脆性骨折的醫(yī)學(xué)處理

脆性骨折的醫(yī)學(xué)處理司空見(jiàn)慣的病例脆性骨折概念脆性骨折是與骨質(zhì)疏松相關(guān)的老年性骨折，與創(chuàng)傷性骨折相對(duì)。損傷輕微發(fā)病部位多位于肱骨近端、橈骨遠(yuǎn)端、髖部及椎體一例脆性骨折的教訓(xùn)GiannottiS1,

BottaiV,

PiniE,

Dell'ossoG,

DePaolaG,

GuidoG.Clinicalandsurgicalapproachofseverebone

fragilityfracture:clinicalcaseof4

fragilityfracture

inpatientwithheavyosteoporosis.ClinCasesMinerBoneMetab.我們尚缺乏對(duì)脆性骨折的認(rèn)識(shí)一份調(diào)查了2021個(gè)骨科醫(yī)生問(wèn)卷顯示：少于10%檢查脆性骨折提到了骨密度32%能開(kāi)出合適計(jì)量的鈣劑和維生素D大約30%提到平地跌倒可能懷疑是脆性骨折SorbiR1,

AghamirsalimMR.Knowledgeoforthopaedicsurgeonsinmanagingpatientswith

fragilityfracture.IntOrthop.中國(guó)已進(jìn)入老齡化社會(huì)HaginoH.Fragility

fracture

prevention:

review

fromaJapaneseperspective.YonagoActaMed.

2012Jun;55(2):21-8.Epub2012Jun30.骨科醫(yī)生的窘境BroderickJM1,

Bruce-BrandR,

StanleyE,

MulhallKJ.Osteoporotichip

fractures:theburdenoffixationfailure.ScientificWorldJournal.面對(duì)脆性骨折骨科醫(yī)生該怎么辦？骨質(zhì)疏松的相關(guān)知識(shí)骨重塑（Boneremodeling）骨重塑單元(BRC)多細(xì)胞骨單位(BMU)成骨細(xì)胞(osteoblasts)破骨細(xì)胞(osteoclasts)骨細(xì)胞(osteocytes)骨轉(zhuǎn)換(turnover)OPG/RANKL/RANK信號(hào)系統(tǒng)骨質(zhì)疏松的篩查骨密度檢查（DXA）骨折風(fēng)險(xiǎn)度評(píng)估（FRAX）rax.骨質(zhì)疏松的治療健康和飲食方法：鈣劑維生素D有規(guī)律運(yùn)動(dòng)戒煙酒藥物療法：抗吸收藥物：raloxifen、二膦酸鹽藥物促合成代謝藥物：Teriparatide、Strontiumranelate未來(lái)方法:CathepsinKinhibitorsDenosumab(RANKLantibody)干細(xì)胞療法FDA和EMA批準(zhǔn)藥物藥物作用機(jī)理什么樣的病人需要治療60歲以上有嚴(yán)重骨折史，

DEXA證實(shí)有脆性骨折風(fēng)險(xiǎn)有腕部或其他部位骨折，DEXA證實(shí)需要治療骨質(zhì)疏松，并呈現(xiàn)其他骨折風(fēng)險(xiǎn)根據(jù)FRAX評(píng)分指導(dǎo)醫(yī)生決定OrcelP1,

Funck-BrentanoT.Medical

management

following

an

osteoporoticfracture.OrthopTraumatolSurgRes.

2011Dec;97(8):860-9.NICE治療指南

如何選擇藥物Raloxifen還有預(yù)防乳腺癌益處，但有嚴(yán)重血栓栓塞史忌用Calcitonin無(wú)增加絕經(jīng)期婦女骨密度作用，有誘癌可能zoledronicacid一年輸一次，嚴(yán)重腎衰忌用Strontiumranelate有嚴(yán)重血栓栓塞史忌用raloxifen和ibandronate對(duì)75歲以上女性有高風(fēng)險(xiǎn)股骨頸骨折無(wú)效Teriparatide用于至少有2次椎體骨折的病人OrcelP1,

Funck-BrentanoT.Medical

management

following

an

osteoporoticfracture.OrthopTraumatolSurgRes.需要治療多長(zhǎng)時(shí)間Raloxifen運(yùn)用10多年未發(fā)現(xiàn)問(wèn)題，合理停藥時(shí)間是非椎體骨折風(fēng)險(xiǎn)降低雙磷酸鹽10年用藥是安全的，短程用藥傾向于5年，非典型骨折發(fā)生于用藥5-7年Teriparatide療程18-24月strontiumranelate2007年上市，數(shù)據(jù)有限，5年有效性和8年安全性令人鼓舞如何監(jiān)測(cè)治療反應(yīng)咨詢(xún)DXA生物標(biāo)識(shí)物二膦酸鹽藥物結(jié)構(gòu)二膦酸鹽藥物副作用胃腸道反應(yīng)急性期反應(yīng)房顫下頜骨壞死非典型股骨骨折骨痛腎功能不全食管癌RizzoliR.Bisphosphonates

forpost-menopausalosteoporosis:aretheyallthesame?QJM.非典型股骨骨折

SchilcherJ1,

SandbergO,

IsakssonH,

AspenbergP.Histologyof8

atypical

femoralfractures.ActaOrthop.脆性骨折愈合特點(diǎn)骨愈合時(shí)相與正常骨相同骨愈合時(shí)間延長(zhǎng)骨痂少骨礦含量下降力學(xué)剛度減低脆性骨折內(nèi)固定失效特點(diǎn)力學(xué)性能下降，把持力不足界面不穩(wěn)，引起微骨折、骨吸收內(nèi)植物松動(dòng)內(nèi)固定失效往往是骨方面問(wèn)題而不是內(nèi)固定折斷脆性骨折外科處理原則降低界面應(yīng)力分散界面應(yīng)力髓內(nèi)釘技術(shù)骨嵌插支撐板角穩(wěn)定骨強(qiáng)化關(guān)節(jié)置換不同部位骨折的治療方法抗骨質(zhì)疏松藥物能降低再骨折風(fēng)險(xiǎn)LylesKW1,

Colón-EmericCS,

MagazinerJS,ZoledronicAcid

inReducing

Clinical

Fracture

and

Mortality

after

HipFracture.NEnglJMed.

2007;357:nihpa40967.雙磷酸鹽藥物會(huì)延遲骨折愈合嗎？Therewasnoclinicallydetectabledelaytofracturehealingviaexternalcallusformationfollowingbisphosphonatestreatment.Consideringthebenefitaspectsofbisphosphonatesforosteoporosistreatment,werecommendbisphosphonatesinfusionafterfracturefixationsurgeryandlumbarfusionsurgery.XueD,

LiF,

ChenG,

YanS,

PanZ1.Do

bisphosphonates

affectbonehealing?Ameta-analysisofrandomizedcontrolledtrials.JOrthopSurgRes.用藥時(shí)機(jī)ZOLhasnoclinicallyevidenteffecton

fracture

healing,evenwhenthedrugisinfusedintheimmediatepostoperativeperiod.Colón-EmericC1,

NordslettenL,

OlsonS,Associationbetweentimingof

zoledronicacid

infusionand

hipfracture

healing.OsteoporosInt.

2011Aug;22(8):2329-36.防跌倒問(wèn)題超過(guò)30%65歲以上老人都有跌倒經(jīng)歷，這些跌倒中有一半是再跌倒。1/10跌倒引起嚴(yán)重?fù)p傷如骨折、硬膜外出血15%跌倒是外在原因15%跌倒是暈厥、或神經(jīng)失調(diào)7