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.
Diagnostic points of osteoporotic fracture.
1. History of osteoporotic fracture or minor trauma;
2. Pain, swelling, functional impairment and other symptoms may occur;
3, deformity, bone rubbing sensation (sound), abnormal activity and other physical signs;
4.Vertebral compression fracture may lead to short height or hunchback deformity.
Examination methods
1.Imaging examination
(1) General X-ray examination: ①The film should include the adjacent joints above and below the injury site, and the hip fracture should include bilateral hip joints; ②In addition to fracture signs, there are also signs of osteoporosis; ③When the 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; while CT and/or three-dimensional 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): suitable for patients who cannot perform MRI examination, which can help to determine the vertebrae responsible for pain.
2.Bone density examination
Dual-energy X-ray absorptiometry (DXA) measurement: 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 is in line with the diagnostic criteria of osteoporosis, and accompanied by one or more fractures is serious osteoporosis.
3.Laboratory examination
Routine preoperative tests, such as blood calcium and phosphorus, 24-hour urine calcium, 25(OH)VitD, calcitonin and parathyroid hormone should be performed 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 muscle strain.
Treatment methods.
(1) Non-surgical treatment
Non-operative treatment is available for 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
①Indications: 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 degeneration, vertebral necrosis; can tolerate surgery.
② Absolute contraindications: patients who cannot tolerate anesthesia or 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 posterior kyphoplasty (PKP) or percutaneous vertebroplasty (PVP) is optional, and intraoperative biopsy is recommended.
(3) Open surgery treatment
Open surgical treatment may be considered for patients with signs and symptoms of neurological compression or who require osteotomy orthopedics, as well as for patients with unstable fractures that are not suitable for minimally invasive surgery. If necessary, local injection of bone cement enhancement technique can be used around the internal fixation to enhance the stability of internal fixation.
2.Hip fracture
Osteoporotic fractures of the hip mainly include intertrochanteric fractures and femoral neck fractures, which are serious osteoporotic fractures and generally require surgical treatment. Non-surgical treatment includes bed rest, traction, brace fixation, nutritional support and other therapeutic measures. 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.
3.Intertrochanteric fracture of femur
If conditions allow, early surgery should be performed and early partial or full weight-bearing activities are recommended.
(1) Intramedullary fixation: Intramedullary fixation can be chosen for both stable and unstable intertrochanteric fractures;
(2) Extramedullary fixation: mainly for stable fractures;
(3) Artificial hip joint replacement: only for some special cases, such as patients with severe osteoporosis, femoral inter-rotor comminuted fracture relying on internal fixation is difficult to achieve reliable fixation; or fracture accompanied by hip joint disease, or old fracture patients.
4.Femoral neck fracture
Surgical treatment, including.
(1) Hollow compression screw internal fixation: suitable for stable fractures without displacement or low-displacement tendency.
(2) Power hip screws: for patients with near-vertical fracture line and high tendency of displacement.
(3) Hip replacement: for displaced or unstable fractures. Half hip replacement is recommended for patients of advanced age, little activity, poor physical condition, many comorbidities and no obvious degeneration of the acetabulum. Other patients can choose total hip replacement.
5.Distal radius fracture
It is often comminuted, involving the joint surface, easily residual deformity and pain, causing dysfunction of forearm, wrist joint 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, and the height of the radial styloid process, non-operative treatment such as manual repositioning and plaster fixation can be used.
(2)Surgical treatment
Surgery is recommended for patients whose radial shortening exceeds 3 mm, whose lateral radiographs show a dorsal angle of more than 10 degrees, and whose articular surface step exceeds 2 mm.
Depending on the specific conditions of the fracture, techniques such as percutaneous prying and internal fixation with a pincer pin, internal fixation with an incision and locking compression plate (LCP), external fixation brace, and intramedullary nailing of the distal radius fracture are recommended.
6.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
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 and senior patients with severe comminuted fractures or with pus head fractures, artificial peptide head replacement is feasible. Early functional exercise of the shoulder joint should be performed after surgery.
Other treatments for osteoporotic fractures
1.Systematic management
Comprehensively assess the patient’s systemic condition, organ function, risk and prognosis, and implement 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, and such large bone 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 K: favor osteogenesis.
Salmon calcitonin: It can relieve bone pain of osteochondrosis, and intermittent repetitive administration can be used if necessary.
3.Medication
(1) Basic treatment drugs: active vitamin D, calcium preparations. Additional supplementation of elemental calcium 500-600 mg per day is recommended, or replaced by calcium-containing herbal medicines (such as natural bone powder). In elderly people with renal insufficiency and 1a hydroxylase deficiency, active vitamin D should be supplemented and blood and urine calcium should be monitored.
(2) Anti-bone resorption drugs: diphenhydramine, calcitonin, etc.
(3) Bone formation promotion drugs: DTH fragments, androgens, active vitamin D, etc.
(4) Traditional Chinese medicine or herbal medicine: for example, bone-strengthening drugs, herbal medicine containing flavonoids and other biologically active ingredients.
Early stage of fracture: basic drugs plus anti-bone resorption drugs.
Middle and late stage: continue to apply basic drugs plus anti-bone resorption drugs or choose to promote bone formation drugs.
Medication principles.
For those who have used anti-osteoporosis drugs before fracture, they can continue to apply; whether to strengthen anti-bone resorption drugs for those who need to be bedridden for a long time after fracture is decided according to the bone conversion index after 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 who temporarily do not have surgery or conservative treatment after fracture are recommended to have anti-osteoporosis treatment when the systemic trauma response is stabilized at an appropriate time.
4.Physical therapy
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 can be used 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 operation.
6.Exercise therapy
Weight-bearing exercise and resistance exercise should be the mainstay, such as brisk walking, dumbbell exercises, weight lifting, rowing, pedaling, etc. Pay attention to the development of individualized discretionary exercise prescription, choose the exercise mode, frequency, time and intensity according to the individual.