The Nottingham Hip Fracture Score (NHFS) was developed to assess the risk of death following a fracture of the hip, based on pre-operative patient characteristics. We performed an independent validation of the NHFS, assessed the degree of geographical variation that exists between different units within the United Kingdom and attempted to define a NHFS level that is associated with high risk of mortality.

The NHFS was calculated retrospectively for consecutive patients presenting with a fracture of the hip to two hospitals in England. The observed 30-day mortality for each NHFS cohort was compared with that predicted by the NHFS using the Hosmer–Lemeshow test. The distribution of NHFS in the observed group was compared with data from other hospitals in the United Kingdom. The proportion of patients identified as high risk and the mortality within the high risk group were assessed for groups defined using different thresholds for the NHFS.

In all 1079 hip fractures were included in the analysis, with a mean age of 83 years (60 to 105), 284 (26%) male. Overall 30-day mortality was 7.3%. The NHFS was a significant predictor of 30-day mortality. Statistically significant differences in the distribution of the NHFS were present between different units in England (p < 0.001). A NHFS ≥ 6 appears to be an appropriate cut-point to identify patients at high risk of mortality following a fracture of the hip.

Cite this article: Bone Joint J 2015;96-B:100–3.

Title. 3D distribution of cortical bone thickness in the proximal humerus, implications for fracture management. Introduction. CT imaging is commonly used to gain a better understanding of proximal humerus fractures. the operating surgeon however has a limited capacity to evaluate the internal bone geometry from these clinical CT images. our aim was to use clinical CT in a novel way of accurately mapping cortical bone geometry in the proximal humerus. we planned to experimentally define the cortico-cancellous border in a cadaveric study and use CT imaging software to map out cortical thickness distribution in our specimens. Methodology. With ethical approval we used fifteen fresh frozen human proximal humeri. These were stripped of all soft tissue and transverse CT images taken with a GE VCT Lightspeed scanner. The humeral heads were then subsequently resected to allow access to the methaphyseal area. Using currettes, cancellous bone was removed down to hard cortical bone. Another set of CT images of the reamed specimen were then taken. Using Mimics imaging software[Materialise, Leuven] and a CAD interface, 3-matic [Materialise, Leuven], we built 3D model representations of our intact and reamed specimens. We first had to define an accurate CT density threshold for visualising cortical contours. We then analysed cortical thickness distribution based on that experimented threshold. Results. we were able to statistically determine the CT threshold, in Hounsfield Units, that represents the cortico-cancellous interface in the proximal humerus. Our 3D colour models provide an accurate depiction of the distribution of cortical thickness in the proximal humerus. Discussion/Conclusions. Our Hounsfield value for the cortico-cancellous interface in the proximal humerus agrees with a similar range of 400 to 800 HU reported in the literature for the proximal femur. Knowledge of regional variations in cortical bone thickness has direct implications for basic science studies on osteoporosis and its treatment, but is also important for the orthopaedic surgeon since our decision for treatment options is often guided by local bone quality

Aims

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity.

The mean T-score for the distal radius was −2.97 (sd 1.56) compared with −1.61 (sd 1.62) for the lumbar spine and −1.78 (sd 1.33) for the femur. There was a significant difference between the mean lumbar and radial T scores (1.36 (1.03 to 1.68); p < 0.001) and between the mean femoral and radial T-scores (1.18 (0.92 to 1.44); p < 0.001). The inclusion of all three sites in the determination of the T-score increased the sensitivity to 66% compared with that of 46% when only the proximal femur and lumbar spine were used. This difference between measurements in the upper limb compared with the axial skeleton and lower limb suggests that basing risk assessment and treatment on only the bone mineral density taken at the hip or lumbar spine may misrepresent the extent of osteoporosis in the upper limb and the subsequent risk of fracture at this site.

The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb.