1 / 69

Epidemiology, Diagnosis Prevention and Management of Osteoporotic Fractures

Epidemiology, Diagnosis Prevention and Management of Osteoporotic Fractures. Kenneth A. Egol, MD NYU-Hospital For Joint Diseases Created March 2004; Revised May 2006. Background. Osteoporosis -- a decreased bone density with normal bone mineralization WHO Definition (1994)

stuart
Download Presentation

Epidemiology, Diagnosis Prevention and Management of Osteoporotic Fractures

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Epidemiology, Diagnosis Prevention and Management of Osteoporotic Fractures Kenneth A. Egol, MD NYU-Hospital For Joint Diseases Created March 2004; Revised May 2006

  2. Background • Osteoporosis -- a decreased bone density with normal bone mineralization • WHO Definition (1994) • Bone Mineral Density ≥2.5 SD’s below the mean seen in young normal subjects • Incidence increases with age • 15% of white women age 50-59 • 70% of white women older than age 80

  3. Background • Risk factors for osteoporosis • Female sex • European ancestry • Sedentary lifestyle • Multiple births • Excessive alcohol use

  4. Background • Senile osteoporosis common • Some degree of osteopenia is found in virtually all healthy elderly patients • Treatable causes should be investigated • Nutritional deficiency • Malabsorption syndromes • Hyperparathyroidism • Cushings disease • Tumors

  5. Background • 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 globally • Enormous cost to society

  6. Background • 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 fractures

  7. Background • 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 care

  8. Background • Osteopenia complicates 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 indicated

  9. Pre-injury Status • Medical History • Cognitive History • Functional History • Ambulatory status • Community Ambulator • Household Ambulator • Non-Functional Ambulator • Non-Ambulator • Living arrangements

  10. Pre-injury Status • Systemic disease • Pre-existing cardiac and pulmonary disease is common in the elderly • Diminishes patients ability to tolerate prolonged recumbency • Diabetes increases wound complications and infection • May delay fracture union

  11. Pre-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 incapacitating disease • ASA V- moribund patient

  12. Pre-injury Status • Cognitive Status • Critical to outcome • Conditions may render patient unable to participate in rehabilitation • Alzheimer’s • CVA • Parkinson's • Senile dementia

  13. Hip Fractures • General principles • With the aging of the American population the incidence of hip fractures 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 80

  14. Hip Fractures • Epidemiology • Incidence increases after age 50 • Female: Male ratio is 2:1 • Femoral neck and intertrochanteric fractures seen with equal frequency

  15. Hip Fractures • Radiographic evaluation • Anterior-posterior view • Cross table lateral • Internal rotation view will help delineate fracture pattern

  16. Hip Fractures • Radiographic evaluation • Occult hip fracture • Technetium bone scanning is a sensitive indicator, 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 hours

  17. Hip Fractures • Management • Prompt operative stabilization • Operative delay of > 24-48 hours increases one-year mortality rates • However, important to balance medical optimization and expeditious fixation • Early mobilization • Decrease incidence of decubiti, UTI, atelectasis/respiratory infections • DVT prophylaxis

  18. Hip Fractures • Outcomes • Fracture related outcomes • Healing • Quality of reduction • Functional outcomes • Ambulatory ability • Mortality (25% at one year) • Return to pre-fracture activities of daily living

  19. Hip 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 arteries (90%) • Artery of ligamentum teres (10%)

  20. 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%

  21. Hip Fractures • Femoral neck fractures • Displaced fractures 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 cases

  22. Hip Fractures • Femoral neck fractures • Treatment: Hemiarthroplasty • Unipolar Vs Bipolar • Can lead to acetabular erosion, dislocation, infection

  23. Hip 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 malunion

  24. Hip Fractures • Intertrochanteric fractures • Extracapsular (well vascularized) • Region distal to the neck between the trochanters • Calcar femorale • Posteromedial cortex • Important muscular insertions

  25. Hip Fractures • Intertrochanteric fractures • Treatment • Usually treated surgically • Implant of choice is a hip compression screw that slides in a barrel attached to a sideplate • The implant allows for controlled impaction upon weightbearing

  26. Hip Fractures • Intertrochanteric fractures • Treatment • Primary prosthetic replacement can be considered • For cases with significant comminution

  27. Hip Fractures • Subtrochanteric Fractures • Begin at or below the level of the lesser trochanter • Typically higher energy injuries seen in younger patients • far less common in the elderly

  28. Hip Fractures • Subtrochanteric Fractures • Treatment • Intramedullary nail (high rates of union) • Plates and screws

  29. Ankle 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 bone

  30. Ankle 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 as 8.3 per 1000 Medicare recipients • Figure that appears to be steadily rising.

  31. Ankle Fractures • Presentation • Follows twisting of foot relative to lower tibia • Patients present unable to bear weight • Ecchymosis, deformity • Careful neurovascular exam must be performed

  32. Ankle Fractures • Radiographic evaluation • Ankle trauma series includes: • AP • Lateral • Mortise • Examine entire length of the fibula

  33. Ankle 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 brace

  34. Ankle Fractures • 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 patient

  35. Ankle Fractures • Treatment • Reductions that are unable to be attained 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 closure

  36. Ankle Fractures • Treatment • Fixation may be suboptimal due to osteopenia • May have to alter standard operative techniques • Cement 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 status

  37. Proximal Humerus • 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 motion

  38. Proximal Humerus • Epidemiology • Incidence rises dramatically beyond the fifth decade in women • 71% of all proximal humerus fractures occur in patients older than 60 • Associated with • frail females • Poor neuromuscular control • Decreased bone mineral density

  39. Proximal 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 key

  40. Proximal Humerus • Radiographic evaluation • AP • Scapula Y • Axillary • CT scan can be helpful

  41. Proximal Humerus • Treatment • Minimally displaced (one part fractures) usually stabilized by surrounding soft tissues • Non operative: 91% good to excellent results

  42. Proximal Humerus • Treatment • Isolated lesser tuberosity fractures require operative 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

  43. Proximal Humerus • Treatment • Displaced surgical neck fractures can be treated closed by reduction under anesthesia with 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

  44. Proximal Humerus • Treatment • Closed treatment of 3 and 4 part fractures have yielded poor results • Failure of fixation is a problem in osteopenic bone • Locked plating versus prosthetic replacement

  45. Proximal 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 free shoulders • Functional recovery and ROM variable

  46. Distal 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 coordination

  47. Distal Radius • Epidemiology • Increasing 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 factor

  48. Distal Radius • Radiographic evaluation • PA • Lateral • Oblique • Contralateral wrist • Important to evaluate deformity, ulnar variance

  49. Distal Radius • Treatment • Non-displaced fractures may be immobilized for 6-8 weeks • Metacarpal-phalangeal and interphalangeal joint motion must be started early

  50. Distal Radius • Treatment • Displaced fractures should be reduced with restoration of radial length, 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 required

More Related