I. Overview Osteoporosis is a systemic, metabolic disease of the skeletal system characterized by decreased bone mass, destruction of bone microstructure, increased bone fragility, decreased bone strength, and increased risk of fracture, and can be divided into primary osteoporosis and secondary osteoporosis. The osteoporotic fracture (fragility fracture) referred to in this guideline refers to primary osteoporosis resulting in decreased bone density and bone mass, reduced bone strength, and fractures that can occur with minor violence during daily activities, which is the most serious consequence of osteoporosis. The common fracture sites are the spine, hip, distal radius and proximal humerus. Characteristics and treatment difficulties of osteoporotic fractures: (1) after bed braking, patients with osteoporotic fractures will experience rapid bone loss, which will aggravate osteoporosis; (2) the fracture site has low bone mass and poor bone quality, and most of them are comminuted fractures, which are difficult to reset and not easy to achieve satisfactory results; (3) the stability of internal fixation treatment is poor, the internal fixation and implants are easy to loosen and dislodge, and the bone graft is easy to be absorbed; (4) the fracture (4) slow healing process and long recovery time, prone to delayed healing or even non-healing of the fracture; (5) significantly increased risk of re-fracture at the same site and other sites; (6) mostly seen in the elderly population, often combined with other organs or systemic diseases, poor systemic condition, prone to complications during treatment, increasing the complexity and risk of treatment; (7) high disability and mortality rates, seriously threatening the elderly physical and mental health, quality of life and life expectancy. Therefore, the treatment of osteoporotic fractures is different from general traumatic fractures, and it is necessary to pay attention to both the treatment of the fracture itself and the active treatment of osteoporosis. Zou Depo, Department of Orthopedics, Shandong Qianfo Mountain Hospital II. Diagnosis and Differential Diagnosis Osteoporotic fractures are mostly seen in the elderly, female population, mostly with minor trauma (referring to injuries caused by falls on flat ground or body weight height) or without obvious history of trauma, and can occur even during daily activities. (A) Clinical manifestations 1. General manifestations of fracture: pain, pressure pain, swelling and functional impairment may occur. However, patients with osteoporotic fractures may also have no pain or only mild pain, or show an increase in the original pain. The functional impairment can also be very mild, and even the affected limb can still move.2. Specific manifestations of fracture: deformity, bone rubbing sensation (sound), and paradoxical activity can occur. However, there are patients who lack these typical manifestations after osteoporotic fracture. 3. manifestations of osteoporosis: shortening of height, scoliosis or hunchback deformity may occur. (B) Imaging X-ray examination can determine the site, type, direction of displacement and degree of fracture, which is of great value for diagnosis and treatment. x-ray films have special manifestations of fracture, but also manifestations of osteoporosis, such as reduced bone density, thinning of bone trabeculae, thinning of bone cortex and enlargement of bone marrow cavity. The scope of radiography should include the upper and lower adjacent joints of the injury site, hip fracture should include bilateral hip joints, and spine fracture should be combined with physical examination to determine the projection site and scope to avoid missing diagnosis. CT can accurately show the degree of fracture comminution and compression in the vertebral canal; CT three-dimensional imaging technology can clearly show intra-articular or peri-articular fractures; MRI is important for detecting occult fractures and identifying fresh or old fractures. (iii) Bone density examination is feasible for patients with proposed osteoporotic fractures. There are many methods of bone density examination (such as DxA, pDXA, QCT, pQCT, etc.), among which dual-energy X-ray absorptiometry (DXA) is the internationally accepted method of bone density examination. With reference to the WHO recommended diagnostic criteria, a DXA measurement of BMD less than 1 standard deviation below the peak bone mass of healthy adults of the same sex and race is considered normal (T value ≥ 1.0 SD); a decrease of 1 to 2.5 standard deviations is considered low bone mass or reduced bone mass (1.2.5 SD < T value < 1.O SD); a decrease equal to or greater than 2.5 standard deviations is considered osteoporosis (T value ≤ 1.2.5 SD); and a decrease in the degree of bone mineralization is in accordance with the BMD test. SD); the degree of reduction meets the diagnostic criteria of osteoporosis and is accompanied by one or more fractures as severe osteoporosis. The commonly used clinical measurement sites are Ll scolding and hip. (D) Laboratory tests 1. Blood and urine routine, liver and kidney function, blood glucose, calcium, phosphorus, alkaline phosphatase, sex hormones, 25(0H)VitD and parathyroid hormone can be selected as needed.
2. According to the needs of condition monitoring, drug selection, efficacy observation and differential diagnosis, bone metabolism and bone turnover indexes (including bone formation and bone resorption indexes) can be tested if available, so as to perform bone turnover typing, assess the rate of bone loss, disease progression and risk of re-fracture, and select intervention measures. Bone formation indicators include serum alkaline phosphatase, osteocalcin, bone-derived alkaline phosphatase, type I precollagen C-terminal peptide and N-terminal peptide. Bone resorption indicators included fasting urinary calcium/creatinine ratio, plasma antitartaric acid phosphatase and type I collagen C-terminal peptide, urinary pyridinoline and deoxypyridinoline, urinary type I collagen C-terminal peptide and N-terminal peptide. Low BMD and high bone turnover rate suggest a significantly increased risk of fracture.3. Combined biochemical index testing and assessment is superior to single BMD or bone biochemical index testing. (V) Differential diagnosis Pay attention to differentiate from bone tumors such as bone metastases, multiple myeloma and other metabolic bone diseases such as hyperparathyroidism resulting in secondary osteoporotic fractures. (VI) Diagnosis principle The diagnosis of osteoporotic fracture should be made by a comprehensive analysis of the patient’s age, gender, history of menopause, history of fragility fracture and clinical manifestations, as well as the results of imaging and/or bone density examination. III. Treatment Overview Reset, fixation, functional exercise and anti-osteoporosis treatment are the basic principles of treatment of osteoporotic fractures. The ideal treatment is an organic combination of the above four. The fracture should be repositioned without aggravating the local blood flow obstruction as much as possible, and functional exercise should be performed as early as possible under the premise of firm fixation of the fracture, so that the fracture healing and functional recovery can achieve a more ideal result. At the same time, anti-osteoporosis drugs should be reasonably selected and used to avoid aggravation of osteoporosis or the occurrence of re-fracture. Treatment of osteoporotic fractures should emphasize individualization and can be non-surgical or surgical. The specific method should be determined according to the fracture site, fracture type, degree of osteoporosis and the patient’s general condition, weighing the advantages and disadvantages of non-surgical and surgical treatment and making a reasonable choice. Osteoporotic fractures are mostly seen in the elderly, and the principle of simple, safe and effective methods of revision and fixation should be used to restore the quality of life before injury as early as possible. We should try to choose the method with small shaving injury and less impact on joint function, and should not force the anatomical repositioning of the fracture. Instead, the focus should be on tissue repair and functional recovery. For those who do need surgical treatment, the following measures can be taken as appropriate, taking into full consideration the characteristics of osteoporotic fractures that are different from general traumatic fractures, such as poor bone quality and slow healing: (1) using special internal fixation devices, such as locking compression plates, thick threaded screws, internal fixation devices with special coating materials, etc.; (2) using internal fixation devices with less stress masking to reduce further loss of bone mass; (3) (3) Adopt special internal fixation techniques, such as screw fixation through bilateral bone cortex to increase the holding force; (4) Adopt internal fixation strengthening techniques, such as using bone cement, expanders and biomaterials around the screws; (5) Consider using autologous or allogeneic bone graft and biomaterials (bone cement, calcium sulfate, etc.) to fill the bone defect if it is serious; (6) Depending on the firmness of fracture fixation, the fracture site and the patient’s (6) Depending on the firmness of the fracture fixation, the fracture site and the whole body condition of the patient, external fixation should be selected as appropriate. External fixation should be reliable, maintained for a sufficient period of time, and minimize the fixation of the joints adjacent to the fracture. The rehabilitation of patients with osteoporotic fractures should follow the general rule of postoperative rehabilitation of fractures, but also take into account the characteristics of poor bone quality, poor internal fixation and slow fracture healing. Emphasis is placed on early passive and active exercises for muscles and joints, early movement of unfixed joints, and minimizing the time spent in bed. In addition to the prevention and treatment of local complications caused by fracture, patients with osteoporotic fracture should also pay attention to the improvement of systemic conditions and actively prevent and treat complications such as deep vein thrombosis of the lower limbs, crushing pneumonia, urinary tract infection and decubitus ulcers to reduce the rate of disability and death. Common fracture sites, characteristics and surgical treatment (a) spinal fracture spine is the most common site of osteoporotic fractures, of which about 85% have pain symptoms, the remaining 15% can be asymptomatic. Osteoporotic fractures of the thoracolumbar segment of the spine account for about 90% of the entire spine fractures. Osteoporotic fractures of the spine mainly include vertebral compression fractures and vertebral burst fractures, which are often mildly traumatized or have no obvious history of trauma and are easily missed or misdiagnosed. The diagnosis mainly relies on the patient’s age, medical history and imaging examination, among which post-traumatic thoracic back pain, height reduction, scoliosis or kyphosis, X-ray showing sparse bone trabeculae, thinning of the bone cortex, wedge-shaped change or biconcave deformation of the vertebral body are the main basis for diagnosis. Bone densitometry, usually by DXA, can determine the degree of osteoporosis. ct scan can determine the type of fracture, the degree of vertebral destruction, and the compression in the spinal canal. mri can show the compression of the spinal cord and nerves and help to differentiate between fresh and old fractures. Non-surgical treatment is available for those with mild vertebral compression (height loss less than 1,3) and less severe pain; minimally invasive surgical treatment can be considered for those with significant vertebral compression (height loss greater than l,3), with the posterior wall of the vertebral body still intact, with significant pain, and with no significant results from conservative treatment. Percutaneous vertebroplasty and kyphoplasty are currently recommended minimally invasive surgical treatment measures to reduce pain, stabilize the spine, restore the physiological curvature of the spine and early movement. The surgery should be performed with the assistance of imaging (X-ray, CT and navigation, etc.). The surgeon must have formal training and the surgical technique should be standardized to avoid complications such as bone cement leakage. Vertebral burst fractures are mostly caused by vertical compression or vertical flexion compression violence, with collapse of the anterior and middle columns of the vertebral body, characterized by fractures of the posterior wall of the vertebral body, which often destabilize the spine. Currently, aggressive surgical treatment is the main trend, and the goal of surgical treatment is to obtain and maintain mechanical stability of the spine and to maximize restoration and maintenance of neurological function. The occurrence of spinal osteoporotic fractures predicts a significant reduction in systemic bone strength. The risk of new spinal fractures or non-spinal fractures is significantly increased and is an important time for intensive osteoporosis treatment and fall prevention. (ii) Hip fractures Osteoporotic fractures of the hip mainly include femoral neck fractures and intertrochanteric fractures, which are characterized by high rates of deformity and disability, slow recovery, and high morbidity and mortality. Femoral neck fractures can be treated non-operatively or surgically depending on the patient’s specific situation. If the fracture is not significantly displaced or is an insertional fracture, or if the general condition is too poor to tolerate surgery, non-operative treatment may be used. Non-operative treatment includes bed rest, traction (bone traction or skin traction), brace fixation, nutritional support, etc. Displaced femoral neck fractures often require surgical treatment, including external fixation frame, internal fixation, artificial joint replacement (artificial femoral head replacement, artificial total hip replacement), etc. The choice of artificial femoral head replacement or artificial total hip replacement depends mainly on the patient’s age, general condition, life expectancy, and whether there is damage to the acetabulum. For patients of advanced age, poor general condition, short life expectancy and basically intact acetabulum, artificial femoral head replacement can be considered to shorten the operation time and reduce intraoperative bleeding. The artificial femoral head replacement can basically meet the requirements of daily life for the elderly patients with less postoperative activities; otherwise, artificial total hip replacement is feasible. Femoral rotor question fracture with displacement can be incised and repositioned for internal fixation, which includes intramedullary fixation and extramedullary fixation. Intramedullary fixation system includes Gamma nail, proximal femoral intramedullary nail, femoral reconstruction nail, etc.; extramedullary fixation system includes power hip screw, locking compression plate, hip anatomical plate, etc. Intramedullary or extramedullary fixation can be reasonably selected according to the patient’s specific situation and the operator’s experience. (C) distal radius fracture distal radius osteophyte fractures are mostly comminuted fractures and often involve the articular surface, which are prone to residual deformity and pain after fracture healing and cause wrist and hand dysfunction. The treatment mostly adopts closed reduction by manipulation and external fixation by plaster or small splint. It is advisable to restore the flatness of the articular surface and the normal palmar inclination and ulnar deviation angle as much as possible. For distal radius comminuted fractures involving the articular surface, unstable distal radius fractures, and those with unsatisfactory manual repositioning, surgical treatment can be used. External fixation brace and internal fixation with incision can be used according to the specific situation of the fracture. (d) Non-operative treatment is available for fractures of the proximal humerus without displacement, such as suspension in a neck and wrist sling, fixation with a thoracic bandage or shoulder brace. Displaced proximal humerus fractures require surgical treatment, including closed or incisional internal fixation or artificial humeral head replacement, depending on the patient’s condition. The incisional internal fixation can be done with anatomical plates or locking compression plates of the proximal humerus, which have a low probability of loosening and less interference with the surrounding soft tissues, and are especially suitable for the treatment of osteoporotic fractures. Clinch pins, screws and tension band wires are easy to operate and cause little tissue damage, and can be used to fix the greater tuberosity of the humerus under the premise of ensuring secure fixation of the humeral head and neck, but they are not suitable for severe comminuted fractures. For patients with severe comminuted fractures of three or more parts of the proximal humerus in advanced age, artificial humeral head replacement can be considered. V. Anti-osteoporosis treatment of osteoporotic fractures while performing surgical treatment, special emphasis is placed on active treatment of osteoporosis. (a) Basic measures adhere to a healthy lifestyle, consume a balanced diet rich in vitamin D, calcium, low salt and moderate protein, avoid smoking and alcohol abuse, use drugs that affect bone metabolism with caution, and perform moderate muscle exercise and rehabilitation. The intake of appropriate amounts of calcium can slow down bone loss and improve bone mineralization. When used for the treatment of osteoporosis, calcium should be used in combination with other drugs. Vitamin D deficiency can lead to secondary hyperparathyroidism and increased bone resorption, which can cause or worsen osteoporosis. Intake of appropriate amount of vitamin D is beneficial to enhance calcium absorption in the gastrointestinal tract, promote bone matrix mineralization, reduce urinary calcium excretion, enhance muscle strength, and improve neuromuscular coordination and balance. (B) Pharmacological treatment of osteoporotic fractures originates from osteoporosis, so the use of effective drugs to treat osteoporosis is the necessary therapeutic basis for osteoporotic fractures. The aim of pharmacological treatment is to inhibit rapid bone loss, improve bone quality, increase bone strength, reduce painful symptoms, and treat osteoporosis without preventing fracture healing. Reduce the incidence of re-fracture (see the Guidelines for the diagnosis and treatment of primary osteoporosis for specific pharmacological treatment of osteoporosis). Depending on the patient’s specific situation, the following drugs may be considered (in alphabetical order). Bisphosphonates (Bispho-khonates) inhibit osteoclast-mediated bone resorption, reduce bone turnover, and have a strong effect on inhibiting bone resorption and increasing bone mass. Evidence-based medical research shows that bisphosphonates can increase bone density in the lumbar spine and hip. Reduce the risk of fracture in the vertebrae and hip and other parts of the body. Calcitonin (Cakilonin) moderately inhibits the biological activity of osteoclasts and reduces the number of osteoclasts. Evidence-based medical evidence suggests that calcitonin inhibits bone resorption, increases bone mineral density in the lumbar spine and hip, reduces the risk of vertebral fracture, and has a good central analgesic effect. The mechanism of estrogen (Estmgen) for the treatment of osteoporosis includes effects on calcium-regulating hormones, inhibition of osteoclast-stimulating factors and effects on bone tissue, and is indicated only for postmenopausal female patients. Parathyroid hormone (P1W-a) is known to promote bone formation, increase collagen secretion by osteoblasts, promote matrix formation and matrix mineralization. Selective estrogen receptor modulators (SERMs) have estrogen-like effects in the bone and heart, but act as estrogen blockers in the breast and uterus. sERMs act on bone by targeting estrogen receptors to exert estrogen-like effects and inhibit osteoclast activity. This drug is restricted for use in postmenopausal female patients. Strontium salts (Strontium) have an anti-resorptive as well as an osteogenic effect, helping to restore the dynamic balance of bone turnover, improving bone quality, increasing bone strength, and reducing the risk of vertebral and hip fractures. It is only indicated for postmenopausal female patients. Herbal preparations that have been shown by clinical application to improve patient-related symptoms, increase bone mineral density, reduce bone loss, and decrease the incidence of fragility fractures can be used as appropriate. (C) Anti-osteoporosis medication recommendations after fracture 1. Rational use of calcium. Calcium absorption is mainly in the intestinal tract, so calcium supplements are most effective when taken orally. The calcium requirement is 80 anal 1200 m training, if the calcium supply in the diet is not enough, you can choose to take the appropriate amount of oral calcium supplementation, preferably in several times. The rapid bone loss in patients with osteoporotic fractures should be fully considered, and the dose of calcium supplementation should be increased at this stage as appropriate. The choice of calcium should take into account its safety and effectiveness to avoid the occurrence of kidney stones or cardiovascular disease after excessive intake.2 Active vitamin D, not only enhances intestinal calcium absorption, promotes bone formation and bone mineralization, but also helps to enhance muscle strength, improve neuromuscular coordination and prevent the tendency to fall. It is recommended that elderly patients with osteoporotic fractures be supplemented with active vitamin D3, generally at a dose of 0.25 to 0.5 g/d for adults. clinical application should pay attention to individual differences and safety, and regular monitoring of blood or urine calcium. 3. calcitonin can increase bone density, improve bone quality, enhance bone biomechanical properties, and has a significant effect on reducing the incidence of vertebral osteoporotic fractures. It has a significant effect on reducing the incidence of vertebral osteoporotic fractures. Early application of calcitonin treatment in patients with osteoporotic fractures can both relieve pain and improve or prevent rapid bone loss. No adverse effects on the repair and reconstruction of osteoporotic fractures were seen with conventional doses. The usual dose is 50 IU of salmon calcitonin subcutaneously or intramuscularly, and 200 IU of nasal spray/d. After calcitonin application, a small number of patients may have adverse effects such as facial flushing and nausea, most of which may resolve on their own within a few hours. 4. Bisphosphonates can improve bone density in the lumbar spine and hip and reduce the risk of fracture and re-fracture. Recommended bisphosphonates include alendronate, risedronate, zoledronate, etc. Currently, alendronate is available in 70 mg (tablet)/w and 10 mg (tablet), d orally and should be given in a glass of water (not less than 250 rnl) 30 min before the first meal of the day. To reduce the irritation of the stomach and esophagus, patients should avoid lying down for at least 30 min after taking the drug. Careful consideration should be given to the compliance of bedridden patients with this class of drugs. The main adverse effects of bisphosphonates are gastrointestinal reactions, such as nausea, vomiting, abdominal pain, and diarrhea.5 SERMs have been shown to be effective in improving bone mineral density and reducing the incidence of postmenopausal osteoporotic fractures. The general dose is 60nlg(tablet)/d of raloxifene, and the duration of dosing is not affected by diet. It is contraindicated in perimenopausal women with severe hot flashes and is contraindicated in those with a history of venous embolism and a tendency to thrombosis (e.g., prolonged bed rest, sedentary).6 Strontium salts have a dual mechanism of action, improving bone strength and reducing the risk of vertebral and hip fractures. The usual dose is strontium ranelate 29 (bag), d, taken at bedtime. Common adverse reactions are headache, nausea, diarrhea, loose stools, dermatitis, and eczema. It should be used with caution in patients with a history of venous embolism.7. Chinese herbs may be effective in relieving pain, reducing swelling, and improving bone density, and may be used as appropriate.8. Osteoporosis is a chronic bone metabolic disease, and patients with osteoporotic fractures should adhere to long-term drug therapy under the guidance of a physician to treat osteoporosis and prevent the occurrence of re-fractures. Patients with secondary osteoporosis should undergo etiological treatment. Prevention (a) risk factors 1. primary risk factors: falls, low bone density, history of fragility fracture, age >65 years, family history of fracture. 2. secondary risk factors: smoking, alcoholism, low body mass index (k-iso, hack), hypogonadism, early menopause (<45 years), chronic malnutrition, history of drugs affecting bone metabolism (glucocorticoids, heparin, etc.), rheumatoid arthritis, hyperthyroidism, hypothyroidism, metabolic disorders. hyperthyroidism, hyperparathyroidism patients. (2) Preventive measures: 1) Quit smoking and limit alcohol consumption and eat a balanced diet; 2) Maintain a moderate body weight; 3) Insist on daily moderate muscle strength exercise and whole-body balance and coordination exercise; 4) Take appropriate outdoor activities and increase sunlight; 5) Take various measures to prevent falls; 6) Take preventive and correct medication.
[Chinese Medical Association Orthopedic Branch].