1、Background Risk factors for osteoporosis Female sex European ancestry Sedentary lifestyle Multiple births Excessive alcohol useBackground Senile osteoporosis common Some degree of osteopenia is found in virtually all healthy elderly patients Treatable causes should be investigated Nutritional defici
2、ency Malabsorption syndromes Hyperparathyroidism Cushings disease TumorsBackground The incidence of osteoporotic fractures is increasing Estimated that half of all women and one-third of all men will sustain a fragility fracture during their lifetime By 2050-6.3 million hip fractures will occur glob
3、ally Enormous cost to societyBackground The most common fractures in the elderly osteoporotic patient include:Hip Fractures Femoral neck fractures Intertrochanteric fractures Subtrochanteric fractures Ankle fractures Proximal humerus fracture Distal radius fractures Vertebral compression fracturesBa
4、ckground Fractures in the elderly osteoporotic patient represent a challenge to the orthopaedic surgeon The goal of treatment is to restore the pre-injury level of function Fracture can render an elderly patient unable to function independently-requiring institutionalized careBackground Osteopenia c
5、omplicates both fracture treatment and healing Internal fixation compromised Poor screw purchase Increased risk of screw pull out Augmentation with methylmethacrylate has been advocated Increased risk of non-union Bone augmentation(bone graft,substitutes)may be indicatedPre-injury Status Medical His
6、tory Cognitive History Functional History Ambulatory status Community Ambulator Household Ambulator Non-Functional Ambulator Non-Ambulator Living arrangementsPre-injury Status Systemic disease Pre-existing cardiac and pulmonary disease is common in the elderly Diminishes patients ability to tolerate
7、 prolonged recumbency Diabetes increases wound complications and infection May delay fracture unionPre-injury Status American Society of Anesthesiologists(ASA)Classification ASA I-normal healthy ASA II-mild systemic disease ASA III-Severe systemic disease,not incapacitating ASA IV-severe incapacitat
8、ing disease ASA V-moribund patientPre-injury Status Cognitive Status Critical to outcome Conditions may render patient unable to participate in rehabilitation Alzheimers CVA Parkinsons Senile dementiaHip Fractures General principles With the aging of the American population the incidence of hip frac
9、tures is projected to increase from 250,000 in 1990 to 650,000 by 2040 Cost approximately$8.7 billion annually 20%higher incidence in urban areas 15%lifetime risk for white females who live to age 80Hip Fractures Epidemiology Incidence increases after age 50 Female:Male ratio is 2:1 Femoral neck and
10、 intertrochanteric fractures seen with equal frequencyHip Fractures Radiographic evaluation Anterior-posterior view Cross table lateral Internal rotation view will help delineate fracture patternHip Fractures Radiographic evaluation Occult hip fracture Technetium bone scanning is a sensitive indicat
11、or,but may take 2-3 days to become positive Magnetic resonance imaging has been shown to be as sensitive as bone scanning and can be reliably performed within 24 hoursHip Fractures Management Prompt operative stabilization Operative delay of 24-48 hours increases one-year mortality rates However,imp
12、ortant to balance medical optimization and expeditious fixation Early mobilization Decrease incidence of decubiti,UTI,atelectasis/respiratory infections DVT prophylaxisHip Fractures Outcomes Fracture related outcomes Healing Quality of reduction Functional outcomes Ambulatory ability Mortality(25%at
13、 one year)Return to pre-fracture activities of daily livingClosed Reduction and Internal fixationCalcium/Vitamin D SupplementationIn the United States,ankle fractures have been reported to occur in as many as 8.Subtrochanteric Fractures112/100,000 in menTypically higher energy injuries seen in young
14、er patientsDVT prophylaxisFemoral neck fracturesKyphosis and scoliosis may developRadiographic evaluationProximal HumerusPrevention and Treatment of Bone Fragilitypoor results are associated with rotator cuff tears,malunion,nonunionAnkle FracturesMortality(25%at one year)Vertebral Compression Fractu
15、resLocked plating versus prosthetic replacementPoor screw purchaseTender to palpationASA V-moribund patientHip Fractures Femoral neck fractures Intracapsular location Vascular Supply Medial and lateral circumflex vessels anastamose at the base of the neck blood supply predominately from ascending ar
16、teries(90%)Artery of ligamentum teres(10%)Hip Fractures Femoral neck fractures Treatment Non-displaced/valgus impacted fractures Non-operative 8-15%displacement rate Operative with cannulated screws Non-union 5%and osteonecrosis is approximately 8%Hip Fractures Femoral neck fractures Displaced fract
17、ures should be treated operatively Treatment:Open vs.Closed Reduction and Internal fixation 30%non-union and 25%-30%osteonecrosis rate Non-union requires reoperation 75%of the time while osteonecrosis leads to reoperation in 25%of casesHip Fractures Femoral neck fractures Treatment:Hemiarthroplasty
18、Unipolar Vs Bipolar Can lead to acetabular erosion,dislocation,infectionHip Fractures Femoral neck fractures Treatment Displaced fractures can be treated non-operatively in certain situations Demented,non-ambulatory patient Mobilize early Accept resulting non or malunionHip Fractures Intertrochanter
19、ic fractures Extracapsular(well vascularized)Region distal to the neck between the trochanters Calcar femorale Posteromedial cortex Important muscular insertionsHip Fractures Intertrochanteric fractures Treatment Usually treated surgically Implant of choice is a hip compression screw that slides in
20、a barrel attached to a sideplate The implant allows for controlled impaction upon weightbearingHip Fractures Intertrochanteric fractures Treatment Primary prosthetic replacement can be considered For cases with significant comminutionHip Fractures Subtrochanteric Fractures Begin at or below the leve
21、l of the lesser trochanter Typically higher energy injuries seen in younger patients far less common in the elderlyHip Fractures Subtrochanteric Fractures Treatment Intramedullary nail(high rates of union)Plates and screwsHip FracturesThe goal of treatment is to restore the pre-injury level of funct
22、ionProgressive ambulation should be started earlyEstimated that half of all women and one-third of all men will sustain a fragility fracture during their lifetimeIf acceptable reduction is not attained open reduction should be undertakenProximal HumerusProximal HumerusVertebral Compression Fractures
23、Hip FracturesHip FracturesDisplaced fractures should be treated operativelyMortality(25%at one year)Prosthetic replacement can be expected to result in relatively pain free shoulders30%non-union and 25%-30%osteonecrosis rateQuestions/Comments117/100,000May have to alter standard operative techniques
24、Cushings diseaseDVT prophylaxisPre-injury StatusAnkle Fractures Common injury in the elderly Significant increase in the incidence and severity of ankle fractures over the last 20 years Low energy injuries following twisting reflecting the relative strength of the ligaments compared to osteopenic bo
25、neAnkle Fractures Epidemiology Finnish Study(Kannus et al)Three-fold increase in the number of ankle fractures among patients older than 70 years between 1970 and 2000 Increase in the more severe Lauge-Hansen SE-4 fracture In the United States,ankle fractures have been reported to occur in as many a
26、s 8.3 per 1000 Medicare recipients Figure that appears to be steadily rising.Ankle Fractures Presentation Follows twisting of foot relative to lower tibia Patients present unable to bear weight Ecchymosis,deformity Careful neurovascular exam must be performedAnkle Fractures Radiographic evaluation A
27、nkle trauma series includes:AP Lateral Mortise Examine entire length of the fibulaAnkle Fractures Treatment Isolated,non-displaced malleolar fracture without evidence of disruption of syndesmotic ligaments treated non-operatively with full weight bearing My utilize walking cast or cast braceAnkle Fr
28、actures Treatment Unstable fracture patterns with bimalleolar involvement,or unimalleolar fractures with talar displacement must be reduced Treatment closed requires a long leg cast to control rotation may be a burden to an elderly patientAnkle Fractures Treatment Reductions that are unable to be at
29、tained closed require open reduction and internal fixation The skin over the ankle is thin and prone to complication Await resolution of edema to achieve a tension free closureAnkle Fractures Treatment Fixation may be suboptimal due to osteopenia May have to alter standard operative techniques Cemen
30、t Augmentation Reports in literature mixed Early studies showed no difference in operative vs non-op treatment-with operative groups having higher complication rates More recent studies show improved outcomes in operatively treated group Goal is return to pre-injury functional statusProximal Humerus
31、 Background Very common fracture seen in geriatric populations 112/100,000 in men 439/100,000 in women Result of low energy trauma Goal is to restore pain free range of shoulder motionProximal Humerus Epidemiology Incidence rises dramatically beyond the fifth decade in women 71%of all proximal humer
32、us fractures occur in patients older than 60 Associated with frail females Poor neuromuscular control Decreased bone mineral densityAlzheimersAnkle Fractures112/100,000 in menVertebral Compression FracturesProximal HumerusLiving arrangementsPrevention and Treatment of Bone FragilityRecombinant formu
33、lation of parathyroid hormoneCross table lateralMore common than hip fracturesNumber of elderly is increasing all will have to work together in difficult economic timesDisplaced fractures should be reduced with restoration of radial length,inclination and tiltPre-injury StatusThe goal of treatment i
34、s to restore the pre-injury level of functionAwait resolution of edema to achieve a tension free closureProlonged bedrest should be avoidedCan lead to acetabular erosion,dislocation,infectionImportant muscular insertionsDiminishes patients ability to tolerate prolonged recumbencyOsteopenia complicat
35、es both fracture treatment and healingProximal Humerus Background Articulates with the glenoid portion of the scapula to form the shoulder joint Four parts Combination of bony,muscular,capsular and ligamentous structures maintains shoulder stability Status of the rotator cuff is keyProximal Humerus
36、Radiographic evaluation AP Scapula Y Axillary CT scan can be helpfulProximal Humerus Treatment Minimally displaced(one part fractures)usually stabilized by surrounding soft tissues Non operative:91%good to excellent resultsProximal Humerus Treatment Isolated lesser tuberosity fractures require opera
37、tive fixation only if the fragment contains a large articular portion or limits internal rotation Isolated greater tuberosity associated with longitudinal cuff tears and require ORIF Proximal Humerus Treatment Displaced surgical neck fractures can be treated closed by reduction under anesthesia with
38、 X-ray guidance Anatomic neck fractures are rare but have a high rate of osteonecrosis If acceptable reduction is not attained open reduction should be undertaken Proximal Humerus Treatment Closed treatment of 3 and 4 part fractures have yielded poor results Failure of fixation is a problem in osteo
39、penic bone Locked plating versus prosthetic replacementProximal Humerus Treatment Regardless of treatment all require prolonged,supervised rehabilitation program poor results are associated with rotator cuff tears,malunion,nonunion Prosthetic replacement can be expected to result in relatively pain
40、free shoulders Functional recovery and ROM variableDistal Radius Background Very common fracture in the elderly Result from low energy injuries Incidence increases with age,particularly in women Associated with dementia,poor eyesight and a decrease in coordinationDistal Radius Epidemiology Increasin
41、g in incidence Especially in women Peak incidence in females 60-70 Lifetime risk is 15%Most frequent cause:fall on outstretched arm Decreased bone mineral density is a factorDistal Radius Radiographic evaluation PA Lateral Oblique Contralateral wrist Important to evaluate deformity,ulnar varianceImp
42、ortant muscular insertionsHip FracturesVertebral compression fracturesVertebral Compression FracturesInhibits bone resorption by reducing osteoclast recruitment and activityPrevention and Treatment of Bone Fragilityblood supply predominately from ascending arteries(90%)ASA V-moribund patientCritical
43、 to outcome112/100,000 in menSome degree of osteopenia is found in virtually all healthy elderly patientsContralateral wristInhibits bone resorption by inhibiting osteoclast activityIncidence increases after age 50112/100,000 in men7 billion annuallyMay have to alter standard operative techniquesSen
44、ile osteoporosis commonHip FracturesCalcitononinDistal Radius Treatment Non-displaced fractures may be immobilized for 6-8 weeks Metacarpal-phalangeal and interphalangeal joint motion must be started earlyDistal Radius Treatment Displaced fractures should be reduced with restoration of radial length
45、,inclination and tilt Usually accomplished with longitudinal traction under hematoma block If satisfactory reduction is obtained treatment in a long arm or short arm cast is undertaken No statistical difference in method Weekly radiographs are requiredDistal Radius Treatment:Operative if acceptable
46、reduction not obtained regional or general anesthesia Methods ORIF Closed reduction and percutaneous pinning with external fixation Bone grafting for dorsal comminution Distal Radius Treatment Results are variable and depend on fracture type and reduction achieved Minimally displaced and fractures i
47、n which a stable reduction has been achieved result in good functional outcomesDistal Radius Treatment Displaced fractures treated surgically produce good to excellent results 70-90%Functional limits include pain,stiffness and decreased gripVertebral Compression Fractures Background Nearly all post-
48、menopausal women over age 70 have sustained a vertebral compression fracture Usually occur between T8 and L2 Kyphosis and scoliosis may develop markers for osteoporosisVertebral Compression Fractures Epidemiology More common than hip fractures 117/100,000 Twice as common in females Lifetime risk in
49、a 50 year old white female is 32%Vertebral Compression Fractures Background Present with acute back pain Tender to palpation Neurologic deficit is rare Patterns Biconcave(upper lumbar)Anterior wedge(thoracic)Symmetric compression(T-L junction)Vertebral Compression Fractures Radiographic evaluation A
50、P and lateral radiographs of the spine Symptomatic vertebrae 1/3 height of adjacent Bone scan can differentiate old from new fracturesVertebral Compression Fractures Treatment Simple osteoporotic vertebral compression fractures are treated non-operatively and symptomatically Prolonged bedrest should
