dx.doi.org/10.1016/j.injury.2016.12.027 0020-1383/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
2
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
All study protocols were approved by the Institutional Review Board of our institution (HYUH IRB 2012-R-23).
radiologic correlation with other conditions, such as old healed traumatic lesions or degenerative disease.
2 Patients and methods
2.2 Bone mineral density of dual energy X-ray absorptiometry (DXA)
From February 2010 to April 2013, 234 patients over the age of 55 years were diagnosed with unilateral hip fracture and underwent surgery at our hospital. We excluded 51 patients who did not undergo a bone scan. The remaining 182 patients were included in this study (Fig. 1). All patients visited the emergency department, and hip fracture was diagnosed with radiographs. We reviewed the age, height, weight, body mass index (BMI), and history of previous trauma from the medical records. The cause of hip fracture was reviewed and categorized based on the magnitude of the trauma: low-energy trauma, a slip or fall from standing height or less; high-energy trauma, a traffic accident or falling from higher than standing height. The location of the hip fracture was identified with radiographs.
Areal BMD measurement was performed for the lumbar vertebra and femoral neck in 165 patients using DXA (Discovery QDR, Hologic, Bedford, MA, USA) for evaluation of osteoporosis. Patients were scanned according to standardized procedures. The scanner was calibrated at baseline, and daily quality control scans showed no shifts in scanner performance during the study period. Osteoporosis was diagnosed when the T score was <-2.5.
2.1 Evaluation of simultaneous fracture with a bone scan Bone scan was performed at a mean 15.4 days (range, 7–25) after hip fracture. Anterior and posterior whole body images were obtained with a gamma camera (E-cam, Siemens, Hoffman Estates, IL, USA) equipped with a high-resolution collimator four hours after intravenous injection of 20 mCi of Tc-99 m methylene diphosphonate (MDP). Additional static regional images were acquired for any areas showing increased uptake. A nuclear medicine physician interpreted the lesions. Acute traumatic lesion was suspected if a focal increased uptake lesion had intensity similar to that of hip fracture. An acute traumatic lesion was determined as the presence of tenderness on physical examination and/or a positive finding on radiologic evaluation. If there were other lesions that showed less intense uptake than the acute lesions, a diagnosis was made based on patient history or
2.3 Statistical analysis The prevalence and location of simultaneous fracture were evaluated. We compared baseline characteristics between patients with hip fracture with and without simultaneous fracture using x2 or Fisher exact tests for categorical variables and two-sided t-tests for continuous variables. We used crude analysis to assess the relationship between simultaneous fracture and each of the variables. To identify possible risk factors of simultaneous fracture, multivariable logistic regression analysis was performed. We analyzed the risk factors of simultaneous vertebral fracture with the same procedure. All analyses were conducted with SPSS software (version 21.0; IBM, Armonk, NY, USA), and p values less than 0.05 were considered statistically significant. 3 Results 3.1 Patient demographics There were 61 male and 121 female patients with a mean age at hip fracture of 77.1 years (range, 56–97) and mean BMI of
Fig. 1. Flowchart showing eligible cases of simultaneous fractures with hip fracture.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
22.1 kg/m2 (range, 13.9–33.3). The cause of trauma was low-energy trauma in 170 patients (93.4%) and high-energy trauma in 12 patients (6.6%). One hundred fifty-four patients (84.6%) had no history of previous trauma before the index operation. Femoral neck fractures occurred in 65 patients (35.7%), and trochanteric fractures occurred in 117 patients (64.3%). Bone density was evaluated with DXA in 165 of the 182 patients. The mean BMD was 0.737 g/cm2 (range, 0.134–1.212) in the lumbar vertebra and 0.499 g/cm2 (range, 0.129–0.789) in the uninjured femoral neck. The mean T score was 2.4 (range, 6.2 to 1.8) in the lumbar vertebra and 2.8 (range, 6.3 to 0.4) in the femoral neck. Osteoporosis was diagnosed in 113 patients (68.5%).
3
When assessing the results by number and location of simultaneous fracture, rib fracture was the most common type, occurring in 38 patients (20.9%), followed by rib and vertebral fracture in 20 patients (10.9%), and vertebral fracture in 18 patients (9.9%) (Fig. 2). Eight patients with pneumonia have been confirmed in our study. Among them, four patients have hip fractures with rib fracture (5.4%), and four patients without rib fractures (3.5%). The result confirmed the incidence was slightly higher in the rib fractured patients. However, it was not statistically significant (p = 0.829). 3.3 Risk factors of simultaneous fracture in patients with hip fracture
3.2 Prevalence and location of simultaneous fracture Simultaneous fracture occurred in 102 of 182 patients, a prevalence of 56.0%. Fifty-nine patients (32.4%) had one simultaneous fracture, 36 patients (19.8%) had two, and seven patients (3.8%) had three. Rib fracture was the most common type of simultaneous fracture, occurring in 73 patients (40.1%), followed by vertebral fracture in 48 patients (26.4%). Fracture of the radius occurred in six patients (3.3%), tibia in six patients (3.3%), pelvis in five patients (2.8%), fibula in four patients (2.2%), ulna in three patients (1.7%), foot in three patients (1.7%), humerus in two patients (1.1%), and skull in one patient (0.6%).
Of the 182 patients with hip fracture, 102 had simultaneous fracture. There were no differences in age, sex, BMI, history of previous trauma, cause of hip fracture, location of hip fracture, BMD of the femoral neck, or T score of the lumbar vertebra and femoral neck between hip fracture patients with and without simultaneous fracture. However, the BMD of the lumbar vertebra in patients with simultaneous fracture was significantly lower than that in patients without simultaneous fracture (p = 0.044) (Table 1). In multivariate logistic regression analysis, BMD of the lumbar spine was associated with simultaneous fracture in adjusted analysis (odds ratio: OR 0.05, 95% confidence interval: CI 0.01–0.57) (Table 2).
Fig. 2. Locations and numbers (percentage) of simultaneous fracture.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
4
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Table 1 Comparison of baseline characteristics between patients with and without simultaneous fractures.
Age (years) mean SD Sex (n)
Male Female
BMI (kg/m2) mean SD
Simultaneous fracture (n = 102)
No simultaneous fracture (n = 80)
P
77.5 7.8
76.5 8.6
0.396
34 68
27 53
0.953
22.1 4.2
22.1 3.0
0.977
Location of fracture (n)
Femoral neck Trochanter
38 64
27 53
0.624
Cause of injury (n)
Low energy High energy
93 9
77 3
0.171
Previous injury history (n)
Yes No
19 83
9 71
0.171
Osteoporosis (n)a
Yes No
69 26
44 26
0.182
BMD (g/cm2) mean SDa
Lumbar vertebra
0.715 0.165
0.767 0.157
0.044
Femur neck
0.485 0.119
0.519 0.112
0.070
T-score mean SDa
Lumbar vertebra
2.6 1.4
2.2 1.4
0.067
Femur neck
2.9 1.1
2.7 1.0
0.058
SD standard deviation, BMI body mass index, BMD bone mineral density. a Data are from 165 patients who a BMD value.
Table 2 Risk factors associated with a simultaneous fracture.
Older age Sex
Male Female
Higher BMI(kg/m2)
Crude OR
Adjusted OR (1) (n = 182)
Adjusted OR (2) (n = 165)
1.02 (0.98–1.05)
1.02 (0.98–1.06)
1.02 (0.98–1.06)
Ref. 1.02 (0.55–1.89)
Ref. 1.06 (0.56–2.01)
Ref. 0.59 (0.27–1.27)
0.99 (0.92–1.08)
1.01 (0.93–1.09)
1.06 (0.96–1.16)
Location
Neck Trochanter
Ref. 0.86 (0.46–1.58)
Ref. 0.86 (0.46–1.61)
Ref. 0.77 (039–1.53)
Cause of injury
Low energy High energy
Ref. 2.48 (0.65–9.49)
Ref. 2.64 (0.67–10.39)
Ref. 1.45 (0.34–6.17)
Previous trauma history
1.81 (0.77–4.24)
1.82 (0.77–4.32)
1.77 (0.66–4.74)
Osteoporosis
1.57 (0.81–3.04)
Higher BMD(g/cm2)
Higher T–score
Lumbar vertebra
0.13 (0.02–0.96)*
Femur neck
0.75 (0.00–1.27)
Lumbar vertebra
0.81 (0.65–1.02)
Femur neck
0.742 (0.54–1.01)
0.05 (0.01–0.57)*
Age, sex, BMI, location of fracture, cause of injury, and previous trauma history were adjusted in Model 1; Age, sex, BMI, location of fracture, cause of injury, previous trauma history, and BMD of lumbar vertebra were adjusted in Model 2. OR odds ratio, BMI body mass index, Ref. reference, BMD bone mineral density. * p value < 0.05.
3.4 Risk factors of simultaneous vertebral fracture There were no differences in age, sex, BMI, history of previous trauma, cause of hip fracture, BMD of the lumbar vertebra and femoral neck, or T score of the lumbar vertebra between patients
with and without simultaneous vertebral fracture. However, trochanteric fracture was more common than femoral neck fracture in patients with simultaneous vertebral fracture (p < 0.001), and the T score of the femoral neck was significantly lower in patients with simultaneous vertebral fracture (p = 0.047)
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
5
Table 3 Comparison of baseline characteristics between patients with and without vertebral fracture as a simultaneous fracture.
Age (years) mean SD Sex (n)
Male Female
BMI (kg/m2) mean SD
Simultaneous vertebral fracture (n = 48)
No simultaneous vertebral fracture (n = 134)
P
77.9 7.9
76.7 8.3
0.378
12 36
49 85
0.145
22.2 4.2
22.2 3.5
0.948
Location of fracture (n)
Femoral neck Trochanter
5 43
60 74
<0.001
Cause of injury (n)
Low energy High energy
45 3
125 9
0.911
Previous injury history (n)
Yes No
9 35
13 108
0.092
Osteoporosis (n)a
Yes No
32 12
81 40
0.479
BMD (g/cm2) mean SDa
Lumbar vertebra
0.701 0.173
0.750 0.158
0.090
Femur neck
0.469 0.129
0.511 0.111
0.053
T-score mean SDa
Lumbar vertebra
2.7 1.5
2.3 1.4
0.086
Femur neck
3.1 1.2
2.7 1.0
0.047
SD standard deviation, BMI body mass index, BMD bone mineral density. a Data are from 165 patients who a BMD value.
(Table 3). In multivariate logistic regression analysis, the significant independent predictor of simultaneous vertebral fracture was trochanteric fracture (OD 9.24, 95% CI 2.79–30.58), and the risk of simultaneous vertebral fracture increased by 9.2-fold in the presence of trochanteric fracture (p < 0.001) (Table 4).
4 Discussion The prevalence of simultaneous fracture was 56.0% in patients with hip fracture, and the most common simultaneous fracture was rib fracture (40.1%), followed by vertebral fracture (26.4%). Multivariate analysis identified BMD of the lumbar vertebra as a
Table 4 Risk factors associated with vertebral fracture as a simultaneous fracture.
older age Male Female
Sex
Higher BMI(kg/m2)
Crude OR
Adjusted OR (1) (n = 182)
Adjusted OR (2) (n = 165)
1.02 (0.98–1.06)
1.01 (0.96–1.05)
1.00 (0.95–1.05)
Ref. 1.73 (0.82–3.63)
Ref. 1.97 (0.87–4.44)
Ref. 1.40 (0.55–3.57)
0.99 (0.91–1.09)
0.99 (0.89–1.09)
0.97 (0.87–1.09)
Location
Neck Trochanter
Ref. 6.97 (2.60–18.70)*
Ref. 7.88 (2.84–21.86)*
Ref. 9.24 (2.79–30.58)*
Cause of injury
Low energy High energy
Ref. 0.93 (0.24–3.57)
Ref. 1.53 (0.32–7.31)
Ref. 0.68 (0.07–6.56)
Previous trauma history
2.05 (0.88–4.76)
2.48 (0.97–6.35)
3.20 (0.99–10.29)
Osteoporosis
1.92 (0.95–3.86) 2
Higher BMD(g/cm )
Lumbar vertebra Femur neck
0.15 (0.02–1.35) 0.05 (0.00–1.09)
Higher T-score
Lumbar vertebra Femur neck
0.80 (0.62–1.03) 0.72 (0.51–1.00)*
0.88 (0.59–1.32)
Age, sex, BMI, location of fracture, cause of injury, and previous trauma history were adjusted in Model 1; Age, sex, BMI, location of fracture, cause of injury, previous trauma history, and T-score of femur neck were adjusted in Model 2. OR odds ratio, BMI body mass index, Ref. reference, BMD bone mineral density. * p value < 0.05.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
6
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
risk factor of simultaneous fracture and trochanteric fracture as a risk factor of simultaneous vertebral fracture. We found a relatively high prevalence of simultaneous fracture. Brooks et al. reported that simultaneous fracture was overlooked in 10 of 45 patients in the emergency department, and three of these 10 patients needed to undergo surgery [18]. They emphasized thorough observation after the initial hospital visit in order to rule out the possibility of hidden injury [18]. Wei et al. reported that the average prevalence of missed fractures was 3.7%, and the most common location for overlooked fractures was the foot (7.6%) [16]. We identified a higher prevalence of simultaneous fracture than did other studies. The reasons for this high prevalence were that we included many elderly patients with osteoporosis; these patients are susceptible to light trauma other than the identified fracture. We also used bone scanning, which has a high sensitivity to fracture, as a diagnostic tool to identify simultaneous fracture [19]. The most common locations of simultaneous fracture were the rib and vertebra. Rib fracture can occur easily in elderly patients due to light trauma. In a prospective cohort study, Barret-Connor et al. found that the rib is the most common site for osteoporotic non-vertebral fracture, and that rib fractures account for about 24% of total fractures [20]. They also reported that a history of rib fracture increases the risks of an additional rib fracture, a hip fracture, or a distal radius fracture by more than two-fold; thus, they highlighted the significance of rib fracture. Complications such as bronchitis and pneumonia can occur due to rib fracture because the elasticity of the lung parenchyma, pulmonary alveoli, and vessels is decreased, and pulmonary function becomes impaired due to weak intercostal and diaphragm muscles, decreased thoracic cavity, and impaired gas exchange [21]. Therefore, since the risk of rib fracture in patients with hip fracture is relatively high, proper management of these patients is necessary. In our study, a high proportion of trochanteric fracture was identified in simultaneous vertebral fracture, and the odds ratio of trochanteric fracture was 9.24 in comparison with neck fracture. Vertebral fractures are the most common osteoporotic fractures, but only about one-third of these fractures receive clinical attention [22]. Recently, there has been growing interest regarding the hypothesis that the two main categories of hip fracture, neck and trochanteric, differ in pathophysiological mechanisms and consequently in predisposing factors [23]. Kotowicz et al. reported that, in women with vertebral fracture, the risk of trochanteric hip fracture increases by 2.3-fold (p < 0.05) and the risk of femoral neck fracture by 1.3-fold (nonspecific) compared with women without vertebral fracture; this indicates that trochanteric fractures are more strongly associated with spinal osteoporosis than femoral neck fractures [24]. Moreover, some studies have reported that patients with trochanteric fractures are older, thinner, and have lower BMD and quantitative ultrasound values than patients with cervical fractures [25–27]. Therefore, close examination and proper management are necessary in trochanteric fracture due to the high prevalence of simultaneous vertebral fracture, a major osteoporotic fracture. The simultaneous fracture was identified using bone scan, which has high sensitivity for fracture identification and the ability to scan the whole body without missing a simultaneous fracture. Bone scan is a nuclear scanning test to identify certain abnormalities in bone. It is primarily used to find the location and number of abnormal conditions relating to the bones, especially the diagnosis of fractures that might not be visible on traditional x-ray images. The nuclear medicine scan technique is sensitive to areas of unusual bone-rebuilding activity because the radiopharmaceutical is taken up by osteoblast cells actively remodeling bone. When performing the bone scan, the point of
concern, for examination consists in the use of radioisotopes and exposure of radiation. However, the radiation dose received by the patient for inspection is about 4mSv, which is a half dose of abdominal CT scan, and it is known that this level of exposure is not large influence on the human body. Therefore, the bone scan is useful examination because the inspection of simultaneous fracture in whole body is possible and the test has a high level of sensitivity. This study has several limitations. First, this study was performed in a single center. This might have led to a bias in patient selection, and the statistical power necessary to provide strong evidence and generalized outcomes could be insufficient. Second, we could not determine the exact time of onset of simultaneous fracture using the bone scan. It is impossible to know whether simultaneous fracture occurred at the same time as hip fracture. However, we tried to determine acute injury by interviewing patients about their trauma history and reviewing the medial records. We thought that the most important issue was not the time of simultaneous fracture, but the presence of acute hidden injury other than hip fracture, which could influence the management, rehabilitation, and outcomes of patients. Third, the severity, grade, and level of simultaneous fractures were simplified, and treatment of simultaneous fracture was not investigated. 5 Conclusions The prevalence of simultaneous fracture in patients with hip fracture was relatively high. Rib and vertebral fractures were determined as the most common simultaneous fractures, and the risk factor was low BMD of the lumbar vertebra. Trochanteric fracture showed a higher prevalence of simultaneous vertebral fracture than did femoral neck fracture. Therefore, surgeons should be aware of the possibility of simultaneous fracture when treating patients with hip fracture. Conflict of interest There are no conflicts of interest. References [1] Kanis JA, McCloskey EV, Johansson H, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2013;24(1):23–57. [2] Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of hip: the east Anglian audit. Bmj 1995;310(6984):904–8. [3] Youm T, Koval KJ, Kummer FJ, Zuckerman JD. Do all hip fractures result from a fall? Am J Orthop (Belle Mead NJ) 1999;28(3):190–4. [4] Siris ES, Genant HK, Laster AJ, Chen P, Misurski DA, Krege JH. Enhanced prediction of fracture risk combining vertebral fracture status and BMD. Osteoporos Int 2007;18(6):761–70. [5] Gonnelli S, Caffarelli C, Maggi S, et al. The assessment of vertebral fractures in elderly women with recent hip fractures: the BREAK Study. Osteoporos Int 2013;24(4):1151–9. [6] Black DM, Arden NK, Palermo L, Pearson J, Cummings SR. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1999;14(5):821–8. [7] Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S. Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women: a meta-analysis. J Bone Joint Surg [Am] 2003;85-A(10):1936–43. [8] Chirodian N, Arch B, Parker MJ. Sliding hip screw fixation of trochanteric hip fractures: outcome of 1024 procedures. Injury 2005;36(6):793–800. [9] Petersen MB, Jorgensen HL, Hansen K, Duus BR. Factors affecting postoperative mortality of patients with displaced femoral neck fracture. Injury 2006;37 (8):705–11. [10] Sakamoto K, Nakamura T, Hagino H, et al. Report on the Japanese Orthopaedic Association's 3-year project observing hip fractures at fixed-point hospitals. J Orthop Sci 2006;11(2):127–34. [11] Imai N, Endo N, Hoshino T, Suda K, Miyasaka D, Ito T. Mortality after hip fracture with vertebral compression fracture is poor. J Bone Miner Metab 2014 (in press).
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx [12] Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 2009;301(5):513–21. [13] Ha YC, Baek JH, Ko YB, Park SM, Song SH. High mortality and poor morbidity after hip fracture in patients with previous vertebral fractures. J Bone Miner Metab 2014;33(5):547–52. [14] Tosteson AN, Gabriel SE, Grove MR, Moncur MM, Kneeland TS, Melton LJ. 3rd. Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int 2001;12(12):1042–9. [15] Sosa M, Saavedra P, Gomez-de-Tejada MJ, et al. High prevalence of undiagnosed vertebral fractures in patients suffering from hip fracture at their hospital admission: weak concordance among observers. Aging Clin Exp Res 2015;27(6):835–9. [16] Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY. Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol 2006;47 (7):710–7. [17] Guly HR. Diagnostic errors in an accident and emergency department. Emerg Med J 2001;18(4):263–9. [18] Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury 2004;35(4):407–10. [19] Matin P. The appearance of bone scans following fractures, including immediate and long-term studies. J Nucl Med 1979;20(12):1227–31. [20] Barrett-Connor E, Nielson CM, Orwoll E, Bauer DC, Cauley JA. Osteoporotic Fractures in Men Study G: Epidemiology of rib fractures in older men:
[21]
[22]
[23] [24]
[25]
[26]
[27]
7
osteoporotic Fractures in Men (MrOS) prospective cohort study. Bmj 2010;340:c1069. Roumen RM, Redl H, Schlag G, Sandtner W, Koller W, Goris RJ. Scoring systems and blood lactate concentrations in relation to the development of adult respiratory distress syndrome and multiple organ failure in severely traumatized patients. J Trauma 1993;35(3):349–55. van Wyk PM, Chu CH, Babineau J, et al. Community-based rehabilitation post hospital discharge interventions for older adults with cognitive impairment following a hip fracture: a systematic review protocol. JMIR Res Protoc 2014;3 (3):e47. Latham NK, Bean JF, Jette AM. Home-based exercise and hip fracture rehabilitation–reply. JAMA 2014;311(23):2440–1. Kotowicz MA, Melton 3rd LJ, Cooper C, Atkinson EJ, O'Fallon WM, Riggs BL. Risk of hip fracture in women with vertebral fracture. J Bone Miner Res 1994;9 (5):599–605. Latham NK, Harris BA, Bean JF, et al. Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial. JAMA 2014;311(7):700–8. Gialanella B, Prometti P, Monguzzi V, Ferlucci C. Neuropsychiatric symptoms and rehabilitation outcomes in patients with hip fracture. Am J Phys Med Rehabil 2014;93(7):562–9. Wang CY, Graham JE, Karmarkar AM, Reistetter TA, Protas EJ, Ottenbacher KJ. FIM motor scores for classifying community discharge after inpatient rehabilitation for hip fracture. PM R 2014;6(6):493–7.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture$ Bong-Gun Leea , Yoon-Kyoung Sungb , Dam Kimb , Yun Young Choic, Hunchul Kima , Yeesuk Kima,* a b c
Department of Orthopedic Surgery, College of Medicine, Hanyang University, South Korea Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, South Korea Department of Nuclear Medicine, Hanyang University Medical Center, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 March 2016 Received in revised form 17 September 2016 Accepted 28 December 2016
Purpose: The purpose was to evaluate the prevalence and location of simultaneous fracture using bone scans in patients with hip fracture and to determine the risk factors associated with simultaneous fracture. Patients and methods: One hundred eighty two patients with hip fracture were reviewed for this study. Clinical parameters and bone mineral density (BMD) of the lumbar vertebra and femoral neck were investigated. To identify acute simultaneous fracture, a bone scan was performed at 15.4 4.1 days after hip fracture. The prevalence and location of simultaneous fracture were evaluated, and multivariate logistic regression analysis was performed to determine the risk factors. Results: Simultaneous fracture was observed in 102 of 182 patients, a prevalence of 56.0%. Rib fracture was the most common type of simultaneous fracture followed by rib with vertebral fracture. The BMD of the lumbar vertebra was significantly lower in patients with simultaneous fracture (p = 0.044) and was identified as an independent risk factor (odds ratio: OR 0.05, 95% confidence interval: CI 0.01–0.57). Conclusions: The prevalence of simultaneous fracture was relatively high among patients with hip fracture, and BMD was significantly lower in patients with simultaneous fracture than in patients without it. Surgeons should be aware of the possibility of simultaneous fracture in patients with hip fracture. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Simultaneous fracture Rib Vertebra Hip Bone scan
1 Introduction Osteoporosis is a condition of low bone mass and microarchitecture disruption that results in fractures caused by minimal trauma [1]. The most clinically important fragility fractures are those of the vertebra and hip because they have both high incidence rates and devastating consequences, including early mortality and permanent activity limitations [2]. The vast majority of fragility fractures involving the hip result from a fall from standing height or less [3]. Several studies have shown that a history of vertebral fracture increases the risk of subsequent hip fracture [4,5]. The presence of one fragility fracture is a major risk factor for future fractures because osteoporosis is a systemic
$ This work should be attribute to Department of Orthopedic Surgery, College of Medicine, Hanyang University. * Corresponding author at: Department of Orthopedic Surgery, College of Medicine, Hanyang University, 222 Wangsimni-ro,Seongdong-gu, Seoul, 133-791, South Korea. E-mail address: [email protected] (Y. Kim).
condition of the skeleton, and osteoporosis-related fracture is a hallmark of the disease [6,7]. Hip fracture is known as a high-mortality fracture, and the mortality rate within one year of hip fracture has been reported to range from 10.1% to 31% [8–11]. Several investigators have reported that subsequent fragility fractures are associated with increased mortality risk and poor functional outcome [12–14]. However, vertebral fracture is underdiagnosed, and patients with hip fracture often have vertebral fracture without knowing it [15]. Accurate diagnosis of a fracture is not always possible due to neurological diseases, such as dementia, and the severe pain of the hip fracture, which can lead to delayed diagnosis of the overlooked fracture. This can delay proper treatment and negate the possibility of early rehabilitation due to the long hospital stay. In severe cases, systemic complications, such as sepsis due to pneumonia and sores, can occur and lead to death [16,17]. The purpose of this study was to evaluate the prevalence and location of simultaneous fracture using bone scan in patients with hip fracture and to determine the risk factors associated with simultaneous fracture.
http://dx.doi.org/10.1016/j.injury.2016.12.027 0020-1383/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
2
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
All study protocols were approved by the Institutional Review Board of our institution (HYUH IRB 2012-R-23).
radiologic correlation with other conditions, such as old healed traumatic lesions or degenerative disease.
2 Patients and methods
2.2 Bone mineral density of dual energy X-ray absorptiometry (DXA)
From February 2010 to April 2013, 234 patients over the age of 55 years were diagnosed with unilateral hip fracture and underwent surgery at our hospital. We excluded 51 patients who did not undergo a bone scan. The remaining 182 patients were included in this study (Fig. 1). All patients visited the emergency department, and hip fracture was diagnosed with radiographs. We reviewed the age, height, weight, body mass index (BMI), and history of previous trauma from the medical records. The cause of hip fracture was reviewed and categorized based on the magnitude of the trauma: low-energy trauma, a slip or fall from standing height or less; high-energy trauma, a traffic accident or falling from higher than standing height. The location of the hip fracture was identified with radiographs.
Areal BMD measurement was performed for the lumbar vertebra and femoral neck in 165 patients using DXA (Discovery QDR, Hologic, Bedford, MA, USA) for evaluation of osteoporosis. Patients were scanned according to standardized procedures. The scanner was calibrated at baseline, and daily quality control scans showed no shifts in scanner performance during the study period. Osteoporosis was diagnosed when the T score was <-2.5.
2.1 Evaluation of simultaneous fracture with a bone scan Bone scan was performed at a mean 15.4 days (range, 7–25) after hip fracture. Anterior and posterior whole body images were obtained with a gamma camera (E-cam, Siemens, Hoffman Estates, IL, USA) equipped with a high-resolution collimator four hours after intravenous injection of 20 mCi of Tc-99 m methylene diphosphonate (MDP). Additional static regional images were acquired for any areas showing increased uptake. A nuclear medicine physician interpreted the lesions. Acute traumatic lesion was suspected if a focal increased uptake lesion had intensity similar to that of hip fracture. An acute traumatic lesion was determined as the presence of tenderness on physical examination and/or a positive finding on radiologic evaluation. If there were other lesions that showed less intense uptake than the acute lesions, a diagnosis was made based on patient history or
2.3 Statistical analysis The prevalence and location of simultaneous fracture were evaluated. We compared baseline characteristics between patients with hip fracture with and without simultaneous fracture using x2 or Fisher exact tests for categorical variables and two-sided t-tests for continuous variables. We used crude analysis to assess the relationship between simultaneous fracture and each of the variables. To identify possible risk factors of simultaneous fracture, multivariable logistic regression analysis was performed. We analyzed the risk factors of simultaneous vertebral fracture with the same procedure. All analyses were conducted with SPSS software (version 21.0; IBM, Armonk, NY, USA), and p values less than 0.05 were considered statistically significant. 3 Results 3.1 Patient demographics There were 61 male and 121 female patients with a mean age at hip fracture of 77.1 years (range, 56–97) and mean BMI of
Fig. 1. Flowchart showing eligible cases of simultaneous fractures with hip fracture.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
22.1 kg/m2 (range, 13.9–33.3). The cause of trauma was low-energy trauma in 170 patients (93.4%) and high-energy trauma in 12 patients (6.6%). One hundred fifty-four patients (84.6%) had no history of previous trauma before the index operation. Femoral neck fractures occurred in 65 patients (35.7%), and trochanteric fractures occurred in 117 patients (64.3%). Bone density was evaluated with DXA in 165 of the 182 patients. The mean BMD was 0.737 g/cm2 (range, 0.134–1.212) in the lumbar vertebra and 0.499 g/cm2 (range, 0.129–0.789) in the uninjured femoral neck. The mean T score was 2.4 (range, 6.2 to 1.8) in the lumbar vertebra and 2.8 (range, 6.3 to 0.4) in the femoral neck. Osteoporosis was diagnosed in 113 patients (68.5%).
3
When assessing the results by number and location of simultaneous fracture, rib fracture was the most common type, occurring in 38 patients (20.9%), followed by rib and vertebral fracture in 20 patients (10.9%), and vertebral fracture in 18 patients (9.9%) (Fig. 2). Eight patients with pneumonia have been confirmed in our study. Among them, four patients have hip fractures with rib fracture (5.4%), and four patients without rib fractures (3.5%). The result confirmed the incidence was slightly higher in the rib fractured patients. However, it was not statistically significant (p = 0.829). 3.3 Risk factors of simultaneous fracture in patients with hip fracture
3.2 Prevalence and location of simultaneous fracture Simultaneous fracture occurred in 102 of 182 patients, a prevalence of 56.0%. Fifty-nine patients (32.4%) had one simultaneous fracture, 36 patients (19.8%) had two, and seven patients (3.8%) had three. Rib fracture was the most common type of simultaneous fracture, occurring in 73 patients (40.1%), followed by vertebral fracture in 48 patients (26.4%). Fracture of the radius occurred in six patients (3.3%), tibia in six patients (3.3%), pelvis in five patients (2.8%), fibula in four patients (2.2%), ulna in three patients (1.7%), foot in three patients (1.7%), humerus in two patients (1.1%), and skull in one patient (0.6%).
Of the 182 patients with hip fracture, 102 had simultaneous fracture. There were no differences in age, sex, BMI, history of previous trauma, cause of hip fracture, location of hip fracture, BMD of the femoral neck, or T score of the lumbar vertebra and femoral neck between hip fracture patients with and without simultaneous fracture. However, the BMD of the lumbar vertebra in patients with simultaneous fracture was significantly lower than that in patients without simultaneous fracture (p = 0.044) (Table 1). In multivariate logistic regression analysis, BMD of the lumbar spine was associated with simultaneous fracture in adjusted analysis (odds ratio: OR 0.05, 95% confidence interval: CI 0.01–0.57) (Table 2).
Fig. 2. Locations and numbers (percentage) of simultaneous fracture.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
4
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Table 1 Comparison of baseline characteristics between patients with and without simultaneous fractures.
Age (years) mean SD Sex (n)
Male Female
BMI (kg/m2) mean SD
Simultaneous fracture (n = 102)
No simultaneous fracture (n = 80)
P
77.5 7.8
76.5 8.6
0.396
34 68
27 53
0.953
22.1 4.2
22.1 3.0
0.977
Location of fracture (n)
Femoral neck Trochanter
38 64
27 53
0.624
Cause of injury (n)
Low energy High energy
93 9
77 3
0.171
Previous injury history (n)
Yes No
19 83
9 71
0.171
Osteoporosis (n)a
Yes No
69 26
44 26
0.182
BMD (g/cm2) mean SDa
Lumbar vertebra
0.715 0.165
0.767 0.157
0.044
Femur neck
0.485 0.119
0.519 0.112
0.070
T-score mean SDa
Lumbar vertebra
2.6 1.4
2.2 1.4
0.067
Femur neck
2.9 1.1
2.7 1.0
0.058
SD standard deviation, BMI body mass index, BMD bone mineral density. a Data are from 165 patients who a BMD value.
Table 2 Risk factors associated with a simultaneous fracture.
Older age Sex
Male Female
Higher BMI(kg/m2)
Crude OR
Adjusted OR (1) (n = 182)
Adjusted OR (2) (n = 165)
1.02 (0.98–1.05)
1.02 (0.98–1.06)
1.02 (0.98–1.06)
Ref. 1.02 (0.55–1.89)
Ref. 1.06 (0.56–2.01)
Ref. 0.59 (0.27–1.27)
0.99 (0.92–1.08)
1.01 (0.93–1.09)
1.06 (0.96–1.16)
Location
Neck Trochanter
Ref. 0.86 (0.46–1.58)
Ref. 0.86 (0.46–1.61)
Ref. 0.77 (039–1.53)
Cause of injury
Low energy High energy
Ref. 2.48 (0.65–9.49)
Ref. 2.64 (0.67–10.39)
Ref. 1.45 (0.34–6.17)
Previous trauma history
1.81 (0.77–4.24)
1.82 (0.77–4.32)
1.77 (0.66–4.74)
Osteoporosis
1.57 (0.81–3.04)
Higher BMD(g/cm2)
Higher T–score
Lumbar vertebra
0.13 (0.02–0.96)*
Femur neck
0.75 (0.00–1.27)
Lumbar vertebra
0.81 (0.65–1.02)
Femur neck
0.742 (0.54–1.01)
0.05 (0.01–0.57)*
Age, sex, BMI, location of fracture, cause of injury, and previous trauma history were adjusted in Model 1; Age, sex, BMI, location of fracture, cause of injury, previous trauma history, and BMD of lumbar vertebra were adjusted in Model 2. OR odds ratio, BMI body mass index, Ref. reference, BMD bone mineral density. * p value < 0.05.
3.4 Risk factors of simultaneous vertebral fracture There were no differences in age, sex, BMI, history of previous trauma, cause of hip fracture, BMD of the lumbar vertebra and femoral neck, or T score of the lumbar vertebra between patients
with and without simultaneous vertebral fracture. However, trochanteric fracture was more common than femoral neck fracture in patients with simultaneous vertebral fracture (p < 0.001), and the T score of the femoral neck was significantly lower in patients with simultaneous vertebral fracture (p = 0.047)
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
5
Table 3 Comparison of baseline characteristics between patients with and without vertebral fracture as a simultaneous fracture.
Age (years) mean SD Sex (n)
Male Female
BMI (kg/m2) mean SD
Simultaneous vertebral fracture (n = 48)
No simultaneous vertebral fracture (n = 134)
P
77.9 7.9
76.7 8.3
0.378
12 36
49 85
0.145
22.2 4.2
22.2 3.5
0.948
Location of fracture (n)
Femoral neck Trochanter
5 43
60 74
<0.001
Cause of injury (n)
Low energy High energy
45 3
125 9
0.911
Previous injury history (n)
Yes No
9 35
13 108
0.092
Osteoporosis (n)a
Yes No
32 12
81 40
0.479
BMD (g/cm2) mean SDa
Lumbar vertebra
0.701 0.173
0.750 0.158
0.090
Femur neck
0.469 0.129
0.511 0.111
0.053
T-score mean SDa
Lumbar vertebra
2.7 1.5
2.3 1.4
0.086
Femur neck
3.1 1.2
2.7 1.0
0.047
SD standard deviation, BMI body mass index, BMD bone mineral density. a Data are from 165 patients who a BMD value.
(Table 3). In multivariate logistic regression analysis, the significant independent predictor of simultaneous vertebral fracture was trochanteric fracture (OD 9.24, 95% CI 2.79–30.58), and the risk of simultaneous vertebral fracture increased by 9.2-fold in the presence of trochanteric fracture (p < 0.001) (Table 4).
4 Discussion The prevalence of simultaneous fracture was 56.0% in patients with hip fracture, and the most common simultaneous fracture was rib fracture (40.1%), followed by vertebral fracture (26.4%). Multivariate analysis identified BMD of the lumbar vertebra as a
Table 4 Risk factors associated with vertebral fracture as a simultaneous fracture.
older age Male Female
Sex
Higher BMI(kg/m2)
Crude OR
Adjusted OR (1) (n = 182)
Adjusted OR (2) (n = 165)
1.02 (0.98–1.06)
1.01 (0.96–1.05)
1.00 (0.95–1.05)
Ref. 1.73 (0.82–3.63)
Ref. 1.97 (0.87–4.44)
Ref. 1.40 (0.55–3.57)
0.99 (0.91–1.09)
0.99 (0.89–1.09)
0.97 (0.87–1.09)
Location
Neck Trochanter
Ref. 6.97 (2.60–18.70)*
Ref. 7.88 (2.84–21.86)*
Ref. 9.24 (2.79–30.58)*
Cause of injury
Low energy High energy
Ref. 0.93 (0.24–3.57)
Ref. 1.53 (0.32–7.31)
Ref. 0.68 (0.07–6.56)
Previous trauma history
2.05 (0.88–4.76)
2.48 (0.97–6.35)
3.20 (0.99–10.29)
Osteoporosis
1.92 (0.95–3.86) 2
Higher BMD(g/cm )
Lumbar vertebra Femur neck
0.15 (0.02–1.35) 0.05 (0.00–1.09)
Higher T-score
Lumbar vertebra Femur neck
0.80 (0.62–1.03) 0.72 (0.51–1.00)*
0.88 (0.59–1.32)
Age, sex, BMI, location of fracture, cause of injury, and previous trauma history were adjusted in Model 1; Age, sex, BMI, location of fracture, cause of injury, previous trauma history, and T-score of femur neck were adjusted in Model 2. OR odds ratio, BMI body mass index, Ref. reference, BMD bone mineral density. * p value < 0.05.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
6
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
risk factor of simultaneous fracture and trochanteric fracture as a risk factor of simultaneous vertebral fracture. We found a relatively high prevalence of simultaneous fracture. Brooks et al. reported that simultaneous fracture was overlooked in 10 of 45 patients in the emergency department, and three of these 10 patients needed to undergo surgery [18]. They emphasized thorough observation after the initial hospital visit in order to rule out the possibility of hidden injury [18]. Wei et al. reported that the average prevalence of missed fractures was 3.7%, and the most common location for overlooked fractures was the foot (7.6%) [16]. We identified a higher prevalence of simultaneous fracture than did other studies. The reasons for this high prevalence were that we included many elderly patients with osteoporosis; these patients are susceptible to light trauma other than the identified fracture. We also used bone scanning, which has a high sensitivity to fracture, as a diagnostic tool to identify simultaneous fracture [19]. The most common locations of simultaneous fracture were the rib and vertebra. Rib fracture can occur easily in elderly patients due to light trauma. In a prospective cohort study, Barret-Connor et al. found that the rib is the most common site for osteoporotic non-vertebral fracture, and that rib fractures account for about 24% of total fractures [20]. They also reported that a history of rib fracture increases the risks of an additional rib fracture, a hip fracture, or a distal radius fracture by more than two-fold; thus, they highlighted the significance of rib fracture. Complications such as bronchitis and pneumonia can occur due to rib fracture because the elasticity of the lung parenchyma, pulmonary alveoli, and vessels is decreased, and pulmonary function becomes impaired due to weak intercostal and diaphragm muscles, decreased thoracic cavity, and impaired gas exchange [21]. Therefore, since the risk of rib fracture in patients with hip fracture is relatively high, proper management of these patients is necessary. In our study, a high proportion of trochanteric fracture was identified in simultaneous vertebral fracture, and the odds ratio of trochanteric fracture was 9.24 in comparison with neck fracture. Vertebral fractures are the most common osteoporotic fractures, but only about one-third of these fractures receive clinical attention [22]. Recently, there has been growing interest regarding the hypothesis that the two main categories of hip fracture, neck and trochanteric, differ in pathophysiological mechanisms and consequently in predisposing factors [23]. Kotowicz et al. reported that, in women with vertebral fracture, the risk of trochanteric hip fracture increases by 2.3-fold (p < 0.05) and the risk of femoral neck fracture by 1.3-fold (nonspecific) compared with women without vertebral fracture; this indicates that trochanteric fractures are more strongly associated with spinal osteoporosis than femoral neck fractures [24]. Moreover, some studies have reported that patients with trochanteric fractures are older, thinner, and have lower BMD and quantitative ultrasound values than patients with cervical fractures [25–27]. Therefore, close examination and proper management are necessary in trochanteric fracture due to the high prevalence of simultaneous vertebral fracture, a major osteoporotic fracture. The simultaneous fracture was identified using bone scan, which has high sensitivity for fracture identification and the ability to scan the whole body without missing a simultaneous fracture. Bone scan is a nuclear scanning test to identify certain abnormalities in bone. It is primarily used to find the location and number of abnormal conditions relating to the bones, especially the diagnosis of fractures that might not be visible on traditional x-ray images. The nuclear medicine scan technique is sensitive to areas of unusual bone-rebuilding activity because the radiopharmaceutical is taken up by osteoblast cells actively remodeling bone. When performing the bone scan, the point of
concern, for examination consists in the use of radioisotopes and exposure of radiation. However, the radiation dose received by the patient for inspection is about 4mSv, which is a half dose of abdominal CT scan, and it is known that this level of exposure is not large influence on the human body. Therefore, the bone scan is useful examination because the inspection of simultaneous fracture in whole body is possible and the test has a high level of sensitivity. This study has several limitations. First, this study was performed in a single center. This might have led to a bias in patient selection, and the statistical power necessary to provide strong evidence and generalized outcomes could be insufficient. Second, we could not determine the exact time of onset of simultaneous fracture using the bone scan. It is impossible to know whether simultaneous fracture occurred at the same time as hip fracture. However, we tried to determine acute injury by interviewing patients about their trauma history and reviewing the medial records. We thought that the most important issue was not the time of simultaneous fracture, but the presence of acute hidden injury other than hip fracture, which could influence the management, rehabilitation, and outcomes of patients. Third, the severity, grade, and level of simultaneous fractures were simplified, and treatment of simultaneous fracture was not investigated. 5 Conclusions The prevalence of simultaneous fracture in patients with hip fracture was relatively high. Rib and vertebral fractures were determined as the most common simultaneous fractures, and the risk factor was low BMD of the lumbar vertebra. Trochanteric fracture showed a higher prevalence of simultaneous vertebral fracture than did femoral neck fracture. Therefore, surgeons should be aware of the possibility of simultaneous fracture when treating patients with hip fracture. Conflict of interest There are no conflicts of interest. References [1] Kanis JA, McCloskey EV, Johansson H, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2013;24(1):23–57. [2] Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of hip: the east Anglian audit. Bmj 1995;310(6984):904–8. [3] Youm T, Koval KJ, Kummer FJ, Zuckerman JD. Do all hip fractures result from a fall? Am J Orthop (Belle Mead NJ) 1999;28(3):190–4. [4] Siris ES, Genant HK, Laster AJ, Chen P, Misurski DA, Krege JH. Enhanced prediction of fracture risk combining vertebral fracture status and BMD. Osteoporos Int 2007;18(6):761–70. [5] Gonnelli S, Caffarelli C, Maggi S, et al. The assessment of vertebral fractures in elderly women with recent hip fractures: the BREAK Study. Osteoporos Int 2013;24(4):1151–9. [6] Black DM, Arden NK, Palermo L, Pearson J, Cummings SR. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1999;14(5):821–8. [7] Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S. Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women: a meta-analysis. J Bone Joint Surg [Am] 2003;85-A(10):1936–43. [8] Chirodian N, Arch B, Parker MJ. Sliding hip screw fixation of trochanteric hip fractures: outcome of 1024 procedures. Injury 2005;36(6):793–800. [9] Petersen MB, Jorgensen HL, Hansen K, Duus BR. Factors affecting postoperative mortality of patients with displaced femoral neck fracture. Injury 2006;37 (8):705–11. [10] Sakamoto K, Nakamura T, Hagino H, et al. Report on the Japanese Orthopaedic Association's 3-year project observing hip fractures at fixed-point hospitals. J Orthop Sci 2006;11(2):127–34. [11] Imai N, Endo N, Hoshino T, Suda K, Miyasaka D, Ito T. Mortality after hip fracture with vertebral compression fracture is poor. J Bone Miner Metab 2014 (in press).
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027
G Model JINJ 7031 No. of Pages 7
B.-G. Lee et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx [12] Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 2009;301(5):513–21. [13] Ha YC, Baek JH, Ko YB, Park SM, Song SH. High mortality and poor morbidity after hip fracture in patients with previous vertebral fractures. J Bone Miner Metab 2014;33(5):547–52. [14] Tosteson AN, Gabriel SE, Grove MR, Moncur MM, Kneeland TS, Melton LJ. 3rd. Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int 2001;12(12):1042–9. [15] Sosa M, Saavedra P, Gomez-de-Tejada MJ, et al. High prevalence of undiagnosed vertebral fractures in patients suffering from hip fracture at their hospital admission: weak concordance among observers. Aging Clin Exp Res 2015;27(6):835–9. [16] Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY. Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol 2006;47 (7):710–7. [17] Guly HR. Diagnostic errors in an accident and emergency department. Emerg Med J 2001;18(4):263–9. [18] Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury 2004;35(4):407–10. [19] Matin P. The appearance of bone scans following fractures, including immediate and long-term studies. J Nucl Med 1979;20(12):1227–31. [20] Barrett-Connor E, Nielson CM, Orwoll E, Bauer DC, Cauley JA. Osteoporotic Fractures in Men Study G: Epidemiology of rib fractures in older men:
[21]
[22]
[23] [24]
[25]
[26]
[27]
7
osteoporotic Fractures in Men (MrOS) prospective cohort study. Bmj 2010;340:c1069. Roumen RM, Redl H, Schlag G, Sandtner W, Koller W, Goris RJ. Scoring systems and blood lactate concentrations in relation to the development of adult respiratory distress syndrome and multiple organ failure in severely traumatized patients. J Trauma 1993;35(3):349–55. van Wyk PM, Chu CH, Babineau J, et al. Community-based rehabilitation post hospital discharge interventions for older adults with cognitive impairment following a hip fracture: a systematic review protocol. JMIR Res Protoc 2014;3 (3):e47. Latham NK, Bean JF, Jette AM. Home-based exercise and hip fracture rehabilitation–reply. JAMA 2014;311(23):2440–1. Kotowicz MA, Melton 3rd LJ, Cooper C, Atkinson EJ, O'Fallon WM, Riggs BL. Risk of hip fracture in women with vertebral fracture. J Bone Miner Res 1994;9 (5):599–605. Latham NK, Harris BA, Bean JF, et al. Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial. JAMA 2014;311(7):700–8. Gialanella B, Prometti P, Monguzzi V, Ferlucci C. Neuropsychiatric symptoms and rehabilitation outcomes in patients with hip fracture. Am J Phys Med Rehabil 2014;93(7):562–9. Wang CY, Graham JE, Karmarkar AM, Reistetter TA, Protas EJ, Ottenbacher KJ. FIM motor scores for classifying community discharge after inpatient rehabilitation for hip fracture. PM R 2014;6(6):493–7.
Please cite this article in press as: B.-G. Lee, et al., High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture, Injury (2017), http://dx.doi.org/10.1016/j.injury.2016.12.027