LA CONSULTA SEMANAL

JUNIO 2001

CONSULTA

Mayo Clin Proc 2001 Mar;76(3):295-8
Medical care of elderly patients with hip fractures.
Huddleston JM, Whitford KJ
Division of Area General Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA. huddleston.jeanne@mayo.edu
Medical morbidity associated with hip fractures in the elderly population is considerable. The all-cause mortality rate is 24% at 12 months. The functional limitations of survivors can be pronounced. As the American population ages, hip fractures will substantially affect the utilization of hospital resources. Several issues, including preoperative clearance and related surgical timing, deep venous thrombosis prophylaxis, delirium, nutrition, and urinary tract management, are important in the care of these patients. A close partnership between orthopedic surgeons and clinicians provides the best strategy of care for the subset of patients with multisystemic complications.
Publication Types:
  Review
  Review, tutorial


J Rheumatol 2000 Sep;27(9):2227-31
Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference?
March LM, Cameron ID, Cumming RG, Chamberlain AC, Schwarz JM, Brnabic AJ, O'Meara P, Taylor TF, Riley S, Sambrook PN
University of Sydney Professorial Department of Rheumatology, Royal North Shore Hospital, St. Leonards, NSW, Australia. lmarc@health.doh.nsw.gov.au
OBJECTIVE: To evaluate whether evidence based clinical pathways for acute management of hip fracture have an effect on patient care, short term mortality, or residential status. METHODS: Observational cohort study comparing management, as determined by medical record review, and outcomes, as determined by telephone followup 4 months post-fracture, before (n = 455) and after (n = 481) clinical pathway implementation within pathway hospitals as well as between patients admitted to hospitals with (n = 2) and without (n = 4) pathways. RESULTS: Mean age was 82 years, 80% were women and 30% were admitted from nursing homes. Significant improvement in best practice as recommended by evidence based clinical guidelines was evident in pathway hospitals for most components of care. However, compliance was variable and nonpathway hospitals performed better for some (use of spinal anesthesia, avoidance of urinary catheters). After adjusting for potential confounders, no difference was found in 4 month mortality between the pathway (17.6%) and non-pathway (16.8%) patients (OR 0.8, 95% CI 0.5-1.5). There was a nonsignificant reduction in median acute care hospital length of stay of 1 day (p = 0.200) for non-nursing home patients and a significant reduction of 1 day (p = 0.038) for nursing home patients in the pathway hospitals. There was a nonsignificant decrease in admission rates for new patients to nursing homes in pathway hospitals (18.5%) compared to non-pathway hospitals (24.3%) (OR 0.5, 95% CI 0.3-1.1). CONCLUSION: Clinical pathways were associated with increased use of evidence based best practice, some reduction in acute hospital length of stay, but no significant effect on 4 month mortality or residential status. Their development and maintenance were resource intensive and further work on the implementation of evidence based guidelines is needed to determine whether they can influence patient outcomes.


J Rheumatol 2000 Sep;27(9):2071-3
Integrated care pathways in hip fracture management: demonstrated benefits are
few.
Syed KA, Bogoch ER
Publication Types:
  Comment
  Editorial
  Review
  Review, tutorial


Clin Orthop 2000 Aug;(377):15-23
Diagnosis and imaging studies of traumatic hip dislocations in the adult.
Brooks RA, Ribbans WJ
Department of Orthopaedics, Northampton General Hospital, UK.
Traumatic dislocation of the hip represents a major injury that is associated with significant morbidity. In particular, the risk of osteonecrosis of the femoral head is greatly affected by the time it takes to reduce the hip. Therefore, thorough understanding of the clinical and radiologic features is essential if this injury is to be recognized and treated promptly. Most patients present in severe distress after a high-energy injury such as a motor vehicle accident. Associated injuries, particularly of the knee, are common and the leg usually is held in a specific posture characteristic of the direction of dislocation. Plain anteroposterior radiographs of the pelvis will clearly show the dislocation in most patients but lateral views or a computed tomography scan may be required to confirm the diagnosis and to show the direction if the signs are subtle. Associated acetabular wall fractures and femoral head fractures also may be identified by computed tomography scans. After reduction, plain radiographs alone are not adequate to assess reduction; computed tomography is more sensitive in detecting osteochondral fragments and may reliably detect residual subluxation of 2 mm in any part of the joint. Magnetic resonance imaging is useful in detecting changes of osteonecrosis but rarely is indicated in the early treatment of this condition.
Publication Types:
  Review
  Review, tutorial


Med Clin (Barc) 2000;114 Suppl 2:79-84
[Effect of alendronate on bone mineral density and incidence of fractures in postmenopausal women with osteoporosis. A meta-analysis of published studies].
[Article in Spanish]
Arboleya LR, Morales A, Fiter J
Unidad de Reumatologia, Hospital de Cabuenes, Gijon.
BACKGROUND: To perform a systematic review, completed with a meta-analysis, of the published evidences about the effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal women with low bone mass. METHODS: We search for all alendronate clinical trials in postmenopausal women with low bone mass which were randomized, double blind, placebo controlled, with a duration of one year or more and with bone mineral density measurement and/or fractures as outcomes. We used the weighted average of individual study results as an estimation of the global effect. RESULTS: Seven studies meet all the inclusion criteria. Relative Risks (RR) with 95% Confidence Intervals (CI 95%) for the combined effect under fixed effects model were: RR 0.54 (CI 95%: 0.45 to 0.66) for vertebral fractures, RR 0.81 (CI 95%: 0.72 to 0.92) for non vertebral fractures and RR 0.64 (CI 95%: 0.40 to 1.01) for hip fractures. CONCLUSIONS: Our results demonstrate that alendronate reduces the risk of vertebral, non vertebral and hip fractures in postmenopausal women with low bone mass. This meta-analysis allows the classification of alendronate anti-fracture evidences in the highest level.
Publication Types:
  Meta-analysis


Geriatrics 2000 Apr;55(4):50-2, 55-6 [Texto completo en formato PDF]
Hip fracture. Surgical decisions that affect medical management.
Lichtblau S
Mount Sinai School of Medicine, New York, NY, USA.
Primary care physicians can provide optimal care for their older patients with hip fracture when they are familiar with the repair techniques used by the orthopedic surgeon. For medically stable patients, surgical repair is now recommended 24 to 72 hours after the fracture. The type of surgery depends on the type of fracture and the degree of the patient's prefracture mobility; options range from simple percutaneous pinning to total hip replacement. Surgery is not advisable for bed-ridden or moribund patients, nor for those with very osteoporotic bones and extensively comminuted fractures. Complications of a hip fracture and its surgical repair that require medical management include anemia, phlebitis, pulmonary embolism, decubitus ulcer, fluid or electrolyte imbalance, and pneumonia.
Publication Types:
  Review
  Review, tutorial


Emerg Med Clin North Am 2000 Feb;18(1):29-66, v
Emergency department evaluation and treatment of hip and thigh injuries.
Rudman N, McIlmail D
Department of Emergency Medicine, Cape Cod Hospital, Hyannis, Massachusetts, USA.
This article reviews the clinical and diagnostic evaluation of patients with injuries to the hip and thigh. The history and physical examination, appropriate imaging strategies, complications and associated injuries, analgesia, treatment, and appropriate patient disposition are emphasized.
Publication Types:
  Review
  Review, tutorial


Hosp Pract (Off Ed) 1998 Sep 15;33(9):131-2, 135-6
Evaluation and treatment of hip pain.
Kalb RL
Publication Types:
  Review
  Review, tutorial


Ann Intern Med 1998 Jun 15;128(12 Pt 1):1010-20 [Texto completo]
The medical consultant's role in caring for patients with hip fracture.
Morrison RS, Chassin MR, Siu AL
Mount Sinai School of Medicine, New York, New York 10029, USA. smorriso@smtplink.mssm.edu
BACKGROUND: Hip fractures are an important cause of death and functional dependence in the United States. PURPOSE: To review the evidence for clinical decisions that medical consultants make for patients with hip fracture and to develop recommendations for care. DATA SOURCES: Published reports of clinical studies were found by searching MEDLINE and selected bibliographies. STUDY SELECTION: Studies were included if data were presented on clinical interventions to improve care of conditions typically encountered by medical consultants in the care of patients with hip fracture. Such conditions include timing of surgery, infection prophylaxis, thromboembolic prophylaxis, postoperative nutritional management, urinary tract management, prevention and management of delirium, application and timing of rehabilitation services, and prevention of subsequent falls. Meta-analyses; randomized, controlled trials; or other controlled studies were included if possible. If no such trials were identified, the best evidence from studies with other designs was included. DATA EXTRACTION: Interventions were selected on the basis of their efficacy or potential efficacy in improving functional outcome. Trials with positive and negative results were compared for differences in intervention and strength of study methods. DATA SYNTHESIS: Strong evidence supports medical recommendations for decisions about timing and duration of prophylactic antibiotics, selection of thromboembolic prophylaxis, urinary tract and nutritional management, and rehabilitative services. Many case series support early surgical repair, although patients who would benefit from delay and further medical work-up have not been well identified. Evidence for decisions about assessment of subsequent risk for fall and risk for and management of delirium is based largely on data from patients without hip fracture but is probably applicable. Future research should target optimal duration of thromboembolic prophylaxis, cost-effectiveness of low-molecular-weight heparin compared with that of other thromboembolic prophylactic regimens, management of delirium, rehabilitative services, and efficacy of assessment of risk for later falls. CONCLUSIONS: The data suggest that evidence-based medical care can improve hip fracture outcomes. The medical consultant has a key role in providing this care and managing the preoperative conditions and postoperative complications that may affect optimal functional recovery.
Publication Types:
  Review
  Review, tutorial


Am Fam Physician 1998 Mar 15;57(6):1314-22 [Texto completo]
Pitfalls in the radiologic evaluation of extremity trauma: Part II. The lower extremity.
Shearman CM, el-Khoury GY
University of Iowa College of Medicine, Iowa City, USA.
Fractures of the lower extremity are common reasons for visits to family physicians. Some lower extremity fractures are especially likely to be missed. Examples of lesions that commonly go unrecognized include sacral insufficiency or fatigue fracture, fracture of the femoral neck (especially if the fracture is nondisplaced and/or impacted), tibial plateau fracture, Segond fracture (vertical fracture of the lateral tibia), patellar fracture, calcaneal fracture of the foot, Lisfranc fracture/dislocation of the tarsometatarsal apparatus, and Jones fracture of the fifth metatarsal. Lower extremity fracture in children may suggest the possibility of child abuse, especially in the case of multiple or bilateral fractures.
Publication Types:
  Review
  Review, tutorial


Postgrad Med 1998 Jan;103(1):157-8, 163-4, 167-70
Hip fracture in the elderly. An interdisciplinary team approach to rehabilitation.
Ethans KD, MacKnight C
Division of Physical Medicine and Rehabilitation, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada. ethansk@is2.dal.ca
The rising incidence of hip fractures in the elderly is a disturbing trend with serious health and socioeconomic consequences, including morbidity, loss of function, long-term institutionalization, and mortality. When preventive measures fail, the interdisciplinary healthcare team works together to provide operative treatment, reduce the risk of postoperative complications, and guide the patient through the recovery process. A team approach that ensures appropriate treatment, careful discharge planning, and coordinated rehabilitation can reduce the impact of the injury, speed recovery, and restore patient independence.
Publication Types:
  Review
  Review, tutorial


Am J Med 1997 Aug 18;103(2A):65S-71S; discussion 71S-73S
Prevention of hip fractures: risk factor modification.
Slemenda C
Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.
Factors that influence the risk of hip fracture have been identified, many of which can be eliminated or modified. Even those risk factors that cannot be modified are important for identifying at-risk patients, who may benefit most from therapies that after other risk factors. Bone mineral density (BMD) is the major measurable determinant of the risk of fragility fractures. However, recent prospective studies have identified factors that influence the risk of having a hip fracture independently of the risk associated with low BMD. Skeletal factors other than BMD that may increase the risk of hip fracture in women include hip geometry and height (tallness). Other factors, some of which are potentially modifiable, operate through effects on the risk of trauma, including decreased visual acuity, neuromuscular impairment, cognitive impairment, residence in a nursing home, poor general physical health, and use of medications that diminish alertness. Fall mechanics also play an important role in the etiology of hip fractures. Falls to the side, particularly those with impact on the hip or side of the leg, more often result in hip fractures than do other falls. Protection of the hip with external padding offers great promise in the prevention of hip fracture in patients with very low bone mass or with conditions that make falls almost inevitable. Increases in hip fracture rates in developing countries suggest a possible relationship with declining physical activity (particularly load-bearing activity). Although the role of exercise in the prevention of osteoporosis and hip fracture has not yet been proven, there is evidence of independent protective effects of both past physical activity and moderate levels of recent physical activity on the risk of hip fracture. Low body weight secondary to poor appetite or poor health (as opposed to intentional weight loss) has been associated with increased hip fracture risk, and nutritional deficiencies may also play a role in hip fracture pathogenesis. These are potentially modifiable. Future studies should be aimed at confirming the hip fracture risk factors identified, ascertaining their independence from other factors, assessing their prevalence, and determining the outcomes and costs involved in interventions to modify them.
Publication Types:
  Review
  Review, tutorial


N Engl J Med 1996 Jun 6;334(23):1519-25
Hip fracture.
Zuckerman JD
Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York, NY 10003, USA.
Publication Types:
  Review
  Review, tutorial