The edition · Orthopaedics
The fragility fractures you cannot see on the radiograph are the ones killing people
Two JBJS reviews land together on the same problem from opposite ends: vertebral and pelvic insufficiency fractures that go undiagnosed, and a global care gap that is a health-system failure rather than an evidence one. Plus inflammatory markers and fracture risk, and digital rehabilitation that is finally ready for knee osteoarthritis.
The edition in brief
Two reviews in the Journal of Bone and Joint Surgery frame today's edition around fragility fracture. The first addresses vertebral compression and pelvic insufficiency fractures: common, associated with raised mortality and morbidity, frequently asymptomatic or attributed elsewhere, and hard to see on plain radiographs, particularly in the pelvis and sacrum. Non-operative care suits most patients, with surgery reserved for intractable pain, poor function, radiographic deterioration or neurological deficit, and secondary prevention treated as essential rather than optional. The second review argues that worldwide, fragility fracture care falls short of evidence that is not in dispute — timely surgery, orthogeriatric care, early mobilisation, unrestricted weight-bearing and secondary prevention. In low- and middle-income countries the constraint is workforce, delayed presentation, infrastructure and fragmented pathways, not a lack of evidence. A systematic review and meta-analysis of 48 observational studies found C-reactive protein associated with hip fracture (pooled ratio 1.39, 95% CI 1.17 to 1.67) and vertebral fracture (2.16, 1.47 to 3.18), interleukin-6 with hip fracture (1.40, 1.15 to 1.71) and TNF-alpha or its soluble receptors (1.81, 1.34 to 2.44), all at low GRADE certainty, and the authors are explicit that these must not replace established fracture-risk assessment. A GRADE-appraised review of extended reality found interactive digital rehabilitation improved pain-related functioning in knee osteoarthritis (SMD −0.59, 95% CI −1.11 to −0.06) with no adverse event signal, while evidence after total knee arthroplasty remains thin. And a small Indian trial of a standardised Boswellia serrata extract reported reduced WOMAC scores from day 7 without publishing the effect sizes.
Vertebral and pelvic insufficiency fractures: common, missed, and consequential
Image the older patient who cannot weight-bear despite a normal radiograph, and start bone protection at diagnosis.
Raised CRP tracks with fracture — and should change nothing about how you assess risk
Interesting biology, no change to practice: assess fracture risk the way you already do.
Digital rehabilitation earns its place in knee osteoarthritis, not yet after arthroplasty
Guided digital rehabilitation is reasonable to offer in knee osteoarthritis; after knee replacement, the evidence is not there yet.
A Boswellia trial reports a benefit and does not report how large
Harmless and possibly helpful, but the trial does not say by how much — keep it as an adjunct and keep the core treatment.
The fracture is the referral
Start or explicitly assign bone protection before the patient leaves the ward.
The fragility fracture care gap is a systems problem, and surgeons are the ones positioned to close it
Run the three-indicator audit in your own unit and fix what it shows — the evidence is settled, the delivery is not.
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