Osteoporosis is a systemic, metabolic disease of the skeletal system characterized by reduced bone mass, destruction of bone microstructure, increased bone fragility, decreased bone strength, and susceptibility to fracture, with a high prevalence in postmenopausal women. The content of the guidelines focuses on fractures caused by primary osteoporosis.
Basic principles of osteoporotic fracture treatment.
Displacement, fixation, functional exercise, and anti-osteoporosis.
Key points in the diagnosis of osteoporotic fractures.
1. history of osteoporotic fracture or history of minor trauma.
2. symptoms such as pain, swelling, and functional impairment may be present.
3. signs such as deformity, bone rubbing sensation (sound), and abnormal activity.
4. vertebral compression fractures, which may result in shortening of height or hunchback deformity.
Examination methods
1. imaging examination
(1) General X-ray examination: (1) The radiograph should include the adjacent joints above and below the injury site, and the hip fracture should include bilateral hip joints; (2) In addition to fracture signs, there are also signs of osteoporosis; (3) In the case of vertebral compression fracture, there is a wedge-shaped change or “double concave sign”, and some of them may show the “vacuum sign” and pseudo-joint formation in the vertebral body.
(2) CT examination: CT examination can be considered for intra-articular or peri-articular fractures and intra-vertebral canal compression; and CT and/or 3D imaging is required for complex displaced hip, ankle, and proximal humerus fractures.
(3) MRI examination: ① can diagnose occult fracture; ② can determine whether the fracture is healed or not, the unhealed fracture has low signal in TIWI, high or equal signal in T2WI, and high signal in lipid suppression sequence.
(4) Bone scan (SPECT/ECT): it is suitable for patients who cannot perform MRI, and it can help to determine the vertebrae responsible for pain.
2. Bone density examination
Dual-energy X-ray absorptiometry (DXA): T-value ≥ -1.0 SD is normal; -2.5 SD < T-value < -1.0 SD is low bone mass or reduced bone mass; T-value ≤ -2.5 SD is osteoporosis; the degree of reduction meets the diagnostic criteria of osteoporosis and is accompanied by one or more fractures as severe osteoporosis.
3. Laboratory tests
Routine preoperative tests, including blood calcium and phosphorus, 24-hour urine calcium, 25(OH)VitD, calcitonin and parathyroid hormone, if necessary.
Treatment of common osteoporotic fracture sites
1. Spine fracture
It is the most common osteoporotic fracture. Osteoporotic spine fractures often have mild trauma or no obvious history of trauma and are easily missed or misdiagnosed as lumbar back strain.
Treatment methods.
(1) Non-surgical treatment
Non-operative treatment can be given to those with mild symptoms and signs, mild compression fractures on imaging, and those who cannot tolerate surgery.
Bed rest for 3-4 weeks with a soft pillow for the low back. A brace is recommended when moving to the ground.
Symptomatic treatment: Analgesics may be given for significant pain. Calcitonin can reduce the acute bone loss after fracture and can also relieve the acute bone pain after fracture to some extent.
(2) Minimally invasive surgical treatment
(1) Indications: non-operative treatment is ineffective, pain is obvious; those who are not suitable for prolonged bed rest; unstable compression fracture; fracture block does not heal or internal cystic change, vertebral necrosis; can tolerate surgery.
② Absolute contraindications: patients who cannot tolerate anesthesia and surgery; painless osteoporotic spinal fractures. Relative contraindications; those with bleeding tendency; active infection in other parts of the body; severe compression fracture of the vertebral body.
(3) Treatment: percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP) is optional, and intraoperative biopsy is recommended.
(3) Open surgery treatment
Patients with signs and symptoms of neural compression or those requiring osteotomy orthopedics, as well as patients with unstable fractures that are not suitable for minimally invasive surgery, may be considered for open surgical treatment. If necessary, local cement injection enhancement technique can be used around the internal fixation to enhance the stability of internal fixation.
2. Hip fracture
Osteoporotic fractures of the hip, which mainly include intertrochanteric fractures and fractures of the femoral neck, are serious osteoporotic fractures and usually require surgical treatment. Non-surgical treatment includes bed rest, traction, brace immobilization, and nutritional support. More than 20% of patients with hip fractures will die within 1 year due to various complications, and 20% of patients will have another fracture within 1 year.
(1) Intertrochanteric fracture of the femur
Early partial or full weight-bearing activity is recommended.
Intramedullary fixation: for both stable and unstable intertrochanteric fractures.
Extramedullary fixation: mainly for stable fractures
Artificial hip joint replacement: only for some special cases, such as patients with severe osteoporosis, intertrochanteric comminuted fracture of the femur is difficult to achieve firm fixation by internal fixation; or fracture with hip joint disease, or patients with old fracture.
(2) Femoral neck fracture
Surgical treatment, including
Hollow compression screw internal fixation: for stable fractures without displacement or low displacement tendency.
Power hip screws: for patients with near-vertical fracture line and high tendency of displacement.
Hip replacement: for displaced or unstable fractures. Half hip replacement is recommended for patients with advanced age, low activity, poor physical condition, many comorbidities and no significant degeneration of the acetabulum. Other patients can choose total hip replacement.
3. Distal radius fracture
It is often comminuted, involves the articular surface, and is prone to residual deformity and pain, resulting in functional impairment of the forearm, wrist and hand.
Treatment methods.
(1) Non-surgical treatment
For fractures of the distal radius that can restore the flatness of the articular surface, normal palmar inclination and ulnar deviation angle, and the height of the radial styloid process, non-operative treatment such as manipulation and plaster fixation can be used.
(2) Surgical treatment
Surgery is recommended for patients with radial shortening of more than 3 mm, dorsal angle of more than 10 degrees on lateral radiographs, and articular surface step of more than 2 mm after reduction.
Depending on the specific conditions of the fracture, techniques such as percutaneous prying and repositioning internal fixation with a Kevlar pin, incision and repositioning internal fixation with a locked compression plate (LCP), external fixation brace, and intramedullary nailing of distal radius fractures are used. 4.
4. Proximal humerus fracture
Treatment methods
(1) Non-surgical treatment
Fractures without displacement or mild displacement, or frail patients who cannot tolerate anesthesia or surgery can be treated with neck and wrist sling suspension.
(2) Surgical treatment
For patients with displaced fractures, early surgery is currently advocated. This includes tension band, tension screw, percutaneous kyphosis pin, locking splint fixation, and intramedullary nail internal fixation.
For elderly patients with advanced age, severe comminuted fractures or with humeral head fractures, artificial humeral head replacement is feasible. Early functional exercise of the shoulder joint should be performed after surgery.
Other treatments for osteoporotic fractures
1. Systematic management
Comprehensive assessment of the patient’s general condition, organ function, risk and prognosis, and implementation of comprehensive surgical or non-surgical management.
2. Anti-osteoporotic treatment
Focus on perioperative anti-osteoporosis treatment.
Anti-bone resorption inhibitors: may result in larger bone scabs during fracture repair; such large scabs may also provide higher biomechanical stiffness and strength.
Bisphosphonates: regulated routine dosing has no adverse effect on fracture healing and may be considered sequential therapy over a 3-5 year period.
Parathyroid hormone and vitamin K2: favor osteogenesis.
Salmon calcitonin: reduces acute bone loss and alleviates osteo-sulfuric bone pain; intermittent repeat dosing may be used if necessary.
3. Drug therapy
(1) Basic treatment drugs: vitamin D, calcium preparations. It is recommended to take an additional 500-600 mg of elemental calcium daily and 800-1000 IU of regular vitamin D daily.
(2) Active vitamin D: In elderly people with renal insufficiency and 1a hydroxylase deficiency, active vitamin D should be supplemented and blood and urine calcium should be monitored.
(3) Anti-bone resorption drugs: diphenhydramine, calcitonin, selective estrogen receptor modulators, estrogen-progestin replacement therapy, etc.
(4) Osteopathic drugs: PTH 1-34 tablets.
(5) Bi-directional mechanism of action drugs: active vitamin D, vitamin K2, etc.
(6) Chinese patent medicines or Chinese herbal medicines: e.g., bone-strengthening drugs, Chinese herbal medicines containing flavonoids and other biologically active ingredients.
Medication principles.
Those who have used anti-osteoporosis drugs before the fracture can continue to apply them; whether to strengthen the anti-bone resorption drugs for those who need to be bedridden for a long time after the fracture is decided according to the bone conversion index after the fracture.
Those who did not use anti-osteoporosis drugs before fracture: ① For those who underwent emergency or early internal fixation surgery after fracture, anti-osteoporosis treatment is recommended in due course when the patient’s general condition is stable after surgery. ②Patients with temporary non-operative or conservative treatment after fracture are recommended to have anti-osteoporosis treatment at the appropriate time when the systemic trauma response is stabilized.
4. Physiotherapy
Physiotherapy is simple, non-invasive, effective and safe, and can promote fracture healing. Low-intensity pulsed ultrasound (LIPUS), pulsed electromagnetic field (PEMF), extracorporeal shock wave (ESWT), functional electrical stimulation (FES) and vibration wave are available as physiotherapy methods.
5. Rehabilitation training
It is recommended to use a combination of active and passive exercise, with active exercise as the main mode of exercise. Step by step, avoid rough handling.
6. Exercise therapy
Weight-bearing exercises and resistance exercises, such as brisk walking, dumbbell exercises, weight lifting, rowing, pedaling, etc., are recommended. Pay attention to the development of individualized discretionary exercise prescription, choose the exercise mode, frequency, time and intensity according to the individual.