Abstract: Falls and fractures are major causes of morbidity and mortality in older people. More importantly, previous falls and/or fractures are the most important predictors of further events. Therefore, secondary prevention programs for falls and fractures are highly needed. However, the question is whether a secondary prevention model should focus on falls preven- tion alone or should be implemented in combination with fracture prevention. By comparing a falls prevention clinic in Manizales (Colombia) versus a falls and fracture prevention clinic in Sydney (Australia), the objective was to identify similarities and differences between these two programs and to propose an integrated model of care for secondary prevention of fall and fractures. A comparative study of services was performed using an internationally agreed taxonomy. Service provision was compared against benchmarks set by the National Institute for Health and Clinical Excellence (NICE) and previous reports in the literature. Comparison included organization, administration, client characteristics, and interventions. Several similari- ties and a number of differences that could be easily unified into a single model are reported here. Similarities included population, a multidisciplinary team, and a multifactorial assessment and intervention. Differences were eligibility criteria, a bone health assessment component, and the therapeutic interventions most commonly used at each site. In Australia, bone health assessment is reinforced whereas in Colombia dizziness assessment and management is pivotal. The authors propose that falls clinic services should be operationally linked to osteoporosis services such as a “falls and fracture prevention clinic,” which would facilitate a comprehensive intervention to prevent falls and fractures in older persons.
Hip fractures present an important public health prob- lem. Each year, 87,000 hip fractures occur annually in the UK  with a cost (including medical and social care) of around £2.3 billion a year . Hip fractures usu- ally occur when individuals with underlying osteoporosis fall [3,2]. These patients are a high risk of further frac- tures and premature death [4-6]. The risk of second hip fracture ranges from 2.3% to 10.6% [7,8] and mortality during the first year after fracture ranges from 8.4% to 36% . Effective management of these patients can significantly reduce this risk, which is why professional bodies have produced comprehensive guidance about the management of hip fracture [1,9-12]. Fracture pre- vention services should have four main components: case finding those at risk of further fractures; undertak- ing an evidence-based osteoporosis assessment; treat- ment initiation in accordance with guidelines for both bone health and falls risk reduction and then strategies to monitor and improve adherence to recommended therapies . Since the provision of these services is multi-disciplinary , guidance recommends structuring services around a dedicated co-ordinator who provides a link between all the multi-disciplinary teams involved in fracture prevention , an approach known as a Fracture Liaison Service . However, considerable gaps in patient care following fracture still exist  with marked vari- ation in how services are delivered locally [16,17], and it is unclear how best to implement these services.
The FPS is a multidisciplinary and collaborative team, including orthopedic surgeons, geriatricians, physical therapists, nurses, and general practitioners, which assumes responsibility for secondary fracture prevention. The FPS assures case finding, assessment, and diagnostic evalua- tion, and encourages outpatient primary care physicians to initiate appropriate treatment. During the period April– December 2011, geriatricians, as providers of a fall and fracture clinic, met with orthopedic surgeons, nurses, physi- cal therapists, and primary care physicians to determine the needs and preferences of these groups for collaboration in order to assure the secondary prevention of fragility fractures. The fall and fracture clinic is a hospital-based outpatient ambulatory service provided jointly by a geriatrician and a physiotherapist. Teaching and training activities were undertaken for staff involved in the FPS to raise awareness concerning guidelines for the diagnosis and treatment of osteoporosis. A fragility fracture protocol was established, and written guidelines for assessment and treatment of per- sons with a proximal hip fracture were defined for staff in the orthopedic and traumatology department. In detail, low trauma hip fracture is defined as a fracture sustained as a result of a fall from standing height or less and not occurring as a consequence of a road traffic accident. All persons aged 65 years and older admitted with low trauma hip fracture are identified by the orthopedic surgeons and sent the fragility fracture protocol. The protocol includes BMD and blood testing, assessment of fracture risk, and prescription and monitoring of antiosteoporotic treatment. At discharge, the FPS team members send a letter to the general practitioner explaining that their patient is scheduled for a comprehensive fracture and falls risk assessment, including BMD evaluation and blood tests. The main reason for a FPS in our teaching hospital is the large number of surgical procedures done for
In this survey, Canadian physicians strongly agreed with targeting all LTC residents for hip fracture prevention strat- egies. Furthermore, respondents expressed strong support for the use of calcium, vitamin D, potent oral bisphospho- nates, and physical therapy or exercise programs in the LTC setting. However, potential side effects and compli- ance with use or proper administration were identified by some respondents as important barriers to the implemen- tation of calcium and potent oral bisphosphonates in LTC. Other osteoporosis pharmacotherapies, hormone thera- pies, or vitamins were not strongly favoured for first-line use in secondary hip fracture prevention in the LTC setting. The information gathered in this physician survey should be of interest to clinicians and administrators working in the field of LTC, as well as health policy makers con- sidering the feasibility and acceptability of funding vari- ous potential strategies to reduce hip fractures in nursing homes. In the future, more clinical research is also needed
I performed a systematic review of the literature using MEDLINE (PubMed) to identify randomised controlled trials (RCTs) on fracture prevention with vitamin D sup- plementation that were published after the meta-analysis of 2005. "Cholecalciferol", "ergocalciferol", "25-hydroxy- vitamin D 2", "vitamin D", "fracture" and "fall" were used as search terms (Medical Subject Heading (MeSH) and text word) and the search was limited to randomised con- trolled trials with publication date January 1, 2005 or later. Furthermore, I checked the ongoing trials described in the Cochrane review . As a next step, I applied the same criteria for eligibility as was done in the meta-analy- sis . A trial was included if it was a double-blind RCT that studied oral vitamin D supplementation (cholecalcif- erol or ergocalciferol) with a minimum follow-up of one year and if there was more than a total of one fracture in the trial. Measurement of 25-hydroxyvitamin D levels during follow-up was not required because it would lead to exclusion of two of the largest trials [2,5].
In the context of current primary care reform, second- ary fracture prevention program research must evaluate multidisciplinary and interorganizational strategies, with attention to the regional context of implementation, the providers, and the participants. The present paper in- cludes the design and evaluation procedures for a novel secondary FF prevention program, involving collaboration between secondary healthcare practitioners (orthopedic surgeons and medical bone specialists), primary care physicians (PCPs), group practice nurses, and local and provincial fall prevention programs, being implemented in the province of Quebec, Canada. This work builds on the Osteoporosis and Peripheral fractures: Treatment and Investigation through Multidisciplinary care at the CHUS (OPTIMUS) intervention. The proposed intervention in- volves PCPs in the evaluation and treatment of osteopo- rosis following FFs treated by orthopedic surgeons [32-38] and integrates local and provincial fall prevention pro- grams implemented in the province of Quebec, including the Personalized Multifactorial Intervention (PMI), an individualized program offered to the most frail elders considered at risk for falls ; and a community-based fall prevention program aimed primarily at improving balance and strength through exercise for elders who have fallen or are concerned with falls (Stand Up!) . This integrated program will be orchestrated by site study coordinators.
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Long-term care facilities (LTCFs) are settings with a particularly high risk for falls. In this setting, the fall rate is reported to be about 2 falls per resident-year , which is considerably higher than the fall rate observed in older people living in the community . In LTCFs with 90 beds, for example, a fall can be expected about every other day . Therefore, fall-related injuries such as bruises, lacerations or fractures are common. One of the most serious complications of falls are femoral fractures . They are particularly frequent in residents of LTCFs. In Germany, more than 20% of hip fractures are caused by residents from LTCFs even though their corresponding person-years under obser- vation account only for 4% . Therefore, there is a high interest in measures and programs which reduce the risk of falls and fall-related injuries in residents of LTCFs. At the end of the 1990s two similar cluster-randomized controlled trials from Sweden and Germany demonstrated that a multifactorial approach is able to reduce the fall rate in residents of LTCFs [6, 7]. Motivated by the results of the German trial, a large statutory health insurance com- pany [Allgemeine Ortskrankenkasse Bayern (AOK)] decided to finance the implementation and dissemination of the program in a large number of LTCFs in Bavaria, a federal state with 12.5 million inhabitants in the south of Germany. Compared to the original study, the pro- gram components and the implementation plan of the so-called Bavarian fall and fracture prevention pro- gram (BF2P2) were somewhat modified and simplified. In total nearly 1000 LTCFs started with the BF2P2 after having signed a contract to participate in the program for at least 3 years .
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vulnerable group differ with respect to the level of physical-activity level and performed walking speed. In a 10 year longitudinal study (aged 66 - 76), daily activity level strongly correlated to physical activity and physical performance where walking speed and muscle strength predicted future independency . In line with Frändin’s findings, our results can contribute to economic gain in case of screening those groups who would benefit the most from exercise interventions and from encourage- ment of independency. The importance of exercise in interventions for the prevention of bone loss has been controversial. However, a recent literature review shows that weight bearing and resistance exercise are effective on the BMD of spine, hip and wrists . Moreover, exercise can reduce fall rates if it contributes to balance and muscle strength and is maintained over time [52-55]. Furthermore, studies on exercise interventions report that improved physical capacity increases patients’ specific- activity balance confidence and decreases their risk of falling [56,57]. In light of these findings, we believe that individuals in the health-vulnerable group identified in this study are likely to benefit from interventions aimed to improve their physical capacity as well as their active- ity-specific balance confidence. For individuals in the vulnerable group, low self-efficacy with low sense of coherence might be compared to reduced coping ability (Eriksson, 2007; Bandura 1997) for adherence of second- dary prevention recommendations. Such decreased resil- ience resources are challenging a patient-centred approach in achieving empowered behaviour change. In contrast, the health-resilient group that was identified in this study is likely to benefit fully from health education programmes that encourage them to sustain their healthy lifestyle with high quality of life. Moreover, this health-resilient group would promote fall prevention further by exchanging part of weekly walking for activities designed to improve muscle strength and specific balance training [38,52,54]. A review of post fracture exercise reported that only 4% of the exercise prescriptions to people 45 years or older, contributed to fracture prevention, and in relation to forearm fractures no preventive prescription was found . One underlying dimension of successful multifac- torial fall prevention programmes  might according to these results be programmes that support psychology- cal aspects of empowerment . Our results can be ap- plied in post fracture interventions by combining physic- cal exercise with psychological support in relation to fall related injuries.
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Ibrandronate either orally (daily or monthly schedules) or intravenously successfully reduced markers of bone turnover, increased BMD [144,145], and reduced fractures of the vertebra (relative risk reduction [RRR] = 52%) . Secondary analyses of persons in ibandronate studies with initial BMD at or below –3.0 showed that ibandronate had a protective effect on hip fracture risk reduction as well. Zolendronic acid (zolendronate) is administered as a yearly intravenous infusion and significantly reduced both vertebral (RRR = 70%) and hip (RRR = 41%) fractures in a large multinational study . A subsequent study examined women and men who had experienced a prior hip fracture and showed a significant reduction in subsequent clinical fractures along with a reduction in mortality . Side effects may include an acute-phase response with myalgias and flu-like symptoms in 10% to 15% of patients receiving their first dose. These symptoms most commonly resolve within several days and are attenuated with acetaminophen, prior oral bisphosphonates, and repeated doses of the intravenous therapy. Patients receiving intravenous zoledronic acid must have adequate renal function (creatinine clearance of greater than 30 mL/minute) prior to getting this agent. On the basis of largely uncontrolled reports of osteonecrosis of the jaw and newer questions about atypical femoral fractures, there is increasing scrutiny of particularly longer- term therapy with bisphosphonates as a class . Osteo- necrosis of the jaw has been reported in an estimated 2% of cancer patients receiving higher doses of predominately intravenous bisphosphonates for patients with malignancies in particular . Cases also have been described in patients receiving bisphosphonates for osteoporosis. Although mechanisms are not confirmed for these two adverse outcomes, if a relationship is supported by further studies, this will have further impact on the idea of a ‘drug holiday’ .
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areas are usually confronted with long and unacceptable distances if they want to attend an exercise class. Further- more, bone health is a neglected field in many countries in the world and only few patients with fragility fractures receive osteoporosis investigation or treatment [12, 13]. Part of the problem is that the awareness of osteoporosis and of the potential treatment options is still low . To improve health care in patients with fragility fractures particularly Anglo-Saxon and Scandinavian countries started to implement disease-management programs for secondary prevention of fractures. Most of the programs focus on the diagnosis and treatment of osteoporosis and use specialized persons ( ‘ care manager ’ , ‘ fracture liaison nurses ’ ) to approach and supervise patients. These pro- grams differ due to different included components, diffe- rent intensities, and different settings [14, 15]. The so far most comprehensive approach was performed by a health maintenance organization in Southern California which approached their insured persons at risk actively and addressed not only bone health but also fall risk . All these programs, however, had either only historical control groups or evaluated only process variables like DXA measurements or medical therapy . Coordinated preventive approaches which combine bone health and fall prevention are rare. In Germany such approaches do not exist at all. Even though bone density measurement for primary prevention is generally recommended by the German national guidelines in women above 70 years and in men above 80 years (http://www.dv-osteologie.org/ dvo_leitlinien/osteoporose-leitlinie-2014), it is reimbursed only in few cases and therefore performed rarely.
However the incidence of new hip fractures was not significantly different (2.0% vs 3.5%, a nonsignificant reduction in relative risk of 30%) (Figure 2B). Although in a post hoc analysis, signiﬁ cant divergence in the fracture- free survival curves between the two groups for all clinical fractures was seen as early as 12 months (p = 0.02 by the log- rank test). BMD at the total hip increased in the ZOL group by 2.6%, 4.7%, 5.5% at 12, 24 and 36 months respectively compared with a decline BMD in the placebo group by 1.0%, 0.7%, and 0.9%, respectively. BMD at the femoral neck also increased in the ZOL group by 0.8%, 2.2% and 3.6% at 12, 24 and 36 months respectively and declined in the placebo group by 1.7%, 2.1%, and 0.7%, respectively over the same period. All increases in BMD were statistically signiﬁ cant compared with placebo. Finally, the difference in delayed union of fractured bone between the two study groups was not signiﬁ cant (3.2% in the ZOL group and vs 2.7% in the placebo group; 95% CI, 0.72 to 1.90; p = 0.61).
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Methods: A Markov model represented the possible health state transitions of Spanish postmenopausal women from initiation of fracture prevention treatment until age 100 years or death. The perspective was that of the Spanish National Health System. Fracture efficacy data for denosumab were taken from a randomized controlled trial. Fracture efficacy data for alendronate, ibandronate, risedronate, and strontium ranelate were taken from an independent meta-analysis. Data on the incidence of fractures in Spain were either taken from the published literature or derived from Swedish data after applying a correction factor based on the reported incidence from each country. Resource use in each health state was obtained from the literature, or where no data had been published, conservative assumptions were made. Utility values for the various fracture health states were taken from published sources. The primary endpoints of the model were life-years gained, quality-adjusted life-years (QALYs), and incremental cost- effectiveness ratios for denosumab against the comparators.
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result of falling leads to functional impairment, depend- ency and decreased quality of life . Current hip fracture prevention strategies are based on approaches with limited success that may require a long period of time before becoming effective . Bearing in mind the enormous expenses that were presented in the study, we believe that falls prevention (and consequently hip fractures prevention) or at least reducing the incidence of falls should be a top priority. A national program for falls prevention was recently launched by Israel’s Minis- try of Health in order to reduce healthcare expenditures and improve the quality of life of elderly individuals. In addition, to face the challenges of early prevention in osteoporotic patients at high risk of hip fracture, surgical intervention should be considered .
determined by microstructural features and their associated some seen here. They suggested that this process is initiated influences on the mechanisms of failure. In Figure 7, the by formation of voids at the coarse precipitates at the grain 7150 and 7449 alloys fall in the same region of the strength- boundary, with voids subsequently coalescing and extending toughness line in the T651, T7951, and T7651 conditions, along the grain boundary. This step is followed by the neck- illustrating that the difference in properties between the two ing down of the grain interiors until fracture occurs trans- alloys is related mainly to the higher amount of Zn-con- granularly. It is interesting to note that while failure in our taining strengthening precipitates in the 7449 alloy. This samples is clearly influenced by the decorated grain bound- figure also illustrates the influence of alloy purity on the aries, excessive delamination of the grain structure is not toughness-strength relationship: the 7475 alloy, which is evident. It would appear that for our alloy, once failure known to have a higher purity than the 7075 alloy,  has a
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Tensile properties of three Bi-based lead-free solder which are pure Bi, Bi-1.0Ag-0.3Sn-0.03Ge (mass%), and Bi-2.5Ag (mass%) were investigated and compared with that of Pb-rich Pb-2.5Ag-2.5Sn (mass%) solder. Tensile strength of pure Bi is the minimum among solder in- vestigated regardless of the temperature and strain state. Although tensile strength of Bi-based solder is lower than that of Pb-2.5Ag-2.5Sn at 25C, those of Bi-1.0Ag-0.3Sn-0.03Ge and Bi-2.5Ag improve and become analogous and higher than that of Pb-2.5Ag-2.5Sn at a temperature of 125C or more. The effect of strain rate on elongation is negligible in solder investigated. Although elongations of Bi-based lead-free solder are lower than that of Pb-2.5Ag-2.5Sn at 25C, they increase with increasing temperature. While the elongation of Pb-2.5Ag-2.5Sn relatively stable at approximately 20–30% regardless of temperature, elongations of Bi-1.0Ag-0.3Sn-0.03Ge and Bi-2.5Ag become a same level with that of Pb-2.5Ag-2.5Sn at 125C and 175C. In particular, the ductility of pure Bi which is about 5% improves drastically at temperatures of 75C or more and the elongation rises to approximately 60%. From microstructure observation results, it was confirmed that the addition of small amount of Sn and Ge is effective to form fine microstructure. From fracture surface observation results, it was confirmed that brittle fracture occurs at 25C and the fracture mode changes to ductile fracture when the temperature increases and the ductility improves.
We found that the number of CCI comorbidities was a risk factor for both death and complications. Male gen- der and older age were only statistically significant risk factors for survival. Moreover, fracture type was only a statistically significant risk factor for complications. Duckworth et al. assessed the risk factors for internal fixation failure of cervical fracture among 122 adults aged <60 years and found that the presence of pre- existing comorbidities was a risk factor . However, Karantana et al. did not identify any significant risk fac- tors leading to internal fixation implant failure because the number of failures was too small . We found cervical fracture had a 1.81 times (95% CI: 1.60–2.06) higher sHR of complication than trochanteric fracture among young adults. Previous studies have also re- ported that cervical fracture was associated with a higher complication rate than intertrochanteric fracture among young adults [13,15]. Robinson et al. reviewed 75 subjects with hip fracture aged under 50 years and found that only 57 (76%) had satisfactory outcomes . Robinson et al. found that 7 (23%) of 30 subjects with trochanteric fracture and 14 (31%) of 45 subjects with cervical fracture had surgical complications . Verttas et al. also reported that cervical fracture had slightly higher complications rates, i.e., 22.5% for tro- chanteric fracture and 25% for cervical fracture, among young adults aged <50 years . We found that tro- chanter fracture had a slightly higher risk for mortality (p =0.196). Whether trochanteric has a higher risk for mortality or a lower risk for complications than cervical fracture still remains controversial. Previous studies have shown that trochanteric fracture has a higher risk for mortality than cervical fracture among elderly adults [21-25]. Haentjens et al. reported that the 1-year mortality was 27% for trochanteric fracture and 11% for cervical fracture [26,27]. However, some studies have reported no significant differences in mortality rates between the two fracture types. Kim et al. reported that cervical
The age range was noted that 64% of individuals who sustained maxillofacial fracture were reported to be in their third and fourth decade with highest incidence noted in the third decade (37.9%). 1.8% incidence of maxillofacial fracture in the age group more than 60 years. In Desai 44 study, as described in this group as the unskilled labor force that are weakly paid so that may lead to increased in interpersonal violence with robbery often being the motive. But in our study the motor vehicle accidents are more common as it is easy means of transport and traffic rules are not strict i.e. not wearing helmet , leading to maxillofacial trauma and fracture.
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The patient was taken for open reduction and internal fixation of the radial shaft fracture and closed/open re- duction of the radio-ulnar joints. The radius fracture was addressed by anterior Henry’s approach. The fracture was exposed, cleaned and fixed with a seven holes small DCP with three 3 - 5 mm screws on either side of frac- ture. The interosseous membrane near the fracture site was found disrupted and the exact extent could not be ascertained. After fixation of the fracture the elbow and wrist were examined under image intensifier. The DRUJ seemed reduced but, proximally the radial head was clearly out of the joint. With traction it was possible to re- duce the radial head into normal position which was confirmed in IITV picture, but was unstable. The proximal radio-ulnar joint was first stabilized with a 2 mm K-wire inserted from distal humerus into radial head keeping the elbow flexed to 90 degrees (Figure 2) and then the DRUJ was stabilized with another 2 mm K-wire from Ulna to Radius keeping the forarm in supination (Figure 3 and Figure 4). The K-wires were bent and kept out- side for later easy removal for mobilization (Figure 5). No attempt was made to repair the TFCC as the DRUJ seemed stable under fluoroscopy.
Twenty two patients had fourty six associated injuries and eighteen (51.4%) of them had ipsilateral injuries (fracture patella was seen in seven (20%) patients). Three patients (8.5%) had an associated vascular injury, two of them underwent an above knee amputation and the third patient underwent thrombectomy and stabilization fractures with an external fixator. There were four patients with contralateral lower limb injuries, two had tibial and two had open tibial fractures. Other system injuries were seen in twelve patients who included three patients with clavicle fractures and two patients with rib fractures. Anterior Cruciate Ligament laxity was seen in six patients (17.1%) and Posterior Cruciate Ligament laxity was seen in two (5.7%) patients. The incidence of associated ligamentous injuries varies from 2- 39% (Schiedts et al 25 ), of the eight patients
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For the same thickness B=8mm, two kinds of fracture types were obtained in the specimens under pure mode II loading. Figure 4(a) is the macroscopic fracture appearance of LC4CS. It is seen that surfaces of the crack tip have slipped obviously, and the crack initiated and propagated almost along the crack plane. However, the specimens of 7050-T7452, shown in Figure 4(b), fractured in the direction that kinked at a large angle with the crack plane, and there was not obvious distortion before fracture.