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Background: There is no consensus on the optimal management of clavicle fractures, with advocates of both operative and non‐operative management. The objective of this study is to assess the trends in the management of clavicle fractures in Australia over the past two decades. Methods: The incidence of surgical fixation of clavicle fractures from 2001 to 2020 was analysed using the Australian Medicare Benefits Schedule database, reflective of operations performed on privately insured patients, thus excluding public patients and compensable cases. An offset term was utilized with data from the Australian Bureau of Statistics to account for population changes over the study period. Results: A total of 17 089 procedures for the management of clavicle fractures were performed from 2001 to 2020. The incidence of operative intervention increased from 1.87 per 100 000 in 2001 to a peak of 6.63 per 100 000 in 2016. An overall increase was seen in males (310%) and females (347%) over the study period, as well as across all age groups. A greater proportion of operative interventions was performed on males (n = 14 075, 82%) than females (n = 3014, 18%, P < 0.001). The greatest increase in intervention was noted in those aged 65 or older (14% increase per year, 95% CI 11%–17%, P < 0.05). In 2020, the incidence of operative intervention decreased to a level last seen in 2013. Conclusions: The incidence of operative interventions for clavicle fractures has increased in Australia over the 20‐year study period. This increase is in keeping with recent evidence suggesting several advantages when displaced mid‐shaft clavicle fractures are operatively managed. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is common among fracture patients. However, its association with osteoporosis investigation and treatment to prevent future fractures is unclear. This limited knowledge impedes optimal patient care. This study investigated the association between multimorbidity and osteoporosis investigation and treatment in persons at high risk following an osteoporotic fracture. Methods and findings: The Sax Institute's 45 and Up Study is a prospective population-based cohort of 267,153 people in New South Wales, Australia, recruited between 2005 and 2009. This analysis followed up participants until 2017 for a median of 6 years (IQR: 4 to 8). Questionnaire data were linked to hospital admissions (Admitted Patients Data Collection (APDC)), emergency presentations (Emergency Department Data Collection (EDDC)), Pharmaceutical Benefits Scheme (PBS), and Medicare Benefits Schedule (MBS). Data were linked by the Centre for Health Record Linkage and stored in a secured computing environment. Fractures were identified from APDC and EDDC, Charlson Comorbidity Index (CCI) from APDC, Dual-energy X-ray absorptiometry (DXA) investigation from MBS, and osteoporosis treatment from PBS. Out of 25,280 persons with index fracture, 10,540 were classified as high-risk based on 10-year Garvan Fracture Risk (age, sex, weight, prior fracture and falls) threshold ≥20%. The association of CCI with likelihood of investigation and treatment initiation was determined by logistic regression adjusted for education, socioeconomic and lifestyle factors). The high-risk females and males averaged 77 ± 10 and 86 ± 5 years, respectively; >40% had a CCI ≥2. Only 17% of females and 7% of males received a DXA referral, and 22% of females and 14% males received osteoporosis medication following fracture. A higher CCI was associated with a lower probability of being investigated [adjusted OR, females: 0.73 (95% CI, 0.61 to 0.87) and 0.43 (95% CI, 0.30 to 0.62); males: 0.47 (95% CI, 0.33 to 0.68) and 0.52 (0.31 to 0.85) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively] and of receiving osteoporosis medication [adjusted OR, females: 0.85 (95% CI, 0.74 to 0.98) and 0.78 (95% CI, 0.61 to 0.99); males: 0.75 (95% CI, 0.59 to 0.94) and 0.37 (95% CI, 0.23 to 0.53) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively]. The cohort is relatively healthy; therefore, the impact of multimorbidity on osteoporosis management may have been underestimated. Conclusions: Multimorbidity contributed significantly to osteoporosis treatment gap. This suggests that fracture risk is either underestimated or underprioritized in the context of multimorbidity and highlights the need for extra vigilance and improved fracture care in this setting. Dana Bliuc and team investigate the association between multimorbidity and osteoporosis investigation and treatment in persons at high risk following an osteoporotic fracture. Author summary: Why was this study done?: Osteoporotic fractures are common, costly, and associated with increased risk of future fracture and premature mortality. Effective preventive treatment is available and recommended for high-risk patients with a 10-year fracture risk >20%, but its uptake in this group is suboptimal. High-risk patients often have multiple chronic conditions, and it is important to know to what degree the other chronic conditions might alter the uptake of fracture prevention medication in order to optimise patient care. What did the researchers do and find?: We conducted a prospective study including over 10,000 adults aged 50+ with an osteoporotic fracture and high-risk of future fracture to investigate the association between multimorbidity and osteoporosis investigation and treatment. In this high-risk group, the vast majority of adults were not investigated or treated for osteoporosis following an osteoporotic fracture. Adults with multiple chronic conditions were significantly less likely to be investigated [adjusted OR, females: 0.73 (95% CI, 0.61 to 0.87) and 0.43 (95% CI, 0.30 to 0.62); males: 0.47 (95% CI, 0.33 to 0.68) and 0.52 (0.31 to 0.85) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively] or treated for osteoporosis [adjusted OR, females: 0.85 (95% CI, 0.74 to 0.98) and 0.78 (95% CI, 0.61 to 0.99); males: 0.75 (95% CI, 0.59 to 0.94) and 0.37 (95% CI, 0.23 to 0.53) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively] compared to those without chronic conditions. What do these findings mean?: The presence of additional chronic conditions was associated with a lower likelihood of being investigated and treated for osteoporosis. These findings suggest that fracture preventing treatment is either underprioritised or underestimated in the presence of other chronic conditions. There is a need for more awareness of increased fracture risk in complex patients with multiple chronic conditions. [ABSTRACT FROM AUTHOR]

This single-centre retrospective study aimed to characterise the epidemiology, management, and outcomes of mandibular trauma presenting to the same tertiary trauma centre 30 years apart, including key paradigm shifts in management and techniques. A total of 393 patients presenting with 665 mandibular fractures were managed by the Oral and Maxillofacial Surgery department at The Royal Melbourne Hospital (RMH), Australia, between 2011 and 2016. Data from a previous RMH paper of 205 patients presenting with 376 mandibular fractures between January 1985 and April 1990 were compared. Results showed an increase in presentations (205 to 393 patients) with an increase in the incidence of mandibular trauma (p = 0.0001), females (12% to 14%), and mean age (29 to 31.1) years. Young males remained the dominant cohort (86%) and interpersonal violence (IPV) the most common aetiology (46% to 43%). Mandibular fractures remained commonly associated with other systemic injuries (49% to 42%), occurring most frequently on the left (49%), and at the angle (29.8%), with most occurring at two sites (53%). Significant paradigm shifts in the management of mandibular trauma saw a reduced need for intermaxillary fixation (76% to 30%, p = 0.0001), increased use of extraoral approaches to the fracture, and the use of semi-rigid internal fixation along ideal lines of osteosynthesis (29% to 87%, p = 0.0001). This demonstrated decreased complications including malocclusion, non-union and delayed union, and permanent nerve injury. There was no significant change in infection, dehiscence rates, and temporary nerve damage. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To develop and implement a telehealth‐based model of care for spinal fractures requiring management with thoracic lumbar sacral orthoses that eliminates the need for transfer to a metropolitan tertiary referral hospital. Design: Pre–post design observational study evaluating model of care implementation. Setting: Rural referral hospitals in a large NSW region covering metropolitan, rural and remote hospitals. Participants: Patients presenting with a thoracic or lumbar spine fracture requiring thoracic lumbar sacral orthoses management and rural clinicians caring for them. Outcome measures: Number of patients managed in rural hospitals without transfer to a metropolitan tertiary referral hospital; length of stay and related cost efficiencies; clinicians' perceived skills, knowledge and confidence levels. Results: Model of care was implemented with clinical and system governance processes; and educational workshops across eight rural hospitals. A total of 81 patients managed in rural hospitals under this model between July 2013 and June 2016 without transfer were included in this study. Mean length of stay reduced from nine to four days. Hospital transfers were eliminated from the patient journey, totalling 24 324 km. Workshops were attended by 71 clinicians from nine rural hospitals and survey findings indicated a significant increase in staff knowledge, skill and confidence post education. Cost efficiencies were gained by eliminating 162 inter‐hospital transfers and 405 patient bed days. Conclusion: This model has streamlined patient journeys and reduced transfers and travel, enabling rural clinicians to provide specialised services in local communities and facilitating timely evidence‐based care in local communities without any adverse events. [ABSTRACT FROM AUTHOR]

Introduction: Atypical femoral fractures (AFFs) are rare but a serious complication associated with prolonged use of bisphosphonates. However little is known about clinical outcomes of AFFs. The aim of this study is to compare the characteristics and postoperative outcomes between older patients with AFFs and typical femoral fractures (TFFs).Methods: A retrospective matched cohort study (each AFF was age- and sex-matched with three TFFs) of patients aged 65 years or older who were admitted to The Queen Elizabeth Hospital, South Australia between January 2011 and December 2013 was undertaken. Baseline characteristics of both groups were compared. The primary outcomes evaluated were level of independence in mobility at discharge and 3 months after surgery. Secondary outcomes included length of hospital stay, post-operative complications, rate of surgical revision, discharge destination (after acute hospital stay or rehabilitation), 28-day hospital readmission and 12-month mortality.Results: Ten patients (mean age: 78.1 years) with AFFs were compared with 30 matched TFFs. Patients with AFFs were predominantly female (90%) and 80% had been taking oral bisphosphonate. Nine of the AFFs had their fractures fixed with an intramedullary (IM) nail. The level of independent mobility at discharge (OR 0.31; 95%CI: 0.06-1.71; p=0.26) and at 3 months (OR 0.51; 95%CI: 0.10-2.53; p=0.47) were comparable between the two groups. Only one AFF patient treated with plate and screws required surgical revision, compared with none in the TFF group. Secondary outcomes were not significantly different between the two groups.Conclusion: Recovery of mobility and reoperation rates after surgery of patients with AFFs were favourable and did not differ significantly from TFFs. Further consideration should be given to using IM fixation in the management of AFFs in older people. [ABSTRACT FROM AUTHOR]

Background/aim: The aim of this study was to investigate factors that were associated with receiving anti-osteoporosis treatment (AOT) among patients with minimal trauma hip fracture admitted to an Australian tertiary trauma centre under the Acute Orthogeriatric Service (AOS) over a 6 month period.Design: Observational study using prospectively collected data.Methods: Demographic and clinical characteristics of 211 patients were extracted from the local hip fracture registry and electronic medical records. The outcome measure was receipt of AOT before separation from the AOS. Binary logistic regression was used to identify factors independently associated with treatment.Results: 91 (45%) patients received AOT, including 51 (25.2%) treatment-naive patients. Factors significantly associated with receiving treatment included higher serum vitamin D level (OR 1.44, 95% CI 1.23-1.70, p<0.001) and trochanteric vs. cervical fracture (OR 2.67, 95% CI 1.30-5.49, p=0.007). Living in a residential aged care facility (RACF) prior to the index fracture (OR 0.2, 95% CI 0.08-0.54, p=0.001) and higher American Society of Anaesthesiologists (ASA) physical status score (OR 0.5, 95% CI 0.25-0.98, p=0.04) significantly lowered the likelihood of treatment. Age, gender, cognitive impairment, premorbid walking ability, previous fragility fracture and renal impairment did not correlate with treatment.Conclusion: A significant proportion (55%) of hip fracture patients did not receive AOT in hospital. The probability of receiving treatment appears to be significantly associated with serum vitamin D level, fracture type, place of residence and comorbidity burden. [ABSTRACT FROM AUTHOR]

The Australian Cooper Basin is a structurally complex intra-cratonic basin with large unconventional hydrocarbon potential. Fracture stimulation treatments are used extensively in this basin to improve the economic feasibility; however, such treatments may induce fault activity and risk the integrity of hydrocarbon accumulations. Fault reactivation may not only encourage tertiary fluid migration but also decrease porosity through cataclasis and potentially compartmentalise the reservoir. Relatively new depth-converted three-dimensional seismic surveys covering the Dullingari and Swan Lake 3D seismic surveys were structurally interpreted and geomechanically modelled to constrain the slip tendency, dilation tendency and fracture stability of faults under the present-day stress. A field-scale pore pressure study found a maximum pressure gradient of 11.31 kPa/m within the Dullingari 3D seismic survey, and 11.14 kPa/m within the Swan Lake 3D seismic survey. The present-day stress tensor was taken from previously published work, and combined with local pore pressure gradients and depth-converted field-scale fault geometries, to conclude that SE–NW-striking strike-slip faults are optimally oriented to reactivate and dilate. High-angle faults striking approximately E–W appear most likely to dilate, and act as fluid conduits irrespective of being modelled under a strike-slip or compressional stress regime. Near-vertical SE–NW and NE–SW-striking faults were modelled to be preferentially oriented to slip and reactivate under a strike-slip stress regime. Considering that SE–NW-striking strike-slip faults have only recently been interpreted in the literature, it is possible that many reservoir simulations and development plans have overlooked or underestimated the effect that fault reactivation may have on reservoir properties. Future work investigating the likelihood that fracture stimulation treatments may be interacting, and reactivating, pre-existing faults and fractures would benefit field development programs utilising high-pressure hydraulic fracture stimulation treatments. [ABSTRACT FROM AUTHOR]

Objective: Femoral nerve blocks (FNBs) are commonly administered to patients with a fractured neck of femur (NOF). FNBs reduce complications associated with opioids and are effective for up to 24 h. However, the recognised 'gold standard' time to definitive treatment (surgery) in the patient with a fractured NOF is within 48 h. This leaves a significant period of time in which the patient has no effective analgesia, and might require opioids to alleviate pain. The present study explored the number of NOF patients who received a FNB: their wait for definitive treatment (surgery) and how much opioid analgesia was administered in the preoperative phase. Methods: A retrospective review of electronic patient records was conducted over a 6 month period in 2012. Patients who presented to the ED with a fractured NOF, received a FNB and were transferred to surgery in the same hospital were included in the sample. Results: The median time from FNBs to surgery was 37.5 h. When patients waited more than 20 h for surgery, the volume of opioid received increased significantly (P < 0.001). Conclusion: Even when patients' time to surgery was within the 'gold standard', patients received increasing doses of opioids 20 h after the administration of the FNB. While patients continue to wait extended periods for surgery, the practice of administering a single injection FNB needs to be challenged. ED clinicians might consider FNB infusions rather than single injection FNBs for patients with a fractured NOF. [ABSTRACT FROM AUTHOR]

Objective Distal forearm fractures frequently require reduction in children. We set out to survey how such fractures are currently reduced at Paediatric Research in Emergency Departments International Collaborative ( PREDICT) sites. Methods A survey was completed by paediatric emergency physicians at PREDICT sites. Survey questions covered departmental guidelines and resources and individual practice, agents used and limitations of fracture management using case vignettes. Results One hundred eleven of 145 (77%) possible surveys were returned. All 12 PREDICT sites have guidelines for the use of nitrous oxide and 11 of 12 for ketamine. Guidelines for other agents are less common and highly variable. The most frequently used procedural sedation and analgesia ( PSA) agents were ketamine (27%), nitrous oxide alone (19%) or in combination with intranasal fentanyl (18%) and Bier's block (11%). Most respondents indicated tolerance without reduction in fractures with angulation less than 20° (59%) and 10° (71%) in a 5- and 10-year-old patient, respectively. Most physicians (74%) would reduce up to a 25° angulated fracture in the ED with more displaced fractures being referred to theatre. The 44% of respondents listed the lack of an image intensifier in the ED as a limitation in their ability to reduce fractures. Conclusion Paediatric distal forearm fractures are commonly reduced in the surveyed EDs, most commonly under ketamine or nitrous oxide. Areas of improvement include better defined cut-offs for fracture reduction and for referral to theatre, improved differential efficacy of PSA agents, standardised guidelines for PSA and introduction of image intensifiers into more EDs. [ABSTRACT FROM AUTHOR]

Summary We evaluated the cost-effectiveness of a fracture liaison service prospectively designed to have a parallel control group treated by standard care. The clinical effectiveness of this service was associated with an incremental cost-effectiveness ratio versus standard care of Australian dollars (AUD) 17,291 per quality-adjusted life year (QALY) gained. Introduction Osteoporotic fractures are a major burden for national health services. The risk of re-fracture following an osteoporotic fracture is particularly high. In a study unique in prospectively having a control group treated by standard care, we recently demonstrated that a Minimal Trauma Fracture Liaison (MTFL) service significantly reduces the risk of refracture by 80%. Since the service involves greater use of resources, we have now evaluated whether it is cost-effective. Methods A Markov model was developed that incorporated fracture probabilities and resource utilization data (expressed in AUD) obtained directly from the 4-year MTFL service clinical study. Resource utilization, local cost and mortality data and fracture-related health utility data were used to calculate QALYs with the MTFL service and standard care. Main outcome measures were: additional costs of the MTFL service over standard care, the financial savings achieved through reduced fractures and changes in QALYs associated with reduced fractures calculated over a 10-year simulation period. Costs and QALYs were discounted at 5% annually. Sensitivity analyses quantified the effects of different assumptions of effectiveness and resource utilization associated with the MTFL service. Results The MTFL service improved QALYs by 0.089 years and led to increased costs of AUD 1,486 per patient versus standard care over the 10-year simulation period. The incremental cost-effectiveness ratio versus standard care was AUD 17,291 per QALY gained. Results were robust under all plausible assumptions. Conclusions The MTFL service is a cost-effective intervention to reduce recurrent osteoporotic fractures. [ABSTRACT FROM AUTHOR]

Summary: This study aimed to describe treatment initiation rates for men who had recently sustained a fracture. Most (75.9%) men potentially eligible for subsidised treatment at the time of fracture remained untreated even after a subsequent fracture. Introduction: This study aimed to describe treatment initiation rates for men who had recently sustained a fracture. Methods: The study was conducted as part of the Geelong Osteoporosis Study in south-eastern Australia. Men in the study area who had sustained an incident fracture in the period July 2006 to December 2007 were identified from hospital radiology reports. A self-report questionnaire was sent to eligible participants approximately 12 months after fracture. Respondents were asked for details of medications prescribed for 'osteoporosis/fracture/low bone mass' before and after fracture, and where applicable, reasons for cessation of treatment. We analysed the results for 109 men aged 50 years and older who had sustained fracture in the study period. Results: Most (75.9%) men potentially eligible for subsidised treatment at the time of fracture remained untreated. Of the 87 men who were untreated, nine had osteoporosis at the hip and/or spine and 29 (26.6%) reported having sustained a low trauma prior fracture. Conclusions: Our findings are consistent with previously published data showing low rates of treatment initiation in men eligible for osteoporosis treatment. There appear to be barriers involving participants' and medical practitioners' knowledge, beliefs and attitudes regarding osteoporosis and treatment, as well as in the doctor-patient partnership in osteoporosis management. Establishment of clinical pathways for fracture management beyond orthopaedic care may be one of a range of appropriate responses. [ABSTRACT FROM AUTHOR]

Background: The strength of nursing home residence as a prognostic indicator of outcome following hip fracture has not previously been examined in Australia. The aim of the study was to examine the influence of nursing home residency on mortality after sustaining an acute hip fracture. Methods: A prospective study of all adults aged 65 years and over presenting to a single tertiary referral hospital for management of a proximal femoral fracture between July 2003 and September 2006. Residential status was obtained at admission. Patients were followed up to September 2007 (minimum 12 months). Relative risk values for mortality were calculated comparing nursing home residents with non-nursing home residents. Survival analysis was performed. Results: Relative risk of death was higher in nursing home patients compared with non-nursing home patients. The difference was greater in the immediate period (30 days) post-injury (relative risk 1.9, 95% confidence interval 1.0–3.6, P= 0.04) than after 12 months (relative risk 1.5, 95% confidence interval 1.2–1.8, P= 0.001). Survival analysis showed that 25% of patients in the nursing home group died by 96 days post-injury, compared with 435 days in the non-nursing home group. Conclusions: Nursing home residence confers an increased risk of death following hip fracture; this difference is greater in the immediate post-injury period. The relative risk of death decreases over time to equal previously reported comparative mortality rates between nursing home residents and community dwellers without hip fracture. [ABSTRACT FROM AUTHOR]

Question: What are the costs and utilisation of healthcare resources, their determinants, and quality of life for people attending outpatient physiotherapy after ankle fracture? Design: Longitudinal observational study. Participants: Ninety-four adults (2 dropouts) following cast removal after isolated ankle fracture attending outpatient physiotherapy at three hospitals in Sydney, Australia. Outcome measures: Costs incurred (direct healthcare costs and out-of-pocket costs) and utilisation of healthcare system resources were measured at 4, 8, 12, 16, 20, and 24 weeks. Quality of life was measured shortly after cast removal and at 4, 12, and 24 weeks. Factors known to influence costs and utilisation in other conditions (private health insurance, income level, gender, and pain) were also measured. Results: The total cost per person was AUD 735 (SD 876) over 24 weeks. Outpatient physiotherapy accounted for the highest costs in both direct healthcare (39%) and out-of-pocket (42%) costs. Less than 20% of participants sought private non-medical care in addition to receiving outpatient physiotherapy. None of the factors investigated had a significant influence on costs and utilisation. Quality of life score improved over the 24 weeks by a mean of 6.1 points out of 45 (95% CI 5.2 to 6.9), with most of the improvement occurring in the domain of independent living. Conclusion: Information on costs and utilisation of healthcare resources can be used to plan health services, eg, the number of physiotherapy sessions required after ankle fracture. Private health insurance, income level, gender, or pain did not influence the costs or the decision behind seeking care over and above publicly-provided physiotherapy. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined the impact of a national current affairs television program about the association between osteonecrosis of the jaw and bisphosphonates on subsequent prescription use, fractures and deaths in Australia. Prescription data from the National Pharmaceutical Benefits Scheme were used in the study to estimate the impact of reduced bisphosphonate use on fractures and mortality. One complaint on the television program "The 7:30 Report" is described.

The article presents an incident submitted to the Emergency Medicine Events Register (EMER), an anonymous, confidential and protected incident-reporting system supported by Australasian College for Emergency Medicine (ACEM). Topics discussed include the failure of an emergency department (ED) registrar to correctly identify a triquetral fracture on X-ray and how the missed fracture highlights a system issue that can potentially lead to significant patient harm.

In this article, the author focuses on the importance of Emergency Department (ED) among family of patients. It mentions that general practitioner (GP) take proper care of patient in reference with case of 9-year-old girl who was taken to the Emergency Department due to distal radius buckle fracture. It also mentions that EDs are popular because they work directly for consumers.

The article discusses the need to implement fracture liaison services work at all Australian hospitals as of 2011. It states that osteoporotic fractures increase the chances of injury and death, but that no follow up studies are done to ensure prevention. It cites the burden that this places on the country's health care and describes a study conducted in 2005 at the Concord Repatriation General Hospital in Sydney which performed such studies, reduced repeat injuries, and costs, as well.

The article offers information on the Strontium ranelate drugs for treating fracture in men and women. It states that it used to treat the osteoporosis of postmenopausal women at risk of fracture and men at increased risk of fracture. It notes that it is marketed in Australia under the Protos brand name. It mentions that the drug is linked with increased risk of myocardial infarction and venous thromboembolism.